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NATIONAL LIBRARY OF MEDICINE
NLM  Q01Q7Di4fl 7
NLM001070487 
 
 
A TREATISE
ON THE
PRINCIPLES AND  PRACTICE
OF
MEDICINE;
DESIGNED FOR THE USE OF
PRACTITIONERS AND STUDENTS OF MEDICINE.
                   BY

        AUSTIN FLINT, M.D., LL.D.,
               »■ V-
LATE PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE AND OF CLINICAL MEDICINE
      IN THE BELLEVUE HOSPITAL MEDICAL COLLEGE, NEW YORK, ETC.



         SEVENTH EDITION,


            THOROUGHLY REVISED


                   BY

      FREDERICK P.  HENRY, A.M., M.D.,

PROFESSOR OF THE PRINCIPLES AND PRACTICE OF MEDICINE IN THE WOMAN'S MEDICAL COLLEGE
   OF PENNSYLVANIA ; PHYSICIAN TO THE PHILADELPHIA HOSPITAL ; CORRESPONDING
       MEMBER OF THE ROYAL ACADEMY OF MEDICINE OF ROME, ETC.
     PHILADELPHIA:
LEA BROTHERS  &  CO.
          1894. 

    Entered according to Act of Congress, in the year 1894, by

                  LEA BROTHERS  &  CO.,

in the Office of the  Librarian  of Congress.  All rights reserved.
      Westcott & Thomson,                                     Willia   T~T>—
Slereotypers and Eledrotypers, Philada.                                  p ■ (  ,  p, .,  ,    ' 
PREFACE.
    In the present edition of this work there is but one radical change—the
 omission  of the  section on General Pathology.  This is in accordance with
 the practice of nearly all modern writers, especially those of the  European
 Continent, who draw a strict line of demarcation between  special and gen-
 eral  pathology,  as  well  as with that of the chief medical  schools of the
 world, in which  there  are separate chairs for general pathology and the
 practice of medicine, or special pathology.  Notwithstanding this omission,
 the book  is scarcely reduced in size, for the other alterations have  been
 almost entirely in the way of addition.   The present editor has contributed
 about one hundred  pages of new matter, in which  are included more than
 twenty distinct articles, besides numerous interpolations in every section of
 the book.   Among the new articles are those on Pulsating Pleurisy, Weil's
 Disease,  Syringomyelia,  Beri-beri,  Hereditary Chorea, Acromegaly, Ray-
 naud's Disease,  Leprosy, Influenza,  Lithsemia,  Rickets,  Actinomycosis,
 Anthrax,  and Glanders.   Chapter IV., on the Functional Diseases of the
 Stomach, has been very largely rewritten, and the article on Dyspepsia has
 been expunged.   As remarked on  page 373, the term dyspepsia is a " most
 serviceable cloak for ignorance, but has been worn  threadbare and is about
 to  be discarded."  In place  of the  article  on Dyspepsia are substituted
 articles  on  Nervous  Vomiting,  Peristaltic  Unrest, Nervous  Eructation,
 Merycismus, Incontinence of  the Pylorus, Atony,  Hyperacidity and Hy-
 persecretion, and Nervous Dyspepsia,  these various  subjects being preceded
 by " introductory remarks " on the present methods of research in the diag-
 nosis of gastric disease.
    The classification of Flint has been  practically retained, although, like
 all classifications of disease,  it is  open to criticism,  and has caused the
 editor some little embarrassment.  For example, the most  suitable place
 that could be found for Leprosy  was among the Eruptive Fevers.  On con-
 sulting several recent text-books on  medicine it was  found that this dif-
 ficulty had  been solved  by the omission of this  important  subject.   It
 appears to the  editor much better that it should be retained, even though
 its  situation be not absolutely appropriate.
    The last edition  of this work appeared in 1880, the author being ably
 assisted in its revision by his  son, Prof. Austin  Flint,  M. D., and by Prof.
 William  H.  Welch, M. D., of  the Johns  Hopkins  University.  The latter
 revised and in great part  rewrote the descriptions of the anatomical  charac-
ters of the various diseases  considered in that edition, and also wrote the
                                                               3 
4
PREFACE.
articles or parts of articles  relating to bacteriology.   The  alteration-  in
this portion  of the volume have  not  been numerous, but  some have Ix-en
indispensable.   For example, Aimebic Dysentery and Amoebic Abscess  of
the  Liver were  unrecognized affections  in  1886.   Without entering into
further details, it is believed that the following statement from the Preface
to the fifth and sixth editions is still applicable, viz.:  that the parts of the
work  relating to the  anatomical  characters  of disease and to bacteriology
" will serve as a digest of the essential facts pertaining to  general and special
pathological  anatomy so far as this important  branch of study bears upon
practical medicine."
   The revision of those parts of  the  book devoted to clinical history has
been largely a work of supererogation,  because  the  value of  accurate
descriptions of morbid phenomena is not impaired by  time.   In the depart-
ment of clinical history Flint was  unsurpassed, perhaps unrivalled.
   Special attention  has  been given  to  the department of therapeutics,
because it is the one in which the changes have been  greatest.   Among the
multiplicity of new remedial agents discovered and  advocated during the
last eight  years, a selection has been made of those which have withstood
a thorough clinical test—the only one of value to the practitioner.
   Whatever may be thought of  the superstructure of  this work,  its foun-
dations are imperishable.  Some idea of their  depth  and  breadth  may  be
obtained from  the following extract from the Preface to  the last  edition.
It was written after the death of its  distinguished  author, by  his son, Prof.
Austin Flint: " The basis of the work is an  unbroken series  of records of
cases in private practice and  in hospitals, begun in 1833 and continued for
more than half a century,  covering sixteen thousand  nine  hundred and
twenty-two folio pages of manuscript written with the author's own hand.
These  records  embrace carefully-written  histories  of cases  in  all  depart-
ments  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 inhabitants of the metropolis; patients in  the wards of the almshouse
and hospitals of Buffalo, of the Marine Hospital in Louisville, Kentucky,
the great  Charity  Hospital in  New Orleans, Louisiana, the Bellevue  Hos-
pital, the Charity Hospital, the dispensaries, and similar institutions in the
city of New York; cases observed in the experience of a quarter  of a cen-
tury as a general practitioner, and of more than another quarter of a cen-
tury as a consulting physician, including the  epidemics which have occurred
in this country within  the  last fifty years,—the experience  derived  from
these various  sources  of  observation,  carefully  recorded,  studied,  and
analyzed,  was finally used in the  composition of this  treatise, the first edi-
tion  of which appeared in 1866.  In the  mean time the author's  original
contributions to practical medicine, embodied in special treatises,  in com-
munications published in medical periodicals,  and  in  Transactions of med- 
PREFACE.
5
ical  societies,  have left  their impress  upon many  departments which, in
recent years, have been  classed  as  specialties;  although he was always a
physician, never a specialist.  A student of the history of practical medi-
cine will often find  observations and ideas, assumed to be of recent  date,
which had been  anticipated by  the author many years before. . . .
   " Added to a literary  training and a recorded experience almost without
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,
who have attended his lectures.   The lectures given by the  author in 1*8-")-
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 practi-
tioner, writer, and teacher."
   The editor entered upon his task of revising this book with  a feeling of
reverence for the memory of its distinguished author, and,  as a natural
consequence, if he has erred, it has  been in  the direction of  conservatism.
He has constantly borne in mind the  maxim, " Hold fast  to that which  is
good," and in so doing has held fast to nearly all.
                                              Frederick P.  Henry.
  16!;5 Locust Strket,
          Philadelphia. 
 
CONTENTS.
PRACTICE  OF  MEDICINE, OR  SPECIAL  PATHOLOGY.
                           INTRODUCTION.
                                                                          PAGE
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
   in  this Work................................  19
                          SECTION   FIRST.

         DISEASES  AFFECTING THE  RESPIRATORY SYSTEM.

                               CHAPTER  I.
                              ACUTE  PLEUEITIS.
 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..............   23


                                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..................   32


                             CHAPTER  III.
                         VARIETIES  OF  PLEURITIS.
Chronic Pleuritis: Anatomical Characters; Clinical History: Pathological Character;
   Causation ; Prognosis ;  Diagnosis; Treatment; Thoracentesis.—Empyema,  Pyo- 
8
CONTEXTS.
                                                                             PAOIC
   thorax, or Suppurative Pleuritis:  Diagnosis; Prognosis;  Treatment.—Pulsating
   Pleurisy.—Pleuritis with  Pneumothorax, Pneumo-hydrothorax,  Pneunio-pyo-
   thorax,  or Pneumo-bfemothorax:  Anatomical  Characters;  Clinical  History;
   Causation; Diagnosis;  Prognosis;  Treatment.—Pneumothorax.—Circumscribed
   Pleuritis.—Hydrothorax..........................   -10

                               CHAPTER  IV.

                                 PNEUMONITIS.

Seat of the Inflammation.—Varieties:  Acute Lobar Pneumonitis:  Anatomical Cha-
   racters; Laws of the Disease; Clinical History; Causation; Diagnosis;  Patho-
   logical Character;  Prognosis.........................   63

                               CHAPTER  V.

                          PNEUMONITIS (Continued).

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.—Hypersemia of the  Lungs.—Hypostatic Congestion.—
   Hypostatic Pneumonitis.—Pleurodynia and Dorso-Intercostal Neuralgia  ....  80

                              CHAPTER  VI.

                           PULMONARY  PHTHISIS.
Anatomical Characters; Clinical  History; Pathological  Character; Causation. ...  99

                            CHAPTER VII.

                     PULMONARY  PHTHISIS (Continued).
Diagnosis; Prognosis; Treatment........................115

                            CHAPTER VIII.

Fibroid Phthisis.—Acute Miliary Tuberculosis.—General Tuberculosis.......133

                              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.—Bronchitis with  Fibrinous Exu-
   dation.—Circumscribed Bronchitis.—Chronic Bronchitis...........138

                               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..................154

                              CHAPTER  XI.
   PULMONARY HEMORRHAGE.—PULMONARY GANGRENE.—PULMONARY
                      OEDEMA.—CARCINOMA.—HYDATIDS.
Pulmonary Hemorrhage.—Broiichorrhagia.—Pneumorrhagia.—Hemorrhagic  Infarc-
   tion.—Pulmonary  Gangrene.—Pulmonary  Oedema.—New Growths  within the
   Chest.—Hydatids.—Syphilitic Disease of the Lungs..............1^1 
CONTEXTS.
9
                            CHAPTER XII.

                DISEASES OF THE LARYNX AND  TRACHEA.
* «■ i.-     c                                                              PAGE
A flections 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.........................197
                        SECTION  SECOND.

         DISEASES AFFECTING  THE  CIRCULATORY SYSTEM.

                              CHAPTER I.

                               PERICARDITIS.

Introductory Remarks.—Acute Pericarditis : Anatomical Characters; Clinical  His-
   tory ; Pathological Character; Causation;  Diagnosis;  Prognosis;  Treatment.—
   Chronic Pericarditis.—Pneumo-Pericarditis..................225

                              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..............................237

                            CHAPTER  III.

      VALVULAR  LESIONS  WITH  ENLARGEMENT OF THE HEART.
Anatomical Characters; Clinical History; Pathological Character; Causation; Diag-
   nosis ; Prognosis; Treatment.........................248

                            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..............26?

                             CHAPTER V.

Functional Disorder of the Heart.—Exophthalmic Goitre.—Angina Pectoris.—Tho-
   racic  Aneurism................................275
                         SECTION  THIRD.

       DISEASES  AFFECTING  THE HAEMATOPOIETIC  SYSTEM.

                              CHAPTER  I.
               DISEASES OF  THE HAEMATOPOIETIC SYSTEM.
Introductory Remarks.—Simple or Benign Anaemia.—Chlorosis...........291 
10
CONTEXTS.
                             CHAPTER  II.
                                                                          PAGE
Leucocythsemia................................^

                             CHAPTER  III.

Pseudo-Leucocythseniia.—Hodgkin's Disease...................307

                             CHAPTER  IV.
Pernicious Anaemia...............................  311

                              CHAPTER  V.
Addison's  Disease...............................317
                       SECTION  FOURTH.

    DISEASES  AFFECTING THE DIGESTIVE OR  CHYLOPOIETIC
                                  SYSTEM.

                              CHAPTER  I.

    DISEASES OF THE TONSILS, THE  PHARYNX, THE CESOPHAGUS,
                       AND THE  PAROTID GLANDS.
Introductory Remarks.—Tonsillitis.—Pharyngitis.—Diseases of the  OSsophagus.—
   Parotiditis.—Mumps............................324

                              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........334

                             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 .  .  .  350

                              CHAPTER IV.
       FUNCTIONAL  DISORDERS,  OR  NEUROSES OF  THE STOMACH.
Introductory Remarks.—Motor Neuroses (Nervous  Vomiting;  Peristaltic Unrest;
   Nervous Eructation; Rumination; Incontinence  of the Pylorus;  Atony).—Sen-
   sory Neuroses (Gastralgia;  Polyphagia, Malacia and Pica, Polydipsia, and Dipso-
   mania).—Secretory Neuroses (Hyperacidity and Hypersecretion).—Nervous Dys-
   pepsia.—Gastrorrhagia.—Inanition.................            373

                              CHAPTER  V.

             INFLAMMATORY  DISEASES  OF  THE INTESTINE.

Anatomical Characters of Acute Dysentery.—Sporadic Dysentery.—Epidemic Dysen-
   tery.—Chronic  Dysentery.—Inflammation and Perforation of the Csecum.__Fecal
   Abscess.—Inflammation and Perforation of the Vermiform Appendix.__Colitis.__
   Proctitis.—Acute Enteritis.—Subacute and Chronic Enteritis.........397 
COXTEXTS.
11
                               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..............407


                              CHAPTER  VII.

                FUNCTIONAL DISEASES  OF  THE  INTESTINE.
Diarrhoea. — Enterorrhagia. — Constipation.— Intestinal  Colic. — Enteralgia.— Lead
   Colic—Colic  from  Copper.—Passage of Gail-Stones..............445


                             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;  Prog-
   nosis ; Prevention ; Treatment........................471


                               CHAPTER  IX.
                             INTESTINAL WORMS.
Ascaris lumbricoides.—Oxyuris vermicularis.—Trichocephalus dispar.—Ascaris mys-
   tax.—Taenia}.—Trichina spiralis.—Anchylostoma duodenale......■.  .  .  .  49ri


                               CHAPTER  X.

                      DISEASES  OF  THE PERITONEUM.
Acute  Diffuse Peritonitis:  Anatomical Characters;  Clinical History; Pathological
   Character ;  Causation ;  Diagnosis;  Prognosis ; Treatment.—Circumscribed Peri-
   tonitis.—Chronic Peritonitis.—Hydro-peritoneum  ..............511


                               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. 532


                              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...................550 
12
COXTEXTS.
                             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.—Weil's Disease.—Acute Febrile Icterus.—
   Infectious Icterus.—Functional Affections of the Liver...........•%<

                            CHAPTER XIV.
Diseases of the Spleen—Diseases of the Pancreas................57s
                         SECTION   FIFTH.

           DISEASES  AFFECTING  THE  NERVOUS SYSTEM.

                               CHAPTER  I.
DISEASES RELATING TO THE CEREBRAL AND  THE SPINAL CIRCULATION.
Cerebral Hyperemia.—Cerebral  Amemia.—Cerebral Embolism and  Thrombosis.—
   Thrombosis of the Cerebral Sinuses.—Capillary Embolism and Thrombosis of the
   Brain.—Cerebral Hemorrhage.—Topical Diagnosis of Cerebral Diseases.—Menin-
   geal Hemorrhage.—Insolation,  or Sunstroke.—Hyperaemia and Anaemia of the
   Spinal  Cord and  its Meninges.—Spinal Hemorrhage.............5*5

                              CHAPTER  II.
  INFLAMMATORY  DISEASES  OF  THE  MENINGES OF  THE  BRAIN AND
      OF THE SPINAL CORD.—HYDROCEPHALUS.—HYDRORRHACHIS.
Pachymeningitis and  Hsematoma of the Dura Mater.—Simple Acute Cerebral Men-
   ingitis: Anatomical Characters; Clinical History;  Causation; Diagnosis; Prog-
   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.—Syringomyelia...............631

                              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...........................657

                              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 Polio-
   myelitis.—Acute  Anterior Poliomyelitis in the Adult.—Subacute and Chronic
    Anterior Poliomyelitis.—Progressive  Muscular Atrophy.—Spastic Spinal Paral-
   ysis.—Amyotrophic Lateral  Sclerosis.—Compression of the Spinal Cord.—Intra-
   spinal Tumors.—Pseudo-hypertrophic  (or Myosclerotic) Paralysis.......670 
COX TEXTS.
13
                               CHAPTER  V.

       FUNCTIONAL  DISEASES  OF  THE BRAIN AND SPINAL CORD.
                                                                           PAGE
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.............................707

                              CHAPTER  VI.
                         DISEASES OF THE  NERVES.
Neuritis.—Multiple Neuritis.—Peripheral Paralysis.—Beri-beri—Kak-ke.—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.—Paralysis  of the Cervical Sympathetic  Nerve.—Paralysis
   from Lead.—Paralysis from Arsenic,  Copper,  Mercury,  and Phosphorus.—Neur-
   algia.—Trifacial Neuralgia.—Cervico-occipital Neuralgia.—Cervieo-brachial Neur-
   algia.—Dorso-intercostal Neuralgia.—Lumbo-abdominal Neuralgia.—Crural Neur-
   algia.—Sciatic Neuralgia.—Coccygodynia.—Dermalgia.—Myalgia.—Cephalalgia . 7:23

                              CHAPTER  VII.
                                THE  NEUROSES.
Chorea.—Hereditary Chorea.—Anomalous  Muscular Movements.—Local Spasms.—
   Tremor.—Epilepsy..............................~">o

                             CHAPTER  VIII.
                         THE  NEUROSES  (Continued).
Hysteria.—Hystero-epilepsy.—Catalepsy.—Ecstasy.—Somnambulism.—Tetanus  .   780

                               CHAPTER  IX.
                         THE NEUROSES (Concluded).
 Delirium Tremens, Alcoholism.—Hypochondriasis.—Pathophobia ....        .  . 7!»:J

                                CHAPTER  X.
                   VASO-MOTOR AND  TROPHIC NEUROSES.
 Progressive Unilateral Facial Atrophy.—Scleroderma, or Sclerema.—Myxcedema.—
    Acromegaly.—Raynaud's Disease.—Symmetrical Gangrene..........802



                          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—Paren-
    chymatous Degeneration of the Kidneys.—Fatty Degeneration of the Kidneys.—
    Acute Bright's Disease.—Chronic Blight's Disease...............81'- 
14
COXTEXTS.
                              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..................................S4(i

                             CHAPTER  III.

STRUCTURAL  DISEASES  OF  THE KIDNEY.—H.EMATURIA.—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 Hsematuria.—
   Endemic Hematuria.—Hsemoglobinuria.— Malarial Hsematuria.—Chyluria.—Dia-
   betes Insipidus.—Diabetes Mellitus :  Clinical History ; Causation ; Diagnosis; Prog-
   nosis ;  Treatment. — Involuntary Seminal Emissions. — Spermatorrhoea, — Impo-
   tence....................................SfiO
                       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..............896

                              CHAPTER II.

                      CONTINUED FEVERS (Continued).
Causation  of Typhoid  Fever; Diagnosis ;  Prognosis.—Typhus Fever: Anatomical
   Characters;  Clinical History: Causation; Diagnosis; Prognosis........916

                             CHAPTER III.

                      CONTINUED FEVERS (Continued).
Treatment of Typhus and Typhoid Fevers.—Relapsing Fever: Anatomical Charac-
   ters; Clinical History; Causation; Diagnosis; Prognosis;  Treatment. — Erysipe-
   latous Fever.—Epidemic Fever characterized by Mild Erythematic Pharyngitis .  929

                              CHAPTER IV.

                           PERIODICAL FEVERS.

Intermittent Fever: Anatomical Characters; Clinical History; Causation: Diagnosis;
   Proguosis ; Treatment.—Pernicious  Intermittent Fever............94<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......964 
CONTENTS.
15
                             CHAPTER  VI.

                           ERUPTIVE  FEVERS.
                                                                          PAGE
Variola, or Smallpox: Anatomical Characters; Clinical  History; Causation;  Diag-
   nosis;  Prognosis; Treatment.—Varioloid, or Modified Smallpox.—Vaccinia,  or
   Cowpox.—Varicella, or Chicken-pox.....................981

                             CHAPTER  VII.

                      ERUPTIVE FEVERS  (Continued).
Scarlatina, or Scarlet Fever :  Anatomical Characters ; Clinical History ; Causation ;
   Diagnosis; Prognosis; Treatment......................1004

                            CHAPTER   VIII.

                      ERUPTIVE FEVERS  (Concluded).
Rubeola,  or  Measles: Clinical History;  Causation; Diagnosis;  Prognosis; Treat-
   ment.—Roseola.—Rotheln.—Dengue.—Leprosy................ 1018

                             CHAPTER  IX.

               DIPHTHERIA—MILK SICKNESS.—INFLUENZA.
Diphtheria:  Anatomical Characters;  Clinical  History;  Pathological Character;
   Causation; Diagnosis; Prognosis; Treatment.—Milk Sickness.—Influenza .  . .1032

                              CHAPTER  X.
       ACUTE, SUBACUTE, AND CHRONIC ARTICULAR RHEUMATISM.
Acute Articular Rheumatism: Clinical History; Pathological Character; Causation;
   Diagnosis ; Prognosis; Treatment.—Subacute and Chronic Articular Rheumatism. 1058

                             CHAPTER  XI.
 LITILEMIA ; URIC.EMIA.—GOUT.—RHEUMATOID ARTHRITIS.—RHACHITIS.
Lithsemia;  Uricaemia.—Gout: Anatomical  Characters; Clinical  History;  Patho-
   logical Character; Causation ; Diagnosis ; Prognosis ; Treatment.—Rheumatoid
   Arthritis.—Rhachitis............................1072

                             CHAPTER  XII.
                   SCORBUTUS.—PURPURA.—HAEMOPHILIA.
Scorbutus, or Scurvy:  Anatomical Characters;  Clinical History; Pathological Cha-
   racter: Causation;  Diagnosis;   Prognosis;  Prevention;  Treatment.—Purpura
   Simplex,  Purpura Rheumatica,  and Purpura Hemorrhagica.—Haemophilia  . . 1097
                        SECTION  EIGHTH.

   THE  ZOONOSES, OR  DISEASES TRANSMITTED FROM  ANIMALS
                                  TO MAN.

                               CHAPTER  I.
            ACTINOMYCOSIS.—ANTHRAX—(ILANDERS.—RABIES.
Actinomycosis:  Diagnosis;  Prognosis;  Treatment.—Anthrax:  Diagnosis;  Prog-
   nosis;  Treatment.—Glanders: Symptoms; Diagnosis:  Prognosis;  Treatment —
   Rabies...................................1108 
 
   PRACTICE OF MEDICINE,




             OE




SPECIAL  PATHOLOQY.
2 
 
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.
19 
20                          INTR OD UCTIOX.
   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 consider
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 has 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.
21
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 differences
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, 
22
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.
   [An eighth section has  been added  by the  editor to include the  zoonoses,
or diseases transmitted from animals to man.   The  chief of these are  trichi-
niasis, rabies, actinomycosis, anthrax, and glanders.   It seems most appropri-
ate, however, to classify the first  mentioned among the intestinal parasites, as
was done  by the author.—H.]
   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   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; 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 flat 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 large lymph-spaces lined by a variety of connective-tissue cells called endothelium.
Recent investigations  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.
                                                                23 
24
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.
25
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 usually  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 
26
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, aiid 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 of 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 couch-
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.
27
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 rufe
are the cases in which the development of pleuritis is  preceded by bronchitis.
\\ hen 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 
28
ACUTE  PLEURITIS.
exertion, frequently continues for some  time after  the  termination of the
career  of the  disease.
  Striimpell 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.1
  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.   Pleuritis and  inflammations of
other serous  membranes  are  characterized by fibrinous  exudation as a con-
stant event.   This event, the accumulation of  liquid in the closed cavity,
and the development of connective tissue  are characteristics  of  these inflam-
mations.

  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 glands,
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.
  Pleuritis may be secondary to other diseases of the pleura, such as cancer,
sarcoma, and tubercle.
  1  Lehrbuch der Speciellen Pathologie und Therapie der inneren Krankheiten, Leipsic 1SS5. 
DIAGNOSIS.
29
  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.
  [Most pathologists of the present day regard pleurisy as an infectious dis-
ease, this opinion being based upon the frequency with which micro-organisms
such as the streptococcus pyogenes, the pneumococcus  of Fraenkel, and the
bacillus tuberculosis are found in the  inflammatory products.   It must, how-
ever,  be  admitted that if  the  disease is infectious, its causes are  multiple—a
view  which is confirmed by the diversity of its pathological products and the
variety of its clinical course.   The commonest cause of pleurisy is tubercu-
losis.  The tubercular  origin  of many cases of pleurisy which were at first
regarded as benign has become manifest in the lapse of time by the develop-
ment of pulmonary phthisis.
   The  intimate pathological relationship between pleurisy  and articular
rheumatism is an observation  of comparatively recent date.   Probably most
of  the cases of  acute pleurisy which run a favorable course are of rheumatic
nature.—H.]

   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 wanting.   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 iio 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 
30
ACUTE  PLEURITIS.
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
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 vesiculo-tympanitic resonance.   That this vesiculo-tym-
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 vesiculo-tympanitic 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.
   [This vesiculo-tympanitic percussion-sound is most marked in the first and
second intercostal spaces anteriorly in cases of large effusion.   It is known as
Skoda's resonance, and is attributed by some authorities  to diminished tension
of the compressed  alveoli—that is, to conditions precisely opposite to those
last mentioned.—H.]
  On auscultation the respiratory murmur is either suppressed  or is feebly
appreciable below the  level of  the liquid.  Above  the  liquid it is usuallv
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
                       'Vide Pneumono-dynamics, 1878. 
DIAGNOSIS.
31
 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 lnrue,
 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.
   [In practising auscultation of  the vocal sounds  the ear not applied to the
 chest  should be closed, so  as to  exclude the waves  which issue from the
 patient's mouth.  This is  a point to which considerable  importance is attached
 by von Ziemssen.—H.]
   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
 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
 [Some of these  may be  explained by  the  existence  of  bands of adhesions
 that serve  as bridges across which the vocal vibrations are conducted to the
 chest-wall.—H.J
  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
  1 Vide article bv the  author,  entitled "Large Pleuritic Effusion in the Eight Side,
without Notable Diminution  of Vocal Resonance and Fremitus," Am. Journ. «f Med.
Sciences, April, 1882. 
32
ACUTE PLEURITIS.
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.
   [This pleuro-pericardial  friction  may be recognized  by  the  fact that  it
diminishes in intensity or ceases  entirely when  the breathing is suspended.
It is  also, as  a rule, loudest over the apex of the  heart or limited to  this
region, while the friction-murmur caused by pericarditis is  loudest  over the
base of the heart.—H.J

   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-
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.

rpHE objects of treatment  in acute pleuritis  differ  in its  different stages
 JL and the latter therefore claim, severally, distinct consideration with refer-
ence to therapeutic indications.  The objects in  the first  sta°e are to arrest 
TREATMENT.
33
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-
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 anamiic  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-
        3 
34
ACUTE  PLEURITIS.
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^?* 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
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- 
TREATMENT.
35
 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  rio-ht 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
 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 is held by some that diseases have undergone a notable change
 of type.  They who  hold this opinion suppose that bloodletting and other
 antiphlogistic measures  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, 
36                        ACUTE PLEURITIS.
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
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 pleuritic
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 
TREA TMENT.                           37
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
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 and 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
   1 The word " opium" is here used as a general term, including the alkaloids, mor-
phia and codeia. 
38
ACUTE  PLEURITIS.
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.   Beference 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.
  [The last-mentioned drug is best administered  after the method  of Hay:
From half an ounce to an ounce  and a half of Epsom salts  should be given
every morning before  breakfast, the drug being dissolved in the least possible
amount of water.  The effect of such doses is to  cause  profuse watery dis-
charges, and under their use  effusions sometimes  disappear with remarkable
rapidity.   They should, however, only be  administered to comparatively
robust patients, since they act by draining away  large  quantities of serum
and are  equivalent to a species of depletion.—H.J
  Diuretics are 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.
  [The surest and most powerful diaphoretic is undoubtedly jaborandi, which
may be given either in the form of infusion or fluid extract; or, better still,
the alkaloid pilocarpine, in the form of the nitrate or hydrochlorate, may be
injected beneath the skin.   These substances are, however, decidedly depress-
ing, and should never be administered to weakly individuals.—H.J
  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
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 
TREATMENT.
39
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.
  [Marked success  often attends the treatment of pleurisy with the  salicyl
compounds, many  cases  of the disease being, as previously stated, of rheu-
matic origin.   The  sodium salicylate may be given in divided doses  to the
extent of  from 1  to 2  drachms in  the  twenty-four hours.   The  chief
objection to  this drug is that it is decidedly nauseous to many individuals,
but this may  sometimes be  obviated by  administering  it in  pill  or cap-
sule.—H.J
  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.   AVhen 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, embracing
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
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
lono- within  doors, and with proper  precautions no risk of harm is incurred. 
40
VARIETIES OF PLEURITIS.
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 eithei: 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.—Pulsating Pleurisy.—
   Pleuritis with Pneumothorax, Pneumo-hydrothorax, Pneumo-pyothorax, or Pneumo-
   haemothorax: Anatomical Characters;  Clinical History; Causation; Diagnosis; Prog-
   nosis ; 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.


                          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 
CHRONIC PLEURITIS.
41
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
depression  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 35  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
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. 
42
VARIETIES OF PLEURITIS.
  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
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 onlv in
a lesser degree of the inflammatory  condition.  The  inflammation has no 
CHRONIC PLEURITIS.
43
 special character, but is  of a low grade of  intensity, with  a tendency to
 continuance for  an indefinite period.

   Cassation.—[The belief is universal that pleurisy may arise from exposure
 to cold and dampness, and is supported by the fact that it is  most prevalent
 during the  inclement seasons, the winter and spring. Large statistics compiled
 by von Ziemssen l  show that the largest number of cases occur in January,
 the  smallest  in  October.   It is scarcely necessary to add that the  causal
 relation between cold and pleurisy is indirect.   This is  proved by  the  fact
 that  one  individual  exposed to cold  may develop bronchitis; another, artic-
 ular rheumatism ; a third, nephritis ; and a fourth, pleurisy.    Cold, exposure,
 fatigue, and privation act  merely by reducing  the powers of resistance to the
 specific causes of disease,  and it is in  the same indirect manner that  pleurisy
 is caused  by blows  and  wounds.—H.J   It  occurs occasionally during the
 course of affections 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 proportion 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.
   [It must be admitted also that, from our present bacteriological standpoint,
 the presence or absence of tuberculosis cannot be decided upon by a study of
 the physical signs alone.   A pleural effusion cannot be declared non-tubercu-
 lar until culture experiments and microscopic examination have yielded none
 but negative results so far as the bacillus tuberculosis is concerned.  The fact
 that  a patient recovers from a pleurisy does  not necessarily indicate that it
 is non-tubercular, for tubercular processes in serous membranes, such as the
 peritoneum and  pleura, are often  remarkably benign.
   An important practical contribution to this subject was recently made by Dr.
 Vincent Y. Bowditchof Boston, who investigated the results of the cases of pleu-
 risy occurring in his father's practice from 1849 to 1879.  He obtained  satisfac-
 tory records of 90 cases, which, without entering into minute  details, may be
 summed up in the concluding words of his paper: "The results of this inves-
 tigation show us  at least, first, that whether we can  prove absolutely  by such
 statistics that all pleurisies are tubercular or  not. yet a large  percentage of
 these  patients who were  afflicted with pleurisy, often  in apparently chronic
 forms, recovered their health and  have never  had any  recurrence of  the
 original  trouble  nor  development  of subsequent  pulmonary or  otherwise
 tubercular trouble ; second, that while  undoubtedly there  are  many  cases in
 which an attack of pleurisy is followed within a comparatively short space
of time by  pulmonary trouble—and therefore special  care should be taken
of the patient during convalescence from the former disease—yet we are not
 justified in  giving such gloomy prognosis as we should be  inclined by accept-
ing the extreme views held by Landouzy and  his followers."—H.J
  Chronic as  well as  acute pleuritis occurs rarely in infancy.   It  is  not  of
                          1 Klinische Vortrage, 1889. 
44
VARIETIES OF PLEURITIS.
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-
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.
     1 Practical Observations on Certain Diseases of the Chest, etc.  Amer. ed. 1848
     2 American Journal of the Medical Sciences, January, 1863. 
CHRONIC PLEURITIS.
45
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
 before, and there had been no change in  the condition of the  chest since his
 apparent recovery  from that  disease.
   [Sudden  death is a possible  event in cases of pleurisy with large effusion,
 and  may be due to torsion of the inferior vena cava  at the point where it
 traverses the central tendon  of the diaphragm.  Bartels considers this a not
 uncommon  accident.  It is due to the traction exerted upon the vein  by the
 displaced heart, and can scarcely occur except in cases  of left-sided  effu-
 sion.—H.J

   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 si<ms 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
 ao'ain 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 
46
VARIETIES  OF PLEURITIS.
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.
[Another valuable sign of large left-sided effusion is a diminution or oblitera-
tion  of the  " semilunar space of Traube."   On the  left side, anteriorly and
below, there exists, in  health,  an  area of tympany having the shape of a half
moon with  its convexity upward.  It corresponds to the splenic  end  of the
stomach, and  in  cases of  copious  left-sided  effusion is  replaced  in part or
altogether by dulness  on percussion.   From the fact  that Traube was  the
first  to emphasize the  diagnostic importance  of this tympanitic region, it is
known  as  the '' semilunar space  of  Traube."—H.J    The  diaphragm  is
depressed, pushing  downward the  abdominal organs  in  contact 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 signs
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
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- 
CHRONIC PLEURITIS.
47
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.  Its introduction  is prevented by  the em-
ployment  of  a  suction force  in withdrawing the liquid.   The operation  is
rendered  trivial, because  with suction  a  small exploring  trocar suffices to
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 durin"- 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. 
48                    VARIETIES OF PLEURITIS.
   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, 1
 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
 the quantity removed at one operation, much will be gained  by following the
 injunction  to withdraw the liquid slowly, especially when the  patient begins
 to cough and complain of constriction.   The advantage  of my  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  glass
 receiver, and then  opening a communication  between the latter and a canula
 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. 
CHRONIC PLEURITIS.
49
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.
   [The first and  most  important  step in thoracentesis is disinfection  of  the
skin  of the patient at the site of puncture, the hands  of the  operator, and
the  different  parts of the aspirator.  This is best accomplished by bathing
them successively with a  five per  cent, solution of carbolic acid, a sublimate
solution (1 : 1000), and finally with alcohol.—H.J
   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 means of  a  probe.
   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  ejjteetoration  sero-albvmineuse, 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 dyspixca 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 ease ended in recovery.  It
 is probable that  the  effect in that instance was attributable  to a  too rapid
 withdrawal of  the liquid.   T had previously withdrawn a large quantity of
 pus  in this case without any unpleasant  symptoms.
   [It is rarely  advisable  to remove more than fifty ounces of fluid at a single
 operation, but  no stereotyped rule  can be  laid down with reference to  this
 matter.   I have  removed more than one  hundred ounces at  one time with
 none but favorable results, while, on the  other  hand, I have been compelled
 to withdraw  the canula, on  account of violent cough, before thirty ounces
 had  escaped.
   It is  impossible to withdraw all the fluid from  the pleural sac, and tortu-
        4 
50
VARIETIES  OF  PLEURITIS.
 nately  it is unnecessary,  because its absorption often  goes on  with great
 rapidity when the pleural vessels are relieved  of pressure.
   After aspiration the attempts to promote absorption of the remaining fluid
 by means of  counter-irritants, purgatives, diuretics, and diaphoretics should
 be renewed.  It is  true  that these  various measures may  have been pre-
 viously employed in vain, but experience proves that they may accomplish
 at one  stage  of  the  disease what they  have failed  to do at another.—H.J

         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 
        EMPYEMA—PYOTHORAX—SUPPURATIVE  PLEURITIS.    51

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  micro-organisms.
  [In empyema consecutive to pneumonia the diplococcus of Fraenkel  and
the pneumococcus of Friedlander have both been found.  In other  cases the
streptococcus pyogenes and the staphylococcus pyogenes, aureus, and citreus
are present, and in putrid effusions the  leptothrix pulmonalis.—H.J

  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.
   [Haccelli of Rome maintains that the whispered voice is audible over serous
and inaudible  over purulent effusions, and this  statement, on account of the
recognized authority of its author, has obtained  general currency.  " Bac-
eelli's sign." however, is far from infallible, there being cases of  empyema in
which the whispered voice is  plainly conducted, and cases  of sero-fibrinous
pleurisy in which it is inaudible.—H.J
  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 warrantable 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 
52
VARIETIES  OF PLEURITIS.
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.
   [There are numerous other paths  by which a purulent effusion  may make
its exit.  The diaphragm, for example, may be perforated and the pus  be dis-
charged into the stomach or intestine ; or it may rupture into the peritoneum
or burrow into the posterior mediastinum.   In the latter event it may gravi-
tate downward in the retro-peritoneal connective tissue, and finally reach the
surface in the lumbar region, the buttock, or the thigh.—H.J

   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
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 year.-
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 reso'-ted to, it
will  sooner  or later  make  its way either uito 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- 
        EMPYEMA—PYOTHORAX—SUPPURATIVE PLEURITIS.     53

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.  [Irrigation  of the pleural sac is only permissible
when the effusion is putrid, and should  then be performed with the greatest
care.   Convulsions, paralysis, and fatal  collapse have  followed the washing
out of the pleural cavity.  Such accidents  are sometimes due to the direct
irritation of the heart and lungs;  at  others they are caused by emboli which
are detached from the cavities of the heart or from the walls of the pulmo-
nary blood-vessels by the  impact  of  the  injected fluid.   Owing to their poi-
sonous  properties neither carbolic acid  nor corrosive  sublimate should be
injected.  Salicylic acid, boracic acid, and thymol are the best drugs for this
purpose.—H.J   I should  add that I have  known a complete withdrawal of
the pus by a  single  aspiration to prove sufficient,  but the probability of
this result is  small.   Aspiration repeatedly performed has succeeded in sev-
eral 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-
ing.  Indeed, this is generally advisable.  In children, simple aspiration  not
infrequently effects a cure.
   [A cure of  empyema can  only occur by obliteration of the pleural  sac
through adhesion of its  opposed layers, and an indispensable  requisite to
such adhesion  is  contact between the costal and pulmonary pleurae.   Such
contact must be the result of retraction of the thorax  or expansion of the
lung or of a combination of both these processes.  In recent cases, in which
the lung has been but a short time compressed, expansion predominates  over
retraction, and  the cure is  attended with little or  no deformity.  On the  other
hand, in old cases, in  which the lung is carnified or bound down by adhesions,
the contact of the pleural layers can only be the result of a sinking in of the
chest-wall  which  may give rise to great deformity.   The retraction of the
thorax is greatly facilitated by resection of one or more ribs, and the amount
of bone removed should depend upon the expansive power of the  lung and
the elasticity of the thorax.  A correct decision with reference to this import-
ant matter can  only be the result of  experience.—H.J
   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. 
54
VARIETIES  OF PLEURITIS.
                        [Pulsating Pleurisy.
   On page  51 it was mentioned that the tumor which forms in cases  of
"paracentesis of necessity" may pulsate  synchronously with the  heart's
action.   This remarkable  occurrence demands a more extended notice.  The
term  " pulsating  empyema of  necessity "  was introduced by  MacDonnell,1
who was the first to publish a detailed account of  cases of empyema charac-
terized by one  or  more circumscribed pulsating tumors.   It has since been
ascertained that pulsation  may occur without the pus having forced its way
through  the  chest-wall so as to  form a circumscribed tumor, and also that
there may be pulsation when the effusion is serous.  Pulsating pleurisy is
therefore a  more  acurate term  than  pulsating   empyema.   In the  great
majority of  cases, however, the  effusion is purulent and occupies the left
pleural  sac.
   Pulsating pleurisy is a rare disease.  Alfred Keppler,2 who, with reference
to this  point, examined the  medical  literature of more than  two  hundred
years, found  but 38 cases of the affection.
   There  are different opinions concerning the cause of the pulsation, and it is
probable that it may be produced in different ways.  Fereol believes that a
certain amount of air  in  the  pleural cavity is essential  to its production,
which air must be under  considerable  pressure, and therefore shut off from
communication  with the bronchi. Under  such circumstances it acts as  an
elastic cushion, transmitting  the  cardiac pulsations through the effusion  to
the chest-wall.
   Traube reports two cases of pulsating pleurisy in which pericardial effusion
was  also present.   He believes the pulsation in his cases to have  been due
partly to the unusual  mobility of the  heart, which  was  suspended  in the
effusion and  displaced to the right, and partly to the relaxation of the chest-
wall caused by destruction of the costal pleura.
   A careful  study of the  recorded  cases makes it probable that  the most
important factors  in  the  etiology of pulsating pleurisy are—(1) copious
effusion ; (2) paresis of the  intercostal muscles, inducing relaxation  of the
thoracic  wall; (3)  a somewhat forcible heart-beat.
   Air in  the pleural sac under high tension and adhesion of compressed lung
to the pericardium are co-operating, but not necessary, causes.—H.J


   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.
   [Pneumothorax is apt to be overlooked at post-mortem examinations unless
proper precautions are taken.   As  a rule, the gas in the pleural cavity escapes
with more or less force when the knife penetrates the chest, but this can  only
occur when it is under  positive pressure.  The presence of pneumothorax is
best demonstrated by thrusting into the pleural sac a hollow needle to which
is attached a rubber tube  the  free end of  which is immersed  in water.   If
the pleura contains gas which is under positive pressure, bubbles will be seen

              1 Dublin Journal of Medical Science, March 1, 1844.
              2 Deutsches Archivfiir klin. Med., 1887, Bd. 41, p. 220. 
               PLEURITIS  WITH  PNEUMOTHORAX,  ETC.           55

 rising in the water, and, if desired, the gas may be collected for analysis. If
 the gas in the  pleura is under negative pressure, it may be made to escape by
 forcibly compressing the thorax.—H.J

   Anatomical Characters.—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-pncumothorax),
 but is frequently sero-fibrinous  (sero-pneumothorax).  Sometimes the perfo-
 ration is attended  by hemorrhage into the pleural cavity (liEemato-pneumo-
 thorax).   If  the   disease  be  associated 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 (orthopnoea), 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 eases.  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.  [The general condition will  depend
 largely upon  the  nature of the disease of which the pneumothorax  is a
 complication.—H.J
   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 
56
VARIETIES  OF PLEURITIS.
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-
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, [and it must be acknowledged that  there  are facts which  strongly
support this view.  In the first place, there  are numerous cases of pneumo-
thorax in which the most careful search  has failed to reveal any communica-
tion  with the lung or other air-containing organ ; and, secondly, it is now well
established that there are micro-organisms whose activity is attended with the
evolution  of gas.1—H.J

  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 results of percussion are by no means uniform, being dependent upon
the tension of the air in the pleural sac.  If the effusion is considerable, the
dulness over the lower portion  of the  affected side is of course absolute.
Over the air-containing  portions of the chest there may be either tympanitic
resonance or marked dulness.  The resonance is tympanitic if  the case is one
of "  open " pneumothorax—i. e. if there is a free communication between the
bronchi and the pleural  cavity, so as to render the atmospheric pressure equal
on both sides of the thoracic wall.
  On the other  hand, when  the air in the pleural  sac is under great tension,
as is the  case when  the perforation of  the lung is of such a valvular character
as to permit the entry of air into the  pleura and prevent its exit, the percus-
sion-note  is dull.   It is owing to this   fact that pneumothorax frequently
escapes  detection, for the examiner, finding dulness on  percussion, is apt to
be misled into the belief that it  is  caused  by pulmonary consolidation or
pleuritic  effusion.
  The belief  seems to be almost universally prevalent that air in the  pleural
sac must give rise to tympanitic resonance under all circumstances, and there-
  1 See Bulletin of the  Johns Hopkins Hospital,  July-August, 1892, for an account of the
bacillus a'erogenes capsulatus, by Prof. W. H. Welch,  M. 13. 
              PLEURITIS WITH PNEUMOTHORAX,  ETC.            57

fore the fact is here emphasized that the percussion-note over an air-containing
cavity may be dull.
   Another diagnostic mark of pneumo-hydrothorax is that the fluid is freely
movable in the pleural sac, and therefore the line corresponding to its level may
be made to vary in accordance with the position of the patient.  For example,
when  the  patient is made to lie  on the  sound side  the lateral region of the
diseased  side, which  has  been previously  dull, may become  tympanitic.
Again, when  the  decubitus is  dorsal the  line of dulness is higher  behind
than in front, whereas when the patient assumes  a  sitting posture this  line
becomes horizontal.
   The auscultatory signs of pneumo-hydrothorax  depend largely  upon the
existence or  not  of communication  with the bronchi.   If the aperture of
communication is open, the respiration is amphoric or even distinctly metallic,
whereas if it is closed all respiratory sound may be suppressed.—H.J
   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 tinkling
sounds.   This proof of  the presence of air and liquid is positive, and it  ena-
 bles the diagnosis to be made in an instant.
   [A pathognomonic  sign known as  the coin-sound (bruit d'airairi) may be
 obtained by auscultatory percussion.  The auscultator applies  his  ear to the
 back of the chest while an assistant holds one coin against the anterior portion
 of the affected side and strikes it with another.  There is then conveyed to
 the ear of the examiner a ringing metallic sound which is absolutely diagnostic
 of air in the pleural sac.—H.J
   The affected side  is  frequently dilated, and  presents the  same  appear-
 ances as in  cases of dilatation from liquid either in simple or  suppurative
 pleuritis.
   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 1S45.   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
perforating ulcer  of the stomach.   The differential points are-—the presence
of the respiratory murmur from the clavicle down to the third rib ; the exten-
sion of the respiratory murmur downward  by deep inspiration ; and, at  first,
absence  of cough and  expectoration.   The  abscesses may burst eventually
into the lungs.  A capital  point in the diagnosis is the history of the develop-
ment of the abscess with the signs of peritonitis following symptoms referable
to the stomach or intestine.
   [The  signs of  diaphragmatic hernia and pneumo-hydrothorax are  almost
absolutely&identical.  In both the heart  is displaced and the lung compressed,
and in both  the  signs  derived from percussion and auscultation  are alike.
Metallic tinkling  may also be obtained  in both.  The  chief point of distinc-
                  1 Zeitschrift fur klinische Median, Ed. 1, p. 320. 
58
VARIETIES  OF  PLEURITIS.
tion is that diaphragmatic hernia is either the result of a severe injury or is
congenital.   In  the latter instance the signs may suddenly  disappear  on
account of the return of the bowel to its normal position, and reappear with
equal suddenness.  The peculiar rumbling sounds (" borborygmi ") caused by
the movement of air in the  displaced bowel are  pathognomonic  of hernia.
The  appearance  of the signs  of pneumo-hydrothorax  immediately  after a
severe injury should always excite suspicions of diaphragmatic hernia.—H.J

   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 si\e of an  American
walnut.   The cavity was smooth and lined  by a membraae.  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 
PNE UMO THORAX.
59
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.
   [If an exploratory puncture has shown the effusion to be serous, it is better
to postpone  operation unless the pressure-symptoms are severe.  The reason
for postponing operation in the  absence of urgent symptoms is that the with-
drawal of the fluid  is  apt to be followed by the  escape of fresh quantities
of air into  the pleural  sac;  or,  if  the  pulmonary fistula has  closed, the
removal of the fluid may cause it to reopen.   On the  other hand, by placing
 the patient in the  most favorable hygienic environment and postponing ope-
ration there is a fair chance for both air and fluid to be absorbed.
   In order to diminish the clanger resulting from suddenly-reduced pressure,
 Potain has constructed an apparatus with which sterilized air may be pumped
into the pleural cavity immediately after the performance of paracentesis.
   In most cases the fluid  is purulent, and in that event the treatment is the
same as that of empyema—namely, free incision and drainage.
   If the patient is in an  advanced stage of pulmonary phthisis the question
of operation is a difficult one, and can only be decided by a careful study of
the individual case.  If  the pressure-symptoms are  severe and life seems to
be imperilled, incision  and drainage without resection of ribs should be per-
formed.  The  improvement following this procedure is often  decided, while,
on the other hand, it sometimes appears to stimulate the tubercular process
to renewed activity.—H.J

                            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 either gangrene or phthisis, but is probably connected generally,
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 breathing into the
cavity of the pleura.  Under these circumstances rupture may be caused by
liftin°- a heavy burden,  severe  coughing, or  violent  exertions of any  kind. 
60
VARIETIES  OF PLEURITIS.
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
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
                  1 Clinical Medicine, Edinburgh, 1862, p. 381. 
CIRCUMSCRIBED  PLEURITIS.
61
 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
 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  be sufficient
 to  mark the situation of  inflammation  or  to distinguish  inflammation  from
 pleurodynia.  If from the symptoms  circumscribed  pleuritis be suspected, 
62
VARIETIES  OF PLEURITIS.
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.  [The chief constituent both of
inflammatory effusions  and dropsical transudations is albumin, but the amount
of this substance is much greater in the former than in the latter.  The deter-
mination of the percentage of albumin in a fluid  withdrawn from the pleural
cavity may therefore be of diagnostic importance, but it requires an analysis
too elaborate for clinical purposes.  The specific gravity of the fluid furnishes
all the information that is practically required by the  clinician. In inflamma-
tory effusions this  has been observed to vary between 1015 and 1023, whereas
in mere transudation it is generally below the former figure.   As a general
rule, if  the  specific gravity of the  fluid is above 1018, it may be set down
with certainty  as  inflammatory.—H.J   Hydrothorax 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 
PNEUMONITIS.
63
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.
  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.
                        CHAPTEE   IV.

                             PNEUMONITIS.

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

    HAYING 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 if is.   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 
64
PNEUMONITIS.
alveolar passages, into which open the air-cells, air-vesicles, or alveoli.   I'ha
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 u:
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  (eugouement).    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.
65
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.   When  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  leucocytes are more abundant and con-
 tain  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
 may 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 leucocytes  undergo fatty degeneration, the fibrin

    1 Anatomically, it is customary to reckon four stages  of pneumonitis—viz. engorge-
 ment, red hepatization, grav hepatization, and resolution.  As red hepatization and gray
 hepatization cannot  be distinguished from each other clinically they are here combined
 into one stage, that of  consolidation.
          5 
66
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."  [This
 term, introduced by Laennec, is in most cases a misnomer, for, although there
 is an active immigration of leucocytes into  the alveoli, the process of fatty
 degeneration of the alveolar  contents undoubtedly predominates, and gives
 the exudate its creamy, purulent appearance.—II.J  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 so-called 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 supervenes 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-)>neu-
 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.
   [The  heart  is generally flabby and pale, but the  muscular  fibres  of the
organ are found with the microscope to be in a healthy state.   Occasionally
they present the signs of fatty  degeneration, apparently of recent origin.
 The liver is usually hyperamiic  and enlarged, while the' spleen, as in other
infectious diseases,  is  enlarged, softened, and  congested.   The kidneys  are
 also congested, and often present  the appearances of parenchymatous inflam- 
ACUTE LOBAR PNEUMONITIS.
67
mation.  The mucous membrane of the intestine is frequently in a catarrhal
condition, and its glandular apparatus (solitary follicles and Peyer's patches)
are abnormally distinct.—H.J
   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 net 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
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 lobs 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 lower 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  20 cases it was limited to the
lower lobe of the right, and in 2.") 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 !»  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
  1 " Clinical Keport on Pneumonia, based on an Analysis of 133  Cases," by the author.
Vide American Journal of the Medical Sciences, January, 1861. 
68
PNEUMONITIS.
in the state of active congestion or engorgement.  This stage is called the
stao-e 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 called
the stage of purulent infiltration.1
   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
before the  air-cells  are restored to their normal  condition, and  occasionally
the resolving process  is even much more protracted.
   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,
   1 [This term, which  is retained in conformity with usage and for  the sake of conve-
nience, has  already been commented upon.  The lung may present the appearance of
suppuration without there being any infiltration in the proper sense of the word.   It is
probable that the process which, when observed post-mortem, is called purulent infil-
tration occurs in  every case of pneumonia, and is an indispensable  prerequisite to the
absorption of the exudate.—H.] 
ACUTE LOBAR PNEUMONITIS.
69
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.  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.
   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 careful  examination of the  sputum it is  seen  to
contain opaque  particles which, when separated and  unravelled by shaking in
water, may be demonstrated to be composed of fibrinous casts of the terminal
bronchi.  The microscope is not necessary for their  recognition,  their true
nature becoming apparent when they are dissected out upon a glass slide and
held before a dark  background.  These casts are almost pathognomonic of
acute lobar pneumonitis, the only other affection in  which they are observed
being fibrinous bronchitis.   Microscopically they are seen to be composed of
parallel bundles of fibrin in the  meshes  of which are imbedded  blood-corpus-
cles, both white and red, and fat-granules.  Ciliated epithelial cells may also
be  adherent to them.—H.J  The pyrexia continues, but  with  diminished
intensity.  The pulse in this stage  maybe  small  and  deficient in strength,
especially if more than one lobe be involved,  owing  to the obstruction to the
pulmpnary circulation, which diminishes the quantity of blood received from
the lungs by the left auricle, and owing also to the amount of material with-
drawn 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. 
70
PNEUMONITIS.
   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
 may be  slight; the  respirations may be 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 type of pneumonic fever is continuous, there being, in uncomplicated
 cases, no intermission, and little remission until the crisis arrives.  Up to this
 time the difference between the morning  and  evening temperatures is seldom
 more than 2.5° F.   It is true that, occasionally, between the third  and fifth
 days  there is a fall of temperature so decided  as to give rise to the belief that
 the crisis has arrived.  This idea, however, is soon dispelled by the tempera-
 ture returning in a few hours to its former level and there remaining for several
 days longer. The crisis or critical defervescence may occur at any time between
 the third and  fourteenth days, but in the greater number of  cases is on the
 seventh.   The fall of temperature at this time is so rapid and so great that
 the  diagnosis  of  pneumonia may  be made   with  great  certainty by  mere
 inspection of the  temperature-chart.  The temperature generally begins to
 decline in the evening  or  during the night, and defervescence  may be so
 rapid that by the  following  morning the body-heat is normal  or  subnormal.
 A drop of from six  to seven degrees in the course of twelve  hours is by no
 means rare.   Exceptionally, in favorable cases, the fever may be prolonged
 until  the tenth, twelfth, or fourteenth day.   The defervescence  under such
 circumstances takes place gradually  by lysis—a mode of termination which is
 usually due to some complication.
   The crisis is occasionally preceded by symptoms of an alarming character,
 such  as  chills, convulsions, and delirium.  These are in reality a  part of the
 crisis itself, and were  in fact described by the older writers under  the title
 perturbatio critica.
   With the  decline  of temperature the pulse diminishes in  frequency, the
 skin becomes moist,  sometimes bathed in perspiration, and the patient falls
 into a sound sleep, from which he awakens much refreshed and with a sensa-
 tion of being delivered  from an intolerable burden.   The urine  now voided
 throws down  a copious sediment of urates, which circumstance  caused the
 older writers to believe in a critical elimination of the materies morbi.__H.J
   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 froin^ 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 
ACUTE  LOBAR PNEUMONITIS.
71
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-
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.
[Herpes  labialis occurs  too frequently in the course  of  pneumonia to  be
regarded as  a  mere  coincidence, and not often enough to justify the classi-
fication of the disease   among the eruptive fevers.  In some  epidemics it is
observed in  a large percentage of cases, while in others it is rare.  Statistics
 of  Finkler show that there is a larger percentage of recoveries  in the  cases
attended with  herpes.—H.J
   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 s'igns.   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  witl/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 
72
PNEUMONITIS.
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
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.   [Typhoid  fever may also begin with the signs and
symptoms  of  pneumonia,  constituting the so-called  " pneumo-typhus" of
German writers.  Cases of this  sort are  doubtless sometimes  included under
the head  of typhoid pneumonia.—H.J  There is not sufficient  ground for
considering " alcoholic pneumonia " as a distinct variety, but habits of spirit-
drinking occasion certain distinctive features—namely, jaundice and the phe-
nomena 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.

   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.  [According to E. F. Wells,1 the  mortal-
ity from pneumonia is lowest between the ages  of five and twenty.   " From
twenty to forty years the proportion is increased somewhat, to be again con-
siderably augmented during the next score of years.   Old age  comes on with
a large—the largest—and  increasing prevalence."—H.J  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
           1 Journal of the American Medical Association, March 30, 1889. 
ACUTE LOBAR PNEUMONITIS.
73
abuse of alcohol acts  directly as a cause; probably the disease is caused by
circumstances incidental 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-
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 
74
PNEUMONITIS.
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.  Yet 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.
   [Pneumonia is now universally recognized as an infectious disease, and for
the following reasons:
   (1) Like most infectious diseases, rt runs a definite, self-limited course.
   (2) The relation between the inflammatory process in  the lung and the con-
stitutional  symptoms is  far from  uniform.   The fever and other symptoms
and signs of infection may, and often do, precede the local affection, and it is
the rule for the  fever to vanish before there has been any demonstrable dim-
inution  in  the area  of pulmonary inflammation.  Again, the constitutional
symptoms  may  be of severest  type when the amount of lung  involved is
small; while,  on the other hand, the  course of the  disease may  be  benign
when an entire lobe or lung is consolidated.  Facts like the above cannot be
explained  satisfactorily  on the  theory that the general symptoms are secon-
dary to and  dependent upon  a mere  local inflammation.
   (3) Another proof of the infectious nature  of pneumonia  is that it often
prevails in  epidemic form.  Examples  of its epidemic  prevalence in prisons,
barracks, and asylums  are too numerous  to  mention.   One of the most
remarkable epidemics occurred  in  Middlesborough, England, in  1888.  Out
of a population  of about 70,000 there were 369 deaths  from pneumonia, 288
of which were males.1   There are  accounts of village epidemics in which the
track of the disease was very similar to that of the most  contagious affections ;
that is, it would  show a decided preference for certain streets and  neighboring
houses.   For example, in an epidemic which prevailed in Tubingen in 1881,
" thirty cases  happened  in houses which had in previous years contained
patients with  pneumonia."2
   Although obliged by such facts  as those above mentioned to regard pneu-
monia as an infectious  disease,  it must be confessed  that its precise etiology
is one of the most  difficult  questions in pathology.   The diplococcus of
Fraenkel is the  organism most commonly present in the inflamed lung.   It
was found in 10 consecutive cases  by Dr. Welch of Johns Hopkins Hospital,
and in a much greater number (46) by Dr. Guido Banti  of Florence. Italy.3
In one of  Banti's cases staphylococci were also present, and in 4 of Welch's
cases pus organisms were also found.
   In 1X80. Weichselbaum examined 129  cases of pneumonia with reference
to the organisms in the inflamed tissues.  He found Fraenkel's  diplococcus
in 94 cases (SO  primary, 14 secondary);  Friedl'ander's bacillus  in 9 (8 pri-
mary), while the remainder were associated with the streptococcus pyogenes
in 21 (13 primary), and the staphylococcus pyogenes aureus or albus in 5 (all
secondary).
   From such  observations as those just referred to it  appears evident that
cases  which do not depart either clinically or anatomicallv from the type of
pneumonia may  be associated with different species of infective organisms.
  1 There is a decided discrepancy in  the reports of this  epidemic, E. Klein (Central-
blatt fur Bakteriologie und Parasiten'kuude, May 3, 1889) giving the population  as about
40,000 and the deaths as about 240, while Xturges and Coupland in their work on pneu-
monia (2d ed., 1890) give the figures above quoted.
  2 Xturges and  Coupland, loc. at.
  3 La Sperimentule, Aprile-Maggio, 1890. 
ACUTE LOBAR PNEUMONITIS.
75
   The present views  concerning  the  bacteriology of  pneumonia  may be
 summed  up in the following conclusions  of  Sturges  and Coupland:
   "1.  Pneumonia is a specific general disease  of "which lobar inflammation
 of the lung is the local  manifestation.
   ;< 2.  The most constant cause  of pneumonia is Fraenkel's diplococcus. but
 there are other viruses which may evoke it.
   " 3.  Chill and  other causes, some  more, some less  distinctly observed in
 that relation,  are  to be regarded only as secondary  or predisposing.
   '; 4.  The ' pneumonic virus ' may, and  often does, excite inflammatory dis-
 turbance in other organs tljan the lung, and  sometimes such inflammations
 may be excited without  the lung participating."
   Pneumonia  resembles erysipelas in that one  attack affords no  protection
 against subsequent attacks.—H.J

   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 pneumemia, 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 
76
PNEUMONITIS.
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
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
  1 Vide Physical Exploration of the Chest and  the Diagnosis of Diseases affect in r/ the
Respiratory  Organs, 2d ed., 1866; also, Manual of Auscultation and Percussion, 3d  ed
1885. 
ACUTE  LOBAR PNEUMONITIS.
i i
*ome degree of dulness over the affected lobe or lobes continues for some time
after the auscultatory signs >how 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 rale 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 diseases which  most resemble pneumonia, so far as the physical signs
are  concerned, are sharply-defined  phthisis, especially  of the  apex, hemor-
rhagic infarction, and  oedema pulmonum.  They may all  be  distinguished
with readiness if careful  attention be paid to the history of  the case and the
condition  of the heart, blood-vessels, and kidneys.
   Central  or latent pneumonia  may be  confounded in its early stages  with
typhoid or typhus fever,  but daily physical examinations will sooner or later
reveal the signs of pneumonia  if  this disease is present.   Herpes  labialis
tends  strongly to  exclude typhoid fever and to corroborate  the diagnosis of
pneumonia.—H.J
   The occurrence of suppurative pleuritis is shown by the signs of that affec-
tion.  With this complication, the affected side may be dilated, the intercos-
tal depressions are obliterated, and obvious contraction of the chest may fol-
low  recovery.

   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
inflammator}r 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 i?
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, of which the most  frequently operative  is the " diplo-
coccus lanceolatus capsulatus " of Fraenkel.   It sometimes  aborts spontane-

  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. 
78
PNEUMONITIS.
ously, and it is in some instances arrested by remedies.  If not arrested, it
may  be  favorably modified, its  duration  abridged, and  the danger to life
diminished by treatment addressed not  so much to the pulmonary affection
as 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
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- 
                    ACUTE LOBAR PNEUMONITIS.                  79

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, but 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.   The formation  of such a  thrombus may sometimes
be  determined with much  confidence during life.  In a  case presenting no
symptoms  which denote imminent danger a sudden change 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 mucopuru-
lent expectoration ;  bloody, dark-colored  sputa, commonly known  as the prune-
juice expectoration; active, violent delirium ; low, muttering delirium, with
  1  For cases of thrombosis of the right side of the heart, with remarks, vide Clinical
and Pathological Observations in India, by Xir Joseph Fayrer, p. 95 et seq. 
80
PNEUMONITIS.
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 apixea 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.   (Edema of the portions
of  lung not affected by the  pneumonia (collateral oedema) is an immediate
cause  of  death by apneea 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 become*
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.
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.—Pneumonokoniosis, Anthracosis, etc.—Brown or Pigment Induration of
   the Lungs.—Hyperemia 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 i« not suf- 
ACUTE LOBAR PNEUMONITIS.
81
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, 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 employment are—high fever, the pulse more
or less resisting compression, or, in other  words, arterial tension and a robust
constitution.  It is contraindicated whenever 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 blood-
letting  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 fhe
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
        6 
82
PNEUMONITIS.
 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.   [Dr. D. B.  Lees of England has reported marked success
 from the application  of ice-bags to the  chest, and his  statements have been
 confirmed by Goodhart and others.   The  effect  of  such applications is not
 only to relieve  pain and diminish pyrexia; in addition, they appear to limit,
 and sometimes even to abort, the inflammatory process.—H.J   In some cases,
 however, patients complain of the application, and if so it should not be con-
 tinued.   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.  [This and other similar antipyretics should, how-
 ever, be employed with great circumspection and only in  comparatively robust
 individuals.   They tend to produce cyanosis and collapse—the  very symp-
 toms which, in  pneumonia, are  of the gravest import.—H.J   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 temperature to  as near the  normal
 maximum as  practicable.   Whenever, after this  object is effected, the tem-
 perature rises, cold is to be again applied.  It is desirable that the employ-
 ment of these measures be under the personal  direction  of the physician
 or  an  experienced  assistant.    An  alcoholic  stimulant should  be  given
 whenever the  bath,  the  wet  sheet,  or  sponging is  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 usefulness.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 reference
 to an abortion of  the  disease.   This  remedy may suffice for  the antipyretic
 object, rendering the cold-water  treatment  unnecessary, and it may be con-
 joined  with the latter.   Exposing the surface of the  body to cool or cold
 arris 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
  1 For report of cases treated by the wet sheet by the author, vide Gaillard>« 7l/^7,WJ
Journal,  March, 1881; also, Transactions of the  New York ^iS^aJ^^ 
ACUTE  LOBAR PNEUMONITIS.
83
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 warm 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-
 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  staoe 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 stao-e calls for antipyretic treatment, and the same  measures  may be
 employed.   These measures are indicated whenever the thermometer shows
 a  temperature at or  above 1<>3°.                 ......  xl_       ,
.    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- 
84
PNEUMONITIS.
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-
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 
                    ACUTE  LOBAR PNEUMONITIS.                 85

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.
   Cases  of pneumonitis complicated with  delirium  tremens  call  for the
pretty  free  use of opium, together with alcoholics and  a nutritious diet.
 [Under  these circumstances  great benefit  may  also  be derived  from the
 judicious employment of paraldehyde, chloral, and potassium bromide.—H.J
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, 
86
PNEUMONITIS.
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 have for 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.
  [Recent experiments of Drs. G.  and F. Klemperer are  highly suggestive
of future  possibilities  as to  the prevention and  cure  of pneumonia.  They
found that  the rabbit, which  is very  susceptible to pneumonic infection,
could be rendered immune by hypodermic injection  of  the liquid in which
Fraenkel's diplococcus  had  been cultivated.   They  soon determined,  how-
ever, that such injections exerted no curative effect upon the disease.  Their
next  experiments  were with the blood-serum of animals upon whom immu-
nity had been conferred in the manner above mentioned, and they were induced
to perform them by the discovery of Behring and Kitasato that the blood-
serum of animals that had been rendered immune from diphtheria and tetanus
exerts a curative  effect upon these diseases when induced  experimentally.
They bled an animal that was proof against pneumonic infection, and obtained
from 15 to 20 cc. of serum.  They then injected this  serum into the venous
system of an  animal that had  been inoculated with  the diplococcus and in
which the symptoms of pneumonia  were  well pronounced.   The effect  was
an immediate  improvement of all the symptoms  and rapid recovery.  These
experiments were repeated a dozen  times, and with  similar results in every
instance.  They finally experimented upon man.  In six cases of pneumonia
they injected  subcutaneously a  small quantity of serum  from  an immune
rabbit, and in  all  the operation was followed by a decided fall in  the tem-
perature  and  a  reduction in the frequency of both pulse and  respiration.
  The pneumonic virus circulates  in the  "blood,  and from it  or through its
effect upon the  albumen of the  body an antidote—" antipneumotoxin "—is
formed which neutralizes the poison and causes the crisis.   The  Klemperers
have  isolated the  pneumonic virus—" pneumotoxin "—by precipitating an
albuminous substance from cultures of the pneumococcus,  and the time may
not be far distant when its antidote—antipneumotoxin—will be also  isolated
and dispensed by the apothecary.2—H.J

  1 Am. Journ. 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.)
  2 For details  of the Klemperers'  experiments, See Berliner  klinische  Wochenschrift,
Nos.  U and 35, 1891.                                                    J ' 
            ACUTE LOBAR PNEUMONITIS IN CHILDREN.         87


             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-
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.  Aomiting 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 
88
PNEUMONITIS.
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,
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 (apneumatosi*). 
LOBULAR  PNEUMONITIS,  ETC.
89
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-
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 water.  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 
90
PNEUMONITIS.
 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
 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.   Various 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 
LOBULAR  PNEUMONITIS, ETC.                 91
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
pulse offer variations dependent on the intensity of the fever and the obstruc-
tion to the passage  of blood through the pulmonary vessels.  Corresponding
variations in other constitutional  symptoms are incident to the fever and dis-
turbance of the  circulation.  It follows that broncho-pneumonitis  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 two  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
vesiculo-tympanitic 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 
92
PNEU3I0NITIS.
kinds.   Exposure to the latter causes may be incident to certain occupations.
[The question of the relation between lobular pneumonitis and those infec-
tious diseases to which it is so frequently secondary has been much discussed.
When  secondary to diphtheria, the Klebs-Loftler bacillus  has been found  in
the alveolar products of inflammation, together with the staphylococcus pyo-
genes aureus et albus, and the question arises as to which is the cause of the
pulmonary inflammation.   The weight of authority is  in  favor of the view
that the last-mentioned  organisms are the exciters of inflammation, for they
or similar microbes, such as the  streptococcus, are always  present, no matter
what may be the nature of the primary disease.—H.]   The pneumonitis
which  is liable to accompany exudative  laryngitis (croup) in children  is a
broncho-pneumonitis.  Its occurrence in cases of whooping  cough is not
infrequent.   In the insane,  the delirious,  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  deglutition-pneumonia (Schluck-
pneumonie) of German  writers.  Not infrequently the inspired foreign par-
ticles  are  so irritating that the inflamed  foci terminate in  abscess, and occa-
sionally they lead to gangrene.

  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  lob-
ular 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.
[When the physical  signs and symptoms  denote that the bronchial inflamma-
tion has extended to the  lung, the chest should  be  enveloped in a jacket-
poultice of linseed-meal, to be renewed as  soon as it grows cold.  This measure
appears to have fallen somewhat into disuse, but is  undoubtedly beneficial.
When  the  poultices  are  finally  removed  their place  should be supplied by
absorbent cotton over which  is placed a layer of oiled silk or  waxed paper.
The atmosphere of the sick-room should be charged with moisture with steam
from a croup-kettle or other suitable apparatus, and its  temperature should
not fall below 65°  F. nor exceed 70° F.   Internally, experience sanctions the
use of ammonia, which  is  least disagreeable to children in the form of the
aromatic spirit.  It is rarely objected to when given in the  form of a  "fever-
mixture " with a little citrate of potash and  liquor ammonite acetatis.  If the
respiration is embarrassed by an accumulation of mucus in the air-passages,
the latter  should  be emptied by  means of emetics,  of which the  best for
this purpose is the syrup of ipecac in drachm-doses.   Sulphate of zinc and
alum may also  be employed.  Opium should not be administered  unless the
patient is very restless, and  manifestly from pain.  Under these circumstances
a few drops of paregoric or a drop of the deodorized tincture  of  opium may
be given at suitable  intervals to an infant,  and in larger doses to older chil-
dren.   Where there is decided  pyrexia  the  patient should be immersed in a
warm bath which is  gradually cooled down to about 75° F.  If this  be done
in the  evening, sleep will be promoted and rendered more tranquil and  refresh-
ing. _  If signs of asphyxia appear,  in addition to emptying the bronchi with
emetics, the child should be placed in a warm bath  and  cold water poured
over the head.  The respiratory. centres should also be stimulated by the
internal use of strychnia and belladonna.  The diet should be nutritious and
concentrated, consisting, for the most part, of milk and lime-water  brandy
and egg, milk punch, meat-juice, chicken- and  mutton-broth, arrow-root and 
SUPPURATIVE  PNEUMONITIS, ETC.
93
other farinaceous substances.—H.]   The dorsal decubitus should not be con-
stantly  maintained, changes  of  position being important  as preventive 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  deglutition pneumonia (p.
D2).   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
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 py;emic 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. 
94
PNEUMONITIS.
  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.
  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 pyasmia.  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 pysemic 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  [When the expectoration is copious, the patient's strength declin-
ing, and the physical signs denote that the abscess is superficially seated, the
 proper treatment is undoubtedly surgical. Nearly 50 per  cent, of the recorded
 cases of pneumonotomy for pulmonary abscess have terminated in improve-
 ment or recovery.   The following statistics are given by Eichhorst:2 Opera-
 tions, 13 ; recovery or improvement, 6 (=46.1 per cent.) ; fatal termination,
 7 (= 53.9 per  cent.).  If the  operation is not followed  by recovery, it may
 avert the danger of sudden rupture of the abscess  into bronchi, pleura, or
 pericardium  or its  extension to  neighboring organs.—H.I


        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 anthracosia
                       1 Lancet, 1S84, vol. i. Xo. 2.
                       - Spceielle Pathologie, Band i. s. 519. 
              PNEUMONOKONIOSIS—ANTHRACOSIS, ETC.           95

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.
   Chalieosis pulmonum is the name given to the pulmonary changes induced
by the inhalation  of stone-dust.   It is also called stone-cutter's phthisis.
Tlie  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
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.
   Various 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.

  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 Deutsches Archiv f. klin. Med.,  Bd. 2, p. 116. 
96
PNEUMONITIS.
  The removal of the patient  from the continued  operation of the cause is
of course the first  object of treatment.   In  other  respects the indication*
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 lumina.   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.
Rindfleisch 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
cases of  dilatation or  of fatty  degeneration, and  may be a symptom of
asphyxia and of certain cerebral injuries and diseases.  In  cases  of  gen-
eral dropsy  it occasions a disproportionate amount of hydrothorax.   It gives
rise  to brown or pigment induration of the lungs.   (See p. 96.)
   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 
HYPER JEM I A  OF  THE LUNGS, ETC.
97
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 flark-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, ceteris paribus, 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.
   (Edema of the  lungs will be considered under a separate heading. (Vide
Chapter XI.)

         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 
98
PNEUMONITIS.
who depend on symptoms alone.   The term pleurodynia  is applied to a pain-
ful affection of tlie muscles entering into the composition of the thoracic walls.
Intercostal  or dorso-infercostal 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 vertebra1, 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 Valleix, 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.
   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, 
A NA TO MICA L  CHAR A CTERS
99
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 hypodermically
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  products with  a tendency  to caseous  degeneration.   Other
lesions  which are   often present  are  ordinary  inflammations,  congestion,
emphysema,  atelectasis,, and cedenia.   Another  morbid  change  of great
importance is the formation  of  cavities.   The  multiplicity of lesions  and
of structures involved, and  the differences in different cases in the combina-
tion and relative preponderance of these lesions, render  the morbid  appear-
ances 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.   [It  is true that this peculiar nodule may be caused by other irri-
tations than  that of the bacillus  tuberculosis.   For  example, it  has  been
observed in association  with  such parasites as  the  actinomyces  and  the 
100
PULMONARY PHTHISIS.
strongylus gigas, as well as in the  bases of syphilitic and cancerous  ulcers.
It  is, however, exceptional to find  it under such  circumstances, whereas
its  presence  in association with  the bacillus tuberculosis is the  rule.   A
brief  description  of  the  anatomical  characters  of  tubercle  is  therefore
appropriate.
  Macroscopically, tubercle appears under one of two forms :  (1) As a small
nodule or " granulation," varying in diameter from  0.5 to 2 or o millimetres,
which is transparent in its  early stages, but later becomes opaque or yellow-
ish  in the centre.   These granulations attain their most typical  development
in the serous membranes, where they are often surrounded by an area of con-
gestion ; they are commonly known as miliary tubercles.   (2) As larger nod-
ules,  which  may attain  the size of  a pea or a walnut, or may infiltrate the
affected organ to a great extent, forming  what is commonly called  a caseous
mass.   In either case the  tubercle is made up of aggregations of " element-
ary tubercles "  which only become visible with the  aid of the microscope.
  The ideal elementary  tubercle is  composed  of three zones.   In  its  centre
is a giant-cell—that is, a mass  of protoplasm containing in its  peripheral
portion from twenty to  thirty nuclei arranged in a  circular manner; next
comes a zone of epithelioid cells ;  and outermost of all  a layer or zone of
embryonic  cells.  These  various elements  are united by a network of con-
nective tissue resembling the adenoid tissue of lymph-glands  and continuous
with processes which originate  in the central giant-cell.
  The most  marked anatomical  characteristic of tubercle is that it is non-
vascular, the  vessels originally in its  embrace  becoming  obliterated at an
early  stage of the neoplasm by coagula of a granular character.   The sub-
sequent degeneration of a tubercular infiltration is due  to this absence of
vascularity.
  The specific  bacilli are most abundant  in  the  central giant-cell.  In the
epithelioid zone they may be also found in the interior of the  cells and in the
interstices between  them.  The central bacilli—those contained in the  giant-
cell—do not  behave in a uniform  manner toward the usual stains.   Some of
them  stain  vividly, others feebly or not at all, and the latter are believed to
be Mead.  It  is supposed,  therefore, that the giant-cells act the part of
"phagocytes," and that the presence of the bacilli  in  their interior, instead
of being accidental, is the result of their function—phagocytosis.
  The elementary tubercle  above described is often called, especially by the
French, a tubercular " follicle," probably from  its fancied resemblance to the
Malpighian bodies  or "follicles" of the spleen.   In fact, Virchow  formerly
classified tubercle  among the  lymphomata, on account of its resemblance to
lymphatic structures.
  The foregoing brief description of the minute anatomy of tubercle is essen-
tial to an understanding of the protean gross appearances of tuberculosis in
the  various tissues and organs of the body.
  The progress of  tubercle is either toward caseous  degeneration or fibroid
metamorphosis.  The former begins with cellular changes.  The nuclei both
of the giant and epithelioid cells disappear, and the cell-bodies become fused
into a semi-transparent substance closely resembling the degeneration known
as amyloid or lardaceous.  It  does not, however, giye the^ reactions of the
latter.
  The semi-transparent mass  soon becomes opaque, making it impossible to
distinguish any trace of cellular structure, and finally the bacilli themselves
disappear.  For a long time this " caseous " change was believed to be cha-
racteristic of tuberculosis, but this is now known to be a mistake.  Caseous
degeneration  does not always take  place even in cases of extensive tubercular
infiltration, and, on the other hand, it may occur in the products of non-tuber- 
ANATOMICAL  CHARACTERS.
101
cular inflammation, especially when these are of syphilitic origin.   It is erro-
neous, therefore, to regard this change as due to deficient blood-supply, for
in syphilitic  caseous  foci the vessels continue to be pervious.  The caseous
metamorphosis is most probably due to the action of  soluble products of  the
bacilli.
  A caseous  focus may become indurated or softened.  In the former event
it becomes infiltrated with the salts of lime, which appear first in  the centre
of the mass and  gradually extend to the periphery until it is converted into
a calcareous mass.  It may then become encapsulated  and persist indefinitely
in the lung as an innocuous foreign body.
.  Sometimes  the  process stops short  of complete calcification, the caseous
focus becoming  converted into a pultaceous or mortar-like mass surrounded
by  a capsule.  Finally, the  cheesy deposit may be  completely liquefied  and
absorbed, its  site  being indicated  post-mortem by a puckered cicatrix.  Soft-
ening is most likely to occur when  the tubercular mass is situated near the
surface.   The puriform fluid is possessed of corrosive properties, and makes
its way in the direction of least resistance.   This  tendency to seek an outlet
is constantly  seen in cases of pulmonary tuberculosis, and doubtless because
the methods  of exit from the lung are more numerous than in other organs
of the  body.  A bronchus is perforated, the softened products are expecto-
rated, and there  remains  behind a cavity, which  usually has a tendency to
extend by the progressive  destruction of  its walls.   Neighboring cavities
may unite so as to form vomicse of most irregular contour.   Their walls  are
usually composed of  caseous material which may be scraped away with the
knife.  In the most favorable cases  there is formed upon the inner surface
of the cavity  a kind of granulation tissue which terminates  in the formation
of a smooth   serous-like  membrane,  and although the cavity  still  remains
patulous, it has no tendency toward  further extension, and may be regarded
as healed.
  In the  course  of this cavity-formation the blood-vessels oppose a remark-
able resistance to  the destructive process.  In the lung, vessels of considerable
size  may be  seen traversing a vomica, but, although externally  they may
appear unaltered, on  section their  walls  are seen to be thickened  and their
lumen obliterated.  The  vessels  which ramify on the  walls of  the cavity
remain, as a  rule, patulous, and they frequently undergo aneurismal dilata-
tion.  The occurrence of aneurisms in this situation was first discovered by
Rasmussen of Copenhagen, who  attributed their  origin  to  the unsupported
state of  the  vessels.    They are generally of small  size, and  can only be
detected  by careful dissection.   Their rupture is probably the commonest
cause of suddenly fatal haemoptysis.
  Instead of  caseating, a tubercular focus may undergo a sclerotic or fibroid
change, its cellular elements becoming converted into fibrous tissue.  This
metamorphosis is  most apt to occur in slowly progressive cases, and  especially
in persons advanced in life in whom there coexists a sclerotic condition of the
arteries.   The fibroid  change is most often observed  in  tuberculosis of  the
peritoneum ;  in fact, in this situation the natural tendency of the disease is
toward cure by the excessive development of connective tissue which encloses
and strangles the  bacilli in its meshes.
  From  the foregoing remarks it is plain that in tuberculosis there may  fre-
quently be observed an effort of nature toward the  cure of  the disease, and
this effort is often attended with success, as  is manifested by the  evidences
of healed tuberculosis  in the lungs  of persons  dying  of all kinds of  dis-
eases.—H.]
  In acute miliary tuberculosis, which will be described subsequently, miliary
tubercles are  found scattered throughout both lungs.   In  these  cases  the 
102
P ULMON. 1R Y PHTHISIS.
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 phthisis (phthisis florida)
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  obliterans.   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. 
ANATOMICAL  CHARACTERS.                 103
   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 interstitial pneumonitis, and is pres-
ent in  some degree in all cases of chronic pulmonary phthisis.  The new tissue
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, as previously stated, directly from tubercle-nodules, from dif-
fuse 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
with coal-particles  and  with  melanin,  particularly in newly-formed  fibrous
tissue ; atelectasis ; compensatory emphysema; congestion  and localized and
general oedema.
  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.
   By 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 number of bacilli present in different cases of phthisis is  subject to
considerable variation.   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 rapid 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
communication 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-
oring 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 
104                    PULMONARY PHTHISIS.
 the bacilli  are incapable of development at a  temperature below 2S°  C.
 (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 organs 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 gener-
 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.                                                b     F
   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 
CLINICAL HISTORY.
105
in  small  disseminated nodules  or  tubercles, they  may  be absorbed.   In
some cases, as already stated, the animal constituents of the deposit may be
infiltrated  with  lime salts and become  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 cavi-
ties, even  of considerable size, may gradually contract, and at length per-
fectly cicatrize.

   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 tc
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
that affection.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. 97. 
l()(i
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.
107
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.
   [It is commonly assumed that anaemia is a symptom of the early stage  of
phthisis, and  that the deficiency  in  blood-corpuscles  and haemoglobin  pro-
gressively  increases as the disease  advances.   This is far  from being  the
case.   I have often  examined the blood in cases of far-advanced pulmonary
phthisis without finding the red corpuscles reduced below 75 per cent, of the
normal number.   On February 23, 1888, I examined  the blood of a colored
woman in  the last stages of tuberculosis pulmonum (she died on March 11,
1SSS), and  found 3,660.000 red corpuscles  per cubic m. (73.2 per cent.) and
50 per cent of haemoglobin.  I  was pleased  to find  my observations  con-
firmed by  Dr. O. Oppenheimer,1 who examined the  blood in a considerable
number of cases of well-pronounced phthisis and  found  it normal in all
respects.   The researches of Laache of Christiania yielded similar results.—
H-]
   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
                  1 Deutsche med.  Wochenschrift, Oct. 24, 1S89. 
108
PULMONARY PHTHISIS.
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,
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 sta<*e •
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 
CLINICAL HISTORY.
109
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 signs
of pleurisy with pneumothorax are to be sought for.
  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.   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  sufficiently 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
177G  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 
110                    PULMONARY PHTHISIS.
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.
  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
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.—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 produc- 
CAUSATION.
Ill
tion  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 tuber-
culous constitution  and diathesis.

   Causation.—The causes of pulmonary phthisis relate, first, to the specific
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  does 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
:lust in  the atmosphere.  Tuberculous infection  may  come  from the lower
animals, but probably much less  frequently  than from the human  body. 
112
PULMONARY PHTHISIS.
That it may come from the milk of tuberculous cows is certain.   In children
especially it is liable to be derived from this source.
   [The identity of bovine and human tuberculosis is thoroughly established,
and  the transmission of tuberculosis through the medium of  the alimentary
canal is proved by hundreds of laboratory experiments.   Interested parties
have raised the objection  that the portions of  beef  employed  as  food, which
are chiefly the muscular tissues, are free from bacilli even in  animals whose
viscera are tuberculous,  and that, therefore, if  the tuberculous organs are
rejected the  remainder  may  be  eaten with impunity.   This question has
been subjected  to  the  test  of  experiment.   The juice of the  muscular
tissues of tuberculous oxen has been expressed  and inoculated in animals,
with the  result of making them tuberculous.
   It has also been argued that tuberculous meat may be rendered innocuous
by cooking.  That it  may  be  so  sterilized is obvious, but practically this is
scarcely ever accomplished.  All  " rare " portions of meat—i. c.  all portions
in which  the  albumen is not  coagulated—have  not been exposed to a tem-
perature  high  enough  to destroy  any  bacilli that  they  may  contain.
These  facts demonstrate the importance of systematic  inspection of all meat
prepared for human consumption, and the absolute rejection of all that is
tuberculous.—H.]
   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
mere coincidence ; and it  may  be  true that, sufficient consideration not hav-
ing  been  accorded  to this fact, hereditary  influence  has been overrated.
Facts show that the tuberculous predisposition is sometimes inherent in the
constitution and  inherited.   [They also show that the  bacillus itself—the
seed—may  be  directly transmitted from   parent to child.  Landouzy  and
Martin  have inoculated animals with  the  apparently healthy  tissues of the
foetuses of tuberculous mothers, the  result being the transmission  of tuber-
culosis.1
   Another method by which  the  direct transmission of tuberculosis may be
demonstrated  is  by inoculating  a pregnant  animal  with the  disease  and
observing the  effect  upon  the offspring.   This  experiment  has been per-
formed by fialtier,2 with the result that three  out of a brood  of  five rabbits
exhibited  tuberculous  lesions at birth.—H.]
   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 uui-
                 1 Verneuil, Etude sur la Tuberculose, vol. i.,  1887.
                 2 Vide Arloing, Legons sur la Tuberculose, 1892. ' 
CAUSATION.
113
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, S7 were married  and under forty
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.2  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.3   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
persons affected with pulmonary emphysema.  Persons  affected with cardiac
lesions which interfere with luematosis  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

  1 Herard and Cornil, op. cit.
  1 Phthisis, in a Series of Clinical Studies, Philadelphia, 1875.
  3 The Elements of Prognosis in  Consumption, by James Edward Pollock, M. D., London,
18(55.
8 
114
P ULMONA R Y  PHTHISIS.
 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 anaemia 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  were 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-
 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 tc
 accumulate in the glands of the tonsils,  and to be ejected by  couo-hino- 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 crushed 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 
DIAGNOSIS.
115
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
 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
 -lie 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 
Ill)
P ULMONA R Y PHTHISIS.
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).
  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 
DIAGNOSIS.
117
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 eases  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 vesiculo-tympan-
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
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, being
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 
ITS
PULMONA R Y PHTHISIS.
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) Hemoptysis :  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.   (#)  Pallor  or  anemia  not  otherwise
explicable.  (A) Hoarseness or  huskiness of voice proceeding from  chronic
laryngitis.   (/') Chronic peritonitis  not traumatic,   (f)  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-
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 durin"  a 
PROGNOSIS.
119
period of thirty-four years, are as follows:  Of 070 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-
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-limitatior.
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 
,  120
PULMONARY  PHTHISIS.
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  upost 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
dead  with various diseases.   [Many  years  ago, Prof. Hughes  Bennett  of
Edinburgh made  a series of observations with reference to  this  point, and
found signs of arrested tubercle in the lungs of from one-third  to one-half
of all individuals  dying over the age  of forty.   Similar  observations  in the
Paris hospitals (Salpetriere  and  Bicgtre) resulted in the discovery of healed
tuberculosis  in  the  lungs of  more than one-half the patients dying over
seventy years of  age.—H.]   I have met with  not  a few instances of. as I
supposed, abortive phthisis.  These  cases are  likely to be misapprehended,
the more  so because the general  belief  is that exceptions to the rule of prog-
ress are extremely rare.
  I have learned, however, from  histories wliich 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
  1 Vide paper entitled " Pelf-limitation  in Cases  of Phthisis," by the author  in the
Archives of Medicine, New York,  June, 1879.                           ' 
TREATMENT
121
 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.
   Hemoptysis 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, hemoptysis is a  favorable event as  regards
 prognosis.   My own  clinical  studies  led to  the  conclusion " that cases  in
 which hemoptysis occurs show a  larger number  of recoveries, and  a  nota-
 bly greater proportion of  instances of arrest and of  tolerance, than  cases
 in  which hemoptysis 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.
   Vogel 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
 gave rise to embolism  of  the pulmonary artery and sudden death, the symp-
 toms of phlegmasia dolens not having been present.1

   Treatment.—Begarded  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-
                    1 Virchow u. Hirsch's Jahresbericht, 1SS2. 
122
PULMOXAR Y PHTHISIS.
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 tc
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.
   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. 
TREATMENT.
123
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  1SG3,1 I analyzed the  recorded his-
tories  of 02 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
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 500(1
feet  above the sea,  in the Coast Bange  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-
                      1  Trans. N. Y. Acad, of Med., 1S63. 
124
P ULMONAR Y PHTHISIS.
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, carry 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-
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 o-0?';
  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 
TREATMENT.
125
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-
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 \o 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- 
126
PULMONARY PHTHISIS.
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
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-
                                1 Op. cit. 
TREA TMENT.
127
 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.  Begarded
 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 rice 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.
   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- 
128
PULMONARY PHTHISIS.
   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.   How 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.
   Varick, instead of the cod-liver oil, with  apparent  benefit.2   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
                       1 Vide A7. J'. Med. Journ., March, 1879.
                       'Vide X. Y. Med. Record, Nov. 1, 1S73. 
                              TREATMENT.                          129

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 necessaiy.  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.1
  [It is impossible to enumerate the remedies that have been prescribed, and
with apparent benefit, in the treatment  of pulmonary phthisis.   At present
the one which is most widely  employed and inspires the greatest  confidence
is undoubtedly creosote.  Favorable  results from the continued  use  of this
drug  are  published  in  all quarters of the globe.  Its effects are manifested
in the course of from one to two weeks by diminished  cough and expectora-
tion,  increased strength and weight, improved  appetite,  and cessation  or
diminution  of night-sweats.   Bouchard  in  a recent communication2  states
that he has frequently  observed patients to increase in weight  to the extent
of from thirty to forty pounds after being placed upon  the use of creosote,
and that 55 per cent, of his cases have derived benefit from the drug.   AVith-
out entering into further  details, it must suffice here to  state that there is a
general consensus of opinion in favor of the employment of creosote in the
treatment of pulmonary phthisis.   The  drug has  been  administered in every
conceivable way—by the mouth, by hypodermic injection, by rectal injection,
by inunction,  by inhalation, and finally, mingled  with olive oil, it  has been
injected directly into the trachea and bronchi.   Enormous doses have been
given  by  the  mouth, but it is  doubtful  whether  these " creosotic orgies," as
they are styled by Daremberg, are justifiable.  Sommerbrodt, whose  experi-
ence  with creosote extends  over  many years, obtains  the  best results with
moderate  doses.  It is  doubtful whether it is ever necessary to exceed 15 or
20 drops pro die, although it may be given in much larger amounts, provided
a toleration for the drug be gradually established.  Thus, for example, Edwin
E. Graham of Philadelphia has administered as much as 72  drops thrice daily.
A good vehicle for the  drug is milk, but it may be prescribed in pill, capsule,
or alcoholic solution.  The following are well-known formulae, the dose men-
tioned being the minimum :

                 R.  Creosot,,                     "ixl;
                    Tinct. gentian.,               3|ss ;
                    Spirit, rect.,                  .5>>ss;
                    Yin Tokay,               ad svj.—M.
         S.  One teaspoonful in a glass of water three times a day.

         1 Vide Verhandlungen des Vereinsfiir innere Medicin zu Berlin, 1884.
         2 Vide Daremberg,  Traitement de la Phthisic Pulmonale, 1892. 
130
PULMONARY PHTHISIS.
                R.  Creosot.,                    rn^xxx ;
                    Tinct. aromat.,               3J ;
                    Mthev acet.,                 3J ;
                    Syr. simp.,                   §iss ;
                    Aq. destillat.,        q. s. ad gvi.—M.
       S.  One teaspoonful in half a glass of water three times a day.

                R.  Creosot.,                    §ss ;
                    Tinct. gentian.,               3J-—M.
       S.  3 to 30 drops three times a day.

If used hypodermically, a drachm to a drachm and  a half of a 10 per cent.
solution of creosote in the oil  of sweet almonds  may  be employed.   For
inhalation  the following formula  is recommended:

                R.  Creosot.,                     gtt. x;
                    Spirit, chloroformi,           gtt. x ;
                    Alcohol.,                    gtt. xx.—31.

  Guaiacol, which is the chief  therapeutic ingredient of creosote, has  been
largely  employed of late instead of the latter.  It  may  be given by the
mouth, in pill, or subcutaneously, dissolved in olive oil.   The dose is  prac-
tically identical  with that of creosote, in which it  sometimes exists to the
amount of 90 per  cent.
  Walzer of Aix-la-Chapelle has recently  treated  a number of cases  with
benzoyl-guaiacol, which is  a crystalline  combination of  benzoic  acid  and
guaiacol.   It is  insoluble  in  water  and other ordinary vehicles, but, being
free from  unpleasant taste, may be given with powdered sugar to which has
been added a little oil of peppermint.  In the stomach and small  intestine  it
splits up into guaiacol  and benzoic acid.   Walzer reports improvement in a
number of cases treated with this  drug, and it may be resorted to with a
certain  degree   of  confidence when creosote and  guaiacol  are  not   well
borne.—H.]
  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  hemoptysis  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. 
TREA TMENT.
131
three times daily, has been employed with much success as a cough-palliative.
Its effect upon the stomach is that of  a tonic.1
  With reference to the injection of tuberculous cavities with a solution of
the nitrate  of silver  or other medicated  liquids  through the  larynx and
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 chest-wall.  Prof. Pepper
has reported 12 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 NIL    Diarrhea 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.   [Still more certain
in their effect are  picrotoxin and  agaricin.   The former may be given in pill
in doses of  from ^ to ^ of a grain at bed-time, and if this does not suffice,
the pill may be repeated once or twice during the twenty-four hours.  Agar-
icin  is  equally effective in doses of y1^ of a grain  thrice daily.  Camphoric
acid is  also a valuable remedy for the suppression of night-sweating, and
may be given in doses of from 15 to«30 grains in aqueous or alcoholic solu-
tion.—H]   Dyspnea 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
   1 Vide article bv Dr. Robert Cheesman,  in the X Y. Med. Record, June 12, 1880.
   2 Trans. Amer. Med. Assoc., 1880, p.  23!>. 
132
P ULMOXA R Y PHTHISIS.
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.
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

  [Specific Treatment.—At the Tenth International Medical Congress, held
at Berlin in 1890, Koch announced that he had discovered a substance capa-
ble  of arresting the development of the bacillus tuberculosis in  the  bodies
of animals.  A few months later, the eagerly-expected remedy—the so-called
lymph or tuberculin—was purchasable, and, the  supply being naturally  lim-
ited, the  individuals who were  so  fortunate  as  to obtain the first samples
congratulated  themselves upon their commercial enterprise. _
  The substance was used in all the principal hospitals in this country, and
it is now used in none.  Nothing need be added to show the completeness of
its failure to fulfil the expectations aroused  by its announcement.  If tuber-
culin  were innocuous, it  would  doubtless still be employed, for there are
many who still believe  that it exerts a beneficial  effect upon the course of
tuberculosis, whether of  lungs, joints, or skin.   Unfortunately, however, its
use is attended with danger.   When administered in the manner and dose
recommended by its discoverer, it is followed in four  or five hours by violent
febrile reaction, the rectal temperature sometimes rising to 105° F. or more,
accompanied with vomiting, a sense of thoracic oppression, pains  in the head
and limbs, and  delirium.   On  account of these and  similar alarming symp-
toms, patients who had eagerly  demanded a trial of the remedy have refused
to submit to its repetition.
  Notwithstanding  its manifest  dangers,  physicians would  be  justified  in
urging their  patients to submit to a thorough trial of tuberculin if it could
be  shown that its effect upon the local lesions is beneficial.   Unfortunately,
the reverse  is  the  case.   Examinations  by Virchow of the  bodies  of those
who  had died  while  undergoing  a course  of  treatment with tuberculin
revealed  recent acute inflammation  in the neighborhood of old tubercular
foci and an irruption of miliary granulations in the viscera and serous mem-
branes.  This report gave tuberculin its  death-blow so far as its employment
as  a  remedy for tuberculosis is  concerned.   It is now exclusively employed
by  veterinary surgeons as a  test of the presence of tuberculosis in cattle.
For this  purpose it is of great practical  value, since the febrile reaction and
other symptoms above mentioned do  not make their appearance unless the
animal to which tuberculin is administered is tuberculous.
   The principle upon which the treatment of pulmonary phthisis with tuber-
culin is based is undoubtedly correct.  It is that pathogenic organisms secrete
—or, rather, produce—substances (antitoxines) inimical to their own growth
and development.    This is universally recognized by experimental patholo-
gists, and they are  now searching for a substance, a modified  form of tuber-
culin, containing the supposed curative  virtues of the latter and free from
its  undoubted poisonous properties.  It is too early to speak positively con- 
FIBROID PHTHISIS.
133
cerning any of these  substances.  Suffice it to say that the best-known and
most promising modifications of  tuberculin are those  of Hunter of England,
Klebs  of Germany.^ and Trudeau of the United  States.   The first named
endeavors to free Koch's  tuberculin of its toxic properties by dialysis; the
second endeavors to accomplish the same object by precipitation with platinic
chloride; while Trudeau has obtained excellent curative results in animals
with soluble  products contained in filtered culture-media.
  The writer has employed  Klebs' tc tuberculocidin " at the Home for Con-
sumptives at Chestnut Hill, Philadelphia, and can testify to its being  abso-
lutely  innocuous and probably  beneficial.  He  has  also  seen some of the
animals experimented  upon by Trudeau, and is convinced that his  claim that
" experimental tuberculosis in the rabbit's eye can be cured by injections of
the filtered culture-medium " is fully warranted.
  The reports from these  and other  experimenters serve  to keep alive the
hope that a specific for tuberculosis  in  man will  yet be  discovered.—H.]
                      CHAPTER  VIII.

   FIBROID PHTHISIS.—ACUTE MILIARY  TUBERCULOSIS.—
                     GENEBAL TUBEBCULOSIS.

                          Fibroid Phthisis.

    THEBE 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. 
134   FIBROID PHTHISIS.—ACUTE MILIARY  TUBERCULOSIS, ETC.

  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
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 
 ACUTE MILIARY TUBERCULOSIS—-GENERAL  TUBERCULOSIS.  135

 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.
 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.  [Pneumato-therapy has been
 much employed in  the treatment of this disease, but  may be productive of
 harm.  The object of inhaling compressed or rarefied air is to dilate the con-
 tracted lung, but, unfortunately, such inhalations  cannot be confined  at will
 to any particular branch of  the bronchial tree.   They  penetrate  in the direc-
 tion of least resistance—i. e. toward the comparatively sound lung, which may
 be already in a  state of vicarious  emphysema.—II.]

      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 the article  on Pulmonary Phthisis.   Some  of the tubercles, par-
 ticularly 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  products, particularly  in the
 neighborhood of the tubercles.  Acute inflammation of  the bronchial mucous
 membrane coexists.  More or less  enlargement of  the spleen is usually pres-
 ent.   Certain peculiarities in the structure and the distribution of  the  tuber-
 cles in particular organs will be subsequently mentioned 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. 
136  FIBROID PHTHISIS.—ACUTE MILIARY TUBERCULOSIS,  ETC.

  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 j1  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
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.  Hasmoptysis is an occasional event.  Anion"
the cases  given in  my work on Phthisis is one in which  the disease  began
  1  As in a case reported by Bergkammer ( Virchoiv's Archie, 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.  137

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-
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. 
138
BRONCHITIS.
                        CHAPTER  IX.

                             BBOXCHITIS.

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.—Bronchitis with Fibrinous Exudation.—Circumscribed Bron-
   chitis.—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
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 hyperemia 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.  [The minute blood-vessels are dilated  and
congested, and in their  neighborhood are  numerous emigrated  leucocytes.
The  epithelial cells of the mucosa are in a state  of  active nuclear prolifera- 
    BRONCHITIS AFFECTING  THE  LARGE BRONCHIAL  TUBES. 139

tion, and collections of round cells may be detected in the peribronchial con-
nective tissue.—H.]   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 accompan}- 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.
  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 
140
BRONCHITIS.
 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.

   Causation.—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
 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.
 • Tt- T{ b!i^tT? t.rai,m»ti?»Uy  bJ imitating  gases received with  the
inspired breath.   Inhalation of  chlorine gas will  produce it.  I have known
  \ Y)d,e " Su^'estions as to the Etiology, etc. of Acute Coryza," by the author in Tour-
nal of the American Medical Association, Nov. 14,1885.           J            J 
   BRONCHITIS AFFECTING  THE  LARGE BRONCHIAL  TUBES.  141

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 X.)
   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-
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 
142
BRONCHITIS.
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 apncea.
   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
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  2 ounce, liquor ammoniae  80 minims, and  distilled water 2J 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 
5 UBA CUTE BRONCHITIS.
143
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 inhalation of  steam is often soothing to the inflamed  membrane, and
its efficacy may be increased by adding to the water from which the steam is
generated a few drops  of  oil of turpentine or of the compound tincture of
benzoin.—H.]
   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.
   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-sixteenth of a
grain of the sulphate of morphia or one-eighth 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  iungs  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. 88.)
   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 
144
BRONCHITIS.
uigress 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
apncea 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 alas 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
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. 92),  are to  be mentioned as entering
into  the treatment. 
  BRONCHITIS AFFECTING THE SMALL  BRONCHIAL  TUBES.   145


   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 notha, 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 ©edematous. There is usually compensatory emphysema of the superior
and anterior parts of  the  lungs.
   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
        10 
146
BRONCHITIS.
alon^ 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,
but  labored, the labor being especially marked in  expiration  (expiratory
dyspnoea).   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- 
   BRONCHITIS AFFECTING  THE  SMALL BRONCHIAL  TUBES.  147

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
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.  [Steam  should also be occasionally inhaled
 directly from  an  atomizer.  It is probable that medicated sprays  are more
efficacious  than those of simple water, and  the best solutions for this purpose
are chloride of sodium and carbonate of  sodium,  of the  strength of from 1
to .") per cent.—II.]  The temperature of  the room should be kept at a high
point, So°  to 90°.  The iodide of potassium should be given freely.
    Kinetics  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 exhaus-
tion.  The use of apomorphia  has  been already referred to (p. 144).  Lax-
atives are  useful  by  diminishing the contents of the intestines, and thereby 
148
BRONCHITIS.
giving space for more effective action of the diaphragm in respiration.  Revul-
sive  applications to the chest are useful, but blisters are of  doubtful  utility.
[Warm baths followed by cold sponging are useful both for their general and
local effects.   They  are  tranquillizing to  the  nervous system, and,  by the
more active respiratory movements which they excite, promote expectoration
and prevent collapse of the lung.—H.]
  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.

             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
lamime or concentric layers, and they 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
and  emphysema.  Fibrinous bronchitis  has been associated in  many cases
with phthisis.   I  have known it to occur in  connection with  acute lobar
pneumonitis.    [It  has  also been observed  in  association with skin diseases,
such as  eczema, pemphigus,  and  herpes, and  the view has been entertained
that  in such cases the bronchial affection is  a localization  of  one of these
cutaneous  affections.—II.] 
       CIRCUMSCRIBED BRONCHITIS—CHRONIC BRONCHITIS.    149

  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, ma}r 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 vapors or sprays inhaled will aid in the sepa-
ration  of the false membrane, [and they may be medicated with carbonate of
sodium or potassium (1 per cent.), both of these substances being solvents of
fibrin.  Pilocarpine has been suggested as a remedy  likely  to prove effective
in these cases, on  account  of its property of producing a copious liquid secre-
tion from the bronchial mucous membrane.   Mercury and potassium  iodide
have been administered with the object of preventing a return of the  parox-
ysms; and with apparent  success.   If possible, the winters should  be spent
in a climate, such as the sea-coast of Florida, where the air  is both warm and
moist.—H.]


                    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,
[and is not infrequently a manifestation  of some underlying constitutional
condition such  as  gout, rheumatism, or  renal  disease.—H.]
  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 
150
BRONCHITIS.
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-
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.   AVhen 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, 
             CHRONIC BRONCHITIS—FETID  BRONCHITIS.         151

miseible  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
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.  [The quantity of expectoration in
these cases is generally large, and on standing it separates  into three layers,
of which the  uppermost is  frothy and contains  masses of muco-purulent
material; the lowest presents a granular appearance,  and is largely composed
of small yellowish masses, the  so-called Dittrich's plugs; the intermediate
layer is  of a serous appearance.  It is the lowest layer, and especially the
plugs of Dittrich, which are  characteristic of fetid bronchitis and impart to
the  sputum its fetor.  When  examined microscopically  the  '' plugs" are
found to be mostly composed of minute organisms, among which the lepto-
thrix pulinonalis  is predominant.   They may  contain, besides, fat-granules,
pus-corpuscles, and  crystals  of  margarin.—H.]
   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- 
152
BRONCHITIS.
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 murked 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-
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 
             CHRONIC  BRONCHITIS—FETID  BRONCHITIS.         153

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.   [The remarkable efficacy of
this drug in  many  obstinate cases  is probably due to the fact that the bron-
chitis is the  sole manifestation of a gouty, rheumatic, or  syphilitic  constitu-
tion.—H.]   This remedy is  not always tolerated even in  moderate or small
doses, and it  is by  no  means always successful, even when large doses occa-
sion 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 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  sometimes so marked that it  would seem to  be  almost a
specific remedy.   The spirits of turpentine occasionally prove equally effica-
cious.   A good method  of  giving  the  latter is in what the late Prof. Clark
of  Boston  called the continuous dose—namely,  a drop in an emulsion every
one or two hours throughout the day.   Other balsamic remedies, the balsam's
of  Tolu, Peru, and sandal-wood, are among the  curative  remedies,  to which
are to be  added terebene, 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 
154   EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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.
  [Pneumato-therapy has been used  advantageously in the  treatment of
chronic bronchitis, and is  most effective in cases which are complicated  with
asthma and emphysema.—H.]
  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.
                        CHAPTER  X.

    EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PEBTUSSIS.

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 vesicidar 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- 
EMPHYSEMA.
155
sema, in  distinction from  vicanmis, 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
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 dyspnceic 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, anamic, 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- 
156    EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

Hum.   An apparent thickening of the alveolar walls may result from  their
being compressed and  crowded together by dilated air-vesicles.  Bindfleiseh,
however, claims to have seen an actual hypertrophy of the smooth muscular
elements which, according to him, exist in the alveolar walls.  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
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 
EMPHYSEMA.
157
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
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.   Exceptionall}*, 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 
158    EMPHYSEMA OF THE LUNGS.—ASTHMA.—PERTUSSIS.

so far as destruction of air-ceils 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
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 far 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.   Begarding 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 
EMPHYSEMA.
159
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
the cells which communicate with the obstructed tubes, in the manner already
adverted to in the  chapter on Broncho-pneumonitis (p.  88).   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 clue 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- 
160   EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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.
   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  mayi 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 
EMPHYSEMA.
161
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
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 vesiculo-tympanitic.  This vesiculo-tympanitic
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—ma}r 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 praecordial 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-
        11 
162   EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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
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- 
ASTHMA.
163
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
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.
  Kxercise, 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 dyspmea 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
          1 Vide article by Hertz in Ziemssen's Cyclopaedia, Am. ed., vol. v. 
164   EMPHYSEMA  OF THE  LUNGS.—ASTHMA.—PERTUSSIS.

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
may be sudden and its greatest 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,
                  1  Deutsches Archivf. klin. Med., Bd. 32, p. 1. 
ASTHMA.
165
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
exsudativa. 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.
  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.   Becurrence 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
dyspncea 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 dyspncea.

  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 
166    EMPHYSEMA OF THE LUNGS.-ASTHMA.—PERTUSSIS.
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
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  awa}* 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 early 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 a^e  and  that it
follows some  other pulmonary affection,  such  as  whooping cou^h, bronchitis.
or measles.

  1 For a fuller exposition of the doctrine of Wintrich the reader is referred to the arti-
cle by Riegel in Ziemssen's Cyclopedia, Am. ed, vol. iv.  For its refutation hi  exlemo,
vide paper by Biermer,  Leber Bronchial-asthma," in Volkmann's Sammlunq klinischer
Vortrage 18/0; see  also the  classical work by  Salter, On Asthma: its Pathology and
Treatment, Philadelphia, 1864.                                           yy 
ASTHMA.
167
  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-
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 with 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.
Belief 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 sestivus, 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 known 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
  1 For a full discussion of the  several  theories of the causation of asthma by Cursch-
mann, Kiegel,  Donders, A. Frankel, B. Friinkel, Hecker, Schmidt, Lazarus, Liebig, and
Ungar, see Verhxmdlungen des Congresses fitr innere Mediein, Vierter Congress,  INS.").  In
this country Dr. John  X. Mackenzie, Dr.  William H. Daly, Dr.  John O. Koe, and
others have contributed papers on this subject. (Vide System of Medicine by American
Authors, article by Dr. W. H. Geddings, vol. iii. 1885.)
  2 Autumnal Catarrh (Hay Fever), New York, ]N72.
  3 Hay Fever, or Summer Catarrh, New York, 1876. 
168    EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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.
  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.   Bepeated 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. Bichard  M. Crane  of Hagerstown, Mel,  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 
ASTHMA.
169
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
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 dyspncea 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  mmd
that emphysema  sufficient to occasion dyspncea, 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- 
170   EMPHYSEMA  OF THE  LUNGS.—ASTHMA.—PERTUSSIS.

ratory movements, vesiculo-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 differential 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.

  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.   [One of the best internal remedies is chloral hydrate, which
must, however, be given in full doses to produce an effect.  From  20 to 30
grains should be given at one dose, and repeated in half an hour if the bene-
fit from the first dose is not marked.   It must be employed with circumspec-
tion, especially  in long-standing cases in  which  the  heart is functionally
weak.—H.]   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 
ASTHMA.
171
 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.
 [The smoke, instead  of being  immediately ejected  from the mouth, should
 be inhaled into  the lungs.—H.]  Asafoetida, dracontium or skunk-cabbage,
 and Indian hemp are sometimes efficacious.   The  ethers,  given internally,
 are to some extent useful as palliatives, and occasionally they produce com-
 plete relief.   Belladonna is sometimes signally  efficacious, given  as recom-
 mended by Salter and Binger—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 some-
 times made to abort  by a full dose  of quinia—from  20 to 30 grains to an
 adult.
   Marked 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
 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 inhalation of  chloroform is often success-
 ful, 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 conveniently 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 ammonhe to the fauces by means  of a probang.   ()thers 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
  1 Vide Letteomian 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. 
172   EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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,
tins 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.1
   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,
bibulous  paper dipped in a saturated solution of the  nitrate of  potassa  and
dried—0r 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.   [A rather questionable  palliative for  the  coryzal
symptoms of hay fever is a solution of cocaine  hydrochlorate (gr. iv  ad  |j)
applied directly to the nasal passages.   The application may be made  by
means of a probe to the end of which a little  absorbent cotton is attached.
The probe  should be passed  along the floor of the nares and other sensitive
nasal surfaces until it comes  in contact with  the posterior wall of the phar-
ynx.   The relief obtained by this application is immediate and  lasts for a
variable period,  so that, if it be repeated two  or  three times  daily, the  patient
may be kept in comparative comfort.   This method of treatment is  open to
the objection  of possibly causing vaso-motor paralysis and " relaxed nose,"
and to the more serious criticism of possibly leading  to the  cocaine habit,
In my own experience I. have not seen the cocaine habit acquired in this way
by genuine  sufferers from hay fever.   Atropia  given internally has afforded
                     1 A. Y. Med. Record,  Aug. 15, 1866. 
ASTHMA.
173
relief from  excessive  nasal  sensitiveness  and flow of mucus, and it seems
further to have the power of reducing the systemic disturbance and nervous
susceptibility to the specific irritant.  It should be given cautiously, begin-
ning with a dose of z^ grain, which may be repeated every half hour until
incipient dryness of the mouth appears.—H.]
  Becent observations having shown that  paroxysms  may  be excited by
polypi and  other  affections  of the nose, and by affections of the pharynx,
appropriate  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
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 
174    EMPHYSEMA  OF  THE LUNGS.—ASTHMA.—PERTUSSIS.
 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-
 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 affection  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.
 Ihe duration of this first stage varies from one to two weeks    \fter 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 wboon
which  enters  into  the  name  of  the affection.  Another' se^s  of coughinS
expiratory  acs  succeeds   followed again  by  the   sonorous  inspiration  or
whoop; and  these  alternate  acts of  coughing and whooping are repeated 
PERTUSSIS, OR  WHOOPING  COUGH.
175
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 dyspncea  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.   AVhen 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
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 amemia, 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.  Bupture 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-
  1 Vide case reported by Dr. Wm. V. Xorthrup, in Am. Journ. of Med. Sciences, July, 1883. 
 176   EMPHYSEMA OF THE LUNGS—ASTHMA.-PERTUSSIS.

 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
 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 id 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 
PERTUSSIS, OR  WHOOPING  COUGH.
177
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.

  Caisation.—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
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.
  [Various organisms,  each supposed to be the infectious agent of whooping
cough, have been described by bacteriologists, but, unfortunately, no two of
them are alike.  The bacillus of Afanassjew is at present the one to which
most credit is attached, and chiefly because his bacteriological  methods were
least open to criticism.  Before accepting his conclusions, however, numer-
ous control  experiments should be made.   Points yet to be  determined are
(1) whether the normal  secretions  contain  similar organisms ; (2)  whether
the latter exist in other diseases of the respiratory system ; and (3)  whether
the bacillus  is a  constant accompaniment of whooping cough.—H.]

  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
       12 
178    EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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 fr;e-
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,  yet indirectly it leads
to a considerable loss of life.  Occurring in  the  course  of other  diseases—
for example, measles or during the ailments inoident 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
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  creator.
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 
PERTUSSIS, OR  WHOOPING  COUGH.             179
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.
  [Antipyrin is largely employed in the treatment  of  whooping cough, and
has many advocates.  It may be given to children of ten to twelve years of
age in doses of '1  grains every three hours, and  in proportionate amount to
younger children.   Its employment should be suspended on the first signs of
cyanosis or if it gives rise to profuse sweating.—H.]
  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
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  Commer^ge 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.2  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
      1 A Practical Treatise on Diseases of Children, by J. Forsyth Meigs, M. D.
      2 Vide American Journal of the Medical Sciences, April, 1865. 
180    EMPHYSEMA  OF THE LUNGS.—ASTHMA.—PERTUSSIS.

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 different
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. ^ij,  glycerinae §ij, aquae ^vj.1   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  durin"
the night;  and in such cases food should be  taken freely during the  night
The stomach is sometimes made to tolerate food  by minute  dose's of opium.
Change of  air is sometimes of signal efficacy in modifying  the severity  of the
affection and bringing it to a  close.               k
  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 affection  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.

       1 Vide article in the American Journal of the Medical Sciences Oct. 1879 
PULMONARY HEMORRHAGE.                 181
                       CHAPTER   XI.

  PULMONARY  HEMORRHAGE.—PULMONARY GANGRENE.—
       PULMONARY (EDEMA.—CARCINOMA.—.HYDATIDS.

Pulmonary Hemorrhage.—Bronchorrhagia —Pneumorrhagia.—Hemorrhagic Infarction.
   —Pulmonary Gangrene.—Pulmonary (Edema.—Carcinoma within the Chest.—Hyda-
   tids.—Syphilitic Disease of the Lungs.
                     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
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
haeinatemesis, 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 
 182  PULMONARY HEMORRHAGE,  PULMONARY GANGRENE ETC.

 may generally be ascertained by a close inspection of these parts.   When  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
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 spittin^ of blood
 had taken  place in no instance save after injury of the chest or whentme cata-
 menia were suppressed, concluded that this symptom is almost pathognomonic 
PULMONAR Y HEMORRHA GE.
1S3
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 (>2 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 may 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
HS6 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 danger of fatal consequences  is
  1 "On Hemoptysis as a Symptom," by John Ware, M. D., etc., Publications of the
Massachusetts Medieid Society, I860.
  2 Vide work on Phthisis, 1876. 
184   PULMONARY HEMORRHAGE, PULMONARY  GANGRENE,  ETC.

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,
dyspncea, 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
Bindfleiseh, 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
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.  Bevulsive 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 
PULMONARY HEMORRHAGE.
185
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.   Bepeated
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
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.

   Pneumorrhagia, 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 
186  PULMONARY HEMORRHAGE, PULMONARY GANGRENE  ETC.

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 is 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 ne-
crosis.  The  tissue surrounding  the  infarction is congested, oedematous,  or
solidified with pneumonic products.   Emboli  may lodge in branches  of the
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
(Kuttner), 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 
PULMONARY HEMORRHAGE.
187
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.  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 hemor-
rhagic  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
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 load 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, 
188   PULMONARY HEMORRHAGE, PULMONARY GANGRENE, ETC.

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-
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 
PULMONARY  GANGRENE.
189
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 matte*.
  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 so-called plugs of Dittrich, already  described under
the head  of Fetid  Bronchitis.  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 that the microscopical shreds  of lung-tissue  frequently found
in the expectoration 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.3
   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
  1 Deutsche  Klinil; 1853, 1S.")9, 1861 et seq.
  2 Deutsches Archiv f. klin. Med., ii. p. 4S8.
  8 According to  the experiments of Filehne—" Ueber die Vorgange bei dem Lungen-
brande," Silzungsberichte der Phys. Med. Soe. zu Erlavgen, 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. 
190  PULMONARY HEMORRHAGE,  PULMONARY GANGRENE, ETC.

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 eases.   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
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
  [Various forms of  inhalers have  been devised for use in  cases  of  fetid
bronchitis  and  gangrene.  They  are  made of rubber or celluloid, and are
  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. Journ. of Med. Sciences, Oct., 1881; vide, also, the London Lancet, Mav 31, 1884,  for
cases treated in the same manner by Mr. A. Pearce Gould. 
PULMONARY OEDEMA.
191
fastened over the mouth in such a manner that the air, before being inspired,
is made to pass through a wad of cotton or wool saturated with some power-
ful  disinfectant.   The  drug most  commonly used  with  the inhaler, and
probably the  best for  this purpose, is carbolic acid of the  strength of from
5 to oil per cent.   It is best to begin with the weaker  solution, but if any
benefit is to be derived from  this method, the strength of the  drug must be
rapidly increased.   Patients have been known to saturate the cotton of their
inhalers with pure carbolic acid and to experience no  evil effects from it.
Creosote and turpentine may also be  used  to charge  the  inhaler.
  If the gangrenous  process is superficially situated  and can be accurately
localized by physical examination, the  propriety of surgical measures should
be considered.   These consist in  the  resection of one  or more ribs and the
laying open of the gangrenous cavity, for which purpose the thermo-cautery
may be advantageously employed.  Cases have been successfully incised and
drained; in fact, although recovery has by no means followed in every case,
in none could death be ascribed to the operation alone.—H.]

                        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.1
  (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.   [If  the patient
is icteric, the fluid may be of a  yellow hue; and if the lungs contain much
pigment, as  in  cases of anthracosis, it may be brown,  or even black.—H.]
Microscopical examination in cases of acute general pulmonary oedema shows
the pulmonary 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 scrum, and  free  granular  matter.  The red

  1 Posner (Virchow's Archie, 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
.edema).  I'sually, however—and in the higher grades of oedema always—the serum
escapes also into the air-cells. 
 192  PULMONARY HEMORRHAGE,  PULMONARY GANGRENE, ETC.

 blood-corpuscles, which are always  present  in  the  serum, have escaped by
 diapedesis.   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
 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
 hydrsemic 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 (edema 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
  1 William H■• Welch, "Zur  Pathologie  des  Lungenodems,"  Virchow's Archie f. Path.
Anal.,  Bd.  t'2, 1878.                                                  J 
PULMONARY OEDEMA.
193
 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
 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-motor 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 oedematous  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
      1 See article bv H. F. Borden, M. D., Boston Med. and Surg. Journal, 1880.
        13 
194  PULMONARY HEMORRHAGE, PULMONARY GANGRENE, ETC.

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.

                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.  Beference  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.
   [The causes of primary carcinoma of the lung, like those of  cancer else-
where, are unknown.  Occupation or environment is certainly concerned in
its production, as  shown  by the extraordinary prevalence of primary pul-
monary carcinoma  among the laborers in the cobalt-mines of Schneeberg.  It
is said that 75 per cent, of the  deaths  among  these workmen  are caused by
this disease.  The affection has  been  ascribed to the inhalation of arsenic
which is combined with the cobalt.—H.]
   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 
NEW GROWTHS WITHIN THE  CHEST.            195
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.   [In very rare instances  portions of the sarcomatous growth
may be  expectorated.  A case  of this  sort is  recorded  by Eichhorst, who
states  that there is but one other like it in medical literature.—H.]
   Enchondroma  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 pulmonary7 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 (edema 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 may occasion a double murmur; that  is. a systolic  and  a diastolic murmur. 
 196  PULMONARY HEMORRHAGE, PULMONARY  GANGRENE,  ETC.

 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
 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 
AFFECTIONS OF THE LARYNX  AND  TRACHEA.
197
   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 bronchiectatic  cavities.   In most of the cases
which have been described as syphilitic  phthisis, and which have been exam-
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  AXD  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
   ('haractor;  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 
198        DISEASES  OF  THE LARYNX AND TRACHEA.

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
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 pronation 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 
ACUTE SIMPLE  LARYNGITIS.
199
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 cynanehe,  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
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 rima 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. 
200        DISEASES OF THE  LARYNX AND TRACHEA.

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  dyspixea  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
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

  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.
201
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
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 AVashington.
   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 steam 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 laryngoscopic 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—i.  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 
202         DISEASES  OF  THE LARYNX AND  TRACHEA.

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
from  the lesions which it may induce per se, but it is incidental to  the seat
of the inflammation.  And if a fatal result take place, the dying is by apnoea,
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 apncea.   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.
  Bemedies 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- 
SUBACUTE LARYNGITIS.
203
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,
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  or chiefly 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- 
201         DISEASES OF THE LARYNX AND TRACHEA.

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.
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 
            CHRONIC LARYNGITIS—LARYNGEAL  ULCERS.       205

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-
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 
206         DISEASES  OF  THE LARYNX AND  TRACHEA.
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
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.
   [A dangerous result of chronic laryngitis,  from whatever cause, is hyper-
trophy of the inferior vocal cords, which hypertrophy may be so  great as to
cause  these  processes to project  like a  diaphragm  into the calibre of the
larynx and give rise to the most alarming dyspncea.   In such cases tracheot-
omy must be promptly resorted to.—H.]

  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.affection 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 durino- the act of
inspiration.   During the act, as is well known, foreign  bodies *of lar°e 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 nieans of
the laryngoscope, and the knowledge thus obtained affords aid in  judging as
to the propriety of topical applications and in showing the  particular%oints
at which they are to be made.
  The topical remedy most frequently applied by means of the sponge is the
nitrate of  silver.   A strong  solution is commonly used—namely, from one to 
           CHRONIC LARYNGITIS—LARYNGEAL  ULCERS.        207

two scruples to the ounce of distilled water.   The sponge, moistened by this
solution, is carried between and below 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
eases 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.  [The
effect of this  drug is but transient, and  therefore it should be employed at
such  times  as to be of most benefit  to  the patient.  These are the periods
immediately preceding the principal meals.  By the use of cocaine the pain-
ful deglutition which is so distressing to the patient may be to a great extent
relieved.
   The curative  treatment of laryngeal phthisis is purely surgical, and in-
volves  the  use  of the  curette  and the direct  application of lactic acid,
creosote, nitrate of silver, etc.   The manipulations demanded by such treat-
ment  are of the most delicate description, and should be attempted by none
but an  expert.—H.]
   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
some  reported cases.2  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 hypoglottica.
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).
   It is  important to distinguish between the  anatomical  signification and
the clinical  application of the names croup  and diphtheria.  In  croup we
   1 Vide article by Thomas Bryant, in the Trans. Clin. Soc. of London, vol. i., 1868.
   2 Vide article by Dr. Beverley Robinson, Am- Journ. of Med. Sciences, April, 1879. 
208         DISEASES OF THE LARYNX  AND  TRACHEA.
 may have  diphtheritic  as well  as croupous  inflammation,  the difference
 depending chiefly upon  the seat  of inflammation.  Decided as are  the dif-
 ferences  between  membranous  or  true croup  and  diphtheria  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  pref-
 erence  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.   It has
 been used in a comprehensive sense to signify a variety  of  affections in  chil-
 dren characterized by a peculiar shrill,  barking cough called the  croupal
 cough, and by difficulty in breathing.   These symptoms may accompany  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-
 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, hypergemic, 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 
            LARYNGITIS  WITH FIBRINOUS ENUDATION.        209

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.   The fibrinous material  in the  diphtheritic
and  pseudo-diphtheritic forms of inflammation 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
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  by
the dyspncea. 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
        14 
210        DISEASES  OF  THE LARYNX AND TRACHEA.
 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.—Undoubtedly,  the majority  of cases of
 pseudo-membranous  laryngitis are  neither more  nor  less than  laryngeal
 diphtheria, but in  the  opinion of the writer it is  going too far to deny, as
 some pathologists  do, that there  is such a disease as non-diphtheritic mem-
 branous laryngitis.   The independent existence  of this  disease is proved by
 evidence  both pathological  and clinical.  In the  first place, an inflammation
 of the  larynx  attended with the  exudation of fibrin may be the  result of
 thermal, chemical,  and  mechanical irritants.   For example, such inflamma-
 tion has been  frequently observed in children who have  inhaled steam from
 the spout of a kettle.   It has also been caused by the  action of caustic  sub-
 stances, such as ammonia, caustic  potash, and the mineral acids; and, finally,
 it has  been observed in cases  of foreign bodies in the air-passages.  In such
 cases it is  manifest that the  diphtheritic poison has nothing to do with the
 production  of  the  false membrane.
   A powerful  clinical argument in support of the separate individuality of
 " croup "  and  diphtheria is afforded by the statistics of  tracheotomy, which
 are much more favorable  in the  former.  For example, Henoch of  Berlin
 performed tracheotomy 1 in 70 cases of  diphtheria  of pharynx and larynx
 with but 9 recoveries—i.e. 13 per cent., whereas in  36 cases of "idiopathic
 croup " he had 24 recoveries—4. e. 60 per  cent,  F. Ooldschmidt2 corroborates
 Henoch's statement that the percentage of recoveries after tracheotomy is
 greater in cases  of so-called  idiopathic croup than  in  those of diphtheria.
 For example, in the children's hospital at Niirnberg the statistics of tracheot-
 omy were unusually favorable  during 1887 (in 39 operations there  were 15
 recoveries—i. e. 38.5 per cent.), and  during that year there were  among the
 cases operated  on an unusual number that might be fairly regarded as idio-
 pathic croup.
   As above stated, Henoch's recoveries  after tracheotomy in undoubted cases
 of diphtheria amounted to  only 13  per cent.  This  is much below the pub-
 lished  results  of other  operators,  who  claim a success of from 25 to 40 per
 cent., and according to  Henoch this  apparent superiority is due to a failure
 to recognize the distinction between croup and  diphtheria.  The result of all
 Henoch's  tracheotomies  upon diphtheria  and croup  combined is a recovery
 of from 25 to  30 per cent.
   These facts  are certainly most  significant.   The defenders of the theory
that croup and  diphtheria  are  identical attempt to refute them by the state-
ment that the cases of so-called croup are  in reality cases  of mild diphtheritic
infection with localization of membrane in the larynx alone, but the clinical
history of the two diseases differs quite as  much as the results of tracheotomy
 just mentioned.—H.]
                   1 Deutsche med. Wochenschrift, 1889, No. 44.
                   2 Centralblatl filr klin. Med.,'No. 48, 1889. 
            LARYNGITIS WITH FIBRINOUS EXUDATION.         211

   Causation.—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
 years.  Boys are oftener affected than girls.  It occurs oftener in  some situ-
 ations than in others ; a cold, humid, changeable climate apparently contrib-
 utes to its occurrence.  Cases occur oftener in the spring and autumnal months
 than at other portions of the year, [and the disease  often appears  to take its
 origin from exposure to cold and wet. A negative etiological feature, but one
 of great importance with reference to the nature of the affection, is that it is
 not, like diphtheria, traceable to contagion.—H.]

   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 affection ;  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 
212         DISEASES  OF  THE LARYNX AND TRACHEA.

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 being
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.  Betro-pharyngeal abscess is to be excluded.
  [It must be acknowledged, in spite of what has been said concerning the
pathological character  of this disease, that it is very difficult to draw a clear
line of demarcation between membranous laryngitis and laryngeal diphtheria.
In the  opinion  of the writer,  a diagnosis  of the former  is justified  when,
with hoarseness, cough, partial  or complete aphonia, and  signs of gradually
progressive stenosis of the  larynx,  there  is moderate fever, slight constitu-
tional disturbance, little  or  no enlargement of the cervical glands, no albu-
minuria, and no demonstrable exposure to contagion.   The presence of mem-
brane in the pharynx does not stamp the affection  as diphtheritic.   With
reference to this point, the writer holds with the late  Dr. Fagge, who believed
that in rare cases a diphtheria might begin in and remain limited to the air-pas-
sages, but thought it was much more common for a non-specific membranous
croup to extend to  the tonsils and palate, " leading to the formation of milk-
white patches  of  greater or less extent  upon the surface of those  parts."
  Much of the obscurity which  surrounds this subject is due to the indis-
criminate employment  of the adjective  ''diphtheritic."   German pathologists
are  in the  habit of using this  term in its etymological sense.1  Thus they
speak of diphtheritic membranes  lining the colon in  cases  of dysentery, and
as being present in the  gall-bladder and  renal  pelvis as  the  result of the
irritation of calculi in these situations.   It  is  manifest  that the  specific
infectious disease diphtheria can have nothing to do with the membranous
deposits in  such cases,  and the fact that such deposits may occur on  mucous
surfaces as the result of  mere mechanical irritation is strongly corroborative
of the existence of a non-specific membranous laryngitis.
  In doubtful cases the  diagnosis may be determined by removing a portion
of membrane  from the fauces and examining it with the microscope and by
culture  methods.  The absence of the specific organism  of diphtheria, the
Klebs-Lofner bacillus, would settle the question in favor of the disease being
non-diphtheritic.—H.]

  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
            1  It is derived from 6i<pdepa, a prepared skin or membrane. 
LARYNGITIS  WITH FIBRINOUS EXUDATION.         213
 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
 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.
   [Calomel and  corrosive sublimate are the  best preparations of mercury in 
214         DISEASES OF THE LARYNX  AND  TRACHEA.
this disease, and good results have been claimed for both.  The former may
be  given in doses  of from i grain to 1 grain  every two or three hours and
continued so long  as  it does  not excite diarrhoea.  Corrosive sublimate and
the tincture of iron may be combined in the same prescription, the former in
doses of from Ti7 to y^ grain  and the latter in doses  of 1 to 5 minims, in
accordance with the age of the patient.—H.]
  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
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
if 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
          1 Vide Diseases of Children., by  J. Lewis Smith, 6th ed., p. 581. 
(EDEMA  OF THE  GLOTTIS.
215
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
  [As to  the choice between intubation and tracheotomy there  is little to be
said in this place, the question being a purely surgical  one.   The  statistics
of the  two operations are equally favorable.   Parents, however, will  often
consent to the  performance of  intubation  who would  object to tracheotomy
for manifest reasons.  This is a great  advantage in its favor.  Again, intuba-
tion will certainly give immediate relief, and so may pave the way for trache-
otomy.—H.]
  If  operation prove  unsuccessful, it diminishes  greatly the suffering from
obstruction, and is  fully justifiable with, a view  to euthanasia.

                       (Edema  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, (edema of the glottis  is an inflanmiatory affection.  The effu-
sion  is situated chiefly in the ary-epiglottic folds, about the ventricle of Mor-
yagni 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

  1 Tubage of the  larynx, proposed by Bouchut as a substitute for tracheotomy, has been
successfully employed by Dr. Joseph O'Dwver of  New York. (Vide Diseases of Chil-
dren, by J." Lewis  Smith^ 6th ed., p. ")S9.   Vide, also, article by E. Fletcher Ingals, in
Journal of  the Am. Med. Association, Feb., 1S86.) 
216         DISEASES  OF THE LARYNX AND TRACHEA.
 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.   (Edema  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  (edema 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.
   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
 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 is
 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 cedematous tumors may be
 distinctly felt.
   If the embarrassment of breathing be not too great to permit a satisfactory
  1 A case is reported in Guy's Hospital Reports, April, 1855, which terminated  fatally
within five minutes after difficulty from obstruction was experienced. 
CEDEMA  OF  THE  GLOTTIS.
217
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 Yalleix, 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. Ourdon 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 cedematous 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 cedematous 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
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
danger 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.
  (Edema  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
  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. 
218        DISEASES  OF  THE LARYNX AND  TRACHEA.

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 uedenia. 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
dyspncea 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
cough. This is the pathological condition when the infants are said to have fits
of " holding the breath."   Bespiration 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.  [Bickets and scrofula
are  powerful predisposing factors.  The statement has been made  on good
authority1  that probably nine-tenths  of the children  who suffer from this
affection  are rhachitic.—H.]
  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
                           1 That of Eichhorst. 
NERVOUS  COUGH.
219
perhaps gone to bed apparently in perfect health.   The breathing is labored
and sonorous;  the cough presents  in  a marked degree the shrill,  rinoinw
croupal character.  (Ireat 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 eventration 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

                           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
  1  American 3Iedical Times, 1865.  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. 
220         DISEASES OF THE  LARYNX AND  TRACHEA.
 shrill and the quality of sound croupal, showing spasm of the glottis.  In i
 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 anamiia 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 paralysb
 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 movemevts involved in respiration being unaffected.
  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    \phonia
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- 
NER VO US  A PHONIA.
221
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 byT 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  different muscles of the larymx, 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 different
muscles separately, the  reader is referred to works which treat of diseases of
the  larynx in exteuso}*)
   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
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-
               1 Cohen,  op. cit., treats fully of laryngeal paralyses. 
222
DISEASES  OF  THE LARYNX AND TRACHEA.
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
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 twc
cases of recovery without tracheotomy under the use of the iodide of potas-
sium, the patients having  had  syphilis.1
                     1 New York Med. Journal, Dec, 1878. 
MORBID GROWTHS.                      223
  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 extremely rare.  The number
of reported cases is small;  but it is probable that the  pathological character
of the affection  was 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
by  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
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 ease  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 
224        DISEASES OF THE LARYNX AND TRACHEA.
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-
 niia, 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.  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.
15
225 
220
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.  25).   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 
A CUTE PERICARDITIS.
227
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 affections;  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 pnecordia;  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 orthopncea  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-
mogastric 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 
228
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  cesophagus;
 produced ulceration through this tube and  into the pericardium, giving ris*e 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 63.1   Without having noted sufficient data
                        1 Reynolds's System of Medicine. 
ACUTE  PERICARDITIS.
229
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
affection.   When it follows  the affection 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.  Bheumatic 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.
  Pyaunia, 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.   [It is  believed by most modern pathologists to be  always due to
the direct action of micro-organisms.  Like  pleurisy, however, it  may  be
caused by more than one organism.  For example, in pericarditis  secondary
to pneumonia the pnemococcus has been found in the products of pericardial
inflammation, while in other cases  streptococci and staphylococci have been
the only organisms detected.—II.]
  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 c.cocardial  murmur.
  The friction murmur  is to be distinguished  from the murmur  produced
within the heart, called  endocardial or belloics murmur, by attention to  the
following points : It is double;  that is,  consisting of two adventitious sounds 
230
PERICARDITIS.
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
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 cardiac-pleural friction murmur, and  has
been already alluded to under the  head of Diagnosis of Acute Pleuritis.   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 precordial  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 pnecordia.  The extent of dulness or  flatness at different periods
of the disease will show, on the  one hand, progressive increase or on  the
other har.d, diminution of the quantity of liquid, and at length its complete
removal.   Dr. J. M. Botch has called attention to the fact that  the pericardial 
ACUTE  PERICARDITIS.
231
6ac, 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, althou&Ii
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 ihe
sitting posture, and  it may disappear when the patient lies on the back.   If
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.
[Even when large pericardial effusion  is uncomplicated with  pleural effusion
its  diagnosis  is by no  means easy.  It  is very  apt  to  be mistaken for an
accumulation  of fluid in the pleural  sac.  Dr. Fagge states that " all  the
examples of very large pericardial effusion  which  have  occurred at  Guy's
Hospital have been set down to pleurisy.''—H.]  I have reported a  case in
which the heart  was enveloped in  either a carcinomatous  or  sarcomatous
growth, completely filling and distending the  pericardial 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 punc-
ture, 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
                 1 Vide Treatise on Diseases of the Heart, 2d ed. 
232
PERICARDITIS.
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
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.  Bheumatic 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.  When 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,
                             1 Vide p. 33 et seq. 
ACUTE  PERICARDITIS.
233
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.   [The  safest and  perhaps the
most  effective method of depletion is by leeches, of which from six to twelve
or more may be applied to the praecordial region.—H.]
   I >cpletion 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
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 pnecordia 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 
234
PERICARDITIS.
  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 with rheumatism and renal dis-
  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  tne 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 ounces1  In  a case
reported  by  the  late Dr. Swett the quantity of liquid  was  at least a gallon.
               1 Richmond and Louisville Med. Journal, April, 1872. 
CHRONIC PERICARDITIS.
235
  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  orthopnoea 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
yielding walls of the auricles; and singultus, from  pressure oh 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 blood 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 haemorrhagiea 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 1'Koonosis 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- 
236
PERICARDITIS.
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
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.
  Boberts  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-
    1 Paracentesis of the Pericardium, by John B. Roberts, A. M., M. D.  etc. 1880 
SIMPLE ENDOCARDITIS.
237
carditis not be developed.   The  condition  then is  expressed by  the  term
pne.umo-pericardium.   I have reported a case  exemplifying this statement.1
  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.
  [One of the  most interesting of  the few  recorded cases  of pneumo-peri-
carditis was reported by the late Dr. J.  F. Meigs of Philadelphia, under the
title of '■ pneumo-hydropericarditis."2  The patient was  a young man aet.
IS,  who shortly before death exhibited in perfection the signs of this rare
condition.  Chief  among them was  a splashing or churning sound synchro-
nous with the heart's action and audible at a distance of several feet from the
patient.  In  addition,  the heart-sounds were amphoric or  metallic, and there
were  the  friction-sounds, also metallic in character, of the coincident  peri-
carditis.   In  this case the air was admitted  into the pericardial sac through
an ulcerated opening in the oesophagus, this fact having only been ascertained
after the most careful  dissection.—H.]
  Of 28 cases  collected  by Miiller,3 9 terminated in  recovery.   The  cases
due to traumatism offered the most  favorable prognosis.   Of  II such cases,
•6 recovered.
                       CHAPTER  II.

 EXDOCABDITIS.—MYOCABDITIS.—DISEASES  OF THE COBO-
                          NABY  ABTEBIES.

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 lamella1 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.

  1 Vide  Practical Treatise on Diseases of the Heart, 2d ed.
  2 Am. Journ. Med.  Sci., Jan., 1875.
  :i Miiller, " Drei  Fiille von Pneumopericardie," Deidsches Archiv fur klinische Medicin,
Bd. 24, S. 158, 1879. 
-:>s             ENDOCARDITIS, MYOCARDITIS, ETC.

  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.
   Bedness, 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,
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.
Cpon 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.  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- 
                       SIMPLE ENDOCARDITIS.                    239

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.  Begressive 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
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 
240            ENDOCARDITIS,  MYOCARDITIS,  ETC.
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 79 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  endopericarditis.  Bheu-
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.
  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.
Becurring attacks of endocardial inflammation not  infrequently take place in
connection with existing valvular lesions of the heart.
   [The opinion  is gaining ground that simple endocarditis, like the ulcerative
form  of the  disease, is  due  to the  agency of micro-organisms,  although a
search for the latter often yields negative results.   The results of bacterio-
logical research  favor the view that  the streptococcus pyogenes is  most fre-
quently associated with ulcerative endocarditis, while the staphylococcus pyo-
genes aureus is most commonly present in cases of simple endocarditis.__H.]

   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  °ive 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 
SIMPLE ENDOCARDITIS.
241
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 be 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.
   Beference 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-
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:
         16 
 242             ENDOCARDITIS,  MYOCARDITIS,  ETC.

 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.  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 danger and gives rise to
 no symptoms denoting grawity of disease ; but it is frequently latent, and is
 an important  complication, chiefly because it may be the foundation  for val-
 vular  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;
 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 hvperinosis
 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 Fothergilll  The obiect is
to  secure a normal minimum of the heart's action in  order to prevent changes
    1 The Heart and its Diseases, by J. Milner Fothergill, M. D., etc., 2d ed. 1879. * 
ACUTE  ULCERATIVE ENDOCARDITIS.            243
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-
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 endoca»dium 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 maybe  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-
  1 According to  statistics of malignant endocarditis collected and analyzed by Osier
(The Lancet, March 7, 1885), 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 aiffection was confined to the right heart, the tricuspid valve being  involved 5
times and the pulmonic valve 4  times. 
244
ENDOCARDITIS, MYOCARDITIS,  ETC.
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.1
   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.
   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
  1 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 by injecting cultures of Staphylococcus pyogenes grown
on potato. The material injected contained  particles of the potato  which formed
emboli. 
ACUTE  ULCERATIVE ENDOCARDITIS.             245
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  pyaeuiic.
   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.  [The embolic manifestations in the skin are the signs which are
the most diagnostic of this disease, but, unfortunately, they are not present
in  all cases.   They  usually  appear as petechial  spots  with clear yellow
centres,  sometimes   as  pustules  or  pemphigoid  bullae.   Circumscribed
gangrene of the  skin and suppuration of the  matrix of the  nail  have also
been  observed, and are  the result  of minute  infectious emboli.  The eye-
ground  should be frequently examined for hemorrhages in  cases  of suspected
ulcerative endocarditis.  Betinal  hemorrhage  is extremely rare in typhoid
fever—a disease  with which ulcerative  endocarditis is often  confounded.
In  cases of typhoid type  the stools and the  blood  of  the  petechial spots
should be examined  for typhoid  bacilli.   When endocarditis assumes  the
intermittent  type  the   blood should  be  examined for the  plasmodium
malariae, the absence of which would furnish negative evidence  of great
value.—H.]
   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
of treatment, with our present knowledge, is  to be guided by symptomatic
indications and to endeavor to obviate the tendency to death.  [In short, the
treatment of  ulcerative endocarditis  is practically that  of  septicaemia.
Sodium salicylate, sodium  benzoate, and corrosive sublimate have been given
with  the  object of destroying the micro-organisms in the inflamed tissues,
but it is doubtful whether they possess the slightest efficacy in this respect.
In  a  case of Eichhorst's which terminated in recovery, the diagnosis being 
246
ENDOCARDITIS,  MYOCARDITIS, ETC.
apparently correct, the medical treatment consisted chiefly of a pill composed
of hydrochlorate of quinia and corrosive sublimate.]


      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 sy*philis  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. 
     MYOCARDITIS-DISEASES  OF THE  CORONARY ARTERIES.  247

   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.   Bupture 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 orthopnoea.  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 differential  diagnosis lies between myocarditis, with obstruction of the 
248  VALVULAR LESIONS  WITH ENLARGEMENT OF THE HEART.

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, this 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.
                        CHAPTER  III.

VALVULAB  LESIONS  WITH  ENLARGEMENT OF  THE HEABT.

  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
sases, are due to chronic endocarditis.  When developed after birth, they are
•iearly 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.  Bheumatic 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 
A NA TOMICA L  CHA RA CTERS
249
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
amount  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 
250  VALVULAR LESIONS  WITH ENLARGEMENT OF THE HEART.

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. 
A NA TO MICA L  CHA RA CTERS
251
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 an
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 fetal
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 
252  VALVULAR LESIONS  WITH  ENLARGEMENT OF THE HEART.

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. 96).   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. 186).   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 
CLINICAL HISTORY.
253
 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.   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.   Hyrdrothorax 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 puise;  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- 
254  VALVULAR LESIONS  WITH ENLARGEMENT OF THE HEART.

ularity in the action of the heart is not infrequent.   Intermittency of the
pulse and inequality of successive beats, due 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 different 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 dyspnoea  be a prominent s\Tmptom, 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 cedematous, 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 erythematous  ; 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 liyid.  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- 
CLINICAL  HISTORY.
255
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 hieinoptysis, 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 pnecordia.  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 sphygmograph in cases of aortic obstructive lesions
cive 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 verticaT, 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 "reater or less length.  If this condition of the arteries do not  exist, the 
256  VALVULAR LESIONS WITH ENLARGEMENT OF THE HEART.

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 
DIAGNOSIS.
257
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 bearin<> 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—/. 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
        17 
258   VALVULAR LESIONS  WITH ENLARGEMENT OF THE HEART.
a mitral 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  murmur.
  X 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

  ' 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. 
DIAGNOSIS.
259
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  pulmonic 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 
260  VALVULAR LESIONS WITH ENLARGEMENT  OF  THE HEART.
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  regurgi-
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 proration as 
PROGNOSIS.
2G1
 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 ri^ht
 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 precordial
 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.
 Vet 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 ;l
 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 precordial
  1 Mv  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. 
262  VALVULAR LESIONS  WITH  ENLARGEMENT OF THE HEART.

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-
cumstances, 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 
TREATMENT.
263
 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 eomfort;  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.
   1 Vide Handbuch der Allgemeinen Therapie der Kreislaufs-Storuugen, Leipsic, 1884. 
264  VALVULAR LESIONS  WITH  ENLARGEMENT OF THE  HEART.

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 yiride,
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
frequency7 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 different
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, Friedrichsball, 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 
       HYPERTROPHY AND DILATATION OF THE  HEART.     265

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, dyspmca, 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.
                       CHAPTER  IV.

HYPEBTBOPHY AND DILATATION OF THE  HEART.—ATROPHY
  OF THK HEABT.—OBESITY AND  FATTY DEGENERATION OF
  THE HEABT.—PARENCHYMATOUS  DEGENEBATION  OF  THE
  HEABT.—NEW GBOWTHS AND PABASITES IN THE HEABT.—
  RUPTUBE OF THE HEABT.—THBOMBOSIS 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 simpL 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 
266   HYPERTROPHY AND DILATATION OF THE HEART, ETC.

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,  (treat 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 ventriculorum 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. 
        HYPERTROPHY AND  DILATATION OF THE  HEART.     267

     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 hy|wertrophy 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, contrary7 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. 
268   HYPERTROPHY AND DILATATION OF THE  HEART, ETC.

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  strong
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 t"he 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. 
FATTY DEGENERATION.
269
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 valvular
quality of the first sound as heard over the apex.   The absence of valvular
lesions 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 a3
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 clinical point 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 
270  HYPERTROPHY AND DILATATION  OF THE  HEART, ETC.

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 pnlse 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 pnecordia,
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 {i. e. absence of breathing), succeeded by feeble and  short
inspirations, which gradually  increase in strength and depth until the respiratory act is
carried to the highest pitch of which it seems capable, when the  respirations, pursuing
a descending scale, regularly diminish until the beginning of another apnceal'period." 
FATTY  DEGENERATION.
271
 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 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, pnecordial 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. 
272   HYPERTROPHY AND  DILATATION  OF THE HEART, ETC.


         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.
  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. 
                 THROMBOSIS  OF  THE HEART, ETC.             273

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.   Bupture 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 Avas partial atheromatous occlusion
of both coronary arteries.   Except in the necrosed space the  heart  had not
undergone fatty degeneration.   [In another case, a lady about fifty years of
age, under  the writer's  observation  the heart was universally  fatty, the
degeneration being  of the extremest type.  Over the central portion of the
left ventricle the muscular substance was raised into a circular aneurismal
protrusion about the  size of a silver half-dollar which was adherent to the
parietal pericardium.  The adhesions were, however, easily separable.   The
pericardium  was  distended with  coagula. the blood having escaped from a
small slit-like rupture of  the myocardium just at the edge of the pericardial
adhesion.  Death was instantaneous, but had been preceded for several days
by paroxysms of great dyspnoea  and intense praecordial oppression.—H.]

Thrombosis  of  the  Heart—Embolism of   the  Pulmonary
                                Artery.

  It is important to distinguish ante-mortem thrombi from the coagula formed
after death   \t 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
  1 For an anilvsis of 24 cases of spontaneous rupture of the heart  by Barth, vide
Archives generates de Medeeine. Paris, 1871.  For an analysis of over 100 cases by Quam,
vide The Lancet, 1870.
        IS 
274  HYPERTROPHY AND DILATATION OF  THE HEART,  ETC.

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
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. 244).   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
3f 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 
                      FUNCTIONAL  DISORDER.                   275

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
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  DISOBDEB  OF THE  HEABT.—EXOPHTHALMIC
     GOITBE—ANGINA PECTOBTS.—THOBACIC  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 the above-mentioned 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 151.) or  even  2U0.  The
increased  frequency may persist for  days, weeks, and  even months.   This
form of disorder has  been named tachycardia (za%us, y.apdla).  I have met
with  an instance of such an increase  in the frequency of the heart's  action,
                 1 Vide Clinical Medicine, by the author, p. 248. 
27b'       FUNCTIONAL DISORDER OF THE HEART, ETC.

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.
  [A remarkable example of this affection is reported by H. C. Wood.1   The
patient, an eminent medical  practitioner,  was at  the  time of Dr.  Wood's
publication eighty-seven  years of age, and  had  endured the  paroxysms of
tachycardia for  more  than  fifty years.  They had their origin  in  a sharp
shock  or jerk produced by  stepping from a piazza  to  the  ground.   The
attacks frequently  lasted from  ten  to twenty-six  hours, and  could at one
time be invariably arrested by swallowing cold water rapidly.   This remedy
at last failed, and it was then discoyered that the symptoms could be  arrested
by rapidly drinking  a  cup of hot strong coffee.   During the height of the
paroxysms the pulse rose to 1G0, but slight exertion, such as walking, caused
it to beat at  the rate of 200.   The  attacks have not interfered in the  least
with the general health or business activity.   The effect of the cold and hot
liquids  in  arresting the  paroxysms  is probably due, as  Wood suggests, to
" stimulation of  the inhibitory cardiac  centre  produced by irritation of the
peripheral nerve-filaments of the stomach."]
  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
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.
  Beduplication of the heart-sounds denotes a  variety of functional disorder,
giving rise, however, to no definite  subjective symptoms  and occurring in
various pathological  connections.   Beduplication  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.
the condition being known technically as  bradycardia.   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.2   Physical  explora-
tion 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
                 1 Univ. Med. Mag., March, lSi.U.
                 2 Vide The American Practitioner, January, 1876. 
                        FUNCTIONAL DISORDER.                   277

 chat 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
 important; otherwise it is regarded  as  a symptom pointing to some grave
 cerebral  affection.  It was so  regarded in the cases which I have reported.
 [One of  the most interesting of the recorded cases of  bradycardia is reported
 by  D.  W/ Prentiss  of AVashington.1   The patient, a man aged fifty-three,
 ■■ had a  pulse ranging  from 11 per  minute  to  40  per minute  for over two
 years, being subject to frequent attacks of syncope.   No  disease of heart or
 other organ  could  be  discovered."   An autopsy was obtained, but  threw
 no  light upon  the cause of the persistent slow pulse.—H.]  Before  decid-
 ing 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-
 cpiency 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.  They 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
 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
 eases 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 war, excessive and persistent palpitation
 often leading to discharge on the ground of disability from supposed organic
 disease  of the heart.   Kxcessive vcnery  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 differ-
                     1 Trans. Ass. Am. Phys., vol. vi., 1891. 
 278        FUNCTIONAL DISORDER  OF THE HEART ETC.

 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 dyspncea 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.
  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 sbms
of lesions, will often go  far toward effecting a cure, the  disorder* bein- 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 
           ENLARGEMENT  OF  THE THYROID BODY, ETC.      279

 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 anamiia  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,
 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 b
 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. 
280      FUNCTIONAL  DISORDER OF THE HEART, ETC.

  The prominence of the  eyes is the  most remarkable of the triple events.
Existing in  some cases  in a marked degree, it gives  to  the countenance  a
peculiar  expression.   The  projection of the globes  displays more or les> 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 file  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
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.
[Tremor is a symptom  of Graves' disease to which  attention was first called
by  Charcot.   It  may be continuous or intermittent, universal or  involving
but  a single extremity.  It has  been studied  in detail by Marie, who finds
that it presents features distinguishing it  from  all other forms of tremor.
The chief of these are its rapidity and the regularity of its graphic repre-
sentation.  The to-and-fro  movements of Graves'  disease occur at the rate of
8 to 9 J per second, whereas the tremors of paralysis agitans,  of general pare-
sis, of alcoholism, and of senility are much slower  (about 4 to 5 per second)
and more irregular.  This  symptom is considered so important by Marie that
he believes the diagnosis of Graves' disease to be justified by its presence  in
association with  tachycardia.   Vigouroux  has called attention  to  the fact
that the  electrical resistance of the  skin is  diminished in  this disease.   This
is probably attributable to  the abnormal amount of fluid  in the dilated cuta-
neous vessels.—H.]
   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.   [Certain anomalies of
secretion, such as hyperidrosis, sometimes unilateral, excessive lachrymation.
salivation, diabetes insipidus, and even glycosuria, have often been  observed 
          ENLARGEMENT OF THE THYROID BODY, ETC.       281

in the course of Graves' disease.  Trophic disturbances of the surface of the
body are also by no means rare.  Among them are sclerema and bronzing of
the skin, gangrene of the  lower extremities, and circumscribed loss of hair—
alopecia areata.
  Other  signs  of  disturbed innervation are hemicrania, trifacial  neuralgia,
hemianaesthesia, chorea, and paralysis.  The latter is most apt to affect one
or more of  the  cranial  nerves, although the  extremities are sometimes
involved.  Progressive muscular atrophy and muscular pseudo-hypertrophy
have also been observed.—H.]   Other symptoms are  mental depression and
irritability, insomnia, amenorrhoea, abnormal increase of the appetite followed
by anorexia, hysterical phenomena, and emaciation.   The affection is essen-
tially 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.   [Sudden death with cerebral
symptoms is a possible termination.  In a case recently seen by the writer at
the Woman's Hospital of Philadelphia, delirium suddenly supervened, and the
patient died in a few hours in a state of profound coma.   There was no dis-
ease of kidneys, nor, in fact, any demonstrable morbid condition except the
so-called Graves' disease,  the  three  cardinal symptoms of which  were well
pronounced.  A similar case, made memorable by the fact that the  patient
was of the male sex, was under the  writer's care at. the Philadelphia Hospital
several  years ago.—H.]  Becovery 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 recoveries in 56, and great improvement
in 2(i 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 exclusivelyT 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-
pies of each  of these variations have fallen  under my observation.   I have
met with cases  of  rapid action  of the heart persisting for a longperiodwith-
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 
2*2       FUNCTIONAL DISORDER  OF THE  HEART ETC.

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
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, anaemia
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.  [W. H. Thomson of New York recently reported  suc-
cess from the treatment of Graves' disease with fermented milk ("inatzoon"),
bis  method being based upon its supposed relation to digestive disorders.   In
addition, he administers an occasional mercurial laxative  and intestinal anti-
septics such as salol, bismuth subcarbonate, and naphthalin.—H.]

                          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- 
                           ANGINA  PECTORIS.                      2S.]

 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.
   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.  They
 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 by
 distressing dreams.
   The affection 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 1859. it
 occurred in only 7, and it occurred in 8 out of 188 additional cases analyzed
 in 18(19.  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- 
 284       FUNCTIONAL  DISORDER  OF  THE HEART,  ETC.

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  Aveakness 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
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 Ayith 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 Av-hich 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 endeavor to 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 Aveakness 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 Avork on  Diseases of the Heart (1869).  Such
instances  should not  be lo>t 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 Avhich°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 Avell as to other parts
of the chest, may be explained by anatomical connections with  branches of the 
ANGINA PECTORIS.
285
cervical and dorsal  nerves.   As  remarked  by Eulenburg. the pain  closely
roembles 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, howe\-er, 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
and feeble.   Bevulsive applications to the chest and extremities  are appro-
priate.  SAvallowing 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  Avill 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.   [Nitro-glycerin and iodide of potassium are
valuable remedies in this disease, and with  proper precautions they may be
administered continuously for almost indefinite periods.  In  a case at the
Philadelphia Hospital, in  which, with aortic  stenosis and insufficiency, there
were daily attacks of angina of severest type, complete relief Avas obtained
by the use of small  doses of tincture of aconite (gtt. ij every four hours).
After six  weeks of freedom from pain the aconite was  stopped, and in a day
or two the paroxysms  of angina recurred.   On resuming the aconite they
again  ceased.—H.]   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 praecor-
dia 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 
28(1        FUNCTIONAL DISORDER  OF  THE HEART,  ETC.

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 Avould 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 Avhich  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
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 phxces against Avhich  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 
THORA CIC ANEURISM.
287
 Aalsalva, 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
 70M 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
 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, Avhen the
 aneurism  is seated betAveen 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 sIioavs the
vocal  cord on one  side to be paralyzed, while the  respiratory- movements of
                          1 Med. Anatomy, fasc. v. 
288       FUNCTIONAL DISORDER OF THE HEART, ETC.

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
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 Avhen
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 sign called " tracheal tugging " should always be sought for in
obscure  cases.  It is  elicited in the following manner: The patient sitting
with head bent forward so  as  to  relax the cervical muscles,  the  examiner
seizes  the cricoid cartilage betAveen  the thumb and forefinger and  presses it
upAvard so as to put the trachea on the stretch.  In healthy persons notion"
abnormal is felt,  but  in  cases  of thoracic  aneurism there  is apt to be with
each systole of the heart a plainly-perceptible dragging or " tugging " which
                       1 American Medical Times, 1864. 
THORACIC ANEURISM.
289
 is highly diagnostic.  This sign, first described by Porter, has been carefully
 studied by MacDonnell and Ross of Montreal.—H.]
   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,  (esophagus, 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,
 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 Avithin 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  Ayay 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 Medicine, 1879.
        19 
290       FUNCTIONAL DISORDER  OF  THE HEART, ETC.

  [In  the  treatment of aneurism not  curable  by surgical means the most
important indication is rest  in bed.  The difference between  the number of
the heart-beats in the recumbent and sitting positions is at least  20.   In  one
of Tuffnell's  patients it was 35, which  is equal to more than 50,000 in  the
twenty-four hours.   No remedy in the Pharmacopoeia could, he says, produce
so striking  an effect.   The same author recommends a restricted diet amount-
ing to 10 ounces of solid and 8 of liquid food in twenty-four  hours, namely:
for  breakfast, 2 ounces of bread and  butter and 2 ounces of milk ; for dinner,
3 ounces of  mutton and 3 ounces of potatoes  or bread; and for supper, 2
ounces of bread and butter and 2 ounces of tea.   By this method undoubted
cures have  been effected.
  There is  a  semi-surgical method of treating thoracic aneurism which  has
been successful in a few cases.  I refer to galvano,-puncture.   McCall Ander-
son reports  several cases treated in this manner, and certainly with very encour-
aging results.  The mode of proceeding is as follows:  The needles are insu-
lated to within half an inch of their extremities and oiled before being intro-
duced into  the  aneurismal sac.  They should also be disinfected.   Althaus
recommends that two needles be inserted into the  sac and that  both be con-
nected  with the battery.  If this plan be followed,  a small firm clot will form
around the  positive pole and a larger  softer  clot around  the  negative pole.
Anderson advises that  only one needle be inserted  in the sac  and that it be
connected with the positive pole, a zinc plate  connected with the negative
pole being  placed on the chest in the vicinity of the tumor.  A  large sponge
saturated with salt water is interposed between the zinc plate and the integu-
ment.  The form of  electricity employed is the continuous galvanic current,
the strength of which should not be  great.  Anderson employed in his cases
from six  to eight  cells of Stohrer's battery, and in several instances the lat-
ter  number was too great.   The  length of  the  sitting  should not exceed
half an hour.
  With the  object  of inducing  coagulation  of  its contents,  foreign  bodies
such as horse-hair,  fine wire,  and  the perchloride  of iron have  been intro-
duced into  the  sac.  These  proceedings  have been attended  with  a  certain
measure  of success^ but are only applicable AArhen the tumor is distinctly out-
lined and has therefore attained a considerable size.—H.I 
             SECTION   THIRD.

DISEASES  AFFECTING  THE  HEMATOPOIETIC  SYSTEM.
                           CHAPTER   I.


         DISEASES  OF  THE  HEMATOPOIETIC  SYSTEM.

           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 alua, blood, and iroieu, to make.
   2 White blood-corpuscles are derived from the lymphatic tissues of the body, especially
 from those  organs Avhere 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 (Lovvit).  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 Avell as of other problems in the
phvsiology of the blood-corpuscles will be found in the " ( artwright Lectures on Certain
Problems in the Physiology of the  Blood-corpuscles," by William Osier, The  Medical
Neivs, April 3  et sea., 1880.
                                                                  291 
292        DISEASES OF THE HEMATOPOIETIC SYSTEM.

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, Avithout 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 amentia is
called essential, in that it is not referable to diseases which interfere secondarily
Avith 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 leucocytlnemia and pseudo-leu-
cocythaunia, 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 (ansematosis), 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.

                    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, anaemia  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
anaemia,  as just  defined,  enters largely  into medical practice.
   The obvious causes are—first, loss of blood, or hemorrhages ; second  defec-
tive assimilation ; and third,  expenditure of  certain  blood-constituents as in
lactation  and pregnancy.   Hemorrhages occur under a great variety of cir-
cumstances.   In women  menorrhagia and flooding  with labor  are frequent 
                    SIMPLE OR BENIGN ANEMIA.               29:1

 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 assimila-
 tion.   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 assimilation.  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 Avomen hyperaesthesia
 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 Avith  anaemia.   The varied phenomena considered as hysterical are
 often  associated with,  and  more or  less dependent upon,  anaemia.   The
 special  relations betAveen  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 diff'erent 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
 haemic origin,  and  this  is rendered evident by the  absence of  signs denoting
lesions of the  heart or arteries.  These hamiic murmurs  are  useful not only
in  the diagnosis of amemia, but as criteria by which the  physician  is  aided
in deciding whether the anamiic  condition continue  or Avhether it have been
removed by measures of treatment.  The  diagnosis may be rendered demon- 
294        DISEASES  OF  THE HEMATOPOIETIC SYSTEM.
strative by  ascertaining the number of red corpuscles  and the  amount  of
haemoglobin.
  In  order  to decide that the anamiia 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 anamiic condition.  To  exclude these
diseases is generally not difficult.  Although, as has been seen, anaunia stands
in a causatiA^e relation to a large number  and a great variety of pathological
phenomena,  there are not present symptoms which denote a grave  condition.
Pyrexia is Avanting, and the general  nutrition of the body may be Avell 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.   AVhatever 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.
  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.
  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 
CHLOROSIS.
295
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 Avhen they have a cordial  effect, promoting assimi-
lation and perhaps diminishing waste of tissues, Avithout any excitant effects.
Alcoholic excitation is ahvays to be avoided, and the immediate  effects, if in
any Avay  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.
There  is a reduction in the quantity of  hamioglobin 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 Avhich the number  of  red corpuscles Avas normal, while
less than one-half of the proper amount  of  hamioglobin was present.  This
condition  of  disproportionate  diminution of haemoglobin is called  achroio- 
296       DISEASES  OF  THE HAEMATOPOIETIC SYSTEM.

cythaemia or oligochromaemia.  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.
  [Sir Andrew Clark regards constipation as of such paramount importance
in the causation of chlorosis that he proposes the term "fecal anaemia " as a
synonym for the disease. This opinion is based upon certain signs and symp-
toms  that are more or less  common to all cases of chlorosis.  Chief among
these  are digestive disturbances.   The tongue is generally heavily coated at
the  base, large, flabby, and with its sides indented by the  teeth.  The breath
is disagreeable, and sometimes, according to  Clark, has a distinctly fecal odor.
There is a sense of epigastric oppression after the ingestion of food.  The
boAvels are either confined  or inadequately  relieved, and the feces generally
consist of scybalous  masses imbedded in an offensive mucus  swarming with
bacteria.  Pain in the side, generally  most marked on the left, is a common
symptom, and is believed by Clark to  have  its seat in either  the  hepatic or
splenic flexure of the colon.   This view of the  nature  of the pain  in  the
side is corroborated by the fact that it is sometimes relieved  by large enemata
of warm water.   According to the authority just quoted, it is  a common
thing for young girls to neglect the calls of nature so far as  the bowels  are
concerned.  The feces accumulate, and  by their decomposition ptomaines and
leucoma'ines are generated and absorbed, and by their poisonous action  pro-
duce  the multiform symptoms of  chlorosis.  A treatment based  upon  the
theory that chlorosis is due to fecal retention has been found  eminently suc-
cessful, and will be referred to later in  detail.—H.]
  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 ahvays associated with anaemia.  While  anamiia is a con-
stant  element, there are  doubtless causes Avhich  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 anaunia,  (Vide p. 292.)
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, 
                              CHLOROSIS.                            297

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-
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.
   [Sir Andrew Clark  strongly recommends the following method of  treating
chlorosis: With careful attention to the diet and a tepid  sponge-bath followed
by brisk toAvelling night and morning, he prescribes the following mixture, to
be taken tAvice a day :

        R.  Ferri sulphat.,                            gr. xxiv :
            Magnes. sulphat..                         3yj ;
            Acid, sulph. aromat.,                      3J ;
            Tinct. zingib.,                            ^ij :
            Infus. gentian,  comp.  vel quassia,          3yiij-—^
     S.  One-sixth part twice daily, at eleven and twelve.

'; Occasionally  this acid  mixture produces sickness, dries  the skin,  and  is
otherwise ill borne."   In such cases  he  prescribes the following  alkaline
mixture:

        R.  Ferri sulphat.,                            gr. xxiv;
            Sodii bicarb.,                             3'j j
            Sodii sulphat.,                            3vj j
            Tinct. zingib.,                            3JJ i
            Spt. chloroformi,                          3J ;
            Infus. quassia,                           3v"j-—^1-
     S. One-sixth part twice daily, at eleven and six.

Sometimes  neither mixture agrees with the patient, and  then  he prescribes
sulphate  of iron in pill  with  meals and a saline aperient on first waking  in
the morning.  Bv this plan  Clark  declares that nine out of ten cases of
chlorosis recover in from  one to three months, and by careful attention to the
bowels, taking twice  a week a pill  composed  of  aloes, myrrh, and iron, the
recovery  will" probably be  permanent,—H.] 
298
LE UCOCYTHJEMIA.
                       CHAPTER   II.

                         LEUCOCYTHAEMIA.

   THEBE 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 groAvth 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-leucocythamia.
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 per-
sistent 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.   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
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 
LE UCOCYTILEMIA.
299
 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 leucocythamiia 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 Sbrensen 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 2(1 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, leukamic  blood  often  contains a large number  of
 mononuclear corpuscles, of Avhich 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
 YirchoAV, 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.
 Kiscnlohr 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 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,
 the enlargement is often extreme.  According to Gowers,2 the average weight
 of the spleen in splenic leucocythaemia is a little  less than 6 pounds, and its ave-
 rage length, Hi  inches.   Leucocythaemic spleens weighing 1G and IS pounds
 have been recorded.   The increase in size is usually uniform in all diiections.
 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 Avhitish dots,  or, when greatly enlarged.
 they may even appear as tumors in the substance of the spleen. The whitish
 trabecule may be much thickened, especially in the late stages.  The spleen

  1 Other peculiarities of the Avhite 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
 Avhich stain Avith basic aniline dyes (Mastzellen).  These do not occur normally in the
 blood.  The mononuclear cells may contain  granules which stain with neutral aniline
 dyos, like granules normally found in polynuclear cells (neutrophilic granules).  It 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.
  2 Article " Splenic Leucocythaemia," in Reynolds's System of Medicine. 
300
LEUCOCYTHAEMIA.
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 leucocythaemic spleens.
  In the  splenic and medullary forms of leucocythaemia, 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  sIioavs 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
embrj^os and infants and in profound anaemias.   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
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 leucocythaemia.   Cases have  been reported in which
the changes in the marrow seemed insufficient to account for the alteration in
the  blood.1

  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- 
LEUCOCYTHAEMIA.
301
  Changes are  also  observed in leucocythaemia 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 Avhite blood-corpuscles.   The  circumscribed changes, Avhich are
not common, consist in the nodular accumulation of leucocytes either with
or without a  neAV growth of adenoid reticulum betAveen the  cells.  To these
nodular  accumulations  the   names  heteroplastic  leucocythamic growths.
lymphomata, 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  leukaeniic  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  tire 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  leucocythaemia  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 sAvollen
and ulcerated.   The  lymphoid growths in the intestine may ulcerate.   Pro-
nounced  fatty  degeneration, especially of the heart and kidneys, has beer.
repeatedly observed.
   Various 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
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 leucocythaemia, 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  leucocythaemia
between  the  morbid change in the blood and the hyperplasia of thelymphatic
structures.   Bennett, to whom we owe the first recognition, in 1S45, 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  A'irchow'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-
mia with Ivmph-adenoid marrow, but without changesin the spleen and lymphatic glands.
Neumann also has observed cases in which the medulla of the bones Avas involved with-
out affection of the spleen or lymphatic glands. 
302
LE UCOCYTHAEMIA.
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 syaiptoms, 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 anaemia and chlorosis, for Avhich the
disease in its early stages  is liable  to  be  mistaken.
   Coincident with the anaemic 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 Avhich
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-
cythamia), there may be found over these, particularly  the sternum, tender-
ness and sometimes swelling, but, as a rule, local  symptoms are wanting.
   Dyspncea  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  dyspncea
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  glanoVon 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,

 # 1 The idea has been advanced that leucocythaemia and pseudo-leucocvthaemia 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 '' 
LE UCOCYTH EM I A.
303
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.   M osier emphasizes the
importance  of recognizing this diathesis as contraindicating surgical  opera-
tions in cases  of leucocythaemia.  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 hamiaturia 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 Ayhich peripheral paralysis of several cranial nerves was caused by hemor-
rhage into their sheaths.2  Friedliinder3 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 diff'erent 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
emissions or  sexual  desire  as an  occasional  symptom in leucoeythamia.*
Others have observed this symptom.  Dr. Gr. L. Peabody has reported a case.5
Another case  has been  reported  by Dr. (}. F.  Wetherell.6
   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  Avhite  centres  from an  accumulation of lymphoid
cells, Avhitish 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-
  '"Ueber hiimorrhagische Diathese bei Leukamie,"  Zeitschrift fiir klin. Medicin, Bd. 1,
p. 265.  He obserAred a case in Avhich priapism lasted seven weeks, and when this symp-
tom disappeared the power of erection was lost.
  2 Virchow's Archiv. Bd. 78.                                    3Ibid., Bd. 77
  * Berl. klin. Wochenschr., 1879.                    5 N Y.  Med. Journ., May,  1SXO.
  6 N. Y. Med. Record, Aug. 14, 1880.  Tavo other cases  are reported in the N. Y. Med.
Journal, Sept., 1880. 
304
LEUCOCYTHMMIA.
ing, furuncles, and pustular eruptions  on the skin.   In a case  of leukaemia
with deafness Politzer found leukaemic  growths in the internal  ear.
  The limits of the duration of leucocythaemia 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 tAVO 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.   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.  On  the other
hand, in the  early part of  the disease  the  proportion  may be  considerably
less than 1 in 20 ; and  if on repeated examinations the proportion 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
A\hich 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
  ] A convenient apparatus for counting the corpuscles is the hemacytometer of Gowers
Still more exact is the  apparatus of Zeiss. 
LE UCO CYTHEMIA.
305
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 harna-
cytometer.

   [No well-marked  case of leucocythamia can escape detection if the blood
be properly examined.  It is  evident at a glance  that the white cells as a
whole are  abnormally increased  in number, but it is quite another thing to
determine  the relative share of the different varieties of  white  cells in this
increase.   It is well known that there are in normal blood various kinds of
white cells, which may be classified either morphologically or in accordance
with their reactions to various staining substances.  Morphologically we recog-
nize small  and large lymphocytes, both of  A\hich are mononuclear, polynuclear
leucocytes, and mononuclear transition forms. According to the second method
of classification, the white  cells are divided with reference to the affinity dis-
played  by  their protoplasmic granulations for certain coloring matters.   The
latter is the classification  generally adopted by hamatologists, whose  leader
in this  line of research is,  confessedly,  Ehrlich.  Owing to the researches of
this observer, an entirely new nomenclature has arisen, and we now speak of
cells that are  eosinophile, basophile, neutrophile, and amphophile.  In normal
blood the great majority of the white cells are neutrophile, whereas in leuco-
cythamia  the basophile and eosinophile  cells  are often very abundant.   It
was at one time supposed  by Ehrlich that an increase in  the  number of the
eosinophile cells  Avas  a characteristic sign of leukamia. and that by it the
diagnosis between leucocytosis  and leucocythamia  could be readily made in
doubtful cases.   This theory has not been confirmed, and Ehrlich himself
has abandoned  it.  In  individuals free from  leukamia  an increase in the
eosinophile cells  has  been  observed, and,  on the other hand, in well-marked
cases of leukamia the eosinophile cells  may be absolutely but not relatively
increased ;  in  other  words,  the  leukamic  state of the blood may be chiefly
due to the  increase of other elements.
   Leukamic blood is characterized not  only by excess of elements normally
existing in the  blood, but  by the appearance of a cell not seen  under  any
other circumstances.  This  is the  so-called myelocyte.   It is as large as,  or
even larger than, the large lymphocytes  of normal  blood, and differs from the
latter in that it contains a  large number of neutrophilic protoplasmic granu-
lations.  It is in all probability derived  from the bone-marrow.—H.]

   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.
liOAvever, patients  are  betyveen 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 melano-leuheemia.
   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
        20 
306
LE UCOCYTILEMIA.
 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.1
 The liability to fatal hemorrhage is enough to render the operation unwarrant-
 able.  Were the operation warrantable, or were it practicable  to  reduce con-
 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.
   [Marked success has followed the treatment of leucocythamia with arsenic,
 but to  obtain good results from this drug it must be pushed to the point of
 tolerance.  By  gradually increasing the close  of Fowler's solution it may be
 given to the extent of  25  drops three or four times daily.  Under such doses
 the skin of the patient is apt to assume a bronzed  hue which is especially
 marked upon the abdomen and over the bony prominences, such as those of
 the tuber ischii and the spine of the scapula.
   Bamberger, Sticker,  DaCosta, Hershey, and others have observed improve-
ment to follow the inhalation  of oxygen, and this  measure should be thor-
 oughly tried before regarding  the case as hopeless.
   Mosler recommends  the employment of the oil  of eucalyptus, which he
 administers  in  pill with  piperin and quinia.—H.]
   The  remaining measures of treatment consist in meeting symptomatic indi-
 cations, 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 digestion, hamostatic  remedies and  appli-
ances, 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 reference to nutrition and general invigoration.

in ItaT SUCCeSsM CaSe °f extirPation of the spleen in leucocythaemia has been reported 
PSEUDO-LEUCOCYTILEMIA.
307
                       CHAPTER   III.

       PSEUDO-LEUCOCYTH.EMIA—HODGKIN'S DISEASE.

    PSEUDO-LEUCOCYTH JEMIA 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  Avithout 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-leucocythaemia 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.   While the splenic  variety  of  leucocythamia is much more
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 (Wi'lks),  malignant lymphosarcoma (Langhans),
malignant lymphoma (Billroth), and  lymph-adenosis (Banvier, Crowers).  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
glands, 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 he present in
most parts  of the body.
  1 Hodgkin published his observations in 1832 {Medico-Chirurgical  Trans., vol  xvii.
p 69) before leucocvthaemia was known.  He first called attention to coincident enlarge-
ment of the spleen and of the lvmphatic glands as a distinct  disease.  His description
included  undoubtedly, cases both of leucocythaemia  and of  pseudo-leucocythaemia.
Some writers  apj.ly the name Hodgkin's disease to lymphatic leucocythaemia as well
as to pseudo-leucocythaemia. 
308
PSE UD O-LE UCOCYTHMMIA.
   The  change in the lymphatic glands consists in an increase  of  the  cells
 and of  the reticulum.  Yirchow 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 groAvth 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 betAveen  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 haAring 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 groAvth 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,
 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 Glowers,  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

  1 E. Schulz (Arch. d. Heilkunde, 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. 
S YMPTOMA TO LOGY.
309
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, and Peyer's patches may be diseased, as in leu-
cocythaiiiia.   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.  Ackermann1 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-
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 groAvths  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 H. Hutchinson.2
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 noteAvorthy that in this
case  the spleen and liver Avere  healthy.  An  unusual feature  was the exist-
ence of intracranial lymphatic groAvths.
  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
      1 "Ueber die malignen Lymphome," Diss. Bern., 1879.
      2 Vide Tram. College of Physicians of Philadelphia, 3d Series, vol. i.,  1875. 
310
PSEUDO-LEU COCYTHEMIA.
may be caused by pressure upon the recurrent laryngeal nerves.  Obstruction
of the bronchi may be caused by enlarged bronchial glands.   The  hearty 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 caya. 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 within 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
necrosis  and suppuration which characterize scrofula; nor are  there the grad-
ual invasion of adjacent parts and the ulcerations  which characterize  the local
history of  carcinoma.  [A diagnostic mark of lymphatic pseudo-leucocytha-
mia is the  free movement upon each  other of a group of enlarged glands, the
sensation of which has  been  compared by Southey to that of balls  in a net.
This  free mobility is absent in sarcoma, of which  the small round-celled form
is almost morphologically identical with the enlargement of lymphatic pseudo-
leucocythamia.—H.]
   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 
PERNICIOUS ANEMIA.
311
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 Avould  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,  [Warfwinge has also reported  success from  the latter method__
i. e. from  the intrasplenic and  intraglandular injection of Fowler's solution.
Four drops was the dose invariably employed by him.  Under this treatment
the splenic and glandular swellings diminished rapidly in  size, and no unpleas-
ant results attended or followed the injections.—H]
  Aside from any treatment instituted with the hope of  effecting a cure, the
objects and the measures are those stated in connection with leucocythamia.
                        CHAPTER  IV.

                     PERNICIOUS  AN.EMIA.

    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 1S42.  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
 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 unusually large number of cases  has been reported from SAvitzer-
 land and certain parts of Germany.  In this country it  seems to be less com-
 mon, although it  is by no means a rare disease.   Excluding cases dependent
 upon child-bearing, pernicious  anamia 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 
312
PERNIO 10 US A N EM I A.
which may be either an excessiAre destruction or a lessened production of the
red blood-corpuscles, or both.
   An anamia as intense as pernicious anamia may develop in connection
Avith 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 parasites
Anchylostomum duodenale and  Bothriocephalus lotus.   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.
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
fi in diameter, as well  as small corpuscles less than 6 ;x  in diameter.  There
are frequently diversities in form described under the name " poikilocytosis "
such  as  pear-shaped,  ring-shaped, cup-shaped, kidney-shaped corpuscles,
corpuscles  with tail-like processes, etc.   There may be  alterations in the
                1 Austin Flint, American Medical  Times, 1860. 
ANATOMICAL  CHANGES.                    313
 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 leucocyth;emia.
   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 Avhitish or grayish
 centre.   More  or  less general oedema, Avith  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.
   [It was  at one time supposed that the  iron in the liver was derived from
 that administered to the patient, but it has  been clearly proved that this is
 not  the  case.   The amount  of iron in the  liver appears to  be practically
 uninfluenced  by the medicinal  administration of this substance.  The dem-
 onstration  of an  excess of iron in  the liver in cases  of pernicious anamia
 was  first made by Quincke,  but his observations do  not seem  to  have
 attracted the attention which  they  undoubtedly deserved.  This was partly
 due to the fact that he was not positive in his opinion as to the source of the
 iron.  He  thought it might have  been derived from preparations of that
 metal administered  to the patient.   In 1888, Dr. W. Hunter, in a  series of
 articles  in the British Medical Journal, not only confirmed Quincke's  dis-
 covery, but shoAved that the iron in the liver is deposited in a special manner,
 being contained, for the most part, in the liver-cells, and especially in those
 of the outer  and middle zones of the acini.  The central cells are generally
in a state of fatty degeneration  and  atrophy, and often fail to give any iron
reaction.   In Hunter's opinion, which is based upon the most careful experi-
mentation,  the seat of blood-destruction  is "chiefly the  portal circulation, 
314
PERNICIOUS A N.EM I A.
 more especially that portion of it contained within the spleen and liver, and
 the destruction is effected by the action of certain poisonous agents, probably
 of a cadaveric nature, absorbed  from the intestinal tract."
   Hunter has also called attention to the dark color of the urine  in pernic-
 ious anamia, and has proved it  to be due to the presence  of  pathological
 urobilin, a substance known  to be derived from  the disintegration of hamo-
 globin.
   The proofs  in  favor of the view that pernicious anamia is associated Avith
 increased hamolysis are certainly convincing,  but it is going too far to  say
 that the disease presents no evidence of imperfect hamogenesis.  The  large,
 flabby, misshapen red corpuscles  of pernicious anamia certainly present any-
 thing but a healthy aspect.  In  addition, numerous nucleated red corpuscles
 are often present in the blood of pernicious anamia. and everyone acknow-
 ledges such corpuscles to be  embryonic.   Again, the  red corpuscles of per-
 nicious anamia are often possessed of amoeboid  movement—a fact to which
 attention has  been called  by Hayem, and which I myself  have observed.
 This  property is characteristic   of a  lower  order  of cells,  the leucocytes.
 Finally, Bindfleiseh, who has made a careful study of the marrow in two
 cases of pernicious anamia, concludes that the  disease is  due to defective
 hamogenesis.   He bases this opinion upon  the absence of elements which
 he and others regard as transition forms between the  red nucleated marrow-
 cells, which were unusually large and abundant  in  his cases, and the fully-
 developed  red  corpuscles.
   In  view  of the above-mentioned facts it seems to the writer that  the evi-
 dences  of defective hamogenesis in pernicious anamia are at least as strong
 as those of increased hamolysis.—H.]
   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
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.
315
 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. 369.)  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
 affection 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 Avhich 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
 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,  hoAvever protracted.
 These  events are hemorrhages in  different 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  Avithout venous turgescence.  Func- 
 316                    PERNICIOUS AN.EMI A.

 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 Avhich 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 hamatopoietic system.  Of
 medicinal remedies, arsenic  has  been found  to  be the  most valuable,  and
 should  always  be  given a trial.
   [Dr.  Byrom  Bramwell  of Edinburgh was the first  to  employ this  drug
 systematically  in  the  treatment  of pernicious anamia.   Of eight cases
 reported by him in the  Edinburgh Medical Journal,  1877, he treated three
 with  arsenic, and  they all  recovered.   Following  his  example, Dr. Finny
 treated  three cases with  arsenic,  tAvo  of  which recovered.  In  numerous
 other cases  arsenic  has been of decided  benefit.   Iron is of little avail, as a
 rule, in this disease—another point in which the latter differs decidedly from
 chlorosis.   Iron  often disagrees with the patient on account of the irritable
 state of the  stomach, and only the blandest preparations should be prescribed
 at  first.   In a  case at the  Episcopal Hospital of Philadelphia a few years
 ago, in  which every symptom of pernicious anamia  was present,  recovery
 followed the employment  of dialyzed iron.
  Transfusion has  been employed in a number of  cases, and with variable
 results.   In cases which  resist the  ordinary measures  of treatment  it should
 be  resorted  so.  Like  the  operation  of tracheotomy,  the tendency  is  to
 postpone  it  until the patient is in a hopeless condition.   Brakenridge has
 recently reported to the Medico-Chirurgical  Society  of Edinburgh  five cases
 of pernicious anamia treated by  transfusion of blood, in three of which
 marked  improvement  followed each operation, while in "some" the red cells
 rapidly rose  to  the normal number and  the patients were practically cured
 The transfused  blood was  mingled with  a solution of sodium phosphate to
prevent coagulation.   Subcutaneous  injections  of  defibrinated blood have
also been successfully employed.  The injections  should be performed under
  1 For a full report of three cases, and an analysis of the cases published in America
Society188*5      *            ^ * P'W^S * the P^elphia County MedZ 
ADDISON'S DISEASE.
317
strict antiseptic precautions, and the amount of each should be from °0 to
40 grammes.  Inhalations of oxygen and subcutaneous injections of quinine
have been  recommended by  Henrot of Rheims.  France.   Of equal import-
ance with  drugs is a  nutritious,  easily-digestible  diet.  In case of great
irritability  of the stomach nutritious enemata of peptonized milk  and eg°-s
should be  administered.]
                         CHAPTER  V.

                      ADDISON'S  DISEASE.

   IX the year 1855, 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-
 skin 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 Avithout 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,
1855. 
318
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  (Wilks).  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 ha\re been missed.  Further
 observations upon this point are  needed, as Avell 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-broAvn 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 cases 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 anam'ia 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.
319
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, Avho 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.  Yery 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 different 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  Yirchow,  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.  Bossbach 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. 
 320                     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.
   [In a recent paper upon this  subject1 W. Gilman Thompson arrives at the
 following conclusions:  " First.  That Addison's disease is a condition arising
 from and dependent  upon irritation of the abdominal  sympathetic nerves
 through  lesions of themselves, their  ganglia, or diseased suprarenal  cap-
 sules.   Second. In the  great majority  of instances (fully 80 per cent.)  the
 disease originates as  a secondary or primary tuberculosis of the adrenals,
 and the  sympathetic system  is either involved by extension of pathological
 processes  or  is  functionally  disturbed and irritated through  the  intimate
 anatomical connection  existing between   the  adrenals   and  the relatively
 large number of nerves which  they contain.   Third. Actual lesion of the
 sympathetic  system, Avhile  far  more common  than heretofore  supposed, is
 not necessary to produce the  varied symptomatic phenomena  of the disease.
 Functional disorder, through  irritation  conveyed  from  the  adrenals, may
 sometimes cause  all the symptoms, just as  in chorea and many of the con-
 ditions of  aggravated hysteria and other functional nervous disorders we are
 often unable  to  find  definite  lesions.   Fourth. In a certain  proportion  of
 eases (not over 20 per  cent.) the adrenals  are affected by some other lesions
 than those of tuberculosis, or else they remain normal (in 12 per cent.) and
 the  sympathetic  nerves and ganglia are alone diseased."—H.]
   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:2
   " 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
  1 Trans, of the Association of American Physicians, vol. viii. 1893
  2 Vide  "Croonian Lectures on Addison's Disease," The Lancet  187=1. oW  „ ™
graph published in 1866.                      '         et' lb75j als0>  a mon°- 
SYMPTOMA TOLOG Y.
321
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.   When
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 Avith 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
feAV cases  to have produced the same effect.   I have myself seen dark streaks
on the skin corresponding  Avith  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-
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. Ayith 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 betAveen their pearly  whiteness  and  the
d'.sky 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 Avhich  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, breatblessness and  palpitation, frequent sighing or
yaAvning. 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
        21 
322
ADDISON'S 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.   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.
  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 Wilks, 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 Yoght  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-
  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
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 onrans so
vast and important  as those which secrete the gastric juice be worthy of beine 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! 
TREATMENT.                          323
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 Avith  phthisis, justify the conclusion that a
tuberculous diathesis  may favor the development of the disease.
   Writers 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,
symptomatic  indications  are to  be fulfilled, and treatment, medicinal  and
hygienic, is to be pursued Avith 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, Avhich 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 Vide Med. and Surg. Electricity, by Drs. Beard and KockAvell, 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
" Bronzee maladie," in Nouveau Diet, de Med.  et de Chirurg. pratique, tome xi., 1866;
and to Traite de pathologie interne, tome ii., cinquieme edition, 1877; to Averbeck, Die
Addison'sche Krankheit., Erlangen, 1869; to article by Pepper, in Am. Journ. of Med.
Sciences, April, 1877 ; to Osier, in System of Medicine by American Authors, vol. iii.; and
to F. P. Henry, in the Reference Handbook of the Medical Sciences,  vol. i. 
                   SECTIOX   FOOTH.

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-
•i' ry, 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 Avith 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
       324 
TONSILLITIS.
325
 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
 coyering 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  tAventy-four or forty-eight hours  may
 reach 104° or 105°.   There are often headache, anorexia, insomnia, and other
 symptoms  Avhich 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 A\hich, 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
 SAVollen.   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 Avhich
 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 SAVollen.  A rare  complication  is cedema of the  glottis, which 
326     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.   When crushed, these  whitish  pellets  emit a
very offensive odor.   These concretions, Avhich 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, che inhalation of warm vapor, and anodynes
to lessen discomfort.  Milk  is the form  of  nourishment best taken.   When
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 Avork.
   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
1857.1   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.
327
 movement was in a marked degree  out  of proportion to the local affection.
 Its duration Avas  from three to five days.  The epidemic prevailed extensively
 for about two months, both sexes and different ages  being affected  Avithout
 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 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.   Yiscid 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.
 When the  inflammation extends to the Eustachian tubes or their  openings,
 deafness  is produced in greater or less  degree.  When 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 
328      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 Avear and tear of continued application without physical
and mental relaxation.  The number of persons  is very large  in this coun-
try who overtask the  poAvers of  the system by steady labor in the  office, the
counting-house, or the workshop,  continued  Avithout 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  Avant 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.
  Tuber-cuhus  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 thfese 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.
329
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 Avith infiltration of the subjacent tissue Avith 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, Ayith 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 Avhich the lesions usually respond to  antisyphilitic treatment.
   The prognosis is good.   Destructive ulcerations Avith 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 Ayhite 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 <if 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.  (Edema 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 
 330      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 potas.sa 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 (20 or
 30 grs. to the ounce) in some cases, especially those of the granular variety, is
 highly  useful.  [In  this variety the  best  results are obtained by separate
 cauterization of each granule or follicle.   For this purpose nitrate of silver,
 chromic  acid, sulphate of copper, or, best of all, the galvano-cautery, may be
 employed.  The application of the latter  is attended  with little or no pain,
 but the inflammation which it excites is more destructive to the granulations
 than  that caused  by chemical  substances.  After using the  cautery the
 patient should be directed to suck pieces of ice in  order to keep the inflam-
 matory reaction within moderate bounds.   The  galvano-cautery  is also most
 effective in reducing the bulk of hypertrophied tonsils.   For  this purpose
 the application is a momeutary one, and should not be repeated more  than
 once a week.—H.]  Local applications are made by means of a probang. mop,
 or large  camel's-hair pencil brush.  A solution of tannin is often of senTice.
 The  chloride,  iodide, or sulphite  of zinc and  iodoform are  recommended.
 Inhalations are not appropriate;  they carry the medicated application too
 far.  On the  other  hand,  gargles are  of little use; they do not carry the
 application  far enough.   Projecting  a spray  of medicated solution  into
 the throat is  an efficient  mode.  Applications 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 Avhich 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.   When  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 «aid
almost never to occur.   It may be produced by the ingestion  of  'corrosive 
DISEASES  OF THE OESOPHAGUS.               331
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
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.2
   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 oyer 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.
   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 SAyallowed 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 (oesophagismus) 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 saAv  in consultation, complete  obstruction from spasm had  existed for eight
days, and was instantly and  permanently removed  by a single introduction of
a sound.4
   (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  Authors, vol. ii.)

  1 Vide article by Henry F. Campbell, M. D., in Trans. American Surgical Society, vol.

  '2 Vide case reported by Prof.  Fitz, Am. Journ. of Med.  Sciences, Jan. 1877.
  3 Vide Quincke, '• Ulcus (Esophagi ex  Digestione," Deutsches Archivfur klmische Medi-
an, 1879, Bd. 24, S.  72.
  4 Vide New  York Hospital Gazette, Oct. 18,  1879. 
332      DISEASES  OF  THE  TONSILS, THE PHARYNX,  ETC.
                        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
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. Virchow 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 feAv  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 jaAvs and  difficulty in swallowing are experi-
enced.  The disease  continues for  from four or five days to tAvo  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.   When 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
  1 Lyon med., No. 26, 1879.
  In Laveran's  collection of 432 eases in soldiers, orchitis  occurred 156 times. In 32
eases of orchitis observed by Laurens (out of 118 of parotiditis), one testicle alone Avas
affected in 26 cases, and both testicles in 6 cases.  In 16 of these cases Laurens observed
distinct atrophy within two months. 
                         PAROTIDITIS—MUMPS.                    333

in soldiers, orchitis occurred in llo ;  that  is, in  24 per cent, of the cases.
Atrophy of the  affected  testicle often  folloAvs this inflammation.   According
to (rranier. atrophy occurs in 44 per cent, of the cases of orchitis, and in 10*
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.   When 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.
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 Valleix.   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.   Rloodletting, purgation, or other of the so-called antiphlogistic
measures are not indicated.   [The infusion of jaborandi is recommended on
the ground that  it is excreted by the salivary glands, the function of which
it increases, and  so hastens  the elimination of the micro-organisms which are
believed to be the cause of  the disease.—H.]  The popular apprehension of
danger  from  " taking cold " in  this disease is based on the idea that if the
affection 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, pyamiia, and pneumonic fever. Under these circumstances it is a Avidely
diff'erent affection from mumps.  Suppuration  takes place in the great majority
of cases, the  abscesses eA'acuating 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 Ludovici.  There is pres-
ent in the suprahyoid region diffuse cellulitis, combined often with gangrene
and slouffhine; 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-
ticaemia.  The treatment is mainly surgical. 
334     INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.
                         CHAPTER   II.

 INFLAMMATORY DISEASES  OF THE  ST03IACH AND  OF THE
                              DUODENUM.

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

                           Acute Gastritis.
    THE term acute has been applied to inflammation of the stomach by differ-
     ent authors  with a widely diff'erent scope  of signification.  In the cases
 of gastritis to which heretofore, by many authors, the term acute has been
 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 form's 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- 
ACUTE  GASTRITIS.
D.-> -
ooO
 mont noticed during these attacks of mild  gastric inflammation a livid, ery-
 thematous redness distributed  in irregular, small patches.    Sometimes  the
 mucous membrane Avas 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 aphthous by Beau-
 mont, Avere 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
 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, Avhich  consist of  round or  oval superficial abrasions  of the  mucous
 membrane upon a hemorrhagic base, are not infrequent.1   Upon microscopical
 examination  hyperamiia 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 Avhite corpuscles.  The accumulation
 of white corpuscles or  pus-cells is most evident about the muscularis mucosae.
 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.  In  some  cases  this may he  followed by fatty  degeneration.   Some-
 times the  tubules appear  to  be filled with  a granular matter  containing
 nuclei, but Avithout 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 A\ith a secretion of mucus Avhich
 escapes from  their free ends.  These cells are found in the mucus coating the
 mucous membrane, but to Ayhat  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 SAVollen.   They sometimes seem
 to be increased in number in inflammatory conditions of the stomach.  Wilson
 Fox describes the development of follicular ulcers from these structures.
   It is not intended to describe here the manifold morbid appearances  belong-

  1  Brinton describes a special and  seA'ere 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.
  2 Virchow, in conformity Avith his views of inflammation, describes this parenchy-
matous change as inflammatory, and  designates the  process in this situation as glandular
gastritis or gastradenitis; but Oornil  and  Ranvier justly remark that the inflammatory
nature of this lesion is very doubtful.  Ebstein finds, in eases of poisoning by phosphorus
or by alcohol, the parenchymatous degeneration most marked in the  chief, or adelo-
morphous cells  of  the gastric  tubules (Virchovfs Archiv, 1S72, Bd. 55, S. 469). 
336     INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.

ing to toxic gastritis ;  that is, gastritis produced by SAyallowing 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.  When 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.

   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 Aromiting 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 laro-e 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 
ACUTE  GASTRITIS.
337
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 folloAved sleeping in a cold cellar.  Over-repletion of
the stomach Avith stimulating and indigestible food  may sometimes give 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.    Vomiting,
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.
   With a view to  appropriate  antidotal treatment, and  also in a medico-legal
point of  vieAv 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  he
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 Avhich 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 Avithin a few
hours, patients  falling quickly  into a  condition  of collapse.   These  cases.
hoAvever, are exceptional.   The  mode of dying is by  slow  asthenia.
       22 
338     INFLAMMATORY DISEASES OF THE STOMACH, ETC.

  When 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.   With 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 physician  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
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  Avhich 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
  1 The pancreatic meat emulsion is prepared as folloAvs : To 5 ounces of finely scraped
meat add \\ 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 Avater,  and employing heat  by means of a  Pepin's
digester.  (Vide "Ueber die Therapie der Magenkrankheiten," von W. O. Leube, Samm-
lung klinischer Vortrdge  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.
339
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.
(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 ('opper: 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 Silver: 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.
   ' Taylor on Poisons may  be consulted for this purpose; also, article " Poisons" in
Dunglison's Medical Dictionary. 
 340     INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.

   The degree of inflammation in diff'erent 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 Avith the
 urates.  In some cases there is constipation, and  in  other cases diarrhoea, the
 latter being 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.  When 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.
 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.   Vomiting 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 effectually 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.                                              J
  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.
341
   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 Avhich putrefaction had begun prior to
 its ingestion.  Persons Avho 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  uramiie  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
 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  Avhich subacute  gastritis is closely affiliated is that  to be
 considered under the name of Acute Dyspepsia.  Gastric inflammation doubtless
 enters into  certain  eases of the latter affection, 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 proprietv of con-
 sidering it as a functional affection of the stomach.   The differential 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, arc 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 sj-mptoms denote
 exhaustion  the patient may be supported by rectal alimentation.   The
 abstraction  of blood  either  locally or by  venesection  is never indicated.
 Benefit ma}" 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 boAvels  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 swalloA\ed. or iced water
given in a small quantity at a time and often repeated, if found to be grate- 
342     INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.

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 Avell 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-
ically between chronic  inflammation and  the functional affections embraced
under  the  name of dyspepsia.   The differential points involved in this dis-
crimination will  suffice  for the clinical  history and diagnosis of the affection.
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 Avhitish.    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 al-
terations in  the haemoglobin of extravasated red blood-corpuscles, 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 niammillation or I'etat mamelorme of Louis.  When  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 
CHRONIC GASTRITIS.
343
 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-
 posaj.   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 sAvelling 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
 atrophied, and in some places even obliterated.   According to  W. 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
 yillous 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  narroAver 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 Avith  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 
344    INFLAMMATORY  DISEASES OF  THE STOMACH, ETC.

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 Avere 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.
It occurs also in  connection with gout and with pulmonary phthisis.  Chronic
gastritis occurs in certain cases of renal disease involving uraemia; 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.  [The medicinal  treatment of this disease  has  for its
chief objects the  assistance of  the enfeebled  digestion and the suppression  or
diminution of fermentative processes in the stomach.   Both of these indica-
tions may be fulfilled by the administration  of hydrochloric acid, which not
only supplies a deficient element  of the  gastric juice,  but is also a powerful
antiseptic.   According to Ewald, the quantities of hydrochloric acid usually
prescribed are much too small  to obtain the  best effects from this drug.  He
bases this opinion upon the large quantities of this acid which are present  in
the gastric juice in a state of health—viz. from 0.2 to  0.4 per cent.  Fifteen
drops of dilute acid  may be  given in  water  three times after meals, at inter-
vals of fifteen minutes.  For  the  protection  of the teeth the acid should be
well diluted and taken through a glass tube.   Pepsin has been long given  in
a routine manner in all cases of gastric disease, without reference to its pres-
ence or absence in the stomach.   In  gastric catarrh hydrochloric acid may
be completely absent from the gastric juice  and pepsin continue present;  in
fact, it is always present except in cases attended  with  excessive secretion of
mucus and in  atrophy of the  glandular structure.  Under the latter circum-
stances it  should be  given  freely—for example,  in doses  of from 10 to  15
grains, dissolved  in  water acidulated  with HC1,  fifteen or twenty  minutes
                  1 Hagendie, Journal de Physiologie,  tome viii. 
CHRONIC GASTRITIS.
345
after meals.  These doses of pepsin may seem large in vieAv of the fact that
pepsin is a ferment, and, like other " enzymes," exerts its specific effect when
present in  very small  amount.  The artificial products are, however, much
weaker than the pepsin as secreted  by the gastric glands, where it is in its
nascent state; and, besides, a  certain amount of that prescribed is doubtless
lost by entering into  unusual  combinations  and by being propelled pre-
maturely into the duodenum.
  Probably the most efficacious  therapeutic measure  in cases of chronic gas-
tric catarrh is the  systematic  washing out of the stomach, or,  as it is  called,
lavage.  The organ is first  thoroughly washed out with  warm  water until
the fluid is returned free from  particles of food or mucus ; then with water
to Avhich  some  antiseptic  substance such as borax, sodium  salicylate, or
common salt is  added.   Lavage  not  only cleanses the stomach, but exerts a
tonic effect upon the glands and excites them to a more healthy action.   As
an auxiliary to  lavage, or, in case  it cannot be  employed, as a substitute for
it, benefit  may  be  derived from certain  antiseptic drugs, such as thymol,
creosote, carbolic acid,  benzoic  acid, and salicylic acid.  These substances
should be taken shortly before meals, so  that the food may enter a stomach
that has been  rendered  more or less aseptic.
  There are certain drugs which are believed  to exert a direct  curative effect
upon the diseased  mucous  membrane, but they are of inferior utility to  the
above-mentioned measures.  The chief of these are bismuth, nitrate of silver,
arsenic, and oxide  of  zinc.  It is  too much to expect that these drugs, and
especially the nitrate  of silver, should exert any good effect  upon a mem-
brane covered with a tenacious layer of mucus.   When this  is removed by
lavage they may be  of service.  When  the  gastritis is secondary  to  heart
disease, cirrhosis of liver, emphysema,  or other  disturbance  of circulation,
the treatment must be chiefly addressed to the primary affection.—H.]   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 tenta-
tively, 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 considered in connection Avith
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 im-olved, 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  Avails
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, Avhich  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 
346     INFLAMMATORY DISEASES  OF  THE STOMACH, ETC.

cavity.   In rare instances  recovery may take place  after the escape  of  the
pus i"nto 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
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 doAvn 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 pyaemia 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. 
PHLEGMONOUS GASTRITIS.
347
 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, hoAvever, 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
 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 without clinical interest, being
 unattended by distinctive symptoms.  Pseudo-membranous gastritis is usually
 secondary to some other disease, such as croup and diphtheria, typhoid fever,
 pyamiia, 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 connectiAre
 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 Avails 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.  When 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  neAV 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. 
348    INFLAMMATORY DISEASES  OF THE STOMACH,  ETC.

The subserous  tissue is also thickened and fibrous.   The serous coat is of a
peculiar opaque, pcarly-Avhite  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-
trie glands have  been noticed.
  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, Avhich 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 Xamverk,2 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
few in 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  Xothnagel the
patient presented all of the essential symptoms of pernicious anaemia, 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 ahvays, 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 was  supposed to be  carcinoma.
  When 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.

  1 In a case reported by Nothnagel, and examined microscopically bv IV. Miiller,
glands Avere found only in the pyloric region (Deutsches Archiv f. klin. Med, 1879, Bd.
24, S. 353).                                            J
  2 Deutsches Archie f. klin, Med., 1878, Bd. 21, S. 578. 
•
                        G ASTRO—D UODENITIS.                    349

The symptoms and signs of dilatation of the stomach Avill be considered here-
after.   Xauwerk, 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 sAyallowed  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
stenosis of the pyloric valve  cannot usually be made with any  decree 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 Avell 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 Avith 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.


                 G-astro-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 ohstruction either 
350         STRUCTURAL DISEASES  OF THE STOMACH.
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
skin.   Perforation may occur under these  circumstances.   Ulceration  of the
duodenum, however,  is by no  means a constant effect of an extensive burn.
                        CHAPTEK  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.
   SOFTENING of the mucous tunic of the stomach has been already men-
    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.  Xot
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'stoniach, 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, Avhich
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.  With 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.
351
                            Gastric Ulcer.

   The form of ulcer to he 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  by corrosive  poisons,  reference  has already been made.
 Genuine  tuberculous ulcers occur in the stomach, but they are* very rare and
 require  no further  mention.    [The  last  remarks  are  also  applicable  to
 typhoid ulceration  of  the stomach.—H.]
   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
 cesophagus 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 Avail 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 someAvhat 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
  1 This  is true, unless the rare variety of ulcer described by Clarke and  by  Klebs as
 ulcus corrodens uteri—corroding ulcer of the cervix uteri—be included in this category.
 (Consult  Klebs, Handbuch  der Pathologischcn Anatomic,  Bd. 1, S. 873.)
  - Buffalo Medical Journal, 1846, vol. ii. p. 641.
  3 Cruveilhier has  described an ulcer 6^ inches long and Rl wide; Law, one measur-
ing 6 by  '» inches. 
352        STRUCTURAL DISEASES  OF THE  STOMACH.

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 inv the pyloric region on  the posterior surface and in the im-
mediate neighborhood of the lesser curvature.1  Fleers 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
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
ulcer;  but instead of cicatrizing the ulcer may penetrate  all  of  the  coats of
the stomach.  When 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 Avhich 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 Avhich 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 fistulae  may be produced, but  they are
very rare.   The most frequent are gastro-colic  fistulae.   If the ulcer open
  1 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 Pepper's System
of Practical  Medicine,  by  American Authors, vol. ii.). 
GASTRIC  ULCER.
353
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 folloAving  perforation is
usually general.   It is sometimes, however, localized, in consequence either
of the sIoav escape of the  gaseous and fluid contents of the stomach through
a small  opening or of the formation of previous adhesions.   On  p. 57  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 Avell 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
of the ulcer,  or they may come  from erosion of a large artery or vein.  In
cases of profuse fatal haematemesis 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 knoAvn 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
vieAV 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  Avidely  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
he 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 ag 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
anaemia  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  Avail 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 Bottcher's view, that gastric ulcer is of
  1 In support of this view have been  cited the experiment of Frerichs, Avho found an
ulcer of the  stomach in a cat after division of the splanchnic nerves and of the coeliac
axis,  and the experiments of Fhstein, Avho 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.
        23 
351         STRUCTURAL DISEASES  OF THE STOMACH.

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 diff'erent 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.1  Gastric ulcer is  by no means a frequent
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.  Anaemia,  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.  [Recent
researches have demonstrated that  gastric ulcer has for its etiological basis a
disproportion between  the composition  of the gastric  juice and that of the
blood, consisting  in an  impoverishment of  the latter fluid and a hyperacid
state of  the former.   Of these conjoint causes, the alteration of the'blood is
the more important, because ulcer  has been  observed in  association with a
gastric juice  of  normal  acidity.   Under  such  circumstances,  which  are
exceptional, we are  justified in assuming that the  nutrition  of the gastric
mucosa is lowered to such an extent that, so far as its poAvers of resisting
the  action of the gastric juice are concerned, the  latter fluid  is relatively
hyperacid.—H.]

   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  diff'erent  geographical situations.
In this country gastric  ulcer, although not rare, is less frequent than in  many
parts of  Europe.
  xIn 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.
355
  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 clue 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
increased  by lying on the back and relieved by bending  forward; in other
cases the reverse is observed.  The  explanation is afforded  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 forAvard 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 diff'erent cases, the  act of vom-
iting  usually not violent  but  complete, and the ejection of the  contents of
the stomach folloAved  by notable relief  of pain and distress.  Mucus may be
expelled in more or less abundance Avith 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 Avell 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 Ayas lost from  hemorrhage, although no  blood  Avas vomited, the stomach
being found,  after death,  filled with clots.   The  blood vomited  is dark  or
grumous from the change of  lnemoglobin to haematin by the action  of the
aastric 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
I'xaminatioiir   Blood-corpuscles, usually much shrivelled, can generally be
recognized bv  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 
356         STRUCTURAL  DISEASES  OF  THE STOMACH.
 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 Ayhich vomiting is a  prominent symptom.
 Amenorrhcea is  common.   There is, however, little  foundation for  the idea
 that hemorrhage from the ulcer pccurs vicariously in the place of menstrua-
 tion, but the latter  ceases or is deficient, as in cases  of anaemia produced by
 hemorrhages elseAvhere  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 knoAvn  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 gnaAving
 character limited to a circumscribed  space in the epigastrium, Avith 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
 haematemesis.  Analogous symptoms, it is true, may be present in cases of
 cancer of the stomach, but there are  points of contrast involved in this dif-
 ferential diagnosis  Avhich  will  be  noticed presently in considering cancer.
 Moreover, the absence of a tumor appreciable through  the abdominal walls
 goes far toAvard  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 ; haematemesis does not occur.   Attacks of gastralgia and gastric ulcer
 are,  however, sometimes  associated.   In cases of merely functional disorder
 pain, vomiting,  and haematemesis are all wanting.  Haematemesis, 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:  the  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
   [The  affections with which gastric   ulcer is most apt to be confounded are
gastralgia nervosa and cancer.   The pain attending the  former  bears no con-
stant relation to the ingestion of food-in fact, as above stated, is sometimes
relieved  by  eating   as  well as by pressure  upon the epigastrium-and is
usually  associated with other neuroses, such as cephalalgia, intercostal  neur-
algia, and  clavus.
   Cancer usually occurs  at an  age  more  advanced than that of most of the
sufferers from ulcer,  and is characterized by the rapid development of pro- 
GASTRIC  ULCER.
357
found cachexia, the frequent enlargement of the left supraclavicular <dands
the occasional presence of a palpable tumor in the epigastrium or its imme-
diate  neighborhood, the  absence of free hydrochloric  acid  from the gastric
juice, and the abundant presence of organic acids in that fluid.   Haematem-
esis, when present  in  cases of cancer, is generally small in  amount and fre-
quently recurrent.  The blood is also more apt to be altered by a prolonged
stay in the  dilated stomach—coffee-ground vomit.
   Ewald gives an  elaborate table in which the chief  differential diagnostic
points between nervous  gastralgia, ulcer, and  carcinoma are given with con-
siderable detail, but he  detracts somewhat from its value  by the statement
that the features of the three diseases are much more easily  defined on
paper  than  in  actual  practice—an  opinion  from  which  no  experienced
physician will dissent.—H.]
   Gastric ulcer proves fatal in diff'erent  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 6?
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,
hoAvever, 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 illustrati\7e 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 Avhich 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
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 ami  hemorrhage may occur Avhen 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 Avhich probably
a continuous open ulcer existed for thirty-five years, and of two cases in which 
358         STRUCTURAL DISEASES  OF  THE STOMACH.

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.   Ihe
mortality is estimated by Welch  as about 1.") 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. 338.)  When  the stomach tolerates food—that is, Avhen  pain
and vomiting are no  longer caused  by ingesta per os—the diet should  con-
sist for a time of milk, [which may  continue the sole article of diet for  one,
two, or  more  weeks.  It should be administered warm and mingled  with
lime-water in the proportion of J ounce of the latter  to 4 or 6 ounces of the
former,  or, if the  gastric secretions are very acid, a  little bicarbonate of
sodium may be added.  It is  preferable, however, to increase the proportion
of lime-water, as the  evolution  of gas  Avhich follows the administration of
the bicarbonate may distend  the stomach  to an injurious extent.  In some
cases the milk is better digested  when boiled.   If milk is  found to coagulate
in hard curds Avhich are vomited, or otherwise  to disagree witli the patient, a
trial may  be made  of buttermilk, which  is  an excellent  substitute.   The
formation of hard  indigestible curd in  a  hyperacid  stomach may sometimes
be prevented by adding to the milk  a little  flour previously Avell boiled  Avith
milk or water, or a small quantity of oat-meal or corn-meal gruel;  or, finally,
the milk may  be  peptonized.  RaAV or  soft-boiled eggs, beef-, mutton-, or
chicken-broth, and good  preparations of  beef-peptone are excellent articles
of diet in  these cases.   The approaches are thus  made to a solid diet Avhich
is not resumed- until several weeks  after the beginning of treatment.  Even
then the greatest care must be  taken  for months  afterward to exclude  indi-
gestible  articles of diet,—H.]  Considering the frequency of relapses, care to
adjust the  diet  to the digestive poAver 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 selected being that which is found on  trial to  be the
least objectionable.   [Opium  not only  relieves  pain, but obtunds the sense
of hunger, quiets the  muscular  layer  of the stomach, and so prevents or
diminishes  vomiting.—H.]  Opiates 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 
CARCINOMA OF  THE STOMACH.
359
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
Avords, remedies  which  have reference to  the  first object  of  treatment__
namely, securing rest.

                   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.
   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
   1 Of 31 482 primary cases of cancers collected by Welch, 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 Welch's analysis of 1300 cases of cancer of the stomach gives—pyloric region, b0.8
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, 1.6;
and fundus, 1.5 per cent. 
360         STRUCTURAL DISEASES OF THE STOMACH.
the stomach.   Since  Waldeyer'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 Waldeyer,  is briefly as follows: A group of tubules (from
ten to twenty) enlarge, lengthen,  and give off offshoots.   They are filled
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 mucosae.   When 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 Waldeyer careful microscopical  examination
will always disclose some band of connection with the tubules of the mucous
membrane.   The growth, hoAvever,  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 ; and  this fact  is to be considered in  Aveighing 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 Avith simple ulcer.1'  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-
  i Thus Lebert states that in 9 per cent, of the cases cancer develops from simple ulcer
{Deutsches Archivfiir khnische 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
_   In AY elch s statistics (1574 cases) the lymphatic glands were  the seat of metastases
in 3o 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.
361
 quently through the lymph-vessels, but they may also occur throu-h 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 lar-e  and
 abundant secondary deposits may attend small and insignificant tumorseof the
 stomach which during life may have produced no symptoms, and after death
 may be overlooked on superficial examination.   The blood in cases of cancer
 ol the stomach may present the same alterations as  in pernicious anaemia
   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  may be 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 m 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, sarcinae, and torulae  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,  anamiia, 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.
   As to the primary cause of cancer, we are without any positive  informa-
 tion.   It  is probable that the cachexia is secondary to the  development of
 the cancer.  The cachexia may be explained partly  by  certain facts pertain-
 ing to cancer  in general,  and  in  part by the local injury which  the growth
 inflicts  upon  an organ  of such vital  importance  as the  stomach.  The
 general considerations  are—the  rapid growth  of the tumor; its withdrawal
 in a short time from  the circulation  of a large quantity of nutriment em-
 ployed only for  its  own  noxious  groAvth  and for  no useful purpose; its  de-
 struction 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  oc-
 currence of exhausting hemorrhages.  The local effects of the 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 which 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
 1 In 2214 cases of gastric cancer there was a ratio of  5 males to 4 females (YYelch). 
362         STRUCTURAL  DISEASES  OF  THE STOMACH.
disorder, pain and vomiting are symptoms 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; lueniatemesis
is wanting.   The same  is true of chronic gastritis.   Persistent disturbance
of digestion, especially  if accompanied by  pain and vomiting, leading to con-
siderable loss in weight, diminution of strength, and  amemia 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 ppints 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 Avith  a faint
tint of yelloAV 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 ATon den A'elden  that
hydrochloric acid is habitually absent  from the stomach in cases of  gastric
dilatation due to cancer.  [The claim  that hydrochloric acid in a  free state
is, as a rule, persistently absent from the gastric secretions in cases of cancer
of the stomach has been abundantly verified.   The greatest amount of  clin-
ical  evidence in support of this  proposition  has been  furnished by Riegel.
This observer studied 16 cases of cancer of the stomach,1 in 5 of which the
diagnosis was confirmed by  an  autopsy.  In  these  5 cases  he  made  154
analyses of the contents of the stomach, with a  digestive  test and quantitative
estimate of  the  amount of acid  present.   In  none of these numerous anal-
yses  was free HCl  found, and in  no instance did the filtrate of the  stomach-
contents possess the power of digesting albumen.   In  8 of  the remaining
11 cases 120 analyses  failed to find either HCl or  digestive  power  in the
gastric juice.  In the following  3 there were found at first a very weak HCl
reaction and feeble digestive power.  They were therefore regarded as cases
of incipient carcinoma.   Later, free acid was  no longer  found.  From these
observations Riegel  concludes that in the gastric juice of  a cancerous stomach,
as a rule, both  free HCl and digestive power'are absent, and that,  on  the
other hand,  if in any case free HCl and normal digestive power are present,
carcinoma may be excluded, in spite of the usual  symptoms of that disease!
  The above conclusions of Riegel express the opinion  of all  authorities on
gastric cancer so far as  the presence or absence of HCl is concerned.  With-
                       1 Zeitschrift fur klin. Med., Bd. xii. 
CARCINOMA OF THE STOMACH.
363
out further explanation, however, they  are  misleading, inasmuch as they
exaggerate  the diagnostic  importance of the  acidity of the gastric juice.
HCl  is undoubtedly absent, as a rule,  from the secretion  of a  cancerous
stomach, hut the  same  is  true of other affections, such as  atrophy  of  the
gastric mucosa, amyloid  degeneration, chronic catarrh, simple dilatation,  and
states of impaired innervation.  Anacidity, therefore, instead of being, 'as at
first supposed,  pathognomonic  of cancer, must be relegated  to  the position
of a valuable corroborative sign  of that disease.—H]
  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 s.uffer 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  Avhen  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 SO per cent, of all cases of can-
cer.  The tumor is situated generally betAveen  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 be 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
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.  Hoav 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, Avhereas 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 ahvays  pulsate, and both thrill
and murmur may be wanting.   Under these circumstances in  this differential
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.   Aloreover, 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. 
361         STRUCTURAL DISEASES OF THE STOMACH.
  Cancerous affection of  the  cardiac orifice, leading to stenosis, gives rise to
symptoms quite diff'erent 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 loAver
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.   (Edema  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
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.   WithdraAyal 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.  [In most cases starchy foods—such as arrow-root sa°-o
and tapioca—and the liquid preparations of beef are  best digested.   To these
may be added a small quantity of brandy, which  imparts an agreeable flavor
to most  of the  preparations of starch.   Gelatin may  be given  a  trial and 
DILATATION OF THE STOMACH.
365
although practically devoid of nutriment, is a valuable addition to the dietary
on account of the albumen-sparing property which it undoubtedly possesses.
In other words, an individual Avho consumes a small  amount of  "elatin  can
support life and  maintain his  nutrition with less  albuminous food than can
another Avho  eats no gelatin.  Another valuable property of gelatin in cases
of carcinoma is that it is decidedly laxative.   It is, when properly prepared
and flavored, a most palatable  article  of food, and may be prescribed in the
form of peptonized milk-jelly, which is composed of peptonized milk to which,
while hot, a certain amount of gelatin is added.  It is then sweetened, flavored
with orange, lemon, wine, brandy, or rum, and eaten cold.—H]    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 surgeon
an exploratory  laparotomy is attended Avith little or no danger.


           Dilatation of the Stomach—Gastrectasia.

  Since Kussmaul's publication,1 in 1869, 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
Avide  limits, it  is manifestly impossible  to  give an exact anatomical defini-
tion  of this disease.   While  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.
  When 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 betAveen
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.  AYThen 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
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 verticals)
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 foetal
state, or it may be acquired as a  result of pressure (in women especially by
                  1 Deutsches Archiv f. klin. Med., Bd. 6, p. 455. 
366         STRUCTURAL DISEASES  OF THE STOMACH.
tight  lacing).   As pointed out  by Kussmaul, the  greater  curvature may
occupy an abnormally low position in consequence of the so-called loop shape
(Schlino-en-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.  347);  the pressure
upon the duodenum of  a Avanclering 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 may 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 AA'hich
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  anaemia, 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 Avho 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
 the pylorus reaches a more extreme degree than that from other causes, and
 is accompanied by a greater hypertrophy of the muscular tunic.

   Vomiting 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 Avhich 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
   1 Kussmaul,  ''Die peristaltische Unruhe des Alagens," Volkmann's Sammlung klinischer
 Vortrdge, Leipzig,  1880.
   2 Landerer,  Ueber angeborene Stenose des Pylorus, Tubingen, 1879. 
DILATATION OF THE STOMACH
367
froth containing gas,  sometimes inflammable, in the upper layers.   Sarci-
n;e, the yeast-fungus,  bacteria,  and crystals of fatty acids are often found.
Acetic, lactic,  butyric, and  other  organic acids  are  usually  present.   A'on
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.   Bile is not often found in the  matters vomited  or
withdraAvn 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.   With 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, hoAyever, 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 giA'e rise  to disagreeable  sensations, whereas in health persons are
unconscious of the  peristole  of the  stomach.   The enlargement of the  stom-
ach yaries  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.
  With the object of ascertaining the amount of dilatation by the eye and by
percussion the method of generating gas Avithin 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 20 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 bv the acid.   Some persons with  relaxed, dilated stomachs require 2 
368         STRUCTURAL DISEASES  OF  THE STOMACH.
 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 Avell—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  poAver 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 Avidely within  the
 range of health than the stomach, and an unusuall}T 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
 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.

   [In the treatment of gastrectasia there  are two principal indications  the
one general, the other local.  The first is the nourishment of the patient ■' the
 second,  the relief of the distended stomach.
   The diet should be as dry as possible, for fluids are not only almost useless
for nutritive purposes, on account of the difficulty with which they are absorbed
but are  of positive  injury by increasing the distention  already present    No
better proof of the hindrances to absorption can be adduced than the fact that
 the patient is often suffering from thirst when  his stomach is distended with

  1 Ebstein has described  under the  name insufficiency of the pyloric valve (inconti-
nentia pylori) a condition in Avhich the gas thus generated is not retained in thertom-
ach, but rapidly escapes into the intestines through the pyloric orifice. (vSe"E$£r
JS 18?8)                  7    ' Volkmann's  Sammlung kliniseheriCrdge,lSo. 
DILATATION OF THE STOMACH.
369
 fluid.   These remarks with reference to the ingestion of fluids apply to those
 periods of the disease when the stomach already contains an excessive amount
 of liquid.  After the organ  has been thoroughly emptied of its  contents a
 certain amount of fluid  may be administered, and  preferably in the form of
 peptonized milk.  The main staple of the diet should be meat, either pepton-
 ized (beef-peptones) or finely  scraped  and broiled (Hamburg steak)    The
 digestion of this  animal food  should be assisted by the frequent administra-
 tion of dilute hydrochloric acid—15 to  20 drops in a tablespoonful of water
 every  three  hours.   All starchy foods,  sugar, and beer—in a word all  sub-
 stances  Avhich  ferment readily—should  be prohibited.  AVith a moderate
 quantity  of  peptonized  milk, a considerable amount of scraped broiled beef
 and rectal enemata if necessary the nutrition will be sufficiently provided for!
   To fulfil the second indication the only advisable procedure is lavage. This
 is accomplished by introducing into the stomach a rubber tube to the outer
 extremity of which a funnel  is attached.  Through this, water is poured
 until the stomach is distended, when the funnel is  depressed below the level
 of the umbilicus and the water rushes out in obedience to well-known hydro-
 static  buys, the apparatus  being  neither more  nor  less than a siphon.   The
 manoeuvre  of  filling  and emptying  the  stomach may be  repeated several
 times at one sitting—in fact, it should  be continued  until the water returns
 perfectly clear.   A great deal  of tact and patience  are required to bring the
 first lavage to a  successful conclusion, and the operation  should never be
 undertaken without the  hearty co-operation of the patient.  The relief which
 follows it is, however, so great that he will  surely demand its repetition, and
 in many cases  there is difficulty in dissuading him from abusing it,  Lavage
 sbould not be employed  until at least six  hours have  elapsed from the time
 of eating, and, on the whole,  it is  safest to practise  it in  the  early  hours,
 before breakfast.   If performed  too soon after meals, it may  deprive the
 system of valuable  nutriment.
   After thoroughly washing out the  stomach with  water at or near the tem-
 perature  of  the body it may be finally cleansed with  an antiseptic solution,
 such as salicylic  acid, 3 to 5 pro  mille. or borax, 2  to 4 per cent.   These
 harmless  substances are quite efficacious, although  benzoic  acid, naphthalin,
 potassium permanganate,  and  resorcin are  also recommended by various
 authorities.  The latter substance  is unsafe except  in very weak solution,
 such as  half of 1 per cent.
   The good effects of a  thorough washing out of the stomach are  immediate.
 The aspect of the patient becomes  cheerful; pyrosis  and eructations cease ;
 the bowels become  more regular; the urine increases in  quantity and loses
 its alkaline reaction ;  and the  bodily weight increases, sometimes even in
 cases where the dilatation has cancerous obstruction for its cause.   Alassage
 and electricity are excellent adjuvants to lavage. It was at one time doubted
 whether electricity applied to the abdominal walls  could induce contractions
 of the stomach, but recent researches of Ewald and Sievers have demonstrated
 that the exit of the  gastric contents is hastened by  the energetic application
 of faradization to the abdomen. The most rational employment of  electricity
 in gastrectasia consists in introducing a properly-constructed  electrode into
 the stomach Avhile its  fellow is placed  on the abdomen  or in the rectum.
 Before introducing the  electrode the patient should  be  directed  to drink a
 glass or  two of Avater.
  Strychnia is a remedy of undoubted service in cases of gastrectasia, espe-
 cially in the atonic forms of the disease.   It may be  given by the mouth in
 doses of J^ of a grain thrice daily, or hypodermically if there be any reason
 to suspect that it is not absorbed.  In  the latter mode  of  employment the
initial  dose should not exceed  -£$ of a  grain.
       21 
370         STRUCTURAL  DISEASES OF THE STOMACH.

  Cathartics  are also decidedly beneficial,  not  only on  account of  their
mechanical effect in unloading the boAvels, but also because of the intimate
peristaltic relation between the  stomach  and intestines/  I hey are  most
efficacious when  administered immediately after  washing  out the stomach,
at which  time  a solution of Carlsbad salt may  be poured in through the
stomach-tube before its withdrawal.  Other useful purgatives  are  colocynth,
rhubarb, scammony, and  aloes.   The last mentioned may be given hypoder-
mically in the form of the extract knoAvn as aloin.
  Prophylaxis.—Although  we possess no  certain means of preventing the
obstructive forms of  dilatation, such as those dependent upon pyloric cancer,
the cicatrices of ulcers, and  the pressure  of tumors  of  neighboring  organs,
we  certainly have it  in  our  power to reduce  the number of cases of the
purely atonic variety.  AVith this end in  view the greatest care should be
taken to avoid  distention of the stomach  with fluid in  patients recovering
from febrile affections, and in the anaemic  and debilitated generally.   A cer-
tain number of such  individuals  are placed upon  an exclusive milk diet, and
necessarily consume large quantities of fluid.   To avoid the disastrous effects
of dilatation  they should be  instructed to  take their milk in small amounts
at short intervals, while at the same time their bowels are  kept regular.   In
addition, it is a wise  precaution  to keep such  patients  upon  the daily use
of strychnia so long as their debility continues, and to apply the faradic cur-
rent occasionally to the abdominal muscles.—H.]

  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.   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 intensity,
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 Avhich may be specially mentioned typhus and typhoid
fevers, smallpox, septicaemia, puerperal fever, and yellow fever.  Phosphorus-
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 
DEGENERATION OF THE GASTRIC  TUBULES.
371
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 ejr
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, AA7ilson
Fox, Habershon, Fenwick, and Henry and Osier.  It is generally recognized
that atrophic changes occur  in the mucous membrane of the stomach%s 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
anaemia, I ventured the opinion that degeneration of the gastric tubules is
the anatomical  characteristic in certain  cases  now included under the name
of pernicious anaemia.  (See p. 311 et seq.)}  In the third edition of this work
(1868)  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 vieAvs.
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, anaemia, 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 Avithout diminution of the lumen of the stomach.  The  symptoms resem-
bled closely those which  have been described  in  the article  on Pernicious
Anaemia.   Quincke, in an essay on pernicious  anaemia,4 mentions a case in
which  the gastric symptoms  were even more  marked than is  usual in per-
nicious anaemia,  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  18785 reported a case of general
atrophy  of the  stomach  with absence of organic disease.   The symptoms
during  life were anorexia and extreme  anaemia.  The  walls of the  stomach
were found to be atrophied, but, unfortunately,  no  microscopical examination
was made.  In 1879, Nothnagel6 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  AY.
Miiller.  The clinical history of this case was in all  respects  that of perni-
cious  anaemia, and  this Avas the diagnosis  during  life.   Nothnagel does not
  1 American Med. Times, 1860.
  2 " The  Pathological Relations of the Gastric  and Intestinal Tubules," by Austin
Flint, M. D., New  York Med. Journal, March, 1871.
  3 The Lancet, 1877, July 7 et seq.
  * Volkmunn's Sammlung klinischer Vortrdge, No. 100 [Cane 6).
  5 British Med. Journal, Julv 27, 1878.
  6 Deutsches Archie filr klin. Med,, Bd. 24, p. 353. 
372         STRUCTURAL  DISEASES OF THE STOMACH.

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 anaemia, has been recently reported by Thorowgood,
and °a  similar case has been carefully studied  and reported by Henry and
Osier.1
   The symptoms which have been observed in  cases of atrophy of the gastric
tubules are those of severe anaemia.  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 amemia.  It  is desirable, as Noth-
nagel suggests, to pay special attention  to the  condition  of the  stomach in
death from pernicious anaemia.  The pathological conditions are probably not
the same in  all cases of this  grave form of anaemia.  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 mucosae and  the  mucous membrane.
Here, as elseAvhere, 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-
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 Kuhne. the amyloid  material outside of the body is extremely
resistant to  the action  of the gastric juice,  it would appear from the studies
of Kyber that this substance in the living body may be digested by the gas-
tric  juice.  Amyloid  degeneration  is generally an accompaniment of severe
wasting disease.  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.
   1 Thorowgood, Med. Times. Feb. 5, 1881; Henry and Osier, Amer. Journ. Med. Sciences,
April, 1886. 
                      INTRODUCTORY REMARKS.                  373




                        CHAPTER  IV.

 FUNCTIONAL DISORDERS. OR  NEUROSES OF THE STOMACH.

Introductory Remarks.—Motor Xeuroses (Nervous Vomiting;  Peristaltic Unrest: Xer-
    \-ous Eructation; Rumination; Incontinence of the Pylorus;  Atony).—Sensory
    Xeuroses  (Gastralgia; Polyphagia, Malaria  and  Pica. Polydipsia, and Dipsoma-
    nia i.—Secretory Neuroses (Hyperacidity and Hypersecretion).—XerA-ons Dyspep-
    sia.—Gastrorrhagia.—Inanition.

                         [Introductory Remarks.

    BEFORE beginning the study of the functional diseases of the stomach it
     is necessary to have some knowledge of the  methods by which they are
investigated, especially as. within  the last  few years, great advancement has
been made in  this department.  Formerly  the diagnostic procedures in gas-
tric disease were limited to inspection, palpation,  percussion, and the inspec-
tion, gross and minute, of vomited matters, but the chief reliance Avas on the
anamnesis and other  subjective evidence.  The primary object  of diagnosis
was then, as now, to  distinguish between functional and organic disease, and
if the latter could be excluded, the affection was decided  to be u dyspepsia."
The term :( dyspepsia " is rapidly becoming  obsolete so  far as its  employment
in  scientific writings  is  concerned.   It  Avas  a  most  serviceable cloak for
ignorance, hut has been worn  threadbare and  is about to  be  discarded.   AVe
have  no more scientific right to  speak or write  of dyspepsia as  though it
were a distinct  disease than  we have  to be satisfied with the  diagnosis of
''jaundice"  or  "dropsy."
   Our present knoAvledge of gastric diseases  is  almost  entirely due  to the
use of the stomach-tube, which was first employed for  diagnostic purposes
by Leube in  1871.  The instrument first used was hard and stiff, and was
passed into the stomach with  little or no active  co-operation on the part of
the patient; or if a  soft-rubber tube  was used, it was thought  necessary to
have it stiffened with a stylet  of  whalebone.  By degrees it  was ascertained
that, unless  there existed' a stricture of the oesophagus,  a  soft-rubber tube
open at the end and at the sides just above the end could be introduced with
very  little discomfort to the  patient,  who, besides, was  able to  give  very
valuable assistance in the operation by movements of deglutition.   In fact,
after a little practice the patient can SAvallow the tube  much more readily
than  the  physician can insert  it.   It  is unnecessary to  lubricate  the  tube
with oil or vaselin or anything of the  sort, for the saliva and mucus of the
buccal cavity are sufficient, for this  purpose.   The instrument  is  dipped in
warm water* its  extremity passed rapidly and deftly into the pharynx, and
the patient directed to swallow it.  In most  cases success  will attend the
first efforts, but with  hysterical patients  it  will not be achieved without con-
siderable firmness and perseverance on  the part of the physician.
   The object of introducing the tube  is to obtain a sample of  the contents
of the stomach with  a vieAV to its  chemical analysis, and therefore the time
at which the operation is performed is a matter of great importance.  D»nnS
the intervals of digestion the  stomach contains a very little  fluid which cer-
tainly does not deserve the  name  of  gastric juice.  It is really nothing  more
than  a  feebly acid  mucus,  from  an  examination of which no  legitimate
deductions with  reference to  the digestive power of the  stomach can  be
made.   Before introducing the  tube  the  stomach  must  be stimulated to 
374   FUNCTIONAL DISORDERS,  OR NEUROSES OF THE  STOMACH.

secretion, and for this purpose various means have been resorted to.  Leube's
method is to inject through the tube, previously introduced, 100 cc. of ice-
water, followed ten minutes later  by three times  that amount of water of
ordinary temperature.  The liquid, after a short stay in the stomach, is with-
drawn.'its chemical reactions examined, and its digestive power tested.  This
method has been criticized on  the ground that a genuine gastric juice is only
secreted in response to stimulation  by a substance which it  is capable of
digesting.  This objection is  well  founded, and therefore several  so-called
'•' test-meals" have been proposed by  various investigators.   Among  these
may be mentioned the hard-boiled egg  used by Jaworski to obtain  a sample
of gastric juice, the meal  composed  of  soup, beefsteak, and bread prescribed
by Riegel, and the " test-breakfast"  of  Ewald.  The  latter is composed of a
roll weighing about 35 grammes and  a cup (about 250 ccm.) of weak tea.
Discrepancies in the results  of various investigators  have been  due  to the
fact that the gastric juice  has  been obtained by stimulating the stomach with
food varying in amount and quality.  Food is  the natural stimulant of the
gastric secretion, but the  amount and quality of the  latter and the period at
Avhich digestion is  most active depend upon  the  amount and kind of food
administered.   It  is therefore of  great importance for  experimenters  upon
digestion to agree  upon  the   ingredients and amount of the  so-called test-
meal—in other words,  to carry out their investigations upon a uniform plan.
For  several reasons the test-breakfast (Probefriihstuck) of EAvald  is better
than  any other.   In the  first place, the digestion of such a  meal  is  at its
height in one hour after eating, instead of from four  to  six, as after a meal
composed of soup, bread, and  meat,   Secondly, if vomiting occurs during or
after  the introduction of the tube, the  matter ejected  is  comparatively
inoffensive both to physician  and patient.  These are sufficient grounds on
which to  base  a  decided  preference for the test-meal of Ewald.
   The  tube having entered  the  stomach, the question is how to obtain the
gastric juice.  This may be accomplished either by suction  or pressure.  By
means of  a  syringe or a  rubber ball attached to its  upper end the  requisite
amount  (a few cubic centimetres) of fluid  may  be drawn into the  tube.
This is  the simplest method, and if carefully performed  the  risk of injuring
the gastric mucous membrane, upon which great stress  has been laid, is en-
tirely avoided.  Ewald prefers what he calls  the expression method, which
simply means that the  patient at the word of  command contracts his abdom-
inal muscles so as  to  force the contents of the stomach  into the end of the
tube.   The  latter  should of course  be  compressed during its withdrawal, to
prevent the fluid  escaping by atmospheric pressure.   This method, like all
diagnostic  procedures  requiring  the co-operation of  the patient,  will fre-
quently fail, so that the operator should always be provided with some kind
of suction  apparatus—syringe, rubber ball, etc.
   The requisite amount of fluid haA-ing been  obtained, it is  filtered and ex-
amined with reference to its  chemical  reaction and digestive power.
   First, as to its chemical reaction.  The contents of the stomach are always
acid, but the object of the examination we are now  considering is chiefly to
determine the  presence or absence  of  the  true digestive acid, which is now
universally  agreed to  be  hydrochloric.
   Numerous substances  have been employed as  tests  of the  presence of
hydrochloric acid  in the gastric juice, but, as in testing urine  for sugar or
albumin, so here, it is  better to be thoroughly familiar with two or three of
the  best  tests than superficially  acquainted  with a dozen.  One of those
most frequently  employed is the  methyl-violet test.  It  is  thus applied:
Into each of two tubes is poured a small quantity (50 cc.) of distilled water
followed  by two drops of a two  per  cent, solution  of methyl-violet.   Into 
INTRODUCTORY REMARKS.
37o
one of these tubes is now poured, drop by drop, the fluid, previously filtered
obtained from the  stomach.  To the other is added an equal quantity of
pure  water.   If free  hydrochloric  acid  is present in the gastric secretions
the fluid in the  first tube will  turn blue, while  that in the latter will retain
its  violet hue.   An objection  to this test is  that it is interfered with  to a
greater or less extent by  albuminates and peptone, as well as by certain salts
especially phosphates and sodium  chloride.   The organic  acids, lactic,  bu-
tyric, and acetic, give the same reaction, but only when in a  degree of concen-
tration rarely present in the stomach.  In the  opinion of the writer, the best
test is that devised  by Criinzburg of Frankford.   It is  known as the " phlo-
roglucin-vanillin test," but, for  the sake  of brevity as well as in honor of
its  discoverer, should be called "  Giinzburg's test,"  It is composed of 2
grammes of phloroglucin and  1 gramme of Merck's  vanillin in 30 grammes
of absolute alcohol.  The solution  is of a yellowish-red color, but  alters on
exposure to light, and therefore when  not in use should  be'kept in a box.
If a drop of this solution be placed in a  watch-glass and to it there be added
a trace of concentrated hydrochloric acid, a bright-red color instantly appears
and at the same  time a separation of minute red crystals takes place.  Con-
centrated organic  acids, such  as lactic  and acetic, give no such reactions.
The mineral acid to which the reaction is due must be of a  certain degree of
concentration.   If too dilute, neither the color nor  the crystals appear until
some of the  water is driven off by  heat.    The  following is  the techinque for
the application  of  this  test to  the examination of  the stomach-contents: A
few drops of the  filtrate of the latter  are mingled in a  porcelain  dish or
watch-glass with the same quantity of the test-solution and carefully heated.
If free  hydrochloric acid is present to  the amount of one-tenth of one per
cent., the red  crystals will form ;  when present in smaller quantity there
will be  no  crystalline formation, but bright-red  streaks will appear  in  the
fluid.
   It is often a matter of diagnostic importance to  determine the presence or
absence of lactic acid in the gastric secretions.  For this purpose Uffelmann's
test is invariably employed :  To an aqueous solution of the chloride of iron,
so weak  as to be almost colorless, are added a few drops of  the filtrate of the
gastric  secretions.   If they contain but  a trace of lactic acid, the mixture
becomes of a canary-yellow color.
   Acetic acid is  detected when  present in large quantity by its unmistakable
odor.   To demonstrate it chemically the  filtered gastric secretions are  shaken
up  with  ether and  evaporated.   A part of the  residue  is  then filtered,  and
to it  is  added a drop of a  neutral solution of  chloride of iron.  If acetic
acid is  present  a beautiful  blue color appears.
   For the demonstration of butyric acid the gastric contents are shaken up
as before with ether and evaporated.   A small  fragment  of chloride of lime
is  now  added, and if butyric acid  is present  minute oily drops will  appear
upon  the surface of the  liquid.   This is due to the fact that butyric acid is
insoluble in  saline  solutions.
  For other chemical tests of the gastric secretions, as well as for the meth-
ods of determining  the  percentage of HCl in  them, the reader is referred to
special treatises  upon the diseases of the stomach.  The  tests above given
are amply sufficient for  all  practical  purposes.
  The presence  and, if possible, the  percentage  of HCl having  been ascer-
tained, the gastric secretion is next tested as to its digestive capacity.   For
this purpose equal  quantities of the  filtered secretion are placed in each of
four test-tubes.   To the first nothing  more is  added; to the second is added
two drops of  the official   HCl  of the  German Pharmacopoeia;  to the third
from 0.2-0.5 gramme  of  pepsin ; and  to  the fourth both pepsin and  HCl in 
376   FUNCTIONAL DISORDERS,  OR NEUROSES OF THE  STOMACH.

the amounts just mentioned.   In each of the tubes thus  prepared is  now
placed a  piece of hard-boiled  white  of egg, the size of which must  be the
same  in  each experiment.   These pieces are prepared  by cutting uniform
slices  of  egg with a Valentin  knife  and then punching out a circular frag-
ment  with  a cork-punch.   The tubes, having been  prepared  in  the manner
described, are placed in the  incubator and  kept  at  a proper temperature
(100° F.).   It will  soon be determined Avhether  the  gastric juice is alone
capable of  digesting albumen  or  whether it is deficient in HCl, in pepsin, or
in both.
  Besides pepsin  there  is in the gastric juice a ferment (" Labferment" of
the Germans) Avhich coagulates  milk and which may be conveniently called
the rennet-ferment.  Its presence is  recognized in  the following  manner:
The gastric juice is  first neutralized to prevent the curdling action of HCl or
other  acid, and then added  to an equal quantity of boiled neutral-reacting
milk.   The mixture is placed  in the incubator at a temperature  of 100° F.,
and if the rennet-ferment is present  coagulation will occur in from fifteen to
thirty  minutes.
  AVe have now  to  inquire  concerning the practical results thus far derived
from these clinical applications of chemistry.  Considering that the methods
described were introduced but  a few  years ago  by A'on  den A^elden  and
Leube, these results are remarkable.   In the first place, they have led to the
division of so-called dyspepsias into  three groups :
  1.  Those characterized by a diminution or absence of  HCl—hypacidity or
anacidity.
  2.  Those characterized by an excess of  HCl—hyperacidity.
  3.  A  less  important group—or,  rather,  one not yet so well  defined—
includes  those cases in  which the presence of HCl is variable.
  A  knowledge  of the absorbent power of the  stomach is sometimes of
diagnostic value, and may be obtained by the following test, first  employed
by Penzoldt  and  Faber: Three grains of potassium iodide are administered
in a gelatin capsule, and the saliva, which has been previously demonstrated
to be  free from iodine, is tested every minute for this substance.   In dealing
with a healthy and  empty stomach the first iodine reaction will  be obtained
in from  six and one-half to eleven  minutes.  If the drug be administered
immediately after a meal, the  iodine  reaction will  not appear  until forty-five
minutes  have elapsed.   By this  means it has been  shoAvn that  in various
pathological  conditions, such  as  cancer, ulcer, chronic  catarrh, and atrophy
of the gastric mucosa,  absorption is retarded.
  It is often of diagnostic  value to  obtain some idea of the motor power of
the stomach, Avhich some  authorities  are  inclined  to  regard as  its most
important function.  Until quite  recently the only method of  acquiring such
information Avas that introduced  by  Leube, and consisted in the introduction
of the stomach-tube seven hours after a meal—i.  e. at a time when the  food
should have passed into the intestine.  The presence of food at  such  a  time
would indicate an impairment of motor power, and the degree of the latter
would be in direct ratio  to the quantity of the  former.  This  method  is
crude  and inapplicable to  most  clinical purposes.
  The peculiar properties  of  salol led Ewald and Sievers to employ it for
testing the motor function  of the  stomach.   This drug  remains insoluble
and undecomposed  in  the stomach, but splits up  into  carbolic and salicylic
acids  when it comes in  contact with  the alkaline secretions of the intestine.
The salicylic acid is excreted with the urine, in Avhich it may be  detected by
suitable  reagents, and  the time  between the administration of the  salol and
the detection of  the salicylic acid in the urine is indicative of the motor
power of the stomach.  I mention  this ingenious test for the  purpose of 
NERVOUS  VOMITING—EMESIS NERVOSA.
377
Motor neuroses.
Increased motor activity.
showing the direction of present research  in the diagnosis of diseases of the
stomach, although I believe  it can never come into general use.  In the first
place, the chemical  test for salicylic  acid in the urine is an elaborate one
and, in the next, it is impossible for most persons to urinate at such frequent
intervals as it demands.
  Betol has recently been recommended by Fodera and Corselli as an agent
for measuring  the motor power of the stomach, on the ground that it is less
soluble in that viscus than salol.  In a healthy man salicylic acid appears in
the urine in from seventy to eighty minutes after the administration of betol.
A longer interval will therefore show diminished motor activity of the stomach.
  The foregoing remarks will obviate  the necessity of frequent repetitions,
and are indispensable to a proper understanding of the  functional diseases
of the stomach.—H.]

    [Functional  Disorders, or Neuroses of the Stomach.
  By this term Ave  designate certain  disorders of motion, sensation, and se-
cretion,  which  may exist either singly or combined in various  proportions.
The  chief of them  are  placed in  the  following table :

                                              Nervous ATomiting.
                                              Peristaltic unrest.
                                              Nervous eructation.
                                              Rumination.
                                              Incontinence of pylorus.
                   Diminished motor  activity.— Atony.
                   {Gastralgia.
                   Polyphagia, Malacia and Pica, Polydipsia, and Dipsoma-
                     nia.
  .,               f Anacidity.
 Secretory   neur-   ^      r,.
        J        <  Hyperacidity.
                 [_ Hypersecretion.
 Mixed forms.     —Nervous dyspepsia.

                       MOTOR  NEUROSES.,

              Nervous  Vomiting—Emesis Nervosa.
  Etiology.—Nervous vomiting is distinguished  etiologically  more by its
negative than  by its positive  features.   Under this  head are included all
forms of vomiting which do not depend upon  excessive quantity or  altered
quality  of the food or upon  organic affections of  the  stomach, such as
catarrh, ulcer,  cancer, etc.  In a word,  the causes of nervous vomiting are all
reflex.  The irritation which induces emesis may be conveyed by the special
senses, especially  those of taste and smell—a fact so well known that we are
accustomed  to speak of certain substances as nauseous.   It is even said that
shrill  sounds will  induce vomiting in certain hyperaesthetic individuals.  It is
evident  from the  foregoing  remarks that  the  so-called nervous vomiting is
nothing more than a symptom, which is studied separately, as though it were
an independent affection, chiefly to impress its  distinctive features upon the
mind, and  thereby  prevent them from diverting  the  attention  from the
primary disease.
  The chief organs  from  which the  irritation giving rise to nervous vomit-
ing is propagated are those of the central  nervous system, the abdomen, and
the pelvis.                                                    ,   , ,
  Disordered states of the cerebral circulation, such as may be produced by a 
378  FUNCTIONAL DISORDERS, OR NEUROSES OF THE STOMACH.

violent blow on the head, by swinging, by travelling by sea or by rail (espe-
cially with the back to the locomotive), are frequent causes of the affection.
It is also a well-known  symptom of meningitis, cerebral  tumors, apoplectic
extravasation, and cerebral abscess.  It is not uncommon in  cases  of tabes
dorsalis, in which disease it may be attended with severe gastralgia, constitut-
ing the affection described by the French under the name of crise gastrique.
   The chief abdominal  causes  of nervous  vomiting  are  gall-stone, renal cal-
culus, intestinal parasites, hernia,  peritonitis,  and movable  kidney.
   Irritations from  the  pelvis  giving  rise to this  symptom are pregnancy,
especially in its  beginning, displacements of  the  uterus, and  parametritis.
Massive  tumors of uterus  or ovary are not, as a rule, attended with vomit-
ing.   In  men, injury of the testicle, epididymitis,  and orchitis  are frequent
causes of vomiting.
   Certain causes of nervous vomiting  may be called toxic ; for  example, the
forms dependent upon fcholaemia and  so-called  uraemia, as well as the form
of vomiting excited by the systemic emetics, such  as apomorphia, Avhich will
excite emesis when  injected beneath the skin,  and therefore cannot act as a
direct gastric  irritant.
   Finally, nervous vomiting is  the most conspicuous manifestation of certain
forms of  hysteria, and may persist for years in spite of  every therapeutic
effort.

   Svmptoms.—The chief characteristic  of this form  of emesis is the more
or less complete absence  of nausea and the ease and rapidity with which the
act of vomiting takes place.  The food is usually rejected unaltered, and, as
a rule, little or nothing is retained in the stomach.   In other cases the viscus
retains certain of the  ingesta and rejects  others.   Ewald refers to a case in
which all solid food  was retained, liquids  only being vomited.   A marked
peculiarity of the hysterical form of the  disease  is that  it may persist for
years without  any perceptible deterioration of the general nutrition; in
fact, patients who  have vomited  after  every meal  for  a protracted  period
may not only retain  their  weight,  but actually gain  flesh.
   The tongue  often presents a  perfectly normal appearance and the appetite
may be preserved.  The urine  is diminished in quantity during the attacks,
is  of darker color than normal,  and  of high specific gravity.  It often depos-
its a copious sediment of urates.  As a matter of  course, when the affection
is  dependent upon organic disease of brain or spinal cord, or of an abdominal,
uterine, or other organ,  the symptoms will be  complicated by those  of the
primary disease.

   Diagnosis—This  is  made by the  careful  exclusion of  organic  disease
of the stomach, and in many cases by the demonstration  of some affection of
one of the organs above  mentioned.  In all  cases of obstinate vomiting the
urine should be examined, the  eye-ground  inspected, and the uterus and its
appendages  carefully explored.   Retention of the  body-weight, preservation
of the appetite, and a clean tongue furnish strong  evidence in favor of the
view that the vomiting is purely nervous.

   Prognosis.—As  regards life, the prognosis  depends  upon  the nature of
the primary disease when the  affection  is  symptomatic  of some underlying
affection ; while  in  cases of hysteria life is rarely threatened, although the
vomiting may persist for years in  spite of the most intelligent treatment.

   Treatment—The treatment must be, as far as possible, causal.   AAThen
the cause persists the  symptoms may be ameliorated by administering small 
PERISTALTIC  UNREST.
379
 pieces of ice, by the application of an  ice-bladder  to the epigastrium  or bv
 counter-irritation of the same region.   Opium, chloral, ether, and chloroform
 are often of decided service, and the same is true of nervines such as the
 bromides, camphor, and musk.   Benefit is  often derived from laro-e do«es of
 subnitrate of bismuth.  Absolute  rest  in bed should  be insisted upon  and
 nothing be  permitted in the way of nourishment except nutritive fluids such
 as strong beef-essence and milk.  In addition, small quantities of champagne
 and carbonic-acid  water may be administered.  Koumyss is  often retained
 when  all else is  rejected.   Hypnotism is said to  have been  efficacious in
 some cases of hysterical nature.
    Hysterical vomiting- is  undoubtedly  largely the  effect of habit, and  may
 often be cured by  breaking one of the  links  in the chain of actions which
 accompany  it.  My  meaning  will be  rendered plainer by  the following
 extracts from  the  reports  of three cases by  Dr. Henry M. Tuckwell.1
    The first  was a  boy set.  15 who  had vomited all his  food  for about four
 months, was  bed-ridden,  greatly emaciated,  and pitiably nervous, bursting
 into tears when spoken to.   He was  placed on lime-water  and milk, which
 was rejected as soon as the milk was swallowed. The nurse having observed
 that as soon as the milk was swallowed the boy " raised himself into a half-
 sitting posture and began to heave," Tuckwell ordered her to prevent this by
 sitting at the patient's  side and  keeping him flat on his back after each dose
 of milk.  The result was  that  the milk was  retained, and in a few days he
 was able to  keep down  some minced mutton.   From this time recovery was
 rapid, and  the patient was soon discharged "fat  and cheerful."
   The second case  was also a boy between 13 and 14 who had  been vomiting
 incessantly  for several  Aveeks.  The habit in this instance was broken up by
 compelling  him to sit  still instead  of getting  up  and leaAdng the table to
 vomit, as he  had  preAriously done.
   The third case was a girl  of  14  who  was cured by being compelled to lie
 on her back for half an hour after taking  food.  For eighteen months  pre-
 viously, with the exception of a three-months intermission, she had vomited
 her meals, going to the water-closet regularly for this purpose.—H.]

          [Peristaltic  Unrest (Peristaltische Unruhe).

   Under this head  is  designated an habitual state of increased  peristalsis un-
 accompanied with vomiting or eructation and independent of pyloric stenosis.

   Etiology.—Anasmia and neurasthenia constitute the  etiological basis of
 the affection.   The peristalsis is generally most marked just after meals, but
 does not entirely cease  during the intervals.

   Symptoms.—The sole  symptom  of which  the patient complains is the
 rumbling  noise which  often attends  every respiratory  or  other  muscular
 movement.  This is frequently so loud  as to be heard distinctly across a large
 room.  The affection is unattended Avith  pain.

   Diagnosis.—This is  made without difficulty if the physician  has  an oppor-
 tunity of hearing the  sounds referred to, but,  unfortunately, they are apt to
 cease at the  very time of his visit.  In  this respect hyperperistalsis of the
 stomach  does  not  differ from many other neuroses.   AVhile  an attack is in
 progress the stomach may  be seen to contract as in cases  of pyloric stenosis.
 A  wave of contraction  may be  followed with the eye as it  slowly proceeds
from the cardia to the pylorus.
                   1 British  Medical Journal, March 22, 1873. 
380  FUNCTIONAL DISORDERS,  OR  NEUROSES OF THE STOMACH.

  Treatment.—The treatment of this annoying affection consists of a care-
ful  regulation of the diet  and a judicious  management of the  underlying
constitutional  state.   I  have found this  peristaltic unrest to be  a frequent
symptom  of chlorosis, and  have  observed it  to disappear as the state of the
blood improves.  A brief course  of rest-treatment is often of decided benefit,
the patient being put to bed and kept absolutely quiet while the  circulation
is stimulated Avith massage and the muscles exercised with electricity. Warm
cataplasms to  the  abdomen are useful in allaying  the hyperactivity of the
gastric muscles.

  The treatment of this harmless affection should be seriously undertaken,
for  the existence of many a woman  is rendered unhappy by the  explosions
which attend it, and which  occur on  the most inopportune occasions.—H.]

                       [Nervous  Eructation.
  Etiology and Symptoms.—Hysteria, hypochondria, and neurasthenia are
the underlying  causes of this affection, which may exist alone  or combined
with  other manifestations  of a  disordered  nervous system.  It  is  said by
Ewald to  be  a characteristic of  the  hysterical form of eructation that it is
not attended  with other symptoms  referable to  the stomach, while in the
other neurasthenic forms of the affection there are,  in addition, sensations of
Aveight, fulness, and tension in the epigastrium.  Pain  is not an attendant of
any variety of the complaint.
  The attacks are recognized by their paroxysmal character as well as by the
nature of the  gas  belched  up.   The  latter  is odorless and tasteless, and is
shown by chemical examination to  be nothing more than atmospheric air
which has undoubtedly been swallowed with the food and drink or forced
down, independently of the  acts of eating  or drinking, by peculiar moA'ements
of deglutition.  The number of eructations is sometimes  enormous, as many
as 2500 having been  counted in one hour.  During the paroxysms the stom-
ach may either be distended or not,   In  the latter  event it is probable that
the  gas is  brought up from  the oesophagus, for Ewald has demonstrated that
gas may be forced by acts  of deglutition  into this  canal without necessarily
passing through the cardiac orifice of the  stomach.

  Prognosis and Treatment.—The prognosis is intimately bound up with
that of the underlying neurosis, and the treatment is essentially the  same as
that of the "peristaltic unrest" of the stomach just described.—H.]

                    [Rumination—Merycismus.
                     (Mrjpoxt^a), "to cheAV the cud.")
  Definition.—Rumination is  the  voluntary regurgitation  of  food  from
the  stomach for the  purpose of  remastication.  It  differs, therefore, materi-
ally from simple regurgitation, which consists  of the  involuntary eructation of
food, which is either swallowed again immediately or is ejected from  the mouth.
  AVith reference to the mechanism of rumination—or, rather, of the regur-
gitation which is the first  step in the process—it  has been observed that it
is always  preceded by a rapid inspiration and an  equally rapid  expiration.
The  effect of the first  is  to draw the food  by suction  through the cardiac
orifice, which is simultaneously relaxed ; and that of the second,  to prevent
its return into the stomach.  This  view of the nature of the process has
been confirmed  experimentally by Flourens, who was able to render the act
of rumination  in the sheep difficult or impossible by  section of the phrenic 
                     R UMINA TION—MER YCISMUS.                  381

nerves and of the medulla  spinalis at the level of the sixth dorsal vertebra,
the effect of this operation being to paralyze the chief muscles of respiration.

  Etiology.—In the etiology of this disease  heredity  and imitation  play
important  roles.   It  was supposed  by most of the medical writers of the
seventeenth century, previous to which  we  have no records of the disease,
that the victims of the habit of rumination  were descended from corniger-
ous parents, or were themselves either possessed of horns or, like other rumi-
nants, Avere provided Avith  more than one  stomach.   Strange to say, tAvo of
the  earliest  cases on recordx occurred in men Avho had horny growths on
their foreheads, but avIio nevertheless, as demonstrated post mortem by Fabri-
cius of Acquapendente, had each but one stomach.
   Heredity,  nevertheless, is  of  undoubted influence, as is shown  by the
reports of  several cases  contained in  the elaborate article upon this subject
by  Bourneville and  Seglas.'2  The same writers  give instances of the origin
of the disease through mimicry, of which the following is the most striking :
Two children, a boy  of six and a girl of three, acquired  the habit of rumin-
ation from their governess,  who Avas addicted to it.   The  children were cured
by  the dismissal of  their teacher.  Other  cases of supposed mimetic origin
are  more  apocryphal; for  example, a ruminating child  of seven Avho  had
been suckled by  a goat, and a man  aaIio  had spent his life  among cattle.
   The influence of sex is decided.   Of 35  cases reported by Bourneville and
Seglas, only 5 were  females.
   The irritation of the stomach by unmasticated food and  indigestible sub-
stances is  an undoubted cause  of  the habit of rumination,  and  accounts
for its prevalence among idiots.
   The effect of irritation in producing regurgitation  is exemplified by an ex-
perience of the distinguished physiologist BroAvn-Sequard.  In  the course
of  some researches   upon digestion he Avas led  to practise  upon himself an
experiment first performed by Spallanzani, which consisted in  swallowing a
small sponge  attached to a thread for the purpose of obtaining a sample of
gastric juice.  He soon  became unable to retain  the sponge  for the short
period required,  and was obliged to desist  from further  auto-experiments in
this  direction ;  but  for   some time afterward, much to  his annoyance, the
food continued  to be regurgitated.

   Anatomical  Appearances.—There is  no uniformity in the post-mortem
appearances.  The stomach has been  found dilated in some cases, perfectly
normal in size  and  shape  in others,  while the  cardiac orifice may be either
unusually  patent  or  in no  way altered.   A dilated cardiac orifice may be an
effect as well as a cause of  the disease.

   Symptoms— The  interval between  the  repast  and the act of rumination
is  not constant.  It may  vary between  a few minutes  and an hour, but in
the average begins about fifteen  minutes after eating.  The food is returned
to the mouth in an almost  unaltered condition, and seems to be enjoyed with
a keener relish  than when first swallowed.3  This probably accounts for the
time consumed in this second mastication, which has been observed to extend
to several  hours.  Many  of those addicted  to the habit practise it after every
meal, while others  do "so  only  upon special occasions—for example,  when

  'Vide  A. Johannessen, "Ueber das AViederkauen  beim Menschen," Zeitschrift fur
klin. Med., m. 10, S. 274.                     ,,,...
  2 "Du Merveisnie," Archives  de Neurologic, 6 and  7, 1»8<J.                       ,
  » " Indeed, if is sweeter than honey and accompanied with a more delightful relish.
-Anthonv  Rechv.  I have  been unable to verify this quotation, which is from Ewald. 
382  FUNCTIONAL DISORDERS, OR NEUROSES OF THE STOMACH.

they have bolted their  food with unusual haste, or haATe  consumed an inor-
dinate quantity,  or  have taken severe exercise immediately after eating.
   The general health is usually Avell preserved.   In other cases signs of
gastric catarrh manifest themselves, this being generally due to the fact that
even the second mastication is too hastily performed.  AVhen this complication
ensues the patient complains that the taste  of the  regurgitated  food, pre-
viously agreeable, has become sour  or rancid.   The health continues  good so
long as the food  remains  pleasant to the taste, is thoroughly remasticated,
and is again swallowed.

   Diagnosis.—There is no difficulty about the diagnosis of this  condition.
From simple regurgitation it is distinguished  by the  unaltered  character of
the food and the regular recurrence of the  process after meals ; also by the
absence of signs of gastric catarrh  or dilatation.

   Prognosis.—The prognosis is good as to life and health, and as to recovery
also when the patient is willing and able to co-operate with the physician.

   Treatment.—Patients with this affection should be directed to eat slowly,
to masticate their food  thoroughly, and  to  endeavor  by an effort of  the will
to repress the muscular moA^ements associated with the habit.   This may be
aided by the dorsal decubitus  or some other position  unfavorable to the per-
formance of the act.  Bulky food, such as vegetables and bread, is inadmissible,
and the diet should consist for a time chiefly of nutritive fluids.   The inges-
tion of small pieces of ice  after meals has been attended with benefit, and  is
supposed to act by improving  the tonicity of the stomach.   Tonics and pur-
gatives  have seemed  of service in some cases,  and  probably exert  their ben-
eficial  action upon any underlying state of asthenia that may  be present.
Strychnine should be given a thorough trial.   Bourneville and Seglis are of
the opinion that where the affection  has  existed  for  many years  without
impairment of health, it  is unwise to attempt to suppress  it; but surely
the risk of a temporary impairment of health  should not be admitted as an
excuse for persisting in so disgusting a habit.—H.]


                  [Incontinence of the  Pylorus.
   Definition.—For the proper performance of gastric digestion it is essen-
tial that the chyme  be retained for a certain  period  in the stomach.  The
result of its premature  escape is irritation of the intestinal mucosa and con-
sequent diarrhoea.   Such a condition has been described by Ebstein. and is
mentioned  more for the sake  of completeness than  for any practical value
that has been derived from its study.   In fact, its interest is decidedly  more
theoretical than practical, as may be inferred from the fact that Ewald, whose
experience  and knowledge of gastric  disease  is  universally  acknowledged,
declares that he is not  acquainted with the condition described by Ebstein.
Such  a  statement,  of course,  applies  solely to the functional  form of the
affection, for the form of pyloric incontinence  resulting from ulceration of a
tumor in this region is recognized by all.
   According to  Ebstein, incontinence  of the  pylorus may be recognized by
the fact that gas  generated artificially in the stomach by chemical means or
injected into the organ by means of an atomizer does  not give rise  to gastric
dilatation, but, on  the other hand, distends the intestines.   He  accounts  for
the absence of dilatation of the stomach in such cases  by the hypothesis that
the pyloric fibres yield with abnormal readiness and permit the-gas to escape
into the duodenum.  The escape of  the gas from the stomach via the  pylorus 
GASTRALGIA.
383
 is said to depend upon its  nature, carbonic acid being retained longer in the
 organ than atmospheric air.  This is believed to be due to a greater irritation
 of the pyloric muscular fibres by C02.
   Further study is needed before incontinence of the pylorus can be accorded
 a definite clinical rank among the diseases of the stomach.

                                 Atony.

   Atony as a separate disease is  an inference rather than an actual recog-
 nition.  AVe recognize it, as already seen, as the first stage of atonic dilata-
 tion, but only when that stage is  past,   The motor function of the stomach
 is  doubtless impaired in  many cases of neurasthenia, but the functions  of
 secretion and absorption are so intimately bound up with that of motion that
 it  is  doubtful  whether  atony has  an  independent  existence.  It may  be
 recognized  by  the  salol-test.  previously described.—H.]

                       SENSORY NEUROSES.

                               Gastralgia.
   Ixastralgia, 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 tAvo 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 Avrithes and groans with intense  suffering.   A sense
 of constriction  frequently accompanies  the pain.  Vomiting may occur, but
 this is rare.   (renerally,  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 1
 have met with a patient who had ahvays 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 Avhich belongs to  the history of
 gastritis  is Avanting.   Amounting 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 
384  FUNCTIONAL DISORDERS,  OR  NEUROSES  OF  THE STOMACH.
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.  (A'ide p. 284.)
  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
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.
  AVith 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-
  i Vide article on " Gastric Ulcer" by Prof. Welch in the System of Practical Medicine,
by American Authors, vol. n. p. 517. 
GASTRALGIA.
385
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  ao-e!
It is generally considered that women, much more than men, are liable to it,
but of 39 cases analyzed by A'alleix  only'20 were females.   It affects those
of  good  constitution and the robust as Avell 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
of gastralgia may recur with the regularity of the paroxysms of intermittent
fever.  I haA^e known gastralgia to take the place of the cold stage  of the
paroxysm, being  followed by the hot and the SAveating stage.  Finally, causes
which induce anaemia or lead  to debility may be more or less invoked 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.   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.  (Vide p. 98.)
   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 affection.   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.  Aloreover, 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-
        25 
386   FUNCTIONAL  DISORDERS,  OR  NEUROSES OF THE STOMACH

ninth 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 <M)e,
two, or three ounces daily.   These enormous does are not required.  What-
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
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 anaemia 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.


Polyphagia, Malacia and Pica, Polydipsia, and Dipsomania.

   These  names express morbid conditions  which relate to the ingestion  of
solids or liquids—conditions Avhich severally do not  constitute individual  af-
fections,  but which  may be the most prominent, or perhaps  the chief, ailments.
   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 Avhich  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.
387
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 Avho 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.  A'ora-
cious eating characterizes certain cases of mental derangement.  It may be a
symptom of disease attended Avith 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.
   Midacia 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 Avhich
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 Avith anaemia 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 West 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..... 
388   FUNCTIONAL DISORDERS, OR NEUROSES 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   A\ ith  them dirt-eating
proceeds from  the  same propensity Avhich  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.  Water 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 tor
drink   The quantity of urine is proportionately great, so  that this condition
is also denoted  by a term expressing the latter fact-namely, diabetes insijn-
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 Fencer's Southern Medical Reports, vol. i. 
GASTRORRHAGIA.
389
 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
 safety.   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 diff'erent individual diseases, especially those affecting the nerv-
 ous  system.

                     [SECRETORY  NEUROSES.

   These consist of anacidity and hyperacidity—meaning thereby an  absence
 of HCl  from the gastric juice, an excess of  the same  therein, or the secretion
 of gastric juice  by a fasting stomach.
   Anacidity has  been already discussed in connection  with Cancer of  the
 Stomach, and was shown to be decidedly diagnostic of that disease.   It may,
 however, occur  as a pure neurosis, and for a time give rise to great uncer-
 tainty with reference to its  true nature.   Coexisting symptoms of hysteria
 and  neurasthenia  point  strongly toward a  neurotic origin of  the condition.
 In some cases, however,  nothing but time Avill conclusively settle  this diag-
 nostic question.

                Hyperacidity and  Hypersecretion.
   These conditions,  which have been already alluded to  on a previous page,
 are due to  a too-liberal response  of the glands of the stomach to the physio-
 logical demands of the food.  The conditions are not identical, although the
 border-line  between   them is ill  defined.   Hyperacidity consists in a too-
 liberal  response to a physiological summons, while  hypersecretion is, so to
 speak, gratuitous.   In  other words, the secretion of gastric  juice during
 stomach digestion is in the former instance hyperacid, and  probably also
 excessive in amount, while in the latter the secretion is poured out uselessly
 into  an  empty stomach.   Hyperacidity is most  frequently observed  in  con-
 nection  with gastric  ulcer, and  therefore scarcely comes under the head of a
 neurosis.   Hypersecretion, on  the other hand, is a  functional nervous dis-
 order consisting of  the exaggeration of normal processes, for, as  demon-
 strated  by  the researches of  Rosin,1 the  fasting stomach contains an  appreci-
 able  amount of  gastric juice.  The limits within which the secretion of gas-
 tric juice by a  fasting stomach may be considered physiological are as yet
 unknoAvn.  It is certain, hoAvever, that  the functional gastric disorder known
 as hypersecretion  constitutes  a  well-marked pathological condition.   The
recognition of hypersecretion is  usually ascribed to Reiohmann in 1882, and
he was  undoubtedly the first to  study it thoroughly according to  modern
methods ; but, as Ewald  points out, it was recognized in 1821) by Pemberton,
                1 Deutsche med. Wochenschrift, November 22, 1888. 
390  FUNCTIONAL DISORDERS,  OR NEUROSES  OF  THE STOMACH.

who speaks of " a morbidly increased secretion from the stomach, analogous
to a diabetic  secretion  of urine by the  kidneys."   Somewhat later it is evi-
dent that Copland and Budd are familiar  with this condition.  The former
speaks of pyrosis as " produced by the continuance of the secretion of the
gastric juice after  the food  taken into the  stomach  has passed into the
duodenum," and Budd  remarks that " pain may be due to the presence of free
acid in the empty stomach."

  Symptoms.—The principal symptoms of hypersecretion are increased thirst,
acid eructations, nocturnal attacks of epigastric pain, and dilatation of the
stomach.  The  digestion of carbohydrates  is greatly impaired, while that of
the albuminous substances proceeds with abnormal vigor.   Positive proof of
the condition is afforded by the sound, employed  in  the  following manner:
The stomach is thoroughly washed out in the evening and the patient  directed
to fast until the following morning, when the sound is again introduced.  If
hypersecretion exists, a quantity of fluid varying from eight ounces to a pint
may be withdrawn.   This fluid is colorless or slightly greenish, of viscid con-
sistence, strongly acid—the acid being HCl—and digests albumen rapidly. In
a word, it is gastric juice.
  Hypersecretion is always caused  by  disordered gastric innervation,  and
occurs in two forms, the one continuous, the other  paroxysmal.  The  latter is
often a feature of the " crises gastriques " of tabes.

  Treatment.—The  chief  features  of the treatment are the  methodical
washing out of the stomach,  preferably just before the  principal  meal, and
the employment of alkalies and alkaline mineral waters.   In no other affec-
tion is lavage of the stomach more  beneficial. The diet should consist almost
entirely of albuminous substances, and  the thirst, often  excessive,  may be
assuaged by bits of ice, for it is an important point that the dilatation of the
stomach so frequently present should not be maintained by a too-free ingestion
of fluid.   So important is this considered by Riegel that he advises the use
of small  doses  of opium to  obtund an  overpowering sense of thirst.  To
obtain good results  from alkalies  in this  affection, they must be given in
large doses, for, as is well known, a small dose of  an alkali is followed by an
increased  secretion  of  gastic juice.   Sir  AVilliam Roberts of Manchester,
observing a profuse flow of saliva in  cases of :' acid  dyspepsia," to which
he  himself was  subject,  and believing this to be  a provision of  nature for
relieving the surplus activity of the stomach, recommends in such cases the
use  of sialagogues, such as gum lozenges containing a small amount of  gin-
ger, cayenne pepper, or pyrethrum.  He has thus experienced relief in his
own person,  and  given it to  others.

                          MIXED FORMS.

                        Nervous  Dyspepsia.
   Etiology.—Nervous dyspepsia has acquired a permanent position in nosol-
ogy since  its introduction by Leube in 18T9,1 although his  conception of the
affection has undergone  some  decided  modifications.   Leube supposed the
chemistry of digestion to be always  normal in nervous dyspepsia,  whereas
numerous exceptions  to this rule are  now recognized.  For example, the
states of anacidity, hyperacidity, and hypersecretion  above described, when
unassociated with any  demonstrable  gastric lesion, are merely symptoms of
nervous dyspepsia.  A certain number of cases, however, undoubtedly  come
under Leube's too-exclusive definition, and can only be ascribed to an abnor-
                 1 Deutsches Archie fur klin. Med., Bd. 23, 1879. 
NERVOUS DYSPEPSIA.
391
mal  excitability of the sensory gastric nerves.   With improved methods of
research an anatomical basis for all these apparently functional disorders may
yet be discovered, and there can be no doubt that a certain number of them
are due to' degeneration of the nerves supplying the stomach.   The remark-
able observations of Jiirgens have established this fact beyond question.   In
II cases in which during life there had been vague symptoms of gastric dis-
order such as would be  ascribed to nervous dyspepsia, Jiirgens found total
degeneration of Meissner's and Auerbach's plexus.
   Nervous dyspepsia seldom exists alone, but is in most instances a part of
a general  state  of neurasthenia or a reflex manifestation of  cerebro-spinal or
uterine disease or intestinal  parasites.   It may also depend upon constitu-
tional  states such as anaemia, chlorosis, syphilis, and malaria.  A certain
number of cases  are undoubtedly toxic,  and depend  upon uraemia, lead-poi-
soning, or the  excessive use  of tobacco.

   Symptoms.—The chief  symptoms are  eructations—which, unlike those
of gastric catarrh, are mostly tasteless and odorless—a sense of fulness and
pressure  in  the  epigastrium, and pain  which  is often  independent of the
nature  of the  food.  A  glass of water  even may give  rise to pain.   As a
rule, however,  the discomfort  after eating is most marked after the principal
meal of the  day, and is most readily induced by fatty and  acid articles of
food.  Pyrosis  is a symptom of nervous dyspepsia, and is sometimes peculiar
in being associated Avith a sub-acid state  of the  secretions.  Aromiting is rare,
and when it occurs the  matters  vomited consist mostly of small quantities
of mucus  mingled with bile and undigested articles of food, to which a bitter
taste is imparted by peptone, and not,  as  usually supposed, by bile.  A ca-
pricious appetite  is a characteristic feature of many of these cases.   There
may be complete anorexia alternating  with periods  of  hyperorexia or bou-
limia.   This morbid appetite may suddenly manifest itself at the most unsea-
sonable hours,  as in a case reported by Decker l in  his  excellent article on
dyspepsia.  The  individual in question  was constantly roused from  sleep by
a sense of hunger which he was obliged to appease with a hearty meal com-
posed of soup,  eggs, cold beef, etc.   Insomnia is a frequent symptom of the
disorder,  whereas, on the  contrary, in quite as many  cases the  patient is
habitually droAVsy.   Mental lassitude, low spirits, and loss of memory are fre-
quently complained  of.   AVith reference  to the stools, there is nothing charac-
teristic beyond  the fact  that they are seldom regular, a state of constipation
often alternating  with  diarrhoea.

   Diagnosis.__The diagnosis is made by the exclusion of cancer, ulcer, and
catarrh.   The chief difficulty  is in distinguishing this condition of neurasthe-
nia from one of chronic catarrh, but there  are certain points which, if borne
in mind, will prove of gTeat value  in this differential diagnosis.   In catarrh
the feelings of pressure and fulness are  experienced directly after  eating and
reach  their maximum when digestion is at its height,  whereas m nervous
dyspepsia  these  symptoms are very variable with reference to the time of
their appearance, and are often relieved by  eating.  They may also disappear
for weeks  or even months.  The appetite in nervous dyspepsia is  as already
stated, capricious, whereas  in  catarrh it  is permanently absent.   The degree
of anaunia is  never so great as  that commonly present in cases of cancer,
and the pain differs  from that of  ulcer  in being more diffuse.   The absence
of haematemesis is important negative evidence in favor of nervous dyspepsia,
and  the presence of  symptoms of  general  neurasthenia  is  strongly corrobo-
rative  of  its existence.
                  1 Miinchener med.  Wochcnschrift, May 28, 1889. 
392   FUNCTIONAL DISORDERS,  OR NEUROSES OF THE STOMACH.

  Prognosis.__The prognosis  should always be made with reference to the
presence of coexisting nervous derangement or peripheral nervous irritation.
Pronounced symptoms of nervous dyspepsia have ceased on the expulsion of
a tapeAVorm or the  relief of uterine  disease.  As a  rule, the affection is apt
to become  chronic, and  when  apparently  cured  is  liable to recur.

  Treatment.—The treatment of nervous dyspepsia must vary with  the
cause producing it.   One case  will be cured by restoring  the uterus to its
normal position ; another, by relieving a chronic constipation  or expelling a
tapeworm ; still another, by allaying an irritation of the spine.  A restricted
diet or one of milk  only, which is frequently beneficial in catarrh, is of little
or no benefit  in cases of nervous dyspepsia.  General  supporting measures,
massage, electricity, the bromide salts, and, if anaemia  exists, arsenic and a
mild, non-constipating  preparation of iron, such as  the albuminate or potas-
sio-tartrate, are the chief indications.   The chlorine  salts  of iron are believed
by Ewald  to be especially useful in cases of anaemia associated with nervous
dyspepsia.  The sesquichloride may be given in pill  with quinine and arsenic,
the  latter  preferably  in the  form   of  arsenic  acid, as recommended  by
Liebreich.  This form  of arsenic seems  to be better tolerated than the solu-
tion  of Fowler so commonly prescribed.
  Of topical  measures, the best is  lavage with warm  water, which often
proves remarkably soothing to  a hyperaesthetic mucosa.  The certain relief
which may be derived from opiates, chloral, and occasionally from cocaine, is
attended with so  great risk as regards subsequent  addiction  to the use of
these drugs that  they should be prescribed only to meet temporary indica-
tions or be dispensed with altogether.  Remarkable results have been obtained
in these cases by the rest-cure as inaugurated by Weir Mitchell and adopted
by Playfair in England and Burkart, Leyden, and others in  Germany.  With-
out entering into minute details, this  treatment may be said to consist of abso-
lute rest, mental and bodily, isolation from over-sympathetic friends and rela-
tions, passive  exercise in the form of massage and faradization of the muscles,
and a diet which is  carefully regulated as to quality and steadily increased in
quantity up to the  point of tolerance.  The best test of this method is the
scales, which, if it is successful, show a rapid gain in weight.  If the bodily
weight does not speedily increase, the method should be abandoned; but such a
contingency can scarcely result  from anything but a mistaken diagnosis.—H.]

  [The two following articles are retained among the functional diseases of the
stomach, where they were placed by the author. Strictly speaking, they are mis-
placed, and yet their consideration in this connection is most natural, both being.
prominent symptoms of various diseases of the stomach and other organs.—H.]

                           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 
GASTRORRHAGIA.
393
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 sAvalloAved  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  portae from  a thrombus or the pressure of a  tumor.  It may be caused
by aneurisms or by  varices  of  the  gastric blood-vessels.   It coexists with
hemorrhage in  other  situations in cases of purpura hamiorrhagica 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 anaemias and  in
malaria.   It  may occur  in place  of the  menses in cases of  amenorrheea.
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.2  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  haemor-
rbagica, 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 (melama  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
                       1 Vide p. 181.
                       z ATide Clinical Medicine,  p. 2o3. 
394   FUNCTIONAL  DISORDERS,  OR  NEUROSES OF THE STOJ
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, anamna, 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 Avithin the stomach if not vomited passes into  the
intestines and is discharged by stool (melaena).  Hemorrhage  into the stom-
ach  has  been known to occur and death  to take  place from, the loss of blood
without  any vomiting.
   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.  With 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 j>er 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 diff'erent situations
over the  abdomen.  Hot, stimulating foot-baths are useful by way of revul-
sion.  Haemostatic 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  Avith 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 
                              INANITION.                           395

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  anaemia  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 clanger, patients
may recover even when the loss of blood occasions prolonged  syncope and
extreme  anaemia.  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, Aylien there  are no grounds, aside from hemorrhage, to  suspect
gastric ulcer, and Avhen 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
usually associated are wanting.   The microscope may be of use in the detec-
tion of this  kind of deception.   Bennett cites a case in  Avhich a specimen of
blood Avhich 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 anamiia is disproved  by the fact  that  it
persists after the amemic 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
feAy 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 Avith 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 Avhen  abstinence is protracted for only  a few hours
after  the sense of hunger indicates  the need of food.  Every one knoAvs 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  Aveakened, listlessness and hebe- 
396  FUNCTIONAL DISORDERS, OR NEUROSES OF THE STOMACH.

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, hut the
dietetic  treatment of most diseases  contributed to inanition.  The writings
of Graves led to the employment of alimentation in fevers.   It is not less
important  in all other  diseases which  tend  to destroy life  by asthenia.
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 Cbossat, "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 diff'erent 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 
ACUTE  DYSENTERY.                      397
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 less
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, wdiich 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 Avith 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.
   Want 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.
                        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.

                          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
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.
  'Vide "Essays on Conservative Medicine," by the author, American Journalof the
Medical Sciences January and October, 1863.  Vide, also, essay on "Alimentation in
East» New York Med. Journal, 1867, and the work entitled Essays on Conservative
Medicine and Kindred  Topics. 
398       INFLAMMATORY DISEASES OF THE INTESTINE.

  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 caecum, 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
hyperaemia, 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  e\Tident  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 sAvelling 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-Avhite 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
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  agininated 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  broAvnish pigmentation may 
                            ACUTE DYSENTERY.                   399

 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 hyperaemia,
 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 Lieberkuhn,
 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 Lieberkuhn ; 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 Lieberkuhn.  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 mere 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 (oedema).   As already said,  the accu-
 mulation of lymphoid cells may  be sufficient to compress the tubules of Lie-
 berkuhn.   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 Avhich 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
 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 behyeen its lesions and those of diphtheritic 
400      INFLAMMATORY  DISEASES OF THE INTESTINE.
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 Virchow, 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
caecum, 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  Lieberkuhn.  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,
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
caieful inspection may  reveal  traces  of the glands of Lieberkuhn.   These 
SPORADIC DYSENTERY.
401
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.
  When 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.   The cicatrix is composed of dense  fibrous tissue, covered with epithe-
lium 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 intestine, followed by grave  and even fatal symp-
toms, is  produced  by the contraction  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 diarrhoea ;
that  is, more or less frequent and  loose  dejections of  a feculent character.
Of 33 recorded cases which I  have analyzed Avith 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.2   With 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
  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  Sun/ical History of the War of the Rebellion, Washington,
1879.
  2 Clinical Report on Dysentery, based on an analysis of 49 cases, by the author, 1853.
        26 
402      INFLAMMATORY DISEASES  OF THE  INTESTINE.
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, inuco-sanguineous, sero-sangmneous,
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  yellowisb
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 shoAvs 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.   AVhen 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.  When 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 haATe been compared to raAv minced meat,  and
the yellowish-red fluid  containing them  was called by the older writers lotura
carnin,m.  The  microscopical examination of these shreds and particles  fre-
quently shoAvs 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
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. 
SPORA DIC D YSENTER Y.
403
 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 Yirchow, they are colored blue with iodine, and are, in reality'
 undigested granules of starch.  Woodward 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 frequent 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  leucorrhaea 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
 ahvays 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  Avhen  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  affection, the local and gene-
 ral phenomena which make up  the clinical history being symptomatic of this
 affection.   The pathological  character of fhe intestinal affection is the same
 in the sporadic  as  in the epidemic form  of the disease.
   Writers  have  described diff'erent 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 
404      INFLAMMATORY DISEASES OF THE  INTESTINE.

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.   Variations 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
loAver 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 Avell  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 Avhich 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.
  Writers 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.   [Numerous  attempts have been made to  establish a
causative relation between certain organisms  found in the large intestine and
dysentery, but  with  one exception they  have  thus  far  been unsuccessful.
In  1859,  Lambl of   Prague observed  an  association  between an amoebic
organism  and . dysenteric  inflammation.   This observation was confirmed in
1875  by  Losch of St. Petersburg, Avho  gave  the  organism the name  of
amoeba  coll.  The  most extensive investigations of the  subject of :-amoebic
dysentery " have been made by Kartulis of Alexandria, Egypt,  who found
the amoebae in more than five hundred  cases of tropical dysentery, and never
in any other  form  of diarrhoea.   On the other hand, Lewis and Cunningham
have found amoebiform organisms  in  the discharges of cholera, in those of
diarrhoea,  and even in the healthy intestine.  Osier was the first in America
to detect 'the amoeba coli in the evacuations of a dysenteric patient and in
the pus of an hepatic abscess with which the case Avas complicated.  Numer-
ous cases of " amoebic dysentery " have been since reported by Councilman
and Lafleur,  Stengel,1 Dock, Musser,  and others.
  The weight  of present opinion is  undoubtedly in favor of the view that
  1 Stengel's observations were made in cases in the writer's  wards at the Philadelphia
Hospital in the autumn of  1890. 
SPORADIC DYSENTERY.
405
 there is a  distinct form of  dysentery dependent upon the presence of the
 amoeba coli.
   Councilman thinks it possible  that the bacillus  coli communis  may be
 concerned in the production of so-called secondary dysentery—i. e. dysentery
 occurring in late stages  of exhausting chronic diseases.1—HI

   Diagnosis.—The diagnosis of dysentery involves  no difficulty.  The cha-
 racteristic  evacuations are pathognomonic.  It is to be discriminated  from
 cases of bloody evacuations  and  irritation of the rectum incident  to  hem-
 orrhoids, intestinal hemorrhage or melaena, 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.  [A search should  be  made
 in all cases  for  the amoeba  coli.—H.]

   Prognosis.—Sporadic dysentery in temperate climates tends to recovery.
 It is a distressing  disease, but is  attended with little danger  to  life.  A
 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.  With 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 Ayere 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 seATeral 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 diff'erent methods  of treatment were  employed,  gave about
 the same duration in the cases ending in recovery.2   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 Avithholding  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 eff'ectually removed, in order to prevent their continued
passage over the inflamed surface, and to secure so far as may be that import-
  1 Trans. Association of American  Physicians, vol. vii. p. 122.
  2 Vide " A Contribution toAvard the Natural History of Acute Dysentery," in the Am,
Journ. of Med. Sciences, July, 1X75, and a clinical report based on analyses of 49 cases, in
the Buffalo Med. Journ., July, Aug., Sept., and Oct., 1853. 
406       INFLAMMATORY DISEASES  OF  THE INTESTINE.

ant end in ihe treatment of all inflammations—namely, rest  of the  inflamed
part   It would seem  that nature  endeavors to relieve the bowels of their
contents bv 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.  With 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 bv  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
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 Mosler.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 Avith the inflamed surface.
The method claims trial sufficient to  determine Avhether 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.
  [The medicated solutions employed with  the  best results in the treatment
of dysentery are those containing corrosive  sublimate  (1 : 5000), nitrate of
silver (1  or 2  grains  to  the ounce), boracic  acid, and quinine.  The  last,
in the  strength of 1 : 5000  and 1 : 2500, is  believed by Councilman and
Lafleur to  be particularly efficacious in  the treatment  of amoebic dysentery,
this opinion being  based  upon the fact, first  observed by  Lbsch,  that the
amoebae are killed outside of the body by a quinine solution  of  the strength
of 1 : 5000.   From  a pint to a quart of the quinine solution may be injected
thrice daily.—H.]
               1 Deutsches Archie fur klin. Med., 1875, Bd. 15, p. 233. 
SPORADIC DYSENTERY                    407
  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 poAvder, 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 belieATe, 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 ATarious vegetable astringents, such as rhatania, kino, catechu,
haematoxylon, etc., are useful  as adjuvants.   These are to be relied upon, te
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 ansAvers  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.   With 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.
      1 Vide article on dysentery in A System of Medicine, edited by Eeynolds. 
408      INFLAMMATORY DISEASES OF THE INTESTINE.

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.   With 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-
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 
EPIDEMIC D YSENTER Y.
409
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 c;ucum  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 lotura carni.um 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
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 different 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. 
410      INFLAMMATORY DISEASES OF THE  INTESTINE.

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 Avith 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
fatal issue, the collapsed condition  occurring  perhaps in the course  of a feAV
hours.   On the other hand, cases may be protracted to the third and fourth
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 Avorld 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 d'is-
  1 Vide Woodward, second medical volume  of Med. and Surg. History of the War of
the Rebellion, AVashington, 1879. 
EPIDEMIC D YSENTER Y.
411
 cussion of this question I shall content myself with saying that the evidence
 of communicability 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 A'irus 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 shoAvs  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 diff'erent 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-
 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 diff'erent 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 Avith dysen- 
412
INFLAMMATORY DISEASES OF  THE INTESTINE.
tery characterized by  abundant sero-sanguinolent  dejections,  for the  space
of a week, without at any time symptoms denoting narcotism.  1 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
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 Avith  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  Avith 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 betAveen 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.   Woodward even takes the ground that
no distinction  is admissible.  He says •}  " The results of  any attempt to sub-
   1 Woodward, second medical  vol. of the Med. and Surg. History of the  War of the
Rebellion, Washington, 1879, p. 483.                                       J 
CHRONIC DYSENTERY.
413
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 Ayith which I am acquainted,
would not be found to  correspond  with any anatomical classification."  He
therefore  includes under the name chronic diarrhoea  all the chronic  alvine
fluxes Avith the  exception  of those resulting  from  tuberculous ulceration
of the intestine;  but, as in many other, processes Avhich 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.   Tj^pical cases  of  chronic diarrhoea, 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
the war in Mexico, large numbers Avere affected with this disease, and during
the late civil war cases were abundant among the soldiers sent to the Northern
military hospitals from diff'erent 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  follicles.   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-
kuhn.   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 groAvth 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, hoAvever,  less tendency  toward the
development of new fibrillated connective tissue  in chronic  dysentery than
in the  chronic inflammation of most mucous membranes.  Hence, complete
              1 Archives de Phys. norm,  et path., 1873, pp. 406 and 573. 
414      INFLAMMATORY DISEASES OF THE INTESTINE.
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 Woodward.   Swelling and ulceration  of the fol-
licles, however,  frequently occur without any such growth.1
   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
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.   When 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  depth 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 (Woodward).'  Allusion has  already been
made to the occasional  occurrence of  stricture of the intestine  from contrac-
tion of the cicatrices resulting from dysenteric  ulcers.   Waxy  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,
  1 Kelsch  (loc.eit.)  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 Brueke's muscle and infiltrate also  the submucosa.  The  disease be-ins
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 bied
upon an insufficient number of cases.                                      e udseu. 
CHR ONIC D YSENTER Y.
415
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.   Woodward 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 tAventy-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 Avhole  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
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 uraemic
coma and convulsions are rare.  Woodward 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  diarrhoea,  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
                                 1  Op. cit. 
416      INFLAMMATORY DISEASES  OF  THE INTESTINE.
to be discriminated from ulceration of  the large intestine duetto 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.   We 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 wili  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.
Whatever 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
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
Avith 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, rhatany, 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
  1 Vide New York Med. Journ., Jan., 1876, and the author's Clinical Medicine p  292
et seq.                                                              ' r 
  INFLAMMATION AND PERFORATION OF THE CJECUM,  ETC.  417

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^vhich 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 caecum, the  inflammation  limited to this  portion of
the large intestine, constitutes an affection called  typhlitis, typhlo-enteritis, or
csecitis.   Acute inflammation confined to the ea?cum  is not of frequent occur-
rence.  The symptoms are—pain and tenderness within a circumscribed space
corresponding  to the situation of the caecum, with vomiting, sometimes  con-
stipation and sometimes diarrhoea, and febrile movement.    It is liable to be
confounded Avith 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 ca?cum,may accom-
pany the affection.  The pain and  tenderness are then  more marked, and the
caecum 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 caecum.  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 caecum  not  invested
with the peritoneum, the gaseous and other contents of the intestine, escaping
into the areolar tissue,  give rise to inflammation Avhich 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,  Avhich become sAvelled, pitting on pressure as in oedema, with  a feeling
of crepitation due to the permeation of intestinal gas.  If an  incision be made,
       27 
418       INFLAMMATORY DISEASES OF THE INTESTINE.
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 caecum, 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  caecum,
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
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 caecum.  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  caecum 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.
Within 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 caecum, distinguishes
this abscess from phlegmonous suppuration, which is  primarily extra-csecal;
  1 Vide an analysis^of 32 cases, by Prof. Roberts Bartholow, in the Amer. Journ. of
Med. Sciences, Oct., 1866.                                                    J 
      INFLAMMATION, ETC. OF THE VERMIFORM APPENDIN.   419

that is, not  secondary  to  perforation.   An  abscess, hoAvever, originating  in
either the connective tissue behind the caecum 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 caecum 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 folloAV 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. Willard 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
the  treatment of perityphlitic or fecal abscess.  (Further  details belong  to
surgery.2)
   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
                           —Appendicitis.

   The appendix is, in  fact, a part of the caecum, but inflammation and  per-
foration here  may occur independently of any affection of the caecum  proper.
The term typhlitis is applied to  inflammation of the vermiform appendix as
well as to c;ecitis.   Perforation of the caecum 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 caecum 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.3   Whenever
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 Caecum," 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

  •Vide Clinical Medicine.
  2 For a table of 60 eases, with operations and results, collected by Dr. William L. \\ ey,
vide  Trans, of Med. Soc. of the Slate of New  York, 1880.
  » N Y. Med. Record, April 12, 1884. 
420      INFLAMMATORY DISEASES  OF THE  INTESTINE.
 made  and a calculus remoATed  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 caecum than
 with diseases of the latter.   The treatment is that already considered in con-
 nection with inflammation  and perforation  of  the  caecum.
   An  important question  is, whether in cases  of intestinal perforation lapa-
 rotomy be not admissible with a ATiew 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  tAvo 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
 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 caecum.  I  have seen a specimen  in which
 the appendix was attached to the bladder  and perforation had  taken place,
 causing 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.
  [McBurney lays great stress upon the diagnostic importance of determin-
ing the seat of greatest pain on pressure.  In every case  under his observa-
tion "the  seat of greatest  pain determined by the pressure of one finger  has
been very exactly between an  inch and  a half and two inches from the ante-
rior spinous process of the ileum, on a straight line drawn from  that process
 to  the umbilicus.   This may appear to be an affectation of accuracy  but so 
     INFLAMMATION,  ETC.  OF THE  VERMIFORM APPENDIX.   421

far as my experience goes the observation is correct."1  " McBurney's tender
point" is  now ranked among the diagnostic signs of appendicitis.__H.]
   Pain or uneasiness  referred  to  the  right iliac fossa, without other symp-
toms_ of  disease, should  always  excite  apprehension in  the mind of the
physician.   Rest should be enjoined and cathartics avoided.   By these pre-
cautions, if  patients seek advice prior to perforation, its occurrence may per-
haps be prevented.

   [The treatment  of appendicitis depends to some extent upon whether
the  attack  is the first from which the patient has suffered.  If it is  he
should be compelled to keep  in bed  with an ice-bladder applied over the seat
of pain and tenderness, while the diet is limited to milk and animal broths.
In case of  constipation the  bowels should be moved with  small (fractional-
grain) doses of  calomel.  The greatest difference of opinion exists concern-
ing the use of opium in this  disease.  Surgeons, for the most part, are de-
cidedly averse to its  employment, while many physicians are accustomed to
prescribe it  in full  doses.  The truth doubtless lies between these extremes.
The  tranquillity of mind, the relief  from pain, and the sleep obtained by the
judicious  use of opiates exert a  favorable influence upon  the course of the
disease.   On the other hand, some surgeons contend  that the relief obtained
by opium and its alkaloid  morphia  induce a false sense of  security and lead
to the postponement of surgical  measures to a period  when they are em-
ployed under disadvantageous circumstances.   Opium, however, need never
be given  in closes  sufficient  to produce a state of narcosis,  and even if pain
and tenderness are  completely  abolished by it, it must be borne in mind that
these are not the  only symptoms  of  appendicitis.  The febrile  movement
and  the  physical signs of  the  local affection, such  as tumor, induration, and
dulness on  percussion, continue in spite of the use of opium, and afford the
most reliable indications concerning the progress of the case.  The prejudice
against opium on the  part of surgeons is doubtless  partly attributable to the
fact that they are  generally called in by physicians to decide upon the ques-
tion  of operation, and frequently  are called  too late.  They see the cases in
which  medical  treatment  has failed, and  are  apt  to conclude that medical
treatment is always useless.   They  do  not see the numerous cases in which
a cure has been obtained  by strictly medicinal means.   It  must be acknow-
ledged, hoAvever, that the majority of cases—probably two-thirds—sooner or
later demand surgical  treatment, and it is desirable, therefore, to be acquainted
with certain general rules by Avhich  such cases may be recognized.   The fol-
loAving have been formulated by  Prof. Fitz of Harvard :
   Surgical treatment  is indicated for " urgent  symptoms  (rising pulse and
temperature, increasing distention,  and spreading  pain)  with or  Avithout a
tumor, and  for  a  tumor  with or  without urgent  symptoms.   Recurrent
attacks should  be treated  as first attacks.   If recurrence  is so frequent as
to debar the patient from the enjoyment of life or the ability to earn a living,
removal of the appendix between  the attacks should be advocated."—H]


                          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 Avith propriety included among
the infectious diseases, using  the  term  infectious in the sense now generally
adopted.   The terms  colitis  and proctitis may be applied to inflammation in
the colon  and in the   rectum when  it occurs irrespective of a special causa-
                   1 New York Medical Journal, Dec. 21, 1889. 
422      INFLAMMATORY DISEASES OF THE  INTESTINE.

tion.  These terms will  then correspond to the ordinary catarrhal inflamma-
tion of  many authors.
  Colitis, in this  scope  of the term, is  rarely acute, but 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 m  the  small intestine
(enteritis).  In the cases among soldiers grouped by Woodward  under the
name of Acute Diarrhoea, inflammation affected especially the large intestine.
The local symptoms are colicky pains, diarrhoea, 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
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.    Diarrhoea is Avanting, 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
membraniform casts of the intestinal tube.  These have been observed a foot
and more in length.  They have been supposed to be the mucous membrane
itself 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 Wm. H. Welch, 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 diarrhoea, 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  Woodward
gives the preference, as implying no theory.   (The reader is referred to the
               1 American Journal of the Medical Sciences, Oct., 1871. 
ACUTE  ENTERITIS.
423
  Medical History of the War of the Rebellion, p. 363, for a full reference to 'he
  literature of this curious intestinal affection.)


                             Acute Enteritis.

    The term enteritis signifies, literally, intestinal  inflammation.  Various ti$r-
  nifications have been  attached  to  it by different writers.  The older writer*
  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-
  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 Avords dysentery and colitis names for inflammation of
  the large intestine, it  has become a conventional usage in this country, and to
  an extent elseAvhere, 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 cases here described as enteritis  the
  inflammation is most intense in the ileum, the caecum, 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. 398).  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 Avith  mucus
 and muco-pus.   An increased transudation of serum occurs, Avhich, combined
 with rapid peristole, causes fluid stools.  The mucous and submucous tissues
 are swollen in consequence of oedema, 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  SAVollen
 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 caecum,  and frequently diarrhoea, 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.   Diarrhoea 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 
 424       INFLAMMATORY DISEASES OF THE INTESTINE.

 dysentery are wanting.  I have met with fatal cases in Avhich diarrhoea had
 not occurred, the inflammation having been limited  to the small intestine, as
 shown  by the  autopsy.   If diarrhoea be a prominent symptom, it probably
 denotes an extension of  the inflammation into the caecum and colon.   A^omit-
 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
 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 diarrhoea.  These  points are sufficient for its exclusion 
SUBACUTE AND  CHRONIC ENTERITIS.
425
    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.  Diarrhoea! 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-
 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 cases is not a
 disease of great  gravity.   If  it be not  associated with  any other important
 affection, 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 diarrhoea.  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 Avater-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-caecal 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 diarrhoea ; nor is it of much practical  consequence to make
this discrimination, since the indications for treatment in either case do not
materially  diff'er,  embracing mild purgation, followed by anodyne  remedies
and  regulation of the ingesta.
   Enteritis, acute, subacute, and chronic, is described by some authors under 
426      INFLAMMATORY DISEASES OF THE INTESTINE.

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 diarrhoea
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
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, but they are less
marked.  Constipation may alternate with diarrhoea. • As regards  treatment
the  cause should  be, as  far as possible, removed.   This involves in many
cases the treatment of a prior morbid state.  [In  the  so-called idiopathic
cases—i. e. cases  in which the  cause is not ascertainable—benefit may be
derived from the  alternate use of  saline cathartics and intestinal antiseptics.
The former deplete the vessels and empty the bowel of stagnating contents,
while the latter counteract the putrefactive  processes which exert so  inju-
rious an effect upon the intestinal mucosa.  The best intestinal antiseptics
are thymol, naphthalin, and bismuth  salicylate.   The  diet should be limited
to animal broths and tender beef,  mutton, and chicken, and it is  often advis-
able to inaugurate  the treatment with an exclusive diet of  skimmed milk—
from three pints to two quarts daily.  This, with  a little toast or " zwieback,"
will support the patient, proA'ided he be kept at rest, until it  is thought advis-
able to give  the articles above mentioned.   Fatty materials  should be dis-
carded from the  diet as far as possible.   Astringents, such as acetate of lead,
nitrate of silver, gallic acid, and the  styptic  salts  of iron, are of little  more
than temporary benefit unless preceded by the course above outlined.—H] 
INTESTINAL  ULCERS.
427
                         CHAPTEE  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.—Rotation 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 caecum, the sigmoid flexure,
 and the  rectum.   Simple  inflammatory ulcers, also called  catarrhal,  have
 been treated  of in  connection  with  dysentery  and Avith  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
 caecum, vermiform appendix, and sigmoid  flexure.  They have  been consid-
 ered  in connection with  typhlitis (see p. 417 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 be considered in the next article,
 under the head of Duodenal  Ulcer.  Dysenteric  ulcers  have already been
 described.  The so-called  uraemic  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,
 in view of the fact that these ulcers have been produced  by feeding animals
 with tuberculous  substances.   Tuberculous ulceration  affects by preference
 the loAver 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 
428         STRUCTURAL DISEASES OF THE INTESTINE.
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 ATessels.   As a rule, they
present the typical giant-celled  structure.   Woodward  describes  a trans-
verse puckering  of the  mucous  membrane in the neighborhood of tubercu-
lous 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 be 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
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
                   1 Lecons redigees par Ch. Porak, Paris, 1875
                   2 Wiener Med. Presse, 1878, No. 41. 
DUODENAL  ULCER.
429
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 diarrhoea, 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  e\ren 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 are 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 fort}7,  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
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 aac.
  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 
430        STRUCTURAL DISEASES  OF THE INTESTINE.

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, cedematous, 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.  When 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 effect*  follow.
   The  symptoms have been studied  chiefly by  Gerhardt and by Kussmaul.3
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 be  explained by an inde-
pendent disease of the intestine or by portal  obstruction.   3.  Kapid 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.
                 1 Virchow's Archiv, 1875, Bd. 63, S. 2S9.
                 2 Wiirzburger medic. Zeitschrift, 1864, Bd. 4 u. 5. 
            WAXY DEGENERATION  OF  THE INTESTINE.        431

  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 Avine, 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 Avhether 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 be 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.

             Waxy Degeneration  of the  Intestine.

  The intestine as well as the stomach is not infrequently the seat of this struc-
tural 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 mucosae was predominantly affected.  Waxy
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 
432        STRUCTURAL DISEASES OF THE INTESTINE.

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.
  Waxy degeneration  maybe inferred when  diarrhoea 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, shoAved 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 be first considered, and
afterward obstruction by causes which do not occasion strangulation.


                           Intussusception.

  Intussusception, or intestinal invagination, is the reception of one portion
of  the  intestine  into another portion.   Generally,  the invagination is from
above doAvnward, 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
             1 British and Foreign Medico-Chirurg. Review, October, 1857. 
INT USS USCEPTION
433
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
then 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, 63 were of
this class.   An analysis of 600 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  Avith  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 be 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 caecum.   This is shoAvn
in cases of children by  the statistical researches of J. LeAvis 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-c;iecal 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
brings down more and more of the ileum Avith  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  caecum  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-caecal valve.  These two forms of invagination—that in which the
ileum,  passing through the ileo-caecal  valve, successively inverts and draws
after it the caput coli and the divisions of the colon, and that in which ths
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

  1 Vide 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., 1S62. Vide also
Smith on the  Diseases of Children.
        28 
434        STRUCTURAL DISEASES OF THE INTESTINE.
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-caecal in 56 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-caecal 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 aAvay  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. Van   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 New York Academy of  Medicine,  in 1865, 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.
William  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.
  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
  1 Vide Bulletin of the New York Academy of Medicine, vol. ii. Nos. 25-29.
  2 Vide article on " Internal Strangulated Intestine," by Elisha Harris, M. D.  in New
York Journal of Medicine, 1853. 
                          INTUSSUSCEPTION.                       43.5

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 ha\^e
been evacuated there  is persisting obstipation, save  in a few exceptional cases.
Previously there is usually diarrhoea, 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 affection.  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 fayorable 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 Ayhole 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.   Male children are somewhat more liable to it than  female, the relative
proportion in Smith's cases being  32 to 22, and in  Haven's 5!) 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 
436        STRUCTURAL DISEASES OF THE INTESTINE.

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 Leichtenstem, in  the majority of
cases between the eleventh and the tAventy-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 twc
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
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 SAVollen 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
      1 Vide article by Heineman, Archives of Medicine, Niew York, August, 1880. 
INTUSS USCEPTION.
437
exist.  These measures for reduction are of no avail if the seat of the invagina-
tion be above the ileo-caecal valve.
  Exclusive of measures for reduction, the objects of treatment are to secure
as much quietude of the intestinal canal as possible, to palliate sufferins:, 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 Avith 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 Avithout 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 aAvay 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  Avith 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.   Within 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 1877, operated successfully in the case of an infant six months
old, eighteen hours after the occurrence of symptoms denoting invagination.
In  connection with his  report  of this  case he gives an analysis of 20 cases
collected  from different sources, in 7 of which  the operation  was successful.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.
  1 Vide New York Medical 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 London Med. Times and  Gazette,  Xo. 29, 1873, and in the New York
Med. Record, January 15, 1874. Pevrot  has collected 23  cases, of which 9 recovered:
De l'Intervention chirurgicale dans IObstruction intestinale, Paris, 1880.  11ns work con-
tains an analysis of 125 laparotomies for intestinal obstruction. 
438        STRUCTURAL  DISEASES OF THE INTESTINE.

  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. Welch  has met with an  instance it:
which fatal peritonitis was thereby induced, fecal gas and thin feces escaping
into the peritoneal cavity.
  Keference  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 Avas felt.  The  finger, after con-
siderable effort, was passed into  the latter, and two quarts of pasty feces  were
subsequently voided.  Eleven days aftenvard a solid body was felt at the open-
ing of the invaginated bowel. This Avas 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 boAvel  was speedily
effected  by the injection  of carbonic-acid water in large  quantity.   This
patient was seen  by me in consultation.1  Jonathan Hutchinson  relates the
case of a  child in whom  the  invaginated  bowel  extended several  inches
beyond  the anus.   The  case  had  been 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  caecum.


  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 caecum 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-
caecal valve.  From its extremity a solid cord containing the remains of the
omphalo-mesenteric vessels may pass to the umbilicus.  Bands of adventitious
membrane, resulting from peritonitis, may leave spaces for hernial protrusions.
ATarious 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 duodenojejunal
hernia, of Avhich  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 duodenojejunal fossa, Avhich normally is a small pouch situ-
ated in front of the vertebrae, at the beginning of the mesentery.   A crescent-
shaped  fold of peritoneum, passing over the duodenojejunal flexure, bounds
the free opening of this  fossa,  which is directed upward.   All  of the  small
  1 For the report of Dr. Leale's case, vide New York  Med. Record, November 22, 1S79. 
     STRANGULATED HERNIA WITHIN THE ABDOMEN, ETC.  439

intestine has been knoAvn 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 Winslow 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 Leichtenstern's 1541 cases, embracing obstruction from all  causes,
the  strangulation was  caused by false ligaments in 111, by the  omentum in
58.  by diverticulae in  66, by the appendix  vermiformis  in 34, by  the  dia-
phragm in 215,  and in other ways in 60.   The  cases  collectively  amount
to 544.
   Whatever 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 cause's 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.
    Potation 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  cecum, this  portion of the large intestine being
 exceptionally mobile.   Twisting of  a portion of intestine around  an  axis
 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 S per cent.   In Leichtenstern's 15 11 cases, 54  were in this category.  In
 cases of obstruction and strangulation exclusive of invagination the« propnety
 of resorting to  laparotomy is to be considered.  Ashhurst (op. «/)  collected
 57 cases in which this operation was performed.  ()f these cases, 18 terminated
      -sfullv Rivino- a  mortality of a little over 6S per cent.  It is in  favor of
succe>- 
440        STRUCTURAL DISEASES OF THE  INTESTINE.
resorting to the operation in these cases that  the prospect of recovery with-
out it is much less than in cases of intussusception   Ashliurst 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.  BeloAv
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-
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
(1S78), 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 caecum.
   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. 
COMPRESSION  AND  STRICTURE OF INTESTINE.
  The fact of the obstruction being seated in the lower part of the larsre 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  shoAvn  by the absence  of distension of the large intestine Avith
intestinal  contents, and by the  ability to  fill the colon Avith 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 due 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 caecum  were
enormously distended with feces, and the peritonitis Ayas due to rupture of the
caecum.  This case illustrates the ability of the ileo-caecal  valve to  resist an
amount of pressure sufficient to lead to rupture of the  caecal Avails.
  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,  proA'ided  other measures  to  free  the intestine from an
amount of accumulation  likely to lead to rupture be not successful.   Cases
have been reported in Avhich life has been prolonged and comfortable health
obtained by  means of surgical interference.   C;esar Hawkins  reported the
results of the operation for7 artificial anus in 44 cases.  In 10 of  these cases
death took place within forty-eight  hours, in 21 within  five weeks, and in 13
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
l! cases in which he had performed this operation, collected and tabulated 80
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
  1 Vide Am Journ. of  Med. Sciences,  October,  1873.  A considerable number of eases
has been reported in'different medical journals since the date of  Professor  Masons
article. 
442       STRUCTURAL  DISEASES OF THE INTESTINE.


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 o-eneral 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 Avhen 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 caecum  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  diff'erent 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,  noAV 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 diarrhoea 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, Amounting, 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
purgative  remedies.  The bitter waters (Friedrichshall, 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  causing 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 FROM IMPACTION OF FECES, ETC.     443

   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  caecum
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 caecum, at  the sigmoid flexure,  or in the rectum.   They
may sometimes be felt through the abdominal Avails.  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 transATerse diameter one and a  half inches, its  Aveight
fifteen drachms, Avas sent  to me by Dr. 0. T. Jameson, which was found  after
death in the ileum  just above the caecum.   It  was distinctly felt through the
abdominal walls  during life, and had existed for more than tAventy 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.   AVhen introduced into the stomach they have been
swallowed either  deliberately, as  is done by jugglers, or inadvertently.   Prof.
Gross cites the case of a man who swallowed a bar of lead weighing a  pound,
Avhich 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 Avas 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
  ' Vide case reported by Dr. Draper, in New York  Med. Journal, July, 1SS2, and case
reported by Dr. Johnson, in Medical News, June 27, 1885. 
444        STRUCTURAL DISEASES  OF THE INTESTINE.
 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-
fering from the nervous symptoms associated with so-called spinal irritation.
The probability  of the  affection being functional is increased in proportion as
the obstipation, Avith 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
                  1 Buffalo Med. Journal,  1851, vol. vii. p. 530.
                  2 Ibid., 1852, vol. vii. p. 383. 
DIARRHCEA.
445
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 Gail-Stones.

                               Diarrhoea.

 TpHE term diarrhoea is used to denote morbid frequency of intestinal dejec-
  J_  tions  Avhich are also liquid or morbidly soft, and often otherwise altered
 in  character.   Diarrhoea 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.
   Writers have described several varieties of diarrhoea, 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  diarrhoea is  said to  be fecal, feculent, stercoraceous, or  sinple when  the
 dejections  consist  of  the feces not changed in  character, but  simply morbidly
 soft or liquid.  This form of diarrhoea 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 diarrhoea 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   Kobin states that the  microscope  shows the color-
 ing matter to be biliverdin.2   Diarrhoea is  serous  or watery when there is an
 abundant discharge of liquid; that is, when there is  copious transudation or
 enterorrhoea.   This is represented by  the operation of hydragogue cathartics,
 such  as elaterium, jalap, and the  bitartrate of potassa.  The dejections  are
 called  lienteric when  they  contain  undigested aliment.  This form  of diar-
 rhoea  is met with  especially in children.  A diarrhoea 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 diarrhoea is
represented by the operation of drastic cathartics, such as croton oil.  Finally,
in a rare form, called adipose or fatty diarrhoea, free  fat or oil in greater or
  1 The Lancet, Oct.,  1860.                                  2 Sur les Humeurs. 
 446        FUNCTIONAL DISEASES  OF THE INTESTINE.

 less abundance is found in the evacuations.   This last  form claims  distinct
 consideration.
   In cases of  adipose or  fatty diarrhoea the fat is  generally liquid  Avhen
 passed, resembling melted butter  or grease,  having when cold the  consist-
 ence of butter, beef tallow, or Avax.   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.   When 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
 diarrhoea.  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-
 rhoea  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  diarrhoea;
 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  Avas examined after  death.  Of 25
 cases tabulated by Griscom,s 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  diarrhiea
 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
 involved morbid conditions which  influence the digestion of fat, irrespective
 of the  pancreatic  secretion.  Of the fatal cases  among those  tabulated by
 Cxriscom in which the morbid  appearances Avere 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-
  1 New York Medical Times, Februarv,  1S5-1.
  2 " Cases and  Observations connected with the Diseases of the Pancreas and  Duo-
denum," by Richard Bright, M. D.,  Medieo-Chimrg.  Transactions, yo.  xviii    Vkie
review in British and Foreign Medico-Chirurgical Review, July   1853
  ^ transactions of the American Medical Association for 18!)?.
♦i.  d  thf- Morbi(| Anatomy and Symptoms of Cancer of the Pancreas " extneterl from
the Proceedings of the Pathological  Society of Philadelphia, 1858.       '  6Xtracted from 
DIARRHOEA.
447
 toons, of this form of diarrhoea.   Jaundice was noted in several (six) of Oris
 corn's  cases.  Diabetes  mellitus coexisted in two  cases.   Hemorrhage from
 the bowels, vomiting, and pains in the abdomen sometimes  resembling tho«e
 caused by the passage of gall-stones, are among the symptoms noted in the<e
 cases.   The duration of the affection  varies much in diff'erent 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 few 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 diarrhoea than to the latter.  With 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 Watson states that a case was suc-
 cessfully  treated by Elliotson in the  same way.   In a case observed by Gris-
 com at the NeAv Aork Hospital the discharge of fat invariably ceased when-
 ever the patient took from six to eight ounces of  Avhiskey per diem.   In the
 case reported by Wells, the patient, having had a daily  discharge  of three
 gills of fat for two  years or more, recovered in a few Aveeks after giving up
 the occupation of a carpenter and adopting the life of  a  farmer.
   Exclusive of the form just considered, diarrhoea 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 diarrhoea be purely functional, of course there is no inflamma-
 tion of the mucous membrane.  Practically, it is not always easy to determine
 whether diarrhoea 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 diarrhoea this is not always
 easy.   Lesions are to be suspected if the diarrhoea 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 diarrhoea, conjoined with cough, be the
 latter never so slight, should excite suspicion of pulmonary phthisis.
  Transient diarrh<ea due to arrested  or defective intestinal  digestion is of
 frequent occurrence.  With the diarrhoea-which follows  over-indulgence at
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 diarrhoea.   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 diarrhoea is preceded  and accompanied by griping pains, and 
448        FUNCTIONAL DISEASES  OF  THE INTESTINE.

it may be under  these circumstances an element of another functional affec-
tion__namely, colic.   These attacks of diarrhoea  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 diarrhoea.   A strong mental emotion may have
this effect.  I was present at an operation for hernia Avhen 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  diarrhoea.  In like
manner, diarrhoea 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 diarrhoea depends on dietetic errors, the undigested aliment  in the  large
intestine acting like  a cathartic.
   Diarrhoea 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 diarrhoea 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 diarrhoea, may be feculent, bilious, mucous, lienteric, or,
more rarely, serous.   The diarrhoea 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 diarrhoea may be produced and kept up by various causes inde-
pendent of excess or errors of  diet.
   It has been customary to attribute diarrhoea 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.
   Diarrhoea 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 diarrhoea 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-
diers, especially in campaigns during the summer season or  in warm climates,
diarrhoea is extremely common, and is attributable to irregular habits as regards
diet, conjoined with the exposure, excitement, and  fatigue  incident to a°ctive
service.  Diarrhoea occurs in persons exhausted from the  want of food or
from other deprivations, and in females enfeebled and anaemic from protracted
lactation, due in these cases to intestinal indigestion.   The  same explanation
probably applies  to the diarrhoea which  occurs at  a  late period in cases of
pulmonary phthisis and other chronic affections when not  dependent on intes- 
DIARRHCEA.
449
tinal  lesions.   Under  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 diarrhoea  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 uraemic
diarrhoea  are  serous or watery.
   Another pathological condition occasionally giving rise  to diarrhoea 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 diarrhoea under these circumstances is serous, transudation  taking place
from  the pressure of the blood within the congested veins.
   Crapulous diarrhoea, or transient diarrhoea  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, diarrhoea,  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 diarrhoea
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 diarrhoea among soldiers returning from the  cam-
paigns in Virginia in the summers of 1862 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
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
        29 
 450        FUNCTIONAL  DISEASES OF  THE INTESTINE.

 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 diarrhoea 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, haematoxylon, 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 anaemic, as in cases of diarrhoea 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 diarrlxea,  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 Avith small  doses of a salt  of morphia, as
 recommended above  in  connection  with palliatiATe 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 diarrhoea the various  remedies  which
 have  been named are to be given in  succession and in diff'erent  combinations.
 The curative and palliative remedies are to be combined to meet  the indica-
 tions  in individual cases.
  Diarrhoea dependent on uraemia  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 melseua 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-
 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 melaena 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 evacuation's 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- 
ENTER ORRIIA GIA.
451
tinal canal are not cases of enterorrhagia ;  and cases of hemorrhoidal or other
hemorrhages occurring near the anus are not prope.rly 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
Avith 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 diff'erent 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  sloAvly along the tube,  it becomes  dark or blackish, its
appearance  resembling that of the melaenic 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 haemorrhagica, and yelloAV 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
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 Avhich exist in the larger proportion  of cases.
While,  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

  1 Sir William Gull has reported a case of probable thrombosis of the superior mesen-
teric vein and the renal veins, recovery taking place. (Vide Guy's Hospital Reports, vol.
xlii.)   Profuse intestinal hemorrhage was associated with  severe pain, albuminuria,
and a condition of nearly complete collapse.  Pie cites a fatal ease reported by Dr. Hil-
ton Kagge. 
452         FUNCTIONAL DISEASES  OF  THE INTESTINE.
 rapid to occasion sudden death, but this is rare.  The repetitions of the hemor-
 rhage may lead to a degree  of exhaustion  and an.vmia from Avhich 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 diff'erent affections or morbid conditions with which
 intestinal hemorrhage is usually connected need not be here repeated. It Avill
 suffice to refer to measures having reference to the hemorrhage.   These  are
 essentially the same as in cases of gastric  hemorrhage.  Best 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 Avithout 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
 haemostatic 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 costivcness  are commonly used  as  synonyms,
 denoting insufficiency of e\Tacuations 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 a serious
 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,
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- 
CONSTIPATION.
453
ence discomfort if temporarily evacuations take place daily.   In determining,
then, the  existence of this affection, 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, diarrhoea,  and colic  pains.  Hemorrhoids are often  attrib-
utable to this affection.  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  shoAvn
bv  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,
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 Avhole muscular system, in anaemia and  in  other  enfeebling conditions.
          ' New Views of Defecation, etc., by James O'Beirne, Am. ed., 1834. 
454        FUNCTIONAL  DISEASES OF THE INTESTINE.

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 Avhen 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 Epsom 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 Friedrichshall, 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  Avithout any difficulty.   If the constipation  be more than  slight, a feAV
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 Avithout 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  Avhich  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  Avheat.   A diet consisting in part of the foregoing
articles  will sometimes succeed in  relieving habitual  constipation;  but Avith
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 of occa-
sion more  disturbance than  medicines.  More harm sometimes  results from
overloading the digestive organs with articles of diet difficult of digestion or
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.  With 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 da vs. and then 
CONSTIPATION.                         455
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 closes 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 Avith 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
Avell suited to the object, a drachm given at bedtime, and repeated, if necessary,
once or  tAvice during the day.   This preparation  loses its disagreeable bitter-
ness Avith age, and it is not generally repulsive Avhen given with a little water
and an abundance of sugar.   The extract of nux vomica combined  Avith bel-
ladonna or hyoscyamus  sometimes answers Avell.   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 poAvder are  good laxative remedies.   There are various modes
of rendering the daily use of a laxative remedy not unpleasant to  the taste.
Prunes  steAved in  an infusion  of senna ansAver well, and  are not unpalatable.
The confection of senna and medicated figs are also suited to  persons Avho
take a pill  or potion Avith 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 Avhich 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 Avhite 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 boAvels.  A
minute dose of strychnia or nux vomica added to a laxative renders the ope-
ration of the latter more successful.  [Probably the best internal remedy for
the relief of constipation  is cascara sagrada.   Thirty minims  of  the  fluid
extract  given at bed-time will usually secure  a  movement on the  folloAving
morning resembling in amount and consistence  the normal fecal discharge.
Another method equally efficacious is to give 10 minims of the same prepa-
ration thrice  daily after meals.  There are  various non-official elixirs of cas-
cara, Avhich, on account of their comparatively agreeable flavor and taste, are
to be preferred in the case of  children.—H.]
  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.
Common molasses candy answers  equally well, an oval mass of the size of a 
 456        FUNCTIONAL  DISEASES OF THE INTESTINE.

 pigeon's eg£  being introduced within the rectum.  This, however, is only a
 temporary expedient, ceasing usually to be effective  after a time.   [Among
 the  mechanical methods  of  treating constipation is  massage.   In practising
 this method the course of the colon should be followed, the first manipula-
 tions being made in the right iliac  fossa and  carried upward, transversely to
 the left, and downward ;  in other words, they should follow the  course pur-
 sued by the feces in  their  passage  along  the large intestine.
   The best suppository for the relief of constipation is one composed of 90
 per cent, of pure  glycerin.  It may be continued almost indefinitely without*
 blunting the  sensibility  of  the  rectum; but  all such  measures should  be
 regarded as temporary makeshifts, to be abandoned  as  soon as the habit of
 regularity of the  bowel-movements is acquired.—H.]
   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  Avill 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 poAver
 Avhich 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 noAV 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  Medical Sciences in  1874 and the
autopsy, in 1876, by Dr. Thomas  D. Strong  of  Westfield. X. Y.  Inthis case 
INTESTINAL  COLIC.
457
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, but 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
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
name 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
aff'ections—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  affection.
  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 fonvard  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 feAv 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  Avith 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 caecum.  During the paroxysms of pain the abdom-
inal muscles are sometimes  spasmodically affected, especially the rectus mus-
cle, the sections  of Avhich 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  Avhich 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 diarrhoea and of symptoms
denoting  inflammation.   The pain  in these  tAvo aff'ections 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-
    1 For synopsis of this case, vide Clinical Medicine, by the author, 1879, p. 354. 
458        FUNCTIONAL DISEASES OF THE INTESTINE.
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
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 A'arieties of colic which writers have generally recognized do not
require separate consideration.   Some of these  \7arieties 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 Avhich sometimes fol-
low over-indulgence at the table,  ending frequently in crapulous diarrhoea.  A
colic is called flatulent when it is accompanied with tympanites or by the expul-
sion of gas Avith relief.  This variety occurs especially in infancy.  The term
bilious colic has been used Avhen 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 Avhich
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 
INTESTINAL  COLIC.
459
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 aaTio 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.
   Although  attended  with great and, if  not efficiently treated, often pro-
tracted  suffering, 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 boAvels Avere 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 boAvels 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 Avater, 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 asafoetida 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.
X«.t  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. 
460        FUNCTIONAL DISEASES  OF THE INTESTINE.

  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.


                              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.  Castralgia
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 aff'ections from which
colic is to be  discriminated,  and the exclusion of the latter  affection. (Vide
p. 457.)   The so-called  rheumatism of the abdominal Avails (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 aff'ections. (Vide p. 385.)


               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 anaemia, 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 
LEAD COLIC.
461
different 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 suffering 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  meteorized 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-
able space,  is  generally well borne, and often  affords  relief.  Patients are
inclined to lie upon  the belly Avith 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
affection, 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 diff'erent periods ;  and relapses, after
all the symptoms have ceased for  days or weeks, without any fresh introduc-
tion of lead, are not uncommon.
   B. 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. 
462         FUNCTIONAL DISEASES OF THE  INTESTINE.
   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.
More 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
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 Avas  due to wine, and that of Devonshire  to  cider adulterated Avith
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 artioles  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 Avas 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).   Water 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 Walkill 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 Avith  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  [Another cause of lead-poison-
ing  is the lead  chromate (chrome yellow) sometimes  used  by ignorant  or
unscrupulous  bakers  as  a cake-dye.   Dr. David D. Stewart of  Philadelphia
in lMs'7 traced sixty-four cases of the disease to this source.4__H.]  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 alimentary canal.  The use of lead as a remedy has given rise to

Jr?d-e aPPendif.t0 translation of Tanquerel's treatise, and report of Horatio Adams,
M. U., in Irausaetions oj American Medical Association, vol. v.
  2 Vide case  in Western Lancet, Cincinnati, communicated by Dr. Edward Murphv of

  3 Philadelphia Medical News and Library, Julv, 1866.
  4 Medical News, June 18 and Dec. 21, 1887. 
LEAD COLIC.
463
 colic and other morbid effects.  It may be introduced through the skin, although
 doubtless with difficulty.  Lead-poisoning is sometimes attributable to the lon°--
 continued 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
 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 Avhere 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 AA-henever 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
  1 For the method of testing the  urine for the presence of lead employed by Prof.
Dorenuis, vide my work on Clinical  Medicine, 1879.
  2 Vide Therapeutic Handbook. 
464        FUNCTIONAL DISEASES OF THE INTESTINE.
 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.   Belief 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
 of this affection, are contraindicated.   The Avarm  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 Avhich 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 53
 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 1849
 of a paper by Melsens."   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 Avith  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/    Finally, clinical observation appears to  afford proof of the

  1 Appendix to Tanquerel's Treatise, by Dana.
  2 Annate* de Chimie et de Physique, 1849; also, British and  Foreign Medico-Chirura
 Revieiv,  18o3.                                               y   ^«iou ^turwg.
  3 For facts verifying this  statement,  see  a report of the results of treatment will,
the iodide of potassium in 23 cases in the New York Hospital  bv  H S Swift  Ma
 New York Medical Times, February, 1854.                      y          "' M> D" 
LEAD COLIC.
465
efficacy of this treatment.   With 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  affection 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 Avithin the twelve days—namely, on the third, eighth
and eleventh day.  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
enjoins to begin Avith 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 comes 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 Avhich 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 nos-
trils or the use of masks, under certain circumstances  may be important.
   After  recovery from the colic an anaemic condition, with general debility,
will often claim appropriate medicinal and hygienic measures  of  treatment.
         30 
 466         FUNCTIONAL  DISEASES OF  THE INTESTINE.


                         Colic from Copper.
   Writers 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 diarrhoea with greenish  stools.   These  symptoms denote
 not merely functional disorder, but gastro-enteric inflammation.  An extended
 and careful examination of a number of establishments in which the Avorkmen
 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,
 hoAvever, 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 Avhich 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 Avith propriety be  considered as an individual affection under the
 name of colic.


            Passage of Gall-St ones—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 Avith 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.*  They are  oftener  discharged bv an
ulcerated  opening into the intestinal canal.  The opening may  tike place
  1 Aide Nysten's Dictionnaire de Medecine, etc., 1858 ; also Aalleix op cit torn
  2 For an account of reported cases, and also cases of eholecvstolomv vide artW* K«
Dr. G. W. H. Kemper,  in Transactions of the Indiana State Medical Society  1879 
PASSAGE OF GALL-STONES.                 467
into  the duodenum or colon.   It has been known to take place into the
stomach, the portal vein, and  the pelvis of the kidney.  Call-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 toAvard 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.
   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 by 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 suffering is
often extreme, causing the patient to  Avrithe 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. Aomiting speedily occurs in the majority
of cases, and is repeated more  or less frequently during the continuance  of
the pain.   The  boAvels 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 Avithin 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 diff'er  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
  1 The presence of inspissated bile in the dejections may be ascertained by chemical
tests.  (Vide Bartholow in System of Medicine, by American Authors, vol. n. p. 1076.) 
468        FUNCTIONAL DISEASES OF THE  INTESTINE.

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-
gia  is to be based on the  folloAving 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, hematuria, 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 a^e   but thev al-
most likely to  form in  middle  or advanced life, and in  female's oftener  than
in males.
  In the  great majority  of cases gall-stones escaping from the gall-bladder 
PASSAGE OF GALL-STONES.
469
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 diff'er from intermittent paroxysms due to malaria in the time of their
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 gall-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
suffering be  great, the inhalation of chloroform or ether should be resorted
to.   Warm 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
  1 Vide cases reported by Prof. William Osier, in Medical Times and Gazette (London),
July 30, 1881. 
470        FUNCTIONAL DISEASES OF THE  INTESTINE.
 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 omvard passage of the
 stone.   Opium and  anaesthetics probably promote its passage.  If the dis-
 tended gall-bladder form a tumor Avhich 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 Avithin  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
 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 Avails 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  Avas  concluded
 that the tumor was the gall-bladder distended Avith 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 be 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 anparent 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.                                                    r
  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

  1 American Journal of the Medical Sciences, Julv, 1867 p 51
  2 This remedy is given by Dr. Buckler as follows: Hydrated suppinnto nf  a.
ide of iron ^iss; water, fgviss;. a teaspoonful after each^d^Sued  £V ^° i"
months, and resumed at intervals afterward.               ' contlnued for several 
SPORADIC CHOLERA.
471
calculi.  These  are composed of a concrete form  of fatty matter, like the
bodies passed in  some  of the  cases  of fatty  diarrhoea  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.1
   [Two surgical operations—cholecystotomy and cholecystectomy—are per-
formed for the relief of intractable cases of hepatic colic.  The first consists
in removing  the calculi from the gall-bladder  and returning the latter to the
abdominal  cavity after suturing  the incision made in its wall;  while by cho-
lecystectomy is  understood the excision of the gall-bladder after ligature of
the cystic duct.  If a calculus is impacted in the  common duct, or if the latter
is obliterated by  adhesions of its mucous lining, an artificial outlet may be
made for the bile by the operation of " cholecystenterostomy," which consists
in establishing a communication between the gall-bladder and the small intes-
tine.   The reader  is referred to works on surgery for statistics and  other
details of  these operations.—H.]
                      CHAPTER  VIII.

   SPORADIC  CHOLERA.—CHOLEBA  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 ot
  1 Dunglison''« Practice of Medicine, 1842, vol. i. p.  135.
  The reader is referred to A  Treatise  on Gall-Sfones. by  J. L W. Thudicum, M. D
London, ISfiS, for a  ful1 consideration of their chemistry, pathology, and treatment
Vide  also  Murchison's Clinical Lectures on Diseases of the Liver, etc. 
472     SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

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 aff'ection  under consideration.  The term sporadic
serves  to distinguish this  from another aff'ection known  as  cholera  Avhich
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.   Writers 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.  Vomit-
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
vomited, sometimes  in large  quantity, often ha\Ting 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.
   With 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 
SPORADIC CHOLERA.
473
 and purging  continue, the evacuations  from the bowels occur involuntarily
 the pulse becomes more and more feeble, coldness  of  the surface is more aiid
 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.  Vomiting and purging denote
 in  these cases the coincidence of  acute dyspepsia and crapulous  diarrhoea.
 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 gastrorrhcea and  enterorrhcea.  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 aff'ections, 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-
 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 diff'erent 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 aff'ec-
 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 
 474     SPORADIC CHOLERA, CHOLERA INFANTUM, ETC.

 so strongly  marked  that  little need be  said  under this  head; yet there is
 some  liability to errors  of diagnosis.  I have knoAvn 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 diarrhoea occurs, whereas in
 cholera the  purging is  simultaneous with or  folloAvs  quickly the vomiting.
 Moreover, the vomiting in cases of poisoning is out of proportion to the diar-
 rhoea.  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.
   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.   \  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 vll
 iting.  The first  dose will  perhaps be immediately rejected-  if so  a second 
CHOLERA INFANTUM.                     475
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 may be 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
Avater  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-
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  suffering 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 aff'ection peculiar  to this country.   The
morbid phenomena, however, considered by American writers  as belonging
to this affection are described 111 European works under other names.   Cni-
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 diarrhoea.
Weaning  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 
 476        ORADIC CHOLERA,  CHOLERA INFANTUM,  ETC.

 to colo-enteritis,  follicular enteritis,  choleriform  diarrhoea of  children, and
 gastro-intestinal catarrh.  German  authors consider  the  aff'ection  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 diarrhoea and occasional vomiting.
   In  other cases  the affection  is  gastro-intestinal indigestion.  These are
 characterized by diarrhoea, the dejections being lienteric and  Avatery.  Vom-
 iting occurs either  occasionally  and is an accidental symptom, or it may not
 occur.  The diarrhoea  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 Avith blood.  Febrile movement, with remissions, occurs in these
 cases.   There is more or less abdominal  tenderness and pain.   Vomiting  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 diarrhoea 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, diarrhoea 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                 * constitute
   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-
                      1 Vide Smith on Diseases of Children.               =' 
CHOLERA  INFANTUM.
477
 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  Aveaning 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
 aff'ections, 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.
   [Using the term " cholera  infantum " to denote an acute entero-colitis of
 infants, we find that children  under six  months of age enjoy a  comparative
 immunity from it.  According to  statistics  of Emmett  Holt, based on 431
 cases, only 12.8 per  cent,  of the  patients were under  six months  of age,
 while 59.5 per  cent, were between six  months and  two years  old.   These
 great differences as to  susceptibility are explained by the fact that after six
 months  of age  comparatively few children are exclusively fed with breast-
 milk.   " Nursing by hand " is practically synonymous with improper feeding
 in the great majority of  cases.—H.]
   The general  principles which should govern the management  of the same
 affections  after  the period of early childhood  are applicable to the different
 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 bath, 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 deAeloped  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.  With 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.
   With reference to  the diarrhoea, occasionally a laxative is  useful, and a 
478     SPORADIC  CHOLERA,  CHOLERA INFANTUM,  ETC.

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-
meria,  tannic acid, kino, catechu, haematoxylon, geranium, and rubus  villosus
are articles from which a selection may be made or which may be  tried in
succession.   Dr. W. Byford Ryan  claims  remarkably good  results from bel-
ladonna conjoined with nux  vomica and arsenic.1  [Among the most effica-
cious drugs are  intestinal  antiseptics, such as naphthalin,  salicylate of bis-
muth,  and  salicylate of sodium.   It is  probably  through their antiseptic
properties that calomel and creosote are so efficacious.   Emmett Holt claims
excellent results  from salicylate of sodium in doses of from 1 to 3 grains
every  two  hours, according  to the age, from three months to three years.
"In these doses the aqueous  solution is  tasteless, and can be readily given in
the food or drink."—H.]
  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.  Within 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  be made  into a kind of puree by being  reduced to a pulp
in a mortar and pressed through a  fine sieA'e, so as to separate the vessels and
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 taenia as a result
of eating uncooked  meat renders its use of doubtful propriety.
  As regards the administration of different kinds of food, the quantity <riven
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 fortdie
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.
  [When a hand-fed child under two years of age is  attacked with  chol
infantum, it is frequently best  to  suspend the use of milk and farinace
                    1 American Practitioner, June, 1885.
era
ous 
EPIDEMIC CHOLERA.                     479
preparations  and resort  to  chicken-  and mutton-broth, the  juice of "rare"
beef, Avine-whey, and raw scraped beef.   Or, if the feeding  has  been carried
on with milk in a  haphazard  manner, the following  mixture, recommended
by Dr. Arthur V. Meigs of Philadelphia, should  be  given a thorough trial:
  " One  quart of good ordinary milk is placed in a high  pitcher or other
vessel  and alloAved to stand in a cool place for three  hours;  then one pint is
sloAvly poured off  from this, care being  taken that the vessel is not agitated,
the object being to obtain the  upper  layer of fluid, rich in fat, and leave the
lower,  comparatively poor, portion behind.  When the child is to be fed there
are taken of this weak cream 3 tablespoonfuls, of lime-Avater  2 tablespoonfuls,
and of sugar-water 3 tablespoonfuls.  The sugar-water is to be made  in the
proportion of 18 drachms of milk-sugar to 1 pint of water.  This makes only
four ounces  of food, and if the infant is old enough to require eight  ounces
at once, double the quantities of each of the ingredients must be mixed.  This
is simply  Avarmed in a bottle as usual, and is then ready for  use." ]
   The composition  of Meigs's mixture is practically identical with that of
human milk when the secretion  of  the breasts is fully  established.
   At  a foundling institution  of Philadelphia  called  the " Sheltering Arms,"
in which  this food was  introduced by  Dr. Meigs, the mortality, which  had
before amounted to  about one hundred per cent., has been very  materially
diminished.—H.]
   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 Avhich chil-
dren take it in  these aff'ections.
   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 Avav  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 graA-e.  The reason is that the affections. Avhen 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,
                       1 Archives of Pediatrics, Dec., 1889. 
480     SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

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 diff'erent 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
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 1834.  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 march over  the globe in  1864,
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 1852 were ample.   During these 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.  [In the  month of  September, 1887, a steamer from
Marseilles, the  " Alesia,"  entered New  York  harbor  with eight  cases  of
cholera on board, and  about twenty-six more  cases developed among  the
immigrants while  they were in  quarantine.   In  the  same year, in  October,
other cases were brought to the port of New York by a French steamer.  In
1892 the  harbor of the same  city was  again  invaded by  cholera, and  the
greatest apprehension that the  disease might gain a  foothold in the country
during the approaching summer was excited.   By the strictest observance
of  quarantine regulations both  in 1887  and subsequently the  dreaded pest
was excluded.—H.]

   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 presented for a long period  after death, and  there may be even
a post-mortem elation 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  Avhite
flakes, and hence presents a heavy, flabby, sodden  appearance.  The mucous
surface of the small intestine  is  swollen, cedematous, moderately congested,
and may contain ecchymoses.  The congestion and the extravasations are most
  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 bv the Government of
the United States. 
EPIDEMIC CHOLERA.
481
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 *re
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  Avhich 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
Lieberkuhn, 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 sticky substance Avhich  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 someivhat  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 hypersemic 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 fou-nd 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
        31 
482      SPORADIC CHOLERA,  CHOLERA  INFANTUM, ETC.

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 giATen 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 Avith 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 cedematous and  hyper-
asmic.   Pneumonia may develop  in this stage.   The  spleen may be  normal
in size or swollen.  The most  important changes relate to the kidneys.  Fol-
lowing the anaemia 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  diarrhoea, the dejections being greater or less in number,
copious, and painless.   The duration of this preliminary diarrhoea varies in
diff'erent  cases  from a few hours to  several days.  With  this diarrhoea 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 diarrhoea 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 diarrhoea  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  diarrhoea was not
wanting in a single case. Of 142 cases treated in hospital in Paris by  Michel
Levy, the premonitory diarrhoea was wanting in  only 6.  Of  274 cholera cases
treated in the different  Parisian hospitals in 1853, the existence of premon-
itory diarrhoea  was ascertained in 140, in the remainder of the cases it bein^
absent or its existence  not ascertained.   By some  the period during which
the premonitory diarrhoea  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
diarrhoea without the development of  cholera,   The simple diarrhoea Avhich
  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 nf\i f«t«l
eases. (Vide Buffalo Medical Journal, 1850, vol  v )                     d 0t 34 fatal 
EPIDEMIC CHOLERA.
483
 prevails extensively during  the  prevalence  of cholera is called, in  France
 cholerine—* term adopted to a considerable  extent in  other  countries   Bv
 (Jerman 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 diarrhoea  is  very  great,  as will presently appear.
   The development of cholera is generally first denoted by characters  relating
 to the  intestinal evacuations.  If diarrhoea  have existed, the discharges are
 suddenly increased in quantity, or sudden and copious liquid discharge's with-
 out previous diarrhoea  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
 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 ahvays 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 diarrhoeal 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- 
484     SPORADIC  CHOLERA,  CHOLERA INFANTUM,  ETC.

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 folioavs, 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 Avhat 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.  When 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
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.  Dyspnoea 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.
  Very 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 
EPIDEMIC CHOLERA.
185
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  90°, and even  considerably lower, and it  has been known to fall to
73°.  The  skin is  frequently shrivelled  and wrinkled like the  arms of Avasher-
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
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 Avith 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 apnoea.
   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.  Diarrhoea 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  diarrhoea ; somnolency and coma become  developed in  a
certain proportion of cases, dependent  probably on  uraemia;  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.                                         ,              n ,-,    ■,
   Epidemic cholera has a brief duration.   After the occurrence of the cha- 
486      SPORADIC CHOLERA,  CHOLERA INFANTUM,  ETC.

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 uraemia.  Cholesteraemia may
occur, since  the function of  the liver is suspended.
  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 Bobert 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 1HH4
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. (62^° 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. (7<!° F.).  In  the gelatin cultures on plates a typical colony of the  chofera 
EPIDEMIC CHOLERA.
487
 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.  When cultivated and examined in a  drop  of  bouillon
 the  cholera  bacilli are  found to be endowed with the power of rapid  move-
 ment.
   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. 473), those
 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  Avhen 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
 tilled Avith 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  Avell 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

  1 Koch found cholera bacilli in the water of a tank  in India which  was used for
drinking purposes, and Avhich was contaminated  with  the dejecta  and the  linen of
cholera patients. 
488      SPORADIC CHOLERA, CHOLERA  INFANTUM,  ETC.

below  the freezing-point.    They do  not  form  spores,1 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, hoAvever,
may preserve their vitality for five or six months, and after special modes
of cultivation for even a year or more.  When 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,
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 Ayide  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 Avith 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.
  2. 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
from 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
  1 Huppe and others describe a fragmentation  of cholera bacilli into little round bod-
ies, Avhich 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.
489
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 amon°-
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
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 special
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 oivn
experience in  the East Indies :l " 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.  Early the following morning nineteen people
each  swallowed about  an ounce  of this contaminated water: they only par-
took  of it once,  but Avithin 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.  While, 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.
We 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  Avho  are  in close proximity
to cholera patients  are not likely to contract the  disease merely from such
proximity.
                1 Quain's Dictionary of Medicine, article " Cholera." 
490      SPORADIC CHOLERA,  CHOLERA  INFANTUM, ETC.

   We 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  deriA'ed 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 Avith  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 origi.i 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,
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.  We
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 
EPIDEMIC CHOLERA.
491
only to make stained microscopical preparations from  the stools, but also to
prepare cultures ;  which  is done 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,
hoAveArer, is not difficult to  acquire, and at least in every large community
some one should be found Avho is capable of making the diagnostic tests which
have been  mentioned.
   Cholera  is to be discriminated from  the  simple diarrhoea 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 diarrhoea 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
following  the employment of certain  methods of treatment may depend on
cases of simple diarrhoea  being reckoned as cases of cholera.
   This disease is one of the most  insidious in its approaches.   Aside from a
mild diarrhoea 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 diarrhoea 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 choleraphobia.

   Prognosis.—Of those attacked with cholera, a large proportion die.  The
average rate of mortality in hospitals varies from one-half to  one-third.  When
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
Avhich  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 1849.1   The proportion  in 1000 in subjects less  than five
years of a»e was 148 ;  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, 162.  The mode of dying
is in general typical of asthenia.   Accumulation of liquid in the air-tubes
very rarely takes place.

   Prevention op 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
                              1 Valleix, op. cit. 
492      SPORADIC CHOLERA,  CHOLERA  INFANTUM, ETC.

removal, as far as possible, of all the  auxiliary causes of disease  Avhich con-
tribute to render the special cause of cholera efficient, the prevention involves
prompt attention  to  the diarrhoea which in the great majority of cases pre-
cedes the  attack.   This premonitory diarrhoea 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 diarrhoea; and second,  to the fact
that an attack very  rarely occurs when this  diarrhoea 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 diarrhoea  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 diarrhoea did not exist or it was  neglected.
During another epidemic in 1852, I  had about the same number of  cases of
cholera in private practice.  In not a single case had I  been  called upon to pre-
scribe  for  premonitory diarrhoea, and I prescribed for hundreds of persons
with simple diarrhoea, 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 diarrhoea 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 diarrhoea 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-
rhoea 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 diarrhoea during the epidemic.
Very many pay no attention to the premonitory diarrhoea 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 diarrhoea 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 diarrhoea,
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  diarrhoea as
often and  as soon as it occurs.   Abundant proof of the successful operation
of the system of the house-to-house visitation Avas furnished  by its practical
results  in  London  and other towns in Great Britain during  the epidemic 
EPIDEMIC CHOLERA.
493
  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 Avater-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-
rhoea.   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
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, [or the discharges may be-mingled with an
equal bulk of a corrosive-sublimate solution, 1 : 1000.   The mixture, after
standing for one hour in order to ensure  thorough destruction of the disease
germs, should be  thrown into  the  sewer.  The hands  of nurses  should be
washed in the sublimate solution after coming in  contact with the patient,
and after each evacuation the  patient's fundament should be washed with a
solution of  corrosive  sublimate of the strength of 1 : 10,000.   After each
act of  vomiting the  patient's  mouth should  be washed with a saturated
solution of  boracic acid or,  as recommended  by  Shakespeare, with water
slightly acidulated with sulphuric  acid.   No one should be permitted to eat
or  drink  in the sick-room.—H.]   Sulphate  of iron is not an effective  dis-
infectant 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.
   When 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
  1 For further details and  for the processes of disinfection, vide Report of the Metropol-
itan Board of Health, NeAV  York, 18(37. 
 494      SPORADIC CHOLERA, CHOLERA  INFANTUM, ETC.

 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 *tage. 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 Avhich
 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
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 physician
 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 
EPIDEMIC CHOLERA.
495
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
my observation in 1866.  The vomiting, purging,  and  cramps were generally
arrested promptly by  this  measure; recovery, hoAvever, 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.  With 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 Avithout
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 
496     SPORADIC  CHOLERA,  CHOLERA  INFANTUM, ETC.

has sustained in the loss of its  constituents from the transudation Avhich has
already taken  place.   Opiates may be given, and, OAving 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 A\ill
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.   [The best treatment for the
diarrhoea of this stage is that by Avarm astringent enemata, or enteroclysis, as
recommended by  Cantani of Naples.  After each evacuation there is injected
into the bowel by means of a fountain syringe or similar apparatus a quart
or more  of  the  following solution : Boiled  water or infusion of  chamomile
(warm),  2  litres ; tannin,  5 to 10  grammes ;  laudanum, 30 to  50  drops ;
powdered gum arable, 50 grammes.   If the nozzle of the tube is passed  well
into the rectum  and the enema administered  while the patient is  in the
recumbent position, the fluid will traverse the entire  length of the colon, and
may even pass beyond the ileo-coecal valve.  Excellent results  have been
obtained by this method, which, if resorted to early, will in a certain propor-
tion of cases prevent the occurrence of collapse.—II.]
  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
Avas 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
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.
Violent friction  does more  harm than  good.  The  surface  may be  gently
stimulated Avith 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 
EPIDEMIC CHOLERA.
497
 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.
   [At this stage of the disease the chief indication is to restore to the  blood
 the  fluid of  which  it has been  drained.  This  may be accomplished in two
 ways: first,  by saline  transfusion;  secondly, by hypodermoclysis.
   If the  first method  be adopted, from  2 to 21  litres of  the following
 solution are injected into  one of the veins at the bend of the arm :  Distilled
 water, 1 litre; chloride of  sodium, pure,  5 grammes; sulphate  of  sodium
 pure, 10 grammes.   This fluid, which  was devised  by  Havem. should be
 raised to the temperature of the patient's body, as  determined by the ther-
 mometer inserted in the  rectum, and  slowly injected.  The different pieces
 of the apparatus  should,  of course, be sterilized.  In case  of emergency  a
 few yards of rubber tubing with  a canula attached  to one end and a glass
 funnel at the other are the  only appliances  needed  for the  performance of
 this simple operation.  The vein is snipped with a pair of  scissors, the canula
 inserted  in the V-shaped incision thus made, and the fluid  alloived to flow into
 the  veins by gravity.
   The effect of this species  of  transfusion is to produce immediate reaction,
 which in  a  certain proportion  of  cases  is  permanent.  The operation, if
 properly performed, is  entirely  devoid  of  danger, and  may be  repeated once
 or oftener.   As a  rule, however, unless  there is a decided improvement after
 one  or tAvo transfusions, there is no  use in  continuing  this treatment.  In 90
 cases in  which transfusion  Avas performed  by Hayem there  were 27 recov-
 eries.  This percentage of recoveries may seem small until  it is recalled to
 mind that the cases in  Avhich  the  transfusion  Avas performed Avere in a very
 critical condition,  with  little or  no hope  of success from ordinary methods of
 treatment.  When regarded from this point of view the results are decidedly
 encouraging.   The  chief indications for saline  transfusion  are coldness and
 duskiness  of the  skin, great feebleness or extinction of pulse,  and urgent
 thirst.
   Water may be added to the  blood still more easily by the method knoAvn
 as hypodernioclvsis.  As  indicated  by its  name, this consists in the sub-
 cutaneous injection  of fluid,  and  may be  readily  accomplished with  an
 apparatus composed of a hollow needle like that of  an ordinary hypodermic
 syringe,  only much  larger and  stronger, to  which is  attached a rubber tube
 having at its other extremity  a large glass funnel  or other receptable for
 fluid.  The operation  is so  simple  as to be readily performed by an intel-
 ligent nurse.   The funnel  or bag attached to the tube is filled with the fluid
 raised to the  temperature of 100.5° F.; a fold  of skin is  raised between the
 finger and thumb of one hand and the needle thrust well beneath it with the
 other.  The funnel  is  then  raised and  the  fluid allowed to flow under the
 skin  by gravity.   In the course of about fifteen minutes more than a quart
 of fluid  may  be thus  added to the circulation.  This method of treating
 cholera was introduced  by  Cantani  of Naples, who recommends for injection
 a fluid composed of  3 per cent, of sodium chloride and 4 per cent, of  sodium
 carbonate.
  The results of  hypodermoclysis are quite as striking  as  those  of trans-
fusion, while the  greater  ease with  which  it may be performed  gives it  a
decided  advantage over the latter.—II.]
  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 mucilagi-
       32 
498
INTESTINAL  WORMS.
nous drinks, bearing in mind that uramiia is one of the dangers of this stage ;
to restrain diarrhoea, if it occur, by anodynes  and astringents; to strengthen
by tonics ; and  to  palliate  by appropriate  remedies the  various  symptoms
which  ma}'  arise.
   [If reaction is excessive and  attended  with signs of cerebral hyperaemia,
the body should be sponged  with  cool  or tepid water  and cold applications
be made to the head.  A Avarm bath is also  of service under these circum-
stances, as it tends  to restore the functions of the skin and kidneys and to
tranquillize the circulation.   The  reappearance of the  urinary secretion is a
sign  of most favorable omen, but  there are no direct methods by Avhich the
suppressed function of the kidneys may be restored.  It is true that Macna-
mara has recommended the  tincture of cantharides in  10-drop doses for this
purpose, but, to quote the words  of Stille,  if it were not  " recommended by
so competent an  authority its  propriety might  very  properly  be  chal-
lenged."—H.]
   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 diarrhoea.
                      CHAPTER   IX.

                        INTESTINAL WORMS.

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,
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 different species of Tsenia, 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  Avithin the  alimentary  canal, the Trichina
spiralis will be considered in this connection. 
ASCARIS LUMBRICOIDES.                   499
                        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  Avorm 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 ao-e.
 This species of Avorm is not usually  solitary.  In diff'erent 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 vertebrae 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 fistulae  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 giAre 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
 convulsions,  epileptic paroxysms,  chorea, and other affections  of the ner-
 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,
 diarrhoea,  itching of  the  nose, sAvelling 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  Avorms, 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.  When more or fewer of the  above-named symptoms are present a brisk 
500                      INTESTINAL  WORMS.
purgative may be given, the stools being examined with reference to diagnosis.
If one or more Avorms 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 OATa 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 ATarious
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.  AArormseed 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 be relied upon
as proof  positive of the absence of the worms.
  With  a view to  prevent the ingestion of  the  ova of  lumbrici  attention
should be directed  to  the purity of the  water  used as drink.  Water from
shallow wells in the neighborhood of dAvellings 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

  l Trade  des Entozoaires  et des Maladies vermineuses de I'Homme et des Animaux domes-
tiqv.es, 1860. The reader  is referred to this work as treating of entozoa minutelv and
comprehensively.  See, also, Heller, in Ziemssen's Cyclopaedia, vol. vii., Am. ed • Leuck-
art,  Die mensehlichen Parasiten, Leipzic,  1863-76; and Cobbold's  Treatise on Parasites
London, 1879.                                                              ' 
TRICHOCEPHALUS  DISPAR.                 501
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 ATaries 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 youn"
children, but they are not extremely uncommon at any period of life.  I  have
met Avith 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 ahvays 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  leucorrheea.   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,  but 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 Avormwood,
vinegar, empyreumatic  oil, asafcetida, 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,

                      Trichocephalus dispar.

  This worm, as the name trichocephalus 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
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
csvcum 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 c.vcum for it, and I
rarely failed to find  one or more.  It is not  positively known that its presence
<>ives rise  to disorder.  Barth of Paris  reported a case in  which  death  took 
502
INTESTINAL  WORMS.
place with the symptoms of meningitis, and after death no lesions Ayerc found
Avithin 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 Avorms.   Another worm  belonging
to this class  was described by Bellingham under the name of Ascaris alafa.
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 trichocephalus dispar.

                      Taeniae,  or Tapeworms.
  On the natural history of taeniae, constituting the class Cesfoda in helminth-
ology, and commonly known as tapeworms, much light has been shed  by the
researches of Kuchenmeister, Von Siebold, Leuckart, and others.   Referring
the reader to other Avorks  for a full account of these  researches,  suffice it to
say that  diff'erent varieties of taenia have been shown to be the cystic entozoa
known as cysticerci and echinococci in a state of maturity or complete deATelop-
ment.  A cysticercus 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 taenia, each kind of
cysticercus becoming a particular kind of tienia.  A cysticercus, on the other
hand, is the product  of the ovum  of a taenia,  The eggs of the taenia, 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, howeATer. 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
taenia of the  dog, received  into the body of the sheep, becomes the cystic
entozoon called Qeuitrvs eerebralis, found in the brain of the latter, which, if
eaten by the dog. becomes the taenia 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 taenia  or tapeAvorm 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 A\hich, after it attains to  its  full maturity, is
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 cases the  taenia 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 taenia, the one  which has been
supposed to  be  most common  is  the Taenia solium, or solitary  taenia  so
called  because it is supposed always to exist singly.   This is  true  as  a
rule,  with  some  exceptions.   Two or more taeniae  have  been observed to-
gether, but such  instances are rare.    The  taenia solium  varies in length
between  four or five  and  thirty-five feet, the number of segments or joints 
T.ENLE,  OR TAPEWORM.
503
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 rugae, 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 Ioav power it is found to present four projections or suckers
and  a coronet of twenty-six  alternating short and long hooklets  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  Avorms  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  taenia
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 taenia 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 taenia, and  named
Bothriocephedus  latus.   This worm is distinguished  from the taenia 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  taeniae,
while the taenia solium is said to be armed.  The form of the head is elongated,
and  instead of suckers it  has tAvo lateral longitudinal depressions or  fossae;
hence the  name bothrioccphalus, from  poOpiov, a small  pit.  This worm may
attain to even a greater  length than the taenia solium.   Like  the latter, it is
usually solitary.   A taenia called Bothrioccphalus cordatus, distinguished by
the  form of the  head,  is only  known to infest the  inhabitants of  North
Greenland.
  Of these  varieties of tapeworm, taenia mediocanellata and taenia solium are
those commonly met Avith not only in this country, but in  most countries.
As  already remarked, taenia 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
that  it proceeds from a cystic entozoon existing  in  fish.1   The opinion, how-
ever, is also  entertained that the embryos of this Avorm may be taken into
the system in drinking-water, and may  be developed in the intestine Avithout
the intermediate stage of cystic  development  in  the solid parts.   The taenia
solium is attributable to the ingestion of the Cysticercus cellulosse, which is
common  in  the  flesh of SAvine.   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
     1 Kuchenmeister surmises that infection occurs from eating uncooked salmon. 
504
INTESTINIL  WOR MS.
tapeAvorm,  and it  is stated that in Abyssinia, Avhere the custom of eating
uncooked meat prevails, nearly all persons of different ages  become  affected
with taenia.   The production of taenia in children by the use of raAV  meat as
food in cases of so-called cholera infantum has been already referred to.  The
tivnia mediocanellata is derived from a cysticercus  found in  beef.   Taenia
solium is the pork-tapeworm, and taenia 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.   When 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 taenia.  Two months
after the birth of the child the mother was treated for tamia.1  The  frequency
of its occurrence varies much in  different countries  and in diff'erent  sections
of the same  country.   The report of the military  surgeons of the French
army from  1840  to 1848 shoAved  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 ATision 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 Avhich
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 Avas 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 lik'ely 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 profoundest anaemia, identical symptomatically
with pernicious  anaemia, has been frequently observed in patients  the  hosts
of bothriocephalus latus. It is not known why this particular parasite should
give rise to anaemia, but the fact is indisputable,  lleyher has reported a num-
ber of cases of anaemia of  pernicious type in which all the symptoms ceased
after the expulsion  of this worm.—H.]   The pathological effects of  other
forms of taenia  have doubtless been greatly exaggerated.  Tapeworms are
almost invariably found in the intestines of dogs  destroyed for experimental
purposes, 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
long before its existence is ascertained.  If there be 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
                    1 Detroit Review of Medicine, Jan., 1872. 
TAENIA,  OR TAPEWORM.                   505
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.
   With 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 Avhich 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. Cbabert's empyreumatic oil,  Avhich has been much
in vogue as a remedy for  taenia, 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 tamiafuge, 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 diATided doses  in the course of a
few hours, but  the oil and  ethereal extract are  more eligible  preparations.
The  oil may be  giA'-en 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-
position  that milk being a favorite food  of the worm, it  is  more effectually
poisoned by imbibing the remedy in  this vehicle.
  Another effective taeniafuge is the kousso (Brayera anthclminfica), the dried
floAycrs of a tree in Abyssinia, where tapeworm is exceedingly common.  This
remedy  is said to be relied  upon in that country.  Within the past few years
it has been used with much  success in  Furope and in this  country.   Half an 
506
INTESTINAL  WORMS.
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 (Cucurbita pepo). The
emulsion is prepared by pounding  tAvo ounces of the seeds in a mortar Ayith
half a pint of water and straining through  cloth.  This  quantity will con-
stitute a dose Avhich 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 (Punici graua(um') 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.   [The  active  principle of pomegranate has been isolated
by Tanret and called by him  pelletierin.   It has been  given  successfully in
numerous  cases, and on account of  its efficacy in small dose is preferable to
all the taeniafuges  above mentioned.   The tannate of pelletierin is the prep-
aration usually employed.  It may  be administered in doses of 5 or 6  grains
to adults and in 1-grain doses  to children.  Like all other anthelmintics, it is
most efficacious  Ayhen administered after fasting.  A suitable vehicle for the
drug  is simple syrup.—H.]   Kameela, the powder and hairs  from the cap-
sules  of Ilottlcra tincforia, is a powerful  anthelmintic which has been  found
promptly efficacious in  cases  of taenia.  The dose is from 1  to 2  drachms
given in honey or  thick gruel.  It acts efficiently as a purgative.  The rem-
edy 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 Araluable  of  the anthelmintics which experience has
shoAvn to be capable of destroying the tapeworm toxically.  The powder of
tin (jiulris  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 taeniafuge, 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, alloAving sufficient intervals for  recruiting the  strength 
TRICHINA  SPIRALIS.                     507
until a cure is effected.  It is to be borne in mind that if the greater part of
the worm be expelled, although the head may not be found, the death of the
Avorni 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  tapeAvorm  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 1885, 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 trichinae 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 neAV and highly important affection known  as  the
trichinal or trichinatous disease, trichinosis or trichiniasis.
   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.  When expelled from the cyst the  parasites
are seen  to be round worms -^ of an  inch long and g-^ 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 tine 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 trichinae shortly after birth penetrate
the mucous membrane, and find their  Avay 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.
   Trichinae 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 preA^ent 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 
508
INTESTINAL  WORMS.
underdone.   To effectually  secure  their destruction  every portion of meat
which  is eaten  should have  been subjected to thorough cooking.   The cus-
tom Avhich 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 Avere underdone in the centre, although sufficiently cooked on the
outside.  Meat  abounding in trichinae 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 trichinae 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 trichinae 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 trichinae retain their  vitality
for an indefinite time.   In one  case trichinae 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 trichinae.  Moreover, the flesh of a single
trichinous animal ma}' produce trichiniasis in a very large number of persons,
so that the disease in its prevalence may present the character of an  epidemic.
Muscular trichinae, however, may after a  time become completely calcified, in
which case they are innocuous.
  The clinical history of the disease caused by trichinae 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-
rhoea  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 trichinae 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 trichime 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 betyveen 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. 
ANCHYLOSTOMA DUODENALE.
509
 cases, attributable to the presence of trichinae in  the muscles  of phonation.
 Deafness may be  caused  by trichinae in the stapedius muscle.   The danger.
 cseteris paribus, is proportionate to the  abundance of trichinae 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 sloAvly, the illness lasting for several weeks or even
 months.  The trichinae become  encysted in the muscles, thereafter remaining
 quiescent.
   Diarrhoea 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 trichinae in the stools
 may  be ascertained,  and the diagnosis in  this Avay 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  trichinae  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 trichinae in the intestinal canal,  when given in  doses which are
 Ay ell 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-Avater.
 Of this mixture a tablespoonful is to be given every one or two hours.   This
 remedy, hoAvever,  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
 trichinae 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 183S.   Its  relation to a
severe form of anaemia which prevails in Egypt was first made known  by 
510
INTESTINA L WORMS.
Griesino-er in  1851.   The disease to Avhich this  parasite bears a causative
relation has received various names, of which the folloAving are the most im-
portant:  Egyptian chlorosis, anchylostoma disease, ankylostomiasis,  tropical
chlorosis, the anaemia 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 Avas not uncommon among the workmen
engaged in building the St. Gothard tunnel.  It has recently been observed
among Avorkmen 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 Strongylidae 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 (J 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 /j- long and from 23 to  40 p.
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° C. embryos develop and escape from the  eggs, and  then
become encysted as larvae in a clear chitinous layer.  These larvae or embryos
Avhen 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 anaemia, which may become as profound
as pernicious anaemia, and in fact  has often been mistaken  for pernicious
anaemia,   When a large number of anchylostoma embryos  are introduced at
once or rapidly into the intestine, the anaemia develops acutely ; and when
they are introduced more  slowly the  amemia is  chronic in its development.
Other symptoms  are  colicky pains  in the abdomen,  nausea,  vomiting,  con-
stipation  alternating with diarrhoea,  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 anaemia is not always proportionate to the number of worms present.
  The duration of the anchylostoma disease varies between a few  months
and several years.
  The prognosis depends upon the degree  of the anaemia and the obstinacy
of the diarrhoea and other digestive disturbances.   A fatal termination is not 
DISEASES  OF  THE PERITONEUM.
511
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 dollaria, and mixed with
aromatics and some form of iron.   About a drachm of this is giA7en 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,  Iioav-
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 millcpune-
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 Avhen the dog  was killed an hour after  their
introduction.  The  lizards were 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 cavity,
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.   (Cor  a different  conception of the  nature of this
cavity the reader is referred to p. 23.)  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. 
512
DISEASES  OF  THE PERITONEUM.
free communication with the lymphatic system the peritoneum readily receives
infectious and  otherwise  deleterious substances Avhich 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 SAVollen and cedematous,
and contains pus-cells, usually in swarms about the veins.   The other coats
of the intestine may be  somewhat altered.   The muscularis is  usually cede-
matous, and, especially in cases of puerperal peritonitis, there may  be inflam-
mation of the mucous membrane.  AVhile 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  be described as sero-fibrinous, sero-purulent, fibrino-purulent,
etc. Peritonitis with fibrinous exudation and Avith 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 be 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- 
ACUTE DIFFUSE PERITONITIS.
513
 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 Avith 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 inAvard (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.  25).  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 ahvays 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 holloAv 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,
       33 
514
DISEASES  OF  THE PERITONEUM.
in order to lessen the tension of the abdominal muscles and  to  relieve the
abdomen of the weight 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 hover 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 dyspnoea, which if great is accompanied by cyanosis.  The dis-
tension may be sufficient to displace the heart and to  push the liver upAvard.
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, diarrhoea subsequently occurring, and
occasionally diarrhoea 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.  Aomiting is a frequent,
and in some cases a prominent symptom.  The vomited  matter consists of
mucus and the  contents  of the stomach, and afterAvard 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. 
ACUTE  DIFFUSE  PERITONITIS.
515
    Catsation.—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 caecum  is  not  of very rare occurrence.
 (Tide  p. 420.)  Perforation of the stomach  and  of the duodenum  is  an
 occasional event in cases of gastric and duodenal ulcer.   Whatever 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  trauinatically 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 Avith 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 obserAred 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. 
516
DISEASES OF THE PERITONEUM.
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 hyperaesthesia 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 Avith
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
symptoms.  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 
ACUTE  DIFFUSE  PERITONITIS
517
 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 Avhether 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 diarrhoea, 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  caecum,  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,  hoAvever, 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  Ayanting, 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

  1 ATide 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
Alimentarv Canal," 1882;  also  article bv 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  Neics, Jan.
17, 1885. 
518               DISEASES  OF  THE  PERITONEUM.
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 issue.   It may destroy life Avithin
a few hours  if developed as a result of perforation.  Becovery, 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,  (roverned  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 boAvels 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 
ACUTE  DIFFUSE PERITONITIS.
519
 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.
   [Of late years, saline cathartics have been much employed in the treatment
 of peritonitis, the objects being to deplete the vessels of the inflamed serosa
 and  to remove toxic products by intestinal  drainage.  If  the intestinal wall
 is intact the inflammatory process may perhaps be favorably modified by this
 method, but if perforation  exists the danger of the  discharge of feces into
 the peritoneal cavity is greatly increased by it, the effect of the  saline being
 to liquefy  the intestinal contents and increase peristaltic  action.
   Dr. Maurice H. Richardson  has recently called attention  to  the dangers
 attendant  upon the use of these drugs, especially in  cases of perforative
 appendicitis.
   AAThen the peritonitis, from being local,  has become general, salines are  of
 no use whatever.   As  Richardson remarks, " In  a  completely  established
 general peritonitis from whatever cause, with distention,  vomiting, and obsti-
 pation, in my experience salines accomplish absolutely nothing."  J—H.]
   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 aAToid 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
                      1 Therapeutic Gazette, Xov. 15, 1893. 
520
DISEASES  OF  THE PERITONEUM.
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.  Alcnzo
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, 2H0 grains  ;
on the fourth day, 1 20 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
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 diarrhoea 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 
CIRCUMSCRIBED PERITONITIS.                521
 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 IoAva.   Leyden and others in Germany advocate the
 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  affection 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.
 When 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-obphoritis.   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  gynaeco-
 logical practice.  Circumscribed hemorrhagic peritonitis will be considered in
 the folloAving  article.
  1 Vide Yerhandlungen des Yereins  fur innere Median  zu Berlin, 1884; also, Am. Journ.
of Med. Sciences, April, 1885, p. 573. 
522
DISEASES  OF  THE PERITONEUM.
   The svmptoms 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
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 maybe 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.  AATien 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 Avith diar-
rhoea.  The patient emaciates and becomes anaemic.   Sometimes irregularities
due to encysted collections of fluid in the peritoneal cavity may be made out
by inspection, palpation, and percussion. When 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 may be rendered some-
what turbid by the admixture of pus-cells.  In some cases there  is fibrinous 
CHRONIC PERITONITIS.                     523
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-
quent 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, hydraemia, 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
inflammation than  in an ordinary case of ascites.1   Peritonitis complicating
ascites may be  suspected Avhen the  symptoms of the former  disease, which
haATe 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 tAvo 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
 proliferative peritonitis.  The new connective  tissue is in the form either  of
adhesions or of  thickening of the peritoneum.   The tAvo 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 neiv groAvth 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.   Aromiting,' diarrhoea, dull  pain, and emaciation  may be men-
tioned  as frequent symptoms.  The  distinction often  cannot be made from

  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 hvdrothorax and in the tunica vaginalis testis in hydrocele.
  2 " Des Lesions du Peritoine ehez les Alcoolises," Gaz. hebdom., 1879, No. 49. 
524               DISEASES  OF  THE PERITONEUM.
tuberculous peritonitis or from  cancer of some  of the abdominal organs.
 fhe 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 neAV membrane is  reddish or brown in  color, from
infiltration  with blood.  Extensive extravasations of blood form  haematomata.
This peculiar form of peritonitis  is analogous to chronic hemorrhagic pachy-
meningitis, which will be described in the next section of this work.   Fried-
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 Ayith especially in  the  recto-uterine fossa,
where it  causes bloody tumors known as retro-uterine or pelvic  haematoceles.
A similar haematoma may occur in the recto-vesical fossa  in  males.   The
prognosis in pelvic  hematocele is good, the blood being often absorbed with
astonishing rapidity.   The consideration of this form  of disease belongs  to
works on gynaecology.   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. 
CHRONIC PERITONITIS.
525
The>e. as well as softened tubercles, may lead to ulcerations into the intes-
tinal canal  from Avithout.   The adherent  coils of intestine may also ulcerate
into each other.   Even fecal fistulae, opening through the abdominal parietes,
may be formed.
  In 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 Avith  a large number
of tubercles Avhich 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 AVilks 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-
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 Avhich 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—has  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  sloAvly progressive in
its course.   There is usually moderate  fever,  with more  or less  acceleration
of the pulse.   A^omiting  and other  digestive disturbances are more or  less
prominent.   Diarrhoea alternates  with constipation.  Other general symptoms
are—night-SAveats, hectic paroxysms, progressive emaciation, anamiia, 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.  AThen 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
lar»e 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 Avithdrawn by tapping  may be examined for tuber-
cle bacilli,  but failure  to find these would not  exclude tuberculous peritonitis. 
52G               DISEASES  OF  THE PERITONEUM.

  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
or more  large tumors in  the  serous membrane, or there  may be 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 comes 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.  When the primary
cancer is recognized, the diagnosis of cancerous  peritonitis does not usually
involve  much difficulty.  When, 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 belonging  to transudations in general.  Like other dropsies, hydro-peri-
toneum 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 inconvenience and danger,
to Avhich 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 accumulations in  other
serous sacs.
1 British Med. Journ., 1878. 
HYDR 0-PERITONE UM—A SCITES.
527
  AYith very feAV 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 Avhich  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-
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.   AYith the possible
exception of amyloid liver, they all cause  ascites by  interfering  Avith 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
hydraemic 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 hydraemia ; but other cachexiae, as the  tuberculous, the cancerous, the
syphilitic, and the malarial, may also cause  hydraemic dropsy.  From the
foregoing it is eA'ident that dropsy of the peritoneum, as of other parts, may
be  divided into mechanical dropsy  and cachectic  dropsy.   Ascites due to
mechanical causes (obstructions to the circulation in the liver, lungs, or heart)
reaches a  higher degree than that due to  hydraemia.
   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 caAoty the quantity of
albumen is usually less than 21  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 2]  per cent.   Chemical examination of fluid removed by tap-
ping may  thus be of assistance in diagnosis. Ascitic fluid contains fibrinogen,
and it often  coagulates spontaneously when withdrawn from  the body.   At
autopsies  ascitic  fluid is by  no means always  found devoid  of coagulated 
52*
DISEASES  OF  THE PERITONEUM.
fibrin.   Since  Schmidt's investigations as to the coagulation  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 Avith tubercle
of the peritoneum.  In one case  of chylous ascites Avhich followed  residence
in a tropical climate Winckel found  in the fluid  countless parasites  resem-
bling the Filaria 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 oedema 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 diarrhoea 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,  oedema of the lower extremi-
ties  is a pretty constant symptom, the amount  of oedema varying much in
different cases.   The limbs, scrotum, and penis sometimes become enormously
swollen.   Some oedema  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 cedematous lower
extremities  combine to  render the appearance highly characteristic of the
  1 AVinckel, Deutsches Archivfiir klin. Med., 1876, Bd. 17, p. 303.
  2 \Tide 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. 
HYDR 0-PERITONE UM—ASCITES.
529
affection.   Cholaemia or icterus is occasionally present.   It  occurred  in 7 of
the 4G  cases which I haATe  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 uraemia or to retention in the  blood of the  excrementitious  principles of
the bile (cholester.emia).
   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 apnoea and asthenia are combined when coma  precedes death.
   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 Avhich the dropsy disappears or is removed.
The duration of the affection is variable.   In the fatal cases of those  Avhich 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 Avithout 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  Avails, 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 Avith 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  vaginam, together with
auscultation of the abdomen, should  preATent  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 Avhich 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
        34 
530
DISEASES  OF  THE PERITONEUM.
floating upon the  liquid, is usually found at the upper part of the abdomen,
extending beloiv 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 s1ioavu 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 Avhich 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.
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 Avant 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.   When  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.   So.  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
Avater 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 
HYDR 0-PERITONE UM—ASCITES.
531
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
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
ho  clanger 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 drops}.   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
eases 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.
                           1 Aride Clinical Medicine. 
532
DISEASES  OF THE  LIVER.
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.1
  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
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.  AArell-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 Aascera, 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.
  1 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. 
S UPP URA LIVE HE PA TITIS.
533
          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 liyer.
 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.   When very many the individual  abscesses are
 usually of small size.  In a  case under the  author's observation five and a half
 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 Avell as abscesses elsewhere,
 are caused by the invasion  of micro-organisms.  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 zooglcea 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-cayity.   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  Avith 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.
  AVhen the abscess reaches the surface of the  liver a circumscribed inflam- 
534
DISEASES  OF  THE LIVER.
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.   When 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 ensitbrm
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 lumbar 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 rio-ht
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 be 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 
SUPP URA TIVE HEP A TITIS.
535
 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, pyaemia, etc.   If the eyacuation  take place
 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, anaemia, debility, emaciation, and, in cases which
 pursue an unfavorable course, hectic fever, colliquative diarrhoea, 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
 Avhich 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 whereA'er they lodge
 and  develop give  rise to pyaemic  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 pyaemic 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. 
536
DISEASES  OF  THE LIVER.
  [That form of dysentery known as ': amoebic " (see article on Dysentery) is
peculiarly apt to be associated  with hepatic abscess.   This  association has
been carefully studied  by Councilman and  Lafleur, from whose article the
following " conclusions " are quoted :
  " Abscess  of the liver, with or without  involvement of the lung, is a fre-
quent  complication—much more  so than  in any other form of dysentery.
The  involvement of the lung may early follow hepatic involvement, and be
detected by the occurrence of amoebae in the sputum before there is evidence
of liver-abscess.  These abscesses  differ in  their anatomical features  from
those produced by other causes.   The chief difference is found in the absence
of purulent inflammation, the abscess being caused by necrosis, softening, and
liquefaction of the  tissue.  In these liver-abscesses the  amoebae are not asso-
ciated  with any other organisms."—H.]
  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  pyaemia, pylephlebitis,  and
affections involving the  rootlets of the  portal vein are called secondary, pyae-
mic,  or metastatic abscesses.   Pyaemic 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 or'
small abscesses.
  Pyaemic  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.—AAThen abscess of the liver is considered clinically as an indi-
vidual  affection, reference is had not to the small, multiple pyaemic 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. When 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 ahvays to be
taken into account.  Enlargement of the liver frequently, but not invariably 
SUPP URA TIVE HEP A TITIS.
537
 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 lar^e
 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,
 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 recoArery are those in Avhich 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 betAveen 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 vieAv 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 knoAvledge of the existence of the affection.  In a
 case in which the  abscess is  ascertained to  be making  its  Avay 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 
538
DISEASES  OF  THE LIVER.
beneath the integument exterior to the abdominal or thoracic Avails, 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  Avith 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'
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, hoAvever,
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.
   AVhen 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
      1 Vide paper in Transactions of the New York State Med. Association  vol. i. 
                CHRONIC INTERSTITIAL  HEPATITIS.             539

presents in this disease.   These nodules, iioav 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 noduies
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
neAviy-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 anamiic.
   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 Grlisson, 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 Avhich  surround usually a  number of lobules.  The  new
groAvth  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 fhe lack
of nutrition consequent upon  the obliteration of  the interlobular veins   lhe
remaining hepatic cells usually contain  oil-globules and are stained with bile-
pigment.                                                 „ .        .
   There is much plausibility in the view  first advanced by AA eigert 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 
540
DISEASES  OF  THE LIVER.
the kidney and elsewhere the primary change is degeneration of the epithelium
or parenchymatous cells, and the new groAvth 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  alter#d 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.
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.  Tho 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 oedema 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 oedema of  the lower limbs.  After considerable  abdominal enlarge-
ment  has taken place the  oedema increases.   The limbs often are largely
swollen, and the genitalia may become more or less cedematous.   The ced'ema
in these situations is attributable to  pressure  of the peritoneal effusion upon 
                CHRONIC INTERSTITIAL HEPATITIS.              541

the iliac veins.  (Edema of the face and upper  extremities does not occur
except in cases in which  cardiac or  renal disease  coexists.   (Edema 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 anaemic 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
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 portae and the veins of the serous cover-
ing of the liver;  between the coronaria  ventriculi and the oesophageal veins;
and by newly-formed vessels  in  the tissue by  Avhich 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
Medusae.  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.  Haematemesis may proceed  from varices at  the lower end of the
oesophagus.   Enterorrhagia coexisted  with gastrorrhagia  in 2  cases,  and
occurred without it in 2 cases.  A'omiting is occasionally a prominent symp-
tom,  and diarrhoea 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  oedema 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 
542
DISEASES  OF THE  LIVER.
 deficient  secretion  of bile; and the blood-pigment Avhich sorvcsfor 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,
 hoAvever,  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-
 ing.   Hence the significance of the term gin or whiskey liver applied by British
 writers to this affection. 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  trustivorthy 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 Avarrantable.  As  to the action
 of alcohol in producing this affection, 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 AVeigert'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  affection.
   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 late' Prof. It.  Palmer Howard
 of Montreal  published  a report of sixty-three cases of  infantile cirrhosis,
 and  Laure and Honorat have  collected a  series  of fifty-one cases, mostly
 from  English sources.  It  has been suggested by AVesley Carpenter'of Xew
 York that cirrhosis in infants may be  caused  by the milk  of  a  mother or
 nurse addicted to the intemperate use of alcoholic  drinks.__H.]  The affec-
 tion  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
  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.)                                                     r  '      J 
CHRONIC INTERSTITIAL HEPATITIS.             543
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 affection 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  Avails 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
is to be borne in mind, occurs in other pathological connections, as well as in
cirrhosis of the liver.  (Aride p.  526.)   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 Avithout 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. 
544
DISEASES OF THE LIVER.
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-
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 anaemic.  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-
  1 P. Olivier,  Hayem, and especially Hanot, Etude sur une Forme de Cirrhose hyper-
trophique du Foie, Paris, 1876, and Charcot et Gombault, Arch, de Physiologic, 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 biiiary cirrhosis.  There
is another form of biliary cirrhosis Avhich 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. 
ACUTE  YELLOW ATROPHY OF THE LIVER.         545
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
Avhich 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 Virchow, 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
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 Arery 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 dia'gnosis.
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 likeAvise 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-
        35 
546
DISEASES  OF  THE LIVER.
quence of diminution in bulk of the liver-substance.   In the living body the
shrunken liver may sink back  toAvard 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 beloiv 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
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-existhi"- ducts
They are considered  by AValdeyer, Zenker, and  others as  offshoot  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 rows of  pre-existing liver-cells altered in shape   \ttempts 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 
ACUTE  YELLOW ATROPHY OF THE LIVER.         547
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.  Without 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,
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.   When  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 haematuria.  Extravasations  are not uncommon, giv-
ing rise to petechias 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- 
548
DISEASES  OF  THE LIVER.
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 (juantity 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, Avhen 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 mav
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.
   As to the pathological character of the disease,  there have been  many
speculations, most of Avhich 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 yelloAV 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  cholesteraemia is evidenced by  clinical observations show-
ing in this disease a notable accumulation in the blood of cholesterin and bv
experiments showing the production of phenomena analogous to those of this
disease in animals by the injection of  cholesterin into the"blood.1  Uraemia is
  1 Vide " Experimental  Researches into a New  Excretory Function of the Liver " bv
A. Flint, Jr., Am. Journ. of Med. Sciences, 1862 ; also, Flint's textbook of Human
Physiology. 
            ACUTE YELLOW ATROPHY OF THE LIVER.        549

doubtless in many cases a pathological element, but the clinical history >hows
clearly toxical effects other than those referable to that element.

  Causation.—Of 143  cases analyzed by Thierfelder, 88 were Avomen and
55 were men.  Of the SS 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 toxaemic phenomena—namely, delirium, hemor-
rhages, etc.—in connection with jaundice.  The fevers—typhus or typhoid,
remittent, pyaemia, 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
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.
  [The affection  Ayith which  acute  yellow atrophy is most  apt to be con-
founded  is acute phosphorus-poisoning.   The  latter may be recognized by
the history of  the case, the sudden  onset of the symptoms, the severe gas-
tralgia, and  the demonstration of phosphorus  in the vomited matters.—H]

  Prognosis.—It is questionable Ayhether 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 46;  from two
and a half to three days  in 26 ;  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 feAV words will embrace all that is to be  said with refer-
ence to treatment.   With 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- 
5 50
DISEASES  OF THE  LIVER.
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 uraemia, 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 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.—Multi-
   locular 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.

    HAVING 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.

                             Patty 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  fatty infiltration  and fatty degen-
eration of  the liver.  The distinction may be here repeated:  In fatty  infil-
tration or  fatty growth  the protoplasm is displaced by the fat. but does not
suffer materially in  its  integrity, 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  degeneration it appears as small  drops or mole-
cules.   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 Avhich 
FATTY  LIVER.                         551
have  been considered  characteristic of infiltration ; but  these  morphological
appearances  do not suffice  for  the  diagnosis  between infiltration and degen-
eration.
   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 anaemic.   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.   AVe thus find
fatty livers in  conditions apparently the  most opposite—namely,  in cases of
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 hydrocarbonaceous 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 anaemias, etc.   The largest  fatty
livers met Avith 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 llecker and Buhl.2^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-

  1 Perls, Lehrbuch der allgemeinen Pathologie, Bd. 1, p. 177; Platen, Virchovrs Archiv,
Bd. 74, p'. 268.
  2 Klinik der Geburtskunde, 1,  1861. 
552
DISEASES  OF  THE LIVER.
 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 anaemic, 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 Avith 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
 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-poisonings 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.                         553
                            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, which 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 anaemic.   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-
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
mav 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 betAveen 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 
554                   DISEASES  OF  THE LIVER.
Frerichs and  E.  AATagner, 24 occurred at between ten  and twenty  years  of
age ;  'M between twenty and thirty years ; 31 between thirty and fifty years ;
1G 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 be 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
leads to contraction of the  organ ;  but 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 uraemic 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  Avhich  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 
CANCER  OF THE  LIVER.
555
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  Avill  permit
is advisable.  Disorders of any of the functions are to receive  appropriate
attention.  Diarrhoea 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  35S 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 groAvth.
   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
occur in an infiltrated  form, and in this  case the liver sometime^ 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 Avhole 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
bevond the surface, and  in some cases  the peritonitis  becomes general.
  The type of the secondary cancer conforms generally to that of the primary m
growth.   As a rule, the cancerous alveoli are large and  close  together, and
contain irregularly-shaped, polygonal cells.   The  cells  may, hoAvever, 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
  1 Of 1574 cases of  cancer of the stomach analyzed by AVelch, the liver  was the seat
of secondary cancer  in 475 (30.2  per  cent,). 
556
DISEASES  OF  THE LIVER.
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  lite.   Ui 4(^
cases  analyzed by Leichtenstern, the  ages in 87 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 sooneror 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 G7 of 146 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-
cerous tumors or to pressure  upon the portal vein.   In the latter  case the
effused liquid  is serum Avithout 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
diarrhoea not infrequently occurs.  (Edema 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 elseAvhere, 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 Aveeks 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
                         1 A7ide Ziemssen's Handbuch. 
      ECHINOCOCCUS OR HYDATID  TUMORS OF THE  LIVER.  557

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 Avhen 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 vieAv of more or less pain
and  tenderness over the liver, conjoined with a cachectic  condition  and  the
existence of cancer elseAvhere.  The diagnosis is  impossible in the few cases
in Avhich 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  has 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 earl}-  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 endeaAror 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.
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 leucocythaemia and
pseudo-leucocvtluemia. 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
foVmation, 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 tamia echinococcus, a tape-
worm about one-sixth  of an inch in length, which infests  the  small intestine
of the doc   The embryos developed from the eggs of  the tamia 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 
558
DISEASES  OF  THE  LIVER.
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 tapeAvorm  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 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 but a fatty
calcareous nodule, usually containing cholesterin and haematoidin crystals.
The hooklets 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 take
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
  1 The following works may be consulted:  Davaine, Trade des Entozoaires 2me edition
Paris, 1877 ; Leuckart, Die menschhchen Parasiten, i., Leipzig, 1863; Heller' in Ziemssen's
Cyclopaedia of the Practice of Medicine, vol. iii.; Cobbold's Treatise  on Parasites 
      ECHINOCOCCUS OR HYDATID TUMORS OF THE LIVER.   559

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  61 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.1
   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
autopsieal  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.  AAHien 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 dyspnoea on exertion, cough, and palpitation.  Pressure on the
stomach and intestine is liable to produce  vomiting and  constipation.  If the
vena  cava be  compressed, oedema  of the lower extremities follows.   The
growth  of  the tumor  is attended by little or 110  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
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 portas.
  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
               1 Osier, Am. Journ. of the Med. Sciences,  Oct., 1882. 
560                   DISEASES OF THE LIVER.
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 aneurismal 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 peculiar
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
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 to  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- 
ECHINOCOCCUS  OR  HYDATID TUMORS  OF  THE LIVER.   561
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
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, Avhich may be continued  so as to involve danger
from  constitutional  irritation  and exhaustion.
  A simple method of treatment Avhich often suffices for the cure is to Avith-
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  liA-er and elsewhere is to be based on
the source—namely, the ova of the tamia 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.
             1 Vide Heller, in Ziemssen's Cyclopaedia, Am.  ed., vol. iii.
         36 
562
DISEASES  OF  THE LIVER.
                    Multilocular Echinococcus.

  The echinococcus multilocularis represents a peculiar form of  develop-
ment of  this parasite.   With very feAv 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.
  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 cellulosae  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 tamioides,
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. MM.
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.2 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.
  1 Delafield and  Prudden's Handbook of Path. Anat., New York, 1885 p. 354
  '' Vide N. Y. Med. Record,  Jan. 13,1877 ; also Aitken's Science and Practice of Medicine. 
       CHANGES  IN POSITION  AND SHAPE OF THE  LIVER.   563

             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.
AVith our present knowledge, the pigment-liver is hardly entitled to be reck-
oned in  the  list  of hepatic affections.   It  will be referred  to hereafter as
entering  into  the anatomical characters of the periodical 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 seATere anaemia,  particularly in pernicious anaemia, the  liver contains a
large number of colorless  granules  which are stained greenish-black by treat-
ment Avith 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
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.  AA"e 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 Avails  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. 
561
DISEASES  OF THE LIVER.
   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
 diA'ide 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 doAvnward 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 Xew York  Medical and Surgical Society by AVillard Parker the dislo-
 cation Avas 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
   Restoration 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
 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
 hyperaemia 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.                                                    r
   Chronic passh-e 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 cau«e<
passive congestion.   The obstruction is  usualfy 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 oower of
 the heart s action due to myocarditis and obstructions in the pulmonary cir-
                 1 ATide Am. Journ. of Med. Sciences, Jan., 1881. 
          PORTAL THROMBOSIS,  PYLETHROMBOSIS, ETC.      565

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 yelloAvish  from the
comparative  anamiia 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.
  AVhen 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.  AYhole 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-
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 conjunctivae 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 
566
DISEASES  OF  THE LIVER.
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.  The
thrombosed  vessel is  converted  into a fibrous  cord, either solid or canalized.
In the  latter case the circulation may be partially or  completely re-estab-
lished, 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 \reins may become dilated.
Anorexia  and loss of  digestive power are  symptoms occurring  without  much
delay.   Diarrhoea  occurs  frequently.   The lower limbs and genitals become
greatly cedematous.  There is progressive loss of strength  without fever, and
death may take place within a few weeks by asthenia.  Rapidly 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 Avhich 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.   Suppurative 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 pyaemia, 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
    1 Vide paper entitled " Early Tapping in Cases of Ascites."  (See note, p.  532.) 
INFLAMMATION OF THE BILIARY PASSAGES.        567
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 tiyo 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 folloAy  the  course of the  portal vessels
within the liver.
   The diagnosis  of suppurative pylephlebitis  is to be based on the  local
symptoms already  stated, in conjunction with the symptoms of pyaemia 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
cases 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.-Weil's Disease-Acute Febrile Icterus-Infec-
   tious 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 
56S        DISEASES OF THE  BILIARY PASSAGES,  ETC.
consist  in  hyperaemia and swelling of the  mucous membrane  and increased
secretion of mucus.   As  in similar inflammations elsewhere,  these change's
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, bad 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
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 weeks.   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 pyaemia, typhoid fever and cholera.
Sometimes the inflammation  is  secondary  to suppuration or necrosis  of the 
DILATATION OF THE  GALL-BLADDER.            569
tissues  in  the  neighborhood  of  the  ducts.   Purulent  inflammation  of the
bile-ducts  outside of the liA'er 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. 4G6), 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-
toms.   Exceptionally, however, under these  circumstances the gall-bladder
becomes enormously distended with bile, as in a case related by Van Swieten
in which the gall-bladder contained eight pounds of thick bile.
   Some consideration is due 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 fellete, 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 felleae 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
  1 In a case described by Erdmann the amount of fluid is said to have been from sixty
to eighty pounds. 
 570        DISEASES OF THE  BILIARY PASSAGES,  ETC

 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  indiyidual
 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 Avith
 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 (empyaema cystidis felleae).   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 gall-bladder  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.
  The parasites which are  sometimes  found  in the  biliary passages have
already been considered (p. 498).


                       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
 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, where-
as cholaemia 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  cholaemia, 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.
  Whether the bile-pigment be ever formed in the circulating blood is a mat-
ter of  uncertainty.  Haematoidin, a pigment identical  Avith bilirubin, is often
formed in old  blood-extravasation ; and this fact, together with other facts.
has giATen 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 haematogenous jaundice, in distinction from
 that caused  by  the   absorption of  bile, or hepatogenous  jaundice.  The 
JAUNDICE,  OR ICTERUS.
571
hypothesis of a haematogenous jaundice is  advanced to explain certain cases
of jaundice in Avhich none of the recognized causes of  the absorption of bile
from the liver have been found.  A haematogenous origin has been urged es-
pecially for the jaundice occasionally occurring in certain infectious diseases,
such as septicaemia, pyaemia, 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 haematogenous jaundice,
and that  this theory has of late lost, rather than gained support.   Haemo-
globin, Avhich is set free by destruction of red blood-corpuscles in the circulat-
ing blood, is  eliminated by the  kidneys in the form of meth-haemoglobip, and
there is no proof that it is ever converted Avithin the blood into bile-pigment,
although dissolved haemoglobin increases the formation of bile-pigment within
the liver.   There is a tendency to refer  many cases which some Avriters have
regarded as haematogenous 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 haematogenous are in reality of hepatogenous ori-
gin, we possess no satisfactory  explanation of the cause of the jaundice in the
remaining cases.
   In all cases in Avhich 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 Avails of the  ducts ; and  third, as  lesions
causing pressure upon the bile-ducts from Avithout.
   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 
572        DISEASES OF THE BILIARY PASSAGES, ETC.

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 which 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 papillae of the kidneys, and sometimes other organs, contain a
large quantity  of  crystalline pigment.
   Veliowness 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-
pigment  in the transuded liquid which infiltrates the tissues.  Other  things
being equal, the intensity of the yellow color is proportionate to the  degree
of the  cholamiia.   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 yelloAv  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 Avhich it is
unusually infiltrated with  serum, that  is, cedematous.
  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 
JAUNDICE,  OR ICTERUS.
573
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
boAvels 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 aveight 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  deA-oid  of bile, emit an  odor of putrescence,
and the formation of  gas is frequently troublesome, bile  in  the intestinal
canal being an antiseptic as regards the fecal contents.   Generally, the boAV-
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
ivill depend in a great measure  on the pathological conditions with which the
 jaundice is associated.   If the jaundice depend  on obstruction in  connection
Avith  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, Iioav-
ever, the  body wastes,  the patient becomes  anaemic 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.
  When 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 Avith 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 neAV growth of  interstitial tissue, constituting one of the forms of
biliary cirrhosis of French writers.   The persisting distension of the  hepatic 
574        DISEASES OF THE BILIARY PASSAGES PTC.
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 cholesfersemia 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 uraemia 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-
trium.  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 remoA'ing the obstruction by
their  operation.   If, however, the jaundice be connected Avith 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 Avith-
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
laxatiA^e, 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.  Ptemedies 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. 
WEILS DISEASE.                       575
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
Avith 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.  (Vide p. 469.)
   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 cases
in which, after  the persistence  of jaundice for many months, recovery at
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. With 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 cholamiia no longer exists.   Of the continuance of  the cholaemia 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.

  [Weil's Disease—Acute Febrile Icterus—Infectious Icterus.

   In 1886  Prof   Weil of  Heidelberg  reported four cases  of an affection
characterized by fever, headache, vertigo, somnolence, and  delirium,  associ-
ated with swelling of the spleen and liver, albuminuria, digestive  disorders,
and jaundice.  In  a few days-from five to eight-these  symptoms and signs
gradually subsided and the  patient was apparently restored to health,   lhe
disease, however,  was not at an end,  for after an intermission of variable
length—from one to seven  days—a relapse  occurred in  three of the  four
          1  Uebcr Icterus gastro-duodenal is,  von C. Gerhardt, Leipzig, 1871. 
576        DISEASES OF THE BILIARY  PASSAGES, ETC.

cases and the course of  the  primary attack  was  repeated.   Convalescence
was protracted, the patients not  being  discharged  from hospital until from
four to ten weeks  after their  admission. ^
  The folloiving reasons for regarding  this affection as an independent one
have  been  advanced: From acute  yellow atrophy of the liver it is distin-
guished by the swelling  of  that viscus, by  the high temperature, by  the
simultaneous swelling of the spleen, by the involvement of the kidneys,  and
by the absence of hemorrhage;  and  from catarrhal  jaundice, by the higher
range of temperature and the implication of  the spleen, liver, and kidneys.
It resembles relapsing  fever in many respects, especially the variety called
by Griesinger " bilious  typhoid."   The latter disease, however, never exists
in sporadic  form,  and hence may  be excluded even  in the  absence of the
important negative  evidence  that would  be furnished by an examination of
the blood for the  spirillum  of  Obermeier.   The  concurrence of jaundice,
apyretic intervals, and distinct relapses suffices  to exclude the view that the
affection is an abortive  typhoid  complicated with jaundice.  It is admitted
without further parley that the affection belongs to none of these nor to  any
similar category, and in the  absence  of further information we  confess our-
selves unable  to classify the cases reported by Weil.  Happily, such infor-
mation is at hand.  In  the short time that has elapsed since  Weil's publica-
tion a number of similar cases have been reported, several  of which were
fatal and were examined post mortem.   In 1887, under the  title of " acute
parenchymatosis," Aufrecht reported  two cases of  acute fever ivith jaundice
and albuminuria,  which, after  a- rapid course  characterized by brain-
symptoms  such  as  somnolence  and  convulsions, ended in death.  In both
cases necropsies were held. In one  the liver was small, in the  other enlarged.
In the latter the  cellular  elements  of the liver and  kidney were filled with
strongly-refracting granules which Aufrecht, without proving  his supposition
by appropriate staining  methods, regarded as micrococci.
  Nauwerck examined  post mortem two  cases of fatal febrile icterus, in  one
of which* death occurred within forty-eight hours.  In this rapidly-fatal case
the liver was  not enlarged.   In  the  intestine were small superficial ulcera-
tions  and enlargement  of solitary follicles and  Peyer's  patches.   An intes-
tinal mycosis was supposed to  be the fundamental process, inasmuch as the
mucous  membrane  contained  small   foci of  cellular  infiltration,  in  part
necrotic, in  the immediate neighborhood of which  accumulations of bacilli
were  found.   The parenchyma of  the liver and kidneys presented a high
degree of albuminous, fatty, and necrotic degeneration.  In the second case,
which lasted seventeen days, the  intestine was perfectly sound,  while  the
lesions of  the liver  arid  kidneys  were  identical  with  those of the first.
Nauwerck concludes from these examinations  that anatomical and etiological
unity are both wanting  in ': Weil's •disease."   The third case of this affection
in which a necropsy Avas held was  reported by Brodowski and Dunin.   The
patient, a male thirty-six years of age, presented, in addition to febrile icterus
and swelling of the liver and spleen, a symptom that has been wanting in all the
other cases reported—viz. swelling  of all the superficial lymph-glands.  They
were  tender on pressure and  enlarged, some of them  to the size of walnuts.
On section, these, as well as the enlarged mesenteric and  bronchial glands,
were  soft and of a  reddish-gray color.  In the liver could be seen with the
naked eye gray spots and  nodules which corresponded to round-celled infiltra-
tions of the acini and their neighborhood.  The cells were in a well-marked
state of cloudy swelling.   Analogous  appearances  were observed in the
kidneys, and  the interstitial tissue of the lungs was infiltrated with cells.
The spleen was five times the normal size.  No  definite conclusion could be
drawn from  the  bacteriological investigation. 
WEIL'S  DISEASE.
577
  From the reports of these necropsies it is evident (1) that the post-mortem
appearances Avere in no single case identical with those of any other, and (2)
that the only lesion common  to all the cases—the cloudy SAvelling  of the
liver and spleen, with  small-celled  infiltration of the connective  tissue of
these glands—was in nowise typical.   The same appearances  are characteris-
tic of a number of  infectious diseases, such as scarlatina, diphtheria, typhoid
fever, and especially septic infection.
  The  question  next in  natural order is whether any facts support the  view
that sepsis may  give rise to the symptoms described by Weil,  and the answer
is most decidedly in the  affirmative.  Since 1876, Fiedler has  observed  thir-
teen cases of febrile icterus, all of which recovered.  SAvelling of the  spleen
and  liver and albuminuria were  not always  present, and  in  only  two cases
was  there  a distinct relapse.   The  only symptoms invariably present  were
fever, icterus, and pain in the  calves, which latter Fiedler  regards as  path-
ognomonic.   The most remarkable etiological fact in  connection with these
cases is that, out  of the twelve males among  them, nine  were  butchers
who were actively  at work in  the  Dresden  abattoir until  the time of their
seizure.
  The  most remarkable  case of this sort yet reported  was observed by
Fraenkel, and the  evidence  it brings to the  support  of the septic  theory
of " Weil's  disease " is of the strongest kind.  The patient  was  a medical
student who, while fencing, received a wound of the forehead.  In addition
there was a slight excoriation in the right temporal region.   The wound was
dressed antiseptically and  covered with  a bandage, which,  however, did not
protect the excoriation.  On his way home the patient wore a hat which had
been kept  in  the dissecting-room.   The  wound was received on the  3d of
August.  On the 5th there was a chill followed by high fever, and on the
7th  by an erysipelatous redness around the  excoriated spot.  On the  10th
there was pronounced icterus, and, without going into further details,  all the
symptoms  of Weil's cases, including the apyretic  interval, the relapse, and
the protracted convalescence, were well marked.  The spirillum of Obermeier
was sought for in vain.
   Among the widely-varying symptoms and post-mortem appearances  of the
numerous cases  of  " Weil's  disease " now on record, there is nothing distinc-
tive of a hitherto unrecognized disease.   On the other hand,  there is  strong
evidence that some  of them were cases  of septic poisoning.   In Fraenkel's
case, which corresponded in all  respects with the  cases described by Weil.
the point of septic infection was a wound of the head ;  and in Fiedler's cases,
at least in the nine butchers, the infection may have entered  the system in a
similar manner,  through cuts and abrasions too  slight to attract attention or
through the ingestion of decaying  meat.  The designation of such manifes-
tations of sepsis as  " Weil's disease," while it has served the valuable purpose
of directing more special attention to them, is a misnomer.  Much more appro-
priate  is the term septic or infectious icterus, proposed by Fraenkel.—H.]

               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
conversfng 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  manv  to refer a certain group of  symptoms to con-
gestion of the liver.  The nature of these symptoms and the propriety of
         37 
578         DISEASES OF  THE SPLEEN AND  PANCREAS.

considering  them as dependent upon  hepatic congestion have already been
discussed  m the  article on Congestion of the Liver  (p. 564).
  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 glycogen, 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.
  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
to enter into the etiology of diarrhoea, 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 Avhitish 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 
DISEASES  OF  THE SPLEEN.
579
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 jmssive 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.
   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, Avith 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
organ.   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  pyaemia.   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 
 580        DISEASES OF THE SPLEEN  AND  PANCREAS.

 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. 537.)
   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
 pyaemia and septicaemia, 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
 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, leucocythaemia, and pseudo-leucocythaemia.  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 trabeculse.    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.                                                          b 
DISEASES  OF  THE SPLEEN.
581
  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.  When enlarged, its lower border  extends
downward and anteriorly.  Pulsation of an enlarged  spleen, in  connection
with  aortic regurgitation, has been observed.
  The treatment of acute enlargement involves the indications belonging to
the infectious diseases  with Avhich 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 anaemia.  Changing  the  form of the  chalybeate tonic from time to
time is important.   DaCosta  has reported a case of splenic  leucocythaemia
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.   Were 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.                                 .           .          .     ...
   Wan/ 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
                1 Vide Am. Journ. of Med.  Sciences, January, 1875. 
582         DISEASES OF THE SPLEEN AND PANCREAS.

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 cachexias, 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.
   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.  (Vide p. 557.)
   With 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 of 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.
583
                   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
pyicmia,  and apparently as a result of the employment  of mercury.   The
morbid appearances denoting acute inflammation are hyperaemia, 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, diarrhoea, 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
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 Wilks 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. 361),
the presence of jaundice, fatty stools, and sugar in the urine. The connection
between structural disease of the  pancreas and fatty diarrhoea  has been con-
sidered in treating of the latter. (Vide p. 446.)   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

  1 Pathological Anatomy.                                 ,  ,  „ ,. , .  , „  . ,
  2 For an analysis of 37 cases by DaCosta, vide Proceedings of the Pathological Society
of Philadelphia, 1858. 
 584         DISEASES OF THE SPLEEN AND PANCREAS.

 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
 floAV 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.   We know no symptoms referable to lipomatosis of the
 pancreas.
   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 coeliac
 plexus and semilunar ganglion.
   Finally, calcidi 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 Avhich, 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. Jftten Versammlung Deutscher Naturforscher.
  2 Haber, Deutsches Archivf. klin. Med., Bd. 15 p  455
   ....       ...     " .; .:—""- ■-* ™ wmyir.  yioio),  may be  referred to; a so,
"'  Khnische Beitrage zu den Krankheiten des Pancreas," Wiener med. Blatter,
J'tt%°'   VX  ) ^\  r' an ^^V?1?6 on " Calculus and Other Affection
ScilZl, OeT! 1882I    '  7     ^            nS°n' M'D" in the Am-Jmrn- °f ^'d-
  4 Vide article in the Journal of the Am. Med. Association, Oct. 3  1885 Six nrlHitinnal
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  Hypera?uiia.—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.—Meningeal
   Hemorrhage.—Insolation, 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, hyperaemia, 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  hyperaemia,
 anaemia, 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  Hyperaemia.

   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.  While  the possibility  of cerebral hyperaemia is now uni-
                                                              585 
5Sti  DISEASES  OF  THE CEREBRAL AND SPINAL  CIRCULATION.

versally admitted, there is not the same unanimity as to its frequency, import-
ance, and etiology.  Within the last feiv 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 Avhile 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 Avith blood is no
index of cerebral hyperaemia 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 hyperaemia of
the  brain, as of other organs, may leave no trace of  its existence after death.
When, 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 ( pina-to
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-
emia, 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  hyperaemia.   It has been experimentally demonstrated that division
of the sympathetic in the neck causes hyperaemia of the intracranial vessels.1
It may be suspected that  strong mental  emotion may cause hyperemia 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 Mollendorff, ibid., Bd. 41; Berger, ibid., Bd. 59. 
CEREBRAL  HYPERAEMIA.                   5S7
 as giving rise to cerebral hyperemia,   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 hyperemia is an element, but  probably
 not the most  important one, in insolation.

   Rapidly-induced  active  congestion  of great intensity  may  produce sudden
 coma  Avhich  may disappear after a  few hours or may prove speedily fatal.
 Tbis 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.   When 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 Avithin the skull should cause
 coma,  and perhaps  destroy life by depriving the mass of the brain of a due
 supply of arterial blood, yet  the  fact  is sufficiently  intelligible.   Apoplexy
 attributable to active hyperaemia is a rare event, but of its occurrence there
 can  be no  doubt.
   The symptoms of active hyperaemia 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 excessiye 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, Avith 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 hyperaemia is greater or less in degree.
  Simple  hyperaemia 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.   Without
 morbid  changes  in  the  coats  of  the vessels cerebral hyperaemia, 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 uremia.   The differential points cannot be stated
without anticipating the  clinical  histories  of these  affections.  Suffice it to 
588   DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

say here that apoplexy from cerebral hemorrhage and embolism is excluded
by the absence of hemiplegic paralysis, and  that  the  symptoms 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 hyperemia are  also to be considered, such
as simple hypertrophy  of  the left ventricle,  alcoholic  excess, mental excite-
ment, etc.
  Intense active hyperemia 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,  Aveakness 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 Avanting.  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
affection, but a morbid element  entering into  various affections.  When 
CEREBRAL  ANAEMIA.
58 y
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 hyperemia 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.   Hyperemia 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  anemia the brain is pale.  The puncta vasculosa in the white
substance are  feAv or absent. The contrast in color between the gray and white
substance is less  marked than normal.  The perivascular spaces  are  dilated.
Cerebral anemia is often  accompanied by increase in the amount' of cerebro-
spinal  fluid in the  subarachnoid space and  by serous  transudation into the
ventricles.  This edematous condition of the brain is often found in persons
who have died of Avasting 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 Avho 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 edema 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.   Anemia 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, of the
products  of  inflammation (fibrin, serum, and  pus), and of tumors  of dif-
ferent  kinds.  Inasmuch  as the red  globules  are the  chief constituents  of 
        590  DISEASES OF THE  CEREBRAL AND SPINAL  CIRCULATION.

        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  anemia, 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 Avhich supply the brain.  Convulsions are not infrequently symp-
        tomatic  of the  anemia 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 anemia, as  incident to impoverishment of the  blood  calls for  the
        remedies and hygienic measures which  have  been already considered in
        treating  of anemia  as one  of  the diseases of the hematopoietic  system
        (p. 294).  The importance of recognizing  this condition,  with  reference  not 
               CEREBRAL  EMBOLISM AND THROMBOSIS         591

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 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
voluntary muscle—produces, as a rule, no appreciable disturbance of the cir-
culation ; 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 Avhy 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 groAvth,  bac-
teria, other vegetable parasites, fat,  etc.
   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 conies 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. 
592   DISEASES OF THE CEREBRAL AND SPINAL CIRCULATION.

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  change  in the walls of the affected vessels.  The most frequent change
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 already 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 Avhite 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 (plaques jaunes) found in the cerebral cor-
tex are of embolic or of  thrombic origin.
  The first effect of embolism of  a cerebral artery is anemia of the district
supplied  by that  vessel.   If  a sufficient collateral  circulation be established,
this anemia  passes off without  permanent damage ; but if the branches of
the artery do not  anastomose, the anemia 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 anemic 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 anemic spot favors a regurgitant current with
hemorrhagic  softening, and that  low venous pressure opposes  it.  When a
spot of embolic softening is  stained with  extravasated  blood, the process is
railed red softening ; if there be simply anemic 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  Avhite 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 
CEREBRAL EMBOLISM  AND  THROMBOSIS.        593
 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  yelloAv 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 Cliige.  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  hematoidin 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 Htstory.—Cerebral embolism is one of  the several  pathological
 conditions Avhich 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 
594   DISEASES OF THE  CEREBRAL AND SPINAL  CIRCULATION

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 embolio
apoplexy.   The localized anemia, 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 aphemia  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 words 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 
               CEREBRAL  EMBOLISM  AND  THROMBOSIS.        595

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, hoAvever, 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
Avriting 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 Avritten  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 iin'olve more or less impairment of mind.   Ataxic aphasia
as an isolated affection  may exist Avith the intellect  apparently unaffected.
It is doubtful if this  can be  said of amnesic aphasia.  Words are the instru>
merits of thought as well  as the expression of ideas;  and it is difficult to
believe that  the inability to recollect  Avords 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 
596   DISEASES OF THE CEREBRAL  AND SPINAL CIRCULATION.

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, Avith 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  Avords.  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 Vide the  very comprehensive article on Aphasia, by Kussmaul, in  Ziemssen's Cyclo-
 paedia, vol. xiv.
  2 Vide cases reported in Trans. London Clinical Society, vol. xiv. 
               CEREBRAL EMBOLISM AND THROMBOSIS.         597

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 haA'ing 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 Aveighs 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 Aveight 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.  Vomiting, 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 differential points suffice often for a highly probable diagnosis.  They
do not warrant a positive  diagnosis.   The physician who Arentures upon  the
latter incurs a risk of being conAdcted of  an error at  the  autopsy.  If, how-
eATer, 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, Avhereas 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 
598  DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

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
undergoie  the same change, this  being the most frequent of  the conditions
which  are  causatiATe of thrombus.
  Embolism and thrombosis of the basilar artery may produce coma, either
suddenly or more or less slowly, Avithout 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  Avhich 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 folloAved 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 be  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, ow7ing 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 of 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. 
THROMBOSIS OF THE  CEREBRAL  SINUSES.         599
   Treatment.—The object  of treatment in the early stage of embolism
 and thrombosis is  the re-establishment of the circulation Avithin 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.
 Warm  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 ATocal 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 
600   DISEASES OF THE  CEREBRAL AND SPINAL CIRCULATION.

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 anemia in the so-called  hydren-
cephaloid affection of Marshall  Hall—namely, somnolence  and coma, Avith
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
edema 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 pyemia, 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 1SG8
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 
CEREBRAL HEMORRHAGE.
601
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 Aveaken 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, leucocythemia, etc., it is not always possible
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 Avith 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
doivn 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 Avhether 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, Avhich 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 Avell 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." 
602  DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

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  Avay 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 edematous 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 anemic.
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 hematoidin 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-Avails.
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.  When  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 edematous,  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 
CERE BR A L  HEMORRHA GE.
603
of the anterior column of the same side.   Destructive lesions of the interna]
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- beloAv  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 ahvays visible to the naked eye, in the  anterior column near
the median fissure on the side of the lesion.  The contrast in color betAveen
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-
loAved 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 Avhen 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 bloAV;
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  Avas 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.   When complete, the
patient cannot be roused in any degree by efforts to awaken consciousness; but
in many eases there is not this total loss of mental faculties.  Voluntary 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 
604  DISEASES OF THE CEREBRAL  AND  SPINAL  CIRCULATION.

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.   Vomiting 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 sloAvly 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 apnea;  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  apnea combined.
   Patients emerging from the coma appear as if awakened from sleep, and they
rarely evince  surprise or ask Avhat 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.
[This turning of the head and  eyes toward one and  the same side is known
as conjugate deviation.  It is not associated with any particular lesion, but in
the early stages of cerebral hemorrhage conjugate deviation, when present,
is away from  the paralyzed side or toward the lesion ; later, when rigidity of
the paralyzed muscles has taken place, the head and eyes are turned away
from the  lesion—/, e. toAvard  the  paralyzed side.—H.]   With 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 inflammation 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 Avhole 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. 
CEREBRAL HEMORRHAGE.
605
   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
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, edema, 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 Avhich 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 AAdiether the extravasation take place quickly or sloivly.
The  hemiplegia, hoAvever, 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
  1 It is possible that symptoms due to destruction of brain-substance 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
svmptoms 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. 
606  DISEASES OF THE  CEREBRAL  AND SPINAL  CIRCULATION.

paralysis (paralysie alterne), [and is indicative of a lesion in the pons below
the decussation of the facial nerve and above that of the pyramids.—H.]
Only the  muscles of the loiver 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.  Aolun-
tary power over the frontal  muscle and the orbicular 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, ow7ing 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.  W,hen 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 shoAv 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 
CEREBRAL  HEMORRHAGE.
607
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
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 edema 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.
Weir 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 poAver 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. 
608   DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION.

  Aphasia has been already considered as incident to cerebral embolism and
thrombosis.  (Vide p.  504.)   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
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 may be 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. Avith difficult and  noisy respiration from laryn-
geal spasm, will  at once settle  the  character of the attack.   Without 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 
CEREBRAL  HEMORRHAGE.
609
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 epilepsy 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
of the iris, and the restoration of consciousness on resorting to the cold douche.
The coexistence  generally, in uremic 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
folloAving 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.
   [Diabetic coma is distinguished by low temperature, the thermometer fre-
quently  registering 96° F. in the mouth, the  chloroform-like odor  of the
breath, the presence of  sugar  in  the  urine,  and  sometimes by intense
dyspnea.—II.]
   Apoplectic  coma  caused by active hyperemia (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 hyperemia do  not, as  a rule, give rise  to hemiplegia.
The existence or  othenvise 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 ahvays practicable.  For the differential
points the reader is  referred to the diagnosis of embolic apoplexy (p. 596).
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  occur-
rence  of spinal hemiplegia in rare instances is to be remembered in the diagnosis.
        39 
 610  DISEASES  OF THE CEREBRAL  AND  SPINAL  CIRCULATION.

   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.  When it
 proves suddenly fatal, the coma is at once profound and accompanied by great
 disturbance of respiration  and  loss of deglutition, death taking  place  by
 apnea.   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 apnea.  If no improvement take place  Avithin  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 apnea
 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 well as the power of motion,
 is often  lost.  The former 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 different 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- 
CEREBRAL  HEMORRHAGE.
611
 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 hyperemia 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
 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- 
612  DISEASES  OF  THE  CEREBRAL AND SPINAL  CIRCULATION

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
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 Atill.  It pro-
motes  circulation, nutrition,  and is  a substitute for the will as regards  the
functional exercise of the muscles.  With 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.   When 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 Avhich 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 strivring
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 adArisable.
   A liability to hemorrhage  if an attack have never occurred cannot be esti-
mated with any degree of certainty.  Apoplexy and paralysis are  aff'ections
which many persons  apprehend, and if certain cerebral symptoms be experi-
enced, especially vertigo, the apprehension  is  often the source of much un-
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
remoAed by  these assurances. 
            TOPICAL  DIAGNOSIS  OF CEREBRAL  DISEASES.       613

    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-
 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 Avhich 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—anemia and hyper-
 emia, 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 Avhich 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 anesthesia,
 aphasia, and strabismus, the last three symptoms being indirect, as  they are
 referable not, like the hemiplegia, to destruction  of  the part named, but to
 an influence exerted upon other parts by pressure, inflammatory edema, etc.
 After a time  anesthesia and the  other  secondary or indirect symptoms dis-
appear, and  the hemiplegia remains as the direct symptom of the lesion.  It 
614  DISEASES OF THE CEREBRAL AND SPINAL CIRCULATION.

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 be  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
many diffuse and  indirect symptoms,  and by their  slow  development they
frequently displace nerve-elements 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 the 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 Avhen 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 cms with the cerebellum.  Recognized  forms of
                       1 Virchoids Archie, Bd. 49, p. 145. 
           TOPICAL DIAGNOSIS OF CEREBRAL DISEASES.       615

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 Avith  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.  With the
exception of the rotary or " circus" movements and the  peculiar deviation
of the eyes, similar compelled  movements have been  observed in diseases
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 unfavorably 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.  When it is  considered  that
through the pons pass the  bundles of motor and of sensory fibres  Avhich  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 alteme).   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 hemianesthesia 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

  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. 
616   DISEASES OF THE CEREBRAL  AND SPINAL CIRCULATION.

by Wernicke,1 there existed  paralysis only of cranial nerves, and not at all
of the extremities.   When 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-
quent.  It leads almost invariably to death, either instantaneously or within
a feiv 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 ischemic 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 glossopharyngeal.  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 aff'ection of the crus.  Lesions of the crus may produce
simply hemiplegia  or hemianesthesia 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
                        1 Arch.f. Psych., Bd. 7, p. 513. 
TOPICAL  DIAGNOSIS OF CEREBRAL  DISEASES.        617
Fig.
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
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,  how-
ever, is not peculiar to  lesions in this situa-
tion.   Post-heniiplegic 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 top-
ical diagnosis are as yet  known to attend
localized lesions of the optic thalamus.
   8.  Corpus  Striatum  (nucleus caudatus,
nucleus lenticular is, and capsula interna).—
This region is the  most  frequent  seat  of
hemorrhage  and  of softening.  It is im-
portant  to be familiar  with the anatomical
relations  of the parts  here situated.  The
anatomy of this region is shoAvn in Fig.  1,
which   represents   a   horizontal   section
through  the  right cerebral  hemisphere.
The corpus  striatum  is  composed  of the
caudate  nucleus (N C in  Fig. 1) or intra-
ventricular nucleus, the lenticular nucleus
(XL) or extraventricular nucleus, and the
anterior  division of the  internal capsule1
(CIa).   The  caudate  and  the lenticular
nuclei  are masses  of  gray  matter.  The
internal   capsule is  composed  of  white
matter.   The internal  capsule 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 understood.   In the posterior division are
situated  the  motor and  the sensory tracts of  nerve-fibres  supplying  the
opposite half  of the body.  The motor tract forms a compact mass of nerve-
       Jfiome authors include only the caudate nucleus in the corpus striatum.
igi
elll
Cerebral Hemisphere (from Strumpell):
NC, nucleus  caudatus;  NL, nucleus
lentieularis;  Th,  thalamus  opticus;
C la, anterior division of the capsula
interna; CIp, posterior division of the
capsula interna; Fa, fibres belonging
to the facial nerve; P, pyramidal tract
(motor); S, sensory tract; 0, occipital
lobe; F, frontal lobe. 
 618   DISEASES  OF THE  CEREBRAL AND SPINAL  CIRCULATION.

 fibres  called the pyramidal tract  (P), situated in the middle third  of the
 posterior division of the internal capsule.1   The fibres belonging to the facial
 nerve  are probably situated in  front  of the pyramidal tract, nearer the knee
 of the capsule.  The  sensory tract occupies  the  posterior third of the pos-
 terior  division  of the  internal capsule.   The sensory tract includes both the
 nerves of ordinary sensation and the nerves of  special sense.
   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. 619, 620.)
 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,2 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.3  (See Fig. 5, p. 671.)   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.
   When 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 hemianesthesia  or paralysis
 of sensation of the opposite half of the body.   This hemianesthesia 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

  1 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.
  2 Here, too, the situation varies someAvhat 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.
  3 Sometimes all  of the  pyramidal fibres cross to the opposite lateral column.  It is
 believed that very rarely the pyramidal  fibres do not decussate at the crossing' of the
 pyramids, but descend in  that half of the spinal cord Avhich corresponds to the hemi-
 sphere  in Avhich they originate.  In the latter case it has been claimed that a lesion in
 the brain Avould produce hemiplegia on the same side as the lesion. 
           TOPICAL DIAGNOSIS  OF  CEREBRAL  DISEASES.       619

not at all involved.  The affection of sight  is probably in the form of hemi-
anopsia.   Post-hemiplegic hemichorea (which  Avas first described by Weir
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
capsule.   If the pyramidal tracts be not directly involved, the hemiplegia is
often temporary, disappearing when  the effects of pressure 'or of  collateral
edema 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.

                                  Fig. 2.
Diagram showing Position of Motor-centres in the Cortex (after Eichhorst).
  9. Centrum Ovale.—We 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  Avith 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 llitzig, in 18(0, 
 620  DISEASES OF THE CEREBRAL  AND  SPINAL CIRCULATION

 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.  Motoj- Area of the Cortex.—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-
 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
 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

                                 Fig. 3.
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
lHyP9l, 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. 
TOPICAL DIAGNOSIS  OF CEREBRAL  DISEASES.        621
   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
 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  Avith 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 folloAved 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.   When 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 ('entres 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 Beil also contains  centres for  speech.  When
 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 Wernicke  sensory aphasia, and by Kussmaul word- 
DISEASES  OF  THE CEREBRAL AND SPINAL  CIRCULATION.
Diagram showing Semidecussation of
      Optic Nerves (after Landois).
the
622

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
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.
            Fig. 4.                 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  Avhich 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 hematoma
 of the dura mater, due  to pachymeningitis  hemorrhagica, under which head
 it will be  subsequently considered.
   1 Hemianopsia  is designated as right-sided or left-sided Avith reference to the defect
 in the visual field.  Hence with lesions of the  right occipital  lobe, left hemianopsia 
INSOLATION,  OR  SUNSTROKE.
623
   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. When 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
 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
 spicule 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 eases 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 spicule
 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 Webster the  autopsy showed that
 slight meningeal hemorrhage had occurred some time prior to his fatal illness.
 The  hemorrhage was connected with an injury Avhich  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, but by  the action of great  heat com-
bined generally with  other causative  circumstances.  The terms  denote a 
624  DISEASES  OF  THE CEREBRAL AND SPINAL  CIRCULATION.

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 vita]
powers are prostrated, the forces carrying on the circulation give way, and
death takes place by syncope.   In another class of cases the  aff'ection 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 edematous.
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
light 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 toAvard the  fatal termination.   I have
observed death to take place purely by apnea, the pulse having  considerable
force until after the cessation of breathing. The respirations in some cases are
  1  " Observations on Exhaustion from the Effects of Heat," by  H. S. Swift  Resident
Physician of the New York Hospital, A. Y. Journal of Medicine, July 1854. 
                    INSOLATION, OR SUNSTROKE.                625

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. IStiS. was 109?° F., and the lowest observed was
094°.   In a case observed in July, 1872, the  temperature in  the  axilla was
IIO50.   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
temperature was 1104°, the patient recovered.   Convulsions and rigidity of
the muscles  are of frequent  occurrence.   Aomiting 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-
ing and purging.  The duration varies from a few minutes to several hours.
The average duration in the  fatal  eases observed by SAvift was four hours.
If the patient emerge from the comatose state, convalescence is usually speedy.
Of 2<> 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 haATe, hoAvever, 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  diff'erent.  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.  Begarded 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.   Aallin  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 ravs 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 hyperemia 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. Wood.   Aallin is  led to  at-
tribute  these conditions and  death to coagulation of the liquid of the mus-
cular  tissue (sue musculaire, 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 pneumogastrie nerve.   In the latter cases the heart-cavities may
be filled Avith blood.1  The observations  of Prof. Horatio C. Wood lead him
to the conclusion that  the contraction of the Aentricles of the heart found
after  death, especially  Avhen autopsies are  made  within  a short time after
death, is in  most cases of pest-mortem, not of ante-mortem,  occurrence.2
  Excessive heat is the chief  agency in causing insolation, but other circum-
           1 Vide Archives  de Medecine, Feb., 1870.
           2 On Thermic Fever, or Sunstroke, Boylston Prize Essay, 1872.
         40 
626   DISEASES OF THE CEREBRAL AND  SPINAL CIRCULATION

stances  co-operate in the  causation.  Muscular exertion,  unduly  groat 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
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. C,  from  sunstroke in 1824 than
in any tAvelve other  years ;  and in  the city of New York in the summer of
1853  there were 260 eases  reported, whereas  in  no previous year had  tbere
been more than 36 cases.'
  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. m., 17 between  4 and 9 p. Mi, 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 apnea, but in the larger pro-
portion of cases by apnea 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.  Stiniu-
                     1 Elements of Medicine, 2d ed., 1859. 
INSOLATION,  OR SUNSTROKE.
627
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
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.   Bevulsive 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 \Tastly important in some and
is destructive in  other cases.  Never to employ bloodletting or to employ it
in all cases Avould 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.   With  a  sprinkling-pot the cold
water was applied over the whole body at intervals of a few  moments.  This 
628   DISEASES OF THE  CEREBRAL AND SPINAL CIRCULATION.

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
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 10H° and  the  pulse 120.
At 9.45 P. m. the temperature fell to 100|°.  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.  When 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


   Hyperaemia and  Anaemia  of the  Spinal Cord  and  its
                              Meninges.
   As regards hyperemia and  anemia, 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  hyperemia  or anemia 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-
  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. 
                       SPINAL HEMORRHAGE.                    629

tomatic phenomena.  Both conditions are probably not infrequent.  They are
attributable to various  causes, and it is not irrational to refer to these  certain
symptoms.
  Hyperemia here, as  in other situations, may be active or passive.   Active
hyperemia 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 hemorrhoids, and
prolonged exposure to  cold.  Passive  hyperemia is incident to stasis of the
systemic  venous  or  the portal system.
  The svmptoms referred to active hyperemia 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 anesthesia point to passive hyperemia.
  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 wet 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  anemia  (ischemia) 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 anemia 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 anemia 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  anemic  condition, which is incident to general anemia,
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 Avith func-
tional or  so-called reflex paralysis, and of the participation of the spinal cord
in the effects of anemia  as a^blood lesion, the diagnosis of  spinal anemia is
not  warrantable in the present state of knowledge.

                        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 (hemator-
rhachis),  or it may  be in the substance of the cord (hemato-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 floAV 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 irray 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 
630  DISEASES  OF THE  CEREBRAL AND SPINAL  CIRCULATION.

from traumatism, such as fractures  and dislocations of the vertebrae, 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 (hemato-myelitis) ; but there are
very rare  cases  which can hardly be interpreted  otherwise than  as primary
hemorrhage into the cord.  Aneurisms of the aorta, after  having  occasioned
erosion of the vertebre,  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 anesthesia are rarely complete.  If the hemor-
rhage take place in the lumbar region, the lower limbs are paralyzed, together
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
anesthesia 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 (apnea).  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.   Becovery may be expected,  except in cases of
injury of the spinal cord  by fracture  or dislocation of vertebre.  The removal
of the coagulated blood by absorption is, however, a slow process, and recovery
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 im-
portant  of the measures for this object.  Bloodletting is  to be employed under
the conditions which render  this measure advisable in other connections.
  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 A'iolent 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 
    PACHYMENINGITIS—HEMATOMA  OF THE  DURA MATER.   631

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 beloAv the
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 apnea
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 hemato-mye-
litis. however, the paralysis may  develop  with  great rapidity;  but 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 paralysis 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
                         CHAPTEE   II.

 INFLAMMATORY  DISEASES   OF  THE  MENINGES  OF   THE
   BRAIN  AND OF  THE  SPINAL CORD.—HYDROCEPHALUS.—
   HYDRORRHACHIS.

 Pachymeningitis and Hsematoma 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 Avith 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 
632    INFLAMMATORY DISEASES OF THE  MENINGES,  ETC.

mater.  In it is contained the cerebro-spinal fluid.   The  space  between  the
dura mater and the arachnoid, Avhich  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—Hematoma  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), Avith 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 hematoidin, 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 hematoma is applied.  Hemorrhages con-
fined to  the subdural space, and not of traumatic origin, in the o-reat majority
of cases are due to hemorrhagic pachymeningitis.   This fact was first estab-
lished by  Yirchow.  Some recent writers advocate the  view which prevailed
before Virchow's investigations—namely, that the first stage in  hemorrhagic 
     PACHYMENINGITIS—HEMATOMA  OF  THE DURA MATER. 633

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 (hematoma, 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 aurium, 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, Avhich
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 hematoma  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, &Ad 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  sIioav that it  is a disease
             1 Aide Huguenin, in Ziemssen's Cyc, Am. ed.  vol. xii. 
634    INFLAMMATORY DISEASES OF THE MENINGES,  ETC.

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  bloAys, falls, etc.   It
occurs sometimes  in diseases  attended by a hemorrhagic  diathesis, such  as
scurvy, purpura, leucocythemia, and  pernicious anemia.   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 Avhich he could collect:  The duration was from one day to five days  in
31 per cent. -,1 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 hematoma
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.
   Becovery 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.   Yenesection  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  hyperemia.   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.   When 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.  When 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 Huguenin's view that this hemorrhage orecedes the
pachymeningitis.                                                ^ 
SIMPLE ACUTE  CERERRAL  MENINGITIS.          635
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 eortex 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  hyperemia.   There is a marked variation in symptoms at
different  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 hyperemia.  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.  Aromiting 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 Avhich  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.  DroAVsiness 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 
636    INFLAMMATORY DISEASES OF THE  MENINGES  ETC.

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 m 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 vieivs 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.  Yery 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  feAv 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 affection
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.
  Various 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,  pyemia, septicemia, 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 maybe impossible to say after  recovery
whether the affection were meningitis or merely active congestion.   In other 
               SIMPLE ACUTE  CEREBRAL MENINGITIS.           637

 Avords,  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
 sIoav development of the fever; the distinctive events belonging to it—namely,
 diarrhea, meteorism or  tympanites, tenderness in the  iliac regions, together
 with absence of morbid acuteness of the senses, and continuance of the delir-
 ium Avithout 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 Avithout 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
 eases 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 anesthesia,
 feebleness of the pulse, etc.   Strabismus, hemiplegia, and convulsions may be
 present in  cases  which recover.   A feiv 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 Avhich 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 apnea, but
 if life  be prolonged for several  days the mode of dying is by apnea  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 Avith the hope of limiting these 
638    INFLAMMATORY DISEASES  OF THE MENINGES,  ETC.

should be 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 apnea
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, hoAvever, 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 apnea, 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- 
TUBERCULOUS MENINGITIS.
639
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.   Vomiting 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  knoAvn 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 uremia—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 Avith  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- 
640    INFLAMMATORY DISEASES  OF THE  MENINGES,  ETC.

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-white or yelloAvisli 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.   While 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.   When 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 Avithout 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 vertebre, 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 
TUBERCULOUS MENINGITIS.
641
of the apparently primary cases  there will  be 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 change 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 weight, 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.  When the meningitis occurs after a prodromic period
extending, as  it  does in some cases, over several weeks and even  months,
during  Avhich 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
         41 
642    INFLAMMATORY DISEASES OF THE MENINGES, ETC.

of healtli.   It is not infrequently faltering.  It fluctuates in frequency and
may be irregular in rhythm.   The respirations. Avhich 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.   Rolling
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 aivakcned
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.
Various ophthalmoscopic appearances have been described, of which  the most
common are neuro-retinitis and a swelling of the optic papilla,  called choked
disc.   [Tubercles may also be deposited in the choroid coat of the eye, in
which situation they are distinctly visible with  the ophthalmoscope.  In all
doubtful cases the  eye-ground should  be inspected, not once, but  repeatedly,
for tubercles  may  appear in  the  course of  twenty-four hours   in an eye-
ground which had  previously been found normal in every  respect.—H.]
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 apnea 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.  With  the latter  it is  not infrequently confounded.  In making this
differential diagnosis, meningitis is  to be excluded by the  absence  of sensibil- 
TUBERCULOUS MENINGITIS.
643
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, diarrhea,  abdominal  tympanites,  and iliac  tenderness  are
likely  to  be present—symptoms  not belonging to the clinical history of
tuberculous  meningitis.
   It is to be discriminated from the so-called hydrencephaloid  affection inci-
dent in children to exhaustion from diarrhea.  With 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 Avhen 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 Avas 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.
                     1 Vide Clinical Medicine, by the author. 
644    INFLAMMATORY DISEASES  OF  THE MENINGES, ETC


                    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
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, pyemia,  septicemia, typhoid fever,  typhus fever, otler
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  vertebre, such as cancer,
caries,  and fracture, or to inflammations  in the neighborhood of the vertebre.
In the latter case the inflammation may  extend to  the meninges through the
intervertebral  foramina without  involving the  vertebre.  When  the inflam-
mation is  secondary to aff'ections of the vertebre 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 spinal 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.  When the
inflammation is secondary to fractures  and diseases of the vertebre, 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).  With 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-
esthesia). 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 dyspnea.  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 hyperesthesia may persist, as well as tonic contraction  of muscles.
With these local symptoms there is more or  less fever, together with anorexia
and prostration. The pulse is sometimes  abnormally  infrequent, and this may 
                     CHRONIC SPINAL MENINGITIS.               645

be found in striking contrast with the temperature of the body as determined
by the thermometer. In the course of the disease, hoAvever, the pulse becomes
frequent and  feeble.  Profuse perspirations often occur.   Reflex and electrical
excitability are generally preserved.
   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 aff'ection 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 apnea 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 dyspnea, Avhich,  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 sequele 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  apnea, 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
hyperemia by causing  contraction of the small arteries, and in  this way  to
be useful.  When  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- 
646    INFLAMMATORY DISEASES  OF THE MENINGES,  ETC.

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
have  been discovered  only  within a  comparatively  few  years.   Again,
the lesions which have  been  considered as evidence of chronic spinal  men-
ingitis, such  as thickening  and opacity  of  the  pia-arachnoid nembrane,
calcareous plates in  this membrane, and  adhesions between this  membrane
and the spinal cord on the one hand and  the  dura  mater on the 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 vertebre.   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, hyperesthesia, and muscular spasms.   These symptoms of irritation grad-
ually give place to symptoms of loss of function, such as anesthesia, paresis of
the extremities, incontinence  or retention of urine, and incontinence of feces.
There may be a sensation of  constriction,  as of a tight belt, around the body.
If marked  paralysis and anesthesia 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 anesthesia 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.  When 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 be tried, with proper pre- 
CHRONIC SPINAL  MENINGITIS.
647
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
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 are
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 anemic,  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 anes-
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,  anes-
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
vertebre 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 apnea 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. 
648    INFLAMMATORY DISEASES OF THE MENINGES, ETC.

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.
   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 Vork  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.   Epidemic cerebro-spinal meningi-
tis  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 different periods in various
parts of the Old World and in this country.  It prevailed in  New  England be-
tween the years 1867 and 1816, and was then known as spotted fever. For a quar-
ter 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.  Within the spinal canal the inflammatory exwdation 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 hyperemic, 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, Avhich 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  feAv 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 edematous 
                   CEREBRO-SPINAL MENINGITIS.                649

and anemic.  In cases of prolonged duration the ventricles are usually found
greatly distended with serum.  The previously creamy, purulent exudation is
perhaps now desiccated and caseous, or more frequently has nearly disappeared.
  The following embrace the most important of the morbid changes existing
in other parts of the  body: The skin often presents herpetic vesicles and
petechie.   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 SAVollen 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 sequele.

  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 diarrhea.   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 Avhole
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.
Hyperesthesia 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 Avhich are not quickly fatal.  It  Aeries 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 
650    INFLAMMATORY DISEASES OF THE  MENINGES,  ETC.

and falls into coma, which may be of temporary duration or continue until
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 Avhich 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  convalescence is
not near at hand.  The tongue is frequently large and flabby, showing indenta-
tions 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  hematuria, the hemorrhage being
abundant and not occurring in any other  situation.
   The  temperature  of the  skin varies in  different  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 less than in most of the 
                    CEREBRO-SPINAL MENINGITIS.                651

 essential  fevers.   "A rapid fall  was the sure precursor of collapse."1   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
 bulle 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
 Avhich 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 Ames, lti
 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."  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  diATide 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, ISo'T.
  '2 Vide New Orleans Med. and Surg. Journal, 1848.
  3 Article bv 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  1862-63,
bv J. Baxter Upham, M. D., Boston, 1863. 
652    INFLAMMATORY DISEASES  OF  THE MENINGES, ETC.
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 feAv 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 avc 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 Avhich 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 Avinter 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 Avith 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,  diarrhea, 
CEREBR O-SPINA L  MENINGITIS.
653
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 cerebri
spinal meningitis.  The spots of ecchymosis on Avhich 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-spinal 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 Avhich 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 obserAed by Lefevre four-fifths died at the beginning,  and two-thirds
toward the end of the epidemic.  Of 366 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  1>US gave an
average mortality of  7<> per cent., and a similar number of epidemics between
ls.m and 1S65 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  giA'ing  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 apnea, 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 be   expected in a  disease so severe and fatal as
this, various potent therapeutical agents have been employed.  No reliable
abortive  or  curative  treatment has as yet been discovered.  Experience has.
however, shoAvn  the utility of certain measures in the  employment of which
the  physician  is to be goAerned by the rational and symptomatic indications
present in individual cases.
   1 Vide article by Dr. H. Knapp in  the New York Medical Record, Aug. 15, 1872. 
654    INFLAMMATORY DISEASES OF THE MENINGES, ETC.

  Great severity of symptoms, the patient having been attacked in full health
and the pulse being'strong or hard, renders bloodletting appropriate.   Wet
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 anemic or feeble
when  attacked.
  Quinia in  large doses has appeared in some cases to be 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.  Thi3
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 whose 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.   When 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.
  Whenever 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—Syringomyelia.
  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. 
     HYDROCEPHALUS—HYDRORRHACHIS.—SYRINGOMYELIA.  655

Hydrocephalus occurs either as a congenital aff'ection 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 Avas  the  theory  in certain  cases  which  are now  explained
by our knoAvledge  of thrombosis,  embolism, and  uremia.
   Serous effusion into the lateral  ventricles  may occur in  consequence  of
pressure  upon the veins carrying the blood from the ventricles into the sinuses
(vene Graleni), 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 ependymitis 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  Avithin 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 knoAvn 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.
   [The term syringomyelia is used to designate an  affection characterized
anatomically by the presence  of cystic cavities in the cord  independent  of
the normal cavity of the central canal.  Dilatation of the latter is now called
hydromyelia—a term first applied by Virchow to cavities  of every kind in the
spinal cord.   The fact of the existence of these  lacune in  the  medulla has
long been recognized, but it  is  only of late years that we  have learned  to
associate them  Avith distinct clinical phenomena.   Formerly, they were
regarded as mere pathological curiosities.  The most constant  site of this
cystic degeneration  is the cervical and upper dorsal  region of  the medulla,
but in extreme cases the cavity may extend throughout its entire length.   It
is formed, as a rule, at the expense of  the gray  substance, but on examining
the cord  by  numerous transverse sections at  short intervals  it  may be seen
to  deviate into the lateral  or posterior columns.  These anatomical alterations
are in strict  accord with the clinical phenomena, Avhich are for the most part
sensory, but may be combined in greater or less  degree  with the symptoms
of  lateral sclerosis  and  tabes  dorsalis.  The  signs of muscular atrophy  so 
656    INFLAMMATORY DISEASES OF  THE MENINGES, ETC.

commonly present are due to  an involvement of the anterior cornua  in the
destructive process.   The cystic cavities are often separated  by tracts  of
gliomatous tissue, and  consequently they  are  regarded by  pathologists  as
the ': product of a true gliomatosis."
  The statement contained in the last edition of this work, that the diagnosis
of syringomyelia cannot be made during  life, is no  longer tenable.  The
clinical manifestations of Avell-marked cases of the disease are recognizable,
and in numerous instances  the diagnosis  of syringomyelia has been verified
by an autopsy.  J. II. Lloyd and Wharton Sinkler of Philadelphia have quite
recently reported casesx in  which their  diagnosis of the affection was con-
firmed by post-mortem  examination.
  As above stated, the  principal symptoms  are sensory, and the one that is
most  characteristic is the  so-called  " dissociation symptom ;" ;'. e. preserva-
tion of tactile sensibility  and of the muscular sense with  insensibility  to
heat  and  pain—thermo-anesthesia  and  analgesia.    This  dissociation of
cutaneous sensibility  is,  however, observed  also in anesthetic leprosy and
occasionally in peripheral  nervous affections.
  Motor symptoms are  invariably present in well-marked cases, and consist
of progressive muscular atrophy of the Duchenne-Aran type ;  or, if the
pyramidal tracts are involved,  the muscular wasting may be attended with
the spastic symptoms  of amyotrophic lateral  sclerosis.   Trophic disorders are
as common as the symptoms above  mentioned, and manifest themselves by
hyperidrosis,  herpetic and bullous  eruptions,  ulcerations,   and  panaritius
Avhich may proceed with little  or no pain to complete destruction of one  or
more  phalanges.  These painless and  destructive whitlows  have been until
quite  recently regarded  as  pathognomonic of a disease  described by Morvan,
a physician of  Brittany,  and  hence known as Morvan's disease, but the
tendency at present is  to  regard the  latter affection and syringomyelia  as
practically  identical.    Another  form  of   trophic disturbance  frequently
observed is an  arthropathy precisely similar to  the " arthropathie tabeticpie"
first described by  Charcot.
  Lateral  curvature of  the spine—scoliosis—is present in a  large proportion
of the cases,  and is sometimes combined with  posterior curvature—kypho-
scoliosis.  It  is a symptom of muscular  weakness  and atrophy.   The most
common grouping  of  the symptoms of syringomyelia  is muscular atrophy,
most  marked  in  the  arms and  shoulders,  with the peculiar " dissociation
symptom " above mentioned, and trophic disorders of various kinds.
  Inasmuch as  the lesions of syringomyelia are  destructive of  important
nerve-centres and  conducting tracts, its  prognosis  is  hopeless.  Life may,
however, be protracted  for an  indefinite  period, the patients generally suc-
cumbing to some  intercurrent affection.—H.]
  1 Vide University Med. Magazine, March, 1893,  and International Clinics, vol. iii., 3d
series. 
              ENCEPHALITIS—ABSCESS OF THE BRAIN.          657





                        CHAPTER  III.

   INFLAMMATORY  AND  STRUCTURAL  DISEASES  OF  THE
                                BBAIN.

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 hen'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 pyemia 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.
   Cerebral 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.
   Even 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.  When the abscess is secondary  to severe injury to the head  or
        42 
658    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.   Bigors 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.  613.)
   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 aff'ection  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.   When 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 edema 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 be 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.            659

 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-
 ing 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 edematous  brain-tissue.  The microscopical exami-
 nation reveals hyperemia, 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.  Whether  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 in
 ivhich 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, Avholly 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 
660  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.  When  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.   Bhythmical 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.
661
 the form of a monoplegia,  The paralysis is accompanied with more or less
 muscular rigidity and contractures, [causing a flexed  position of the upper
 extremity, so that the arm is held against the thorax, the forearm  flexed at
 a right angle, and the hand  and fingers strongly flexed.  Contractures are
 equally  common  in  the  lower  extremity,  and lead to various  forms  of
 talipes.—H.]  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 com-
 mon.  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.
 [If before  the  attack the  child had acquired the faculty of speech,  this will
 be lost, at least temporarily, if the paralysis is on the right side of the body.
 In cases such as this in which speech  is  gradually regained while the other
 symptoms persist, it is supposed that the right cerebral hemisphere gradually
 assumes the Avork, so far as speech is concerned, of  the left.—H.]
   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 have 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,  pharynx, 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  medulla 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- 
662   INFLAMMA TOR Y AND STR UCTURA L DISEASES OF BRA IN.

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
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.  When 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 apnea 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- 
CHRONIC BULBAR PARALYSIS.                663
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.  Beflex 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
is not affected; the gustatory sense and the other special senses are preserved;
and  the appetite and digestion  may be unimpaired.
  The aff'ection 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 aff'ection 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.
   With 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.   With
reference  to these objects, the patient should, as far as  possible, be withdrawn 
664    INFLAMMATOR Y AND STR UCTURAL DISEASES OF BRAIN.
from every agency which may be supposed to have a causative operation.  All
unsanitary influences pertaining to body and mind  are 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
strychnia and phosphorus ; yet the latter is undoubtedly useful in some cases
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.
  When deglutition becomes difficult, nourishment should be introduced into
the stomach  by  means of the esophageal 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
esophageal 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, Avhich  is frequent,  small, and  intermittent.
There  is often, but not ahvays, 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 tAvo 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 
TUMORS WITHIN  THE  CRANIUM.
665
not from the membranes.  It is met Avith  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
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  Avith 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 ahvays 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.  In this connection  may
be mentioned the  occurrence in the  brain of the parasites  cysticercus cellu-
lose and  echinococcus.  The cerebral arteries are occasionally the seat of
aneurism, aside from those distinguished as  miliary.   Aneurismal tumors are
generally connected with arteries at the base of the  brain, the basilar, the
internal carotid, the middle cerebral,  and the circle of Willis.  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 groAvth.   Special morbid effects
depend on  the  situation  of the tumor.   They cause additional  injury to 
666    INFLAMMATOR Y AND STBUCTUBAL DISEASES OF BBAIN.

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
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 Avhich 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 ; hyperesthesia 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 rarelv,
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 Avhich 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 AToluntary
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 latter 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 has 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.   [Amaurosis is also
a symptom of tumors of the cerebellum  and  of those of the corpora quadri-
gemina.—H.]   Neuralgia and paralysis of sensation on  one  side of the face
result from similar effects upon the fifth nerve.   The third and fourth nerves
may be involved, and not infrequently the paralysis affects, separately or col-
lectivel}', the senses of hearing, smell, and taste.
  The differences in different cases, as regards  the  parts affected Avith paral-
ysis, of course  depend on the  seat  of tumors, their size, and the direction in 
TUMORS WITHIN THE  CRANIUM.
667
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-
tory is in correspondence  with their continued  growth and the  progressively
increasing amount of pressure and of destruction of cerebral substance.  Apha-
sia 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.  [Cases of  cerebral tumor vary greatly with  reference  to the
degree in which the psychical functions are  affected.   In some the intelligence
remains unaffected throughout  the disease, or, at the most, some loss of mem-
ory may  be  apparent, while in  others the patient  gradually becomes com-
pletely demented.—11.]   The ophthalmoscope  is useful  in determining the
existence of intracranial tumors.   Morbid  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 diff'er in size and respond feebly
to light.   With  reference to the localization of tumors the reader is referred
to the article on the topical diagnosis of cerebral lesions.  (Vide p. 613.)  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 diff'erent  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 Avhich  render  it difficult thereby to differentiate  this affection from
tumor.   If the aff'ection  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
aff'ection 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 
 668    INFLAMMA TOR Y AND STR UCTURAL DISEASES OF BRAIN.

 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.   Where no data exist as to
 the variety of tumor, glioma is to be inferred, as being the most common form
 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 different  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 
CEREBRAL  SYPHILIS.
669
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 aff'ections of the brain, nevertheless, for the sake of clearness and in view
of the frequency and  importance of these aff'ections, it is thought best  to
bring them  together in  a  separate article.
  Cerebral  syphilis may be a  manifestation of congenital or of  acquired
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  Avhich 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.   When the gumma is seated at the base of the brain, there 
670
DISEASES  OF  THE SPINAL  CORD.
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.   When 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
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 be 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.—Spastic  Spinal Paralysis.—Amyotrophic
   Lateral  Sclerosis.—Compression of the  Spinal  Cord.—Intraspinal Tumors.__Pseudo-
   hypertrophic (or Myosclerotic) Paralysis.

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 
                     GENERAL CONSIDERATIONS.                  671

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 Turck.  They may be absent in normal cords.   In
the posterior part of the lateral column are situated the pyramidal fasciculi
of the lateral columns  or the  crossed  pyramidal tracts, marked p. I. in the
diagram.  The pyramidal tracts are composed of motor-fibres  Avhich originate
in the central convolutions of the brain, descend through the centrum ovale
to the posterior division of the  internal  capsule
(see p. 617), pass thence through the pes pedun-             Fig. 5.
culi, the pons, and the anterior  pyramids of the
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
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.
When 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 doAvnward  to the termination  of the tracts.
   Between 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 Goll (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 Croll 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  aboATe 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  (loll 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 upAvard.
   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
 
672
DISEASES  OF THE  SPINAL CORD.
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
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.  We  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 Avhich 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.   Spastic 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 
GENERA L CONSIDERA TIONS.
673
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
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.
Unlike the majority of the motor fibres, the sensory fibres decussate in  the
Bpinal 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,
[and, vice versa, tactile sensation may be preserved while the sense  of pain is
lost  (see article  on  Syringomyelia).—H.]   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 nius-
  1 It 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 paralysis.  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.
        43 
674
DISEASES  OF  THE SPINAL  CORD.
cle  is produced by striking quickly with  the  ulnar side of the hand or with
a percussion  hammer the ligamentum patellae when the leg is flexed and the
muscles are relaxed.  This contraction, called the knee-jerk or jm fella >■ refer,1
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 centre 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.
  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 contract ion 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>Avhen
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. C), 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. C), 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.  C, 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.  C. and the A. 0. C.
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
  1  It is assumed that the knee-jerk is a reflex phenomenon, although this view is not
proven. 
GENERAL  CONSIDERATIONS.
675
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
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, but 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. C), 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
faradic muscular  excitability, without qualitative change in the galvanic mus-
cular excitability.  If the muscle be  alone degenerated, the faradic and the
galvanic excitability of the nerve and  the faradic excitability of the muscle
will be preserved, while the above-described characteristic changes following 
676
DISEASES  OF THE SPINAL CORD.
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 Avhite 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 nen^es 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
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.1


                               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.   When  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.  When 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 Airchow'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
  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  Sys'tt'm  Lon-
don, 1882 
MYELITIS.
677
afterAvard 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-
litii is given by Hayem to cases of acute myelitis attended by extensive hem-
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 of softened 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-celfs 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
pyamiic  or consecutive to suppurative  processes  in  the membranes, verte-
brae, 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, 
678
DISEASES  OF THE  SPINAL CORD.
 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.   When 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
 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 Turck,
 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 vertebras,
 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, 
MYELITIS.                           679
therefore, Avhich distinguish  myelitis from spinal meningitis especially claim
attention.
  Disorders of sensation are  often the first local symptoms.   These are pain
in the back, the sensation of  a girdle around the trunk, and tenderness over
certain of the vertebrae.  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
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 (hagmato-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-
aesthesia, 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 
680
DISEASES  OF  THE SPINAL  CORD.
 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 points 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. 643.)   The affection to be
 noticed in connection with the functional affections of the spinal cord, called
 acute ascending paralysis (vide  Chapter V.), 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
 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 aff'ection
 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
 agency.
   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" 
MYELITIS.
681
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
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  Avith long life and good general health.   In the preceding
editions of this work a case is cited in which complete paraplegia  folloAved a
fall of forty feet, and after death there was found atrophy of the cord beloAV
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 Avas  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 Avas 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.   Bemedies 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 shoAvn 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.
                       1 New York Medical Journal,  1853. 
682
DISEASES  OF THE SPINAL  CORD.
   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.1   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
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 change, 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 connectiAre 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,2 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

   1 Charcot,  Gaz. des Hopitaux, 1868; Bourneville et Guerard, De la Sclerose en Plagues
disseminees, Paris, 1869.
   2 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. 
CEREBR O-SPINA L SCLER OSIS.
683
and in cells occupies the sclerotic islands.  This he refers to a fatty defen-
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
extremely Avell 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.  Aarious 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 Avhich 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
Avas 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  Avhich 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 Avhen 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 
684
DISEASES  OF THE SPINAL  CORD.
than the Avord 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 betAveen 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
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
may 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.   With 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 be hoped for in  the Avay of treatment  is that the disease
will remain stationary, or,  if it be progressive,  that  the  progress may  be
retarded.   Various  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 
LOCOMOTOR ATAXIA.
685
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 1S5!)  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 Bomberg, who
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 leucomyelitis.
  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 someAvhat 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
bauds.   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 wTas confined to the external bands, Avhile the columns of Goll were
normal.   When, 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 the 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, hoAvever, 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 may be traced continuously to the
restiform bodies of the medulla oblongata, Avhere 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  nervTes,  and
rarely of the oculo-motor, hypoglossal, and certain other cranial  nerves, has
been observed.
  [Of late years, changes in the peripheral spinal nerves have been recognized ^
and minutely described by Westphal, Dejerine, Pitres and  Vaillard, and others 
686
DISEASES  OF  THE SPINAL  CORD.
It is to this peripheral neuritis that are to be ascribed the neuralgic pains the
anaesthesias, muscular atrophies, and trophic disturbances (arthropathies?) so
often observed in the course of locomotor ataxia.  In fact, according to  some
authorities (for example, Hirt), the disease probably always begins with degen-
erative changes in the peripheral nerves.—H.]
  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-globules which have probably been  derived from the products  of  fatty
degeneration 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 (Vulpian, 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
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 aff'ections 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 gastriques 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-Bobertson  symptom).  Difficulty
of speech from paralysis of the hypoglossus. and paralysis affecting branches 
LOCOMOTOR ATAXIA.
687
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.  When 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
advance slowly, but walks with precipitation.  The legs are thrown forAvard
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, who 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
Avould  fall if not supported.   This has been attributed to the coexistence of
more  or less  anesthesia 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.
  1 Vide report of  a case by Dr. Pepper, in Am. Journ. of Med. Sciences, July, 1871. 
688
DISEASES  OF  THE SPINAL  CORD.
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
anaesthesia and analgesia are  combined.   There is  also  diminution of the
sense of  weight and  of temperature.   The  so-called muscular sense is
impaired.   Betardation 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.
   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  often takes
place after several  weeks or months.  On the other hand, permanent struc-
tural changes  may be the result, leading sometimes to  dislocation* and the
lesions of deforming arthritis.  The patellar reflex  is wanting.   Percussion
over the ligamentum patellae 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.   When 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
          1 Charcot, Lecons sur les Maladies du Systeme nerveux,  Paris 1877. 
LOCOMOTOR  ATAXIA.
689
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  affection being
generally manifested first  in the lower extremities.   General paralysis  of
the insane and locomotor ataxia may occur together,  either affection appear-
ing first,
   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. With proper
attention this cannot be confounded with the ataxic difficulty.   Moreover, the
vertigo is  usually  accompanied b}7 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 affection.  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 Avith exposure to  cold and sexual  excesses.  The disease
occurs very rarely  prior  to adult life.  In  the great majority of  cases the
ages are betAveen 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
aff'ections 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.  [According  to  Erb, the
proportion of cases  in  which a syphilitic history could be obtained was  60
per cent.; according to Fournier, about 90 per cent.   Out of 247 cases stud-
ied by Hirt, syphilis had certainly existed in 21S — i. e. in nearly 90 per cent,
—H.]  The analysis of  the  cases  shoAAs 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 Avhich 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 seA'eral weeks, and it should then  be suspended for a
         u 
690
DISEASES  OF  THE SPINAL  CORD.
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.
[Considering the frequency of a syphilitic  taint in ataxic patients, it might
be supposed that the greatest benefit would be  derived from an antisyphilitic
treatment.   Experience, however, has shown  that, unless signs of syphilis are
still  present or the time  since their subsidence is short, little can be accom-
plished  by  a course of mercurials or potassium iodide.—H.]
  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 name(^
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  pains,  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 afforded 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.
  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.
  [A few years ago the  " suspension method " of treating locomotor ataxia
was universally prevalent, and the reports of its results were almost univer-
sally favorable.  By this method patients were suspended for several minutes
by an apparatus similar to that employed for fitting a plaster-of-Paris jacket
in cases of  Pott's disease.  It seems highly probable that the beneficial effects
of suspension were due entirely to auto-suggestion.   Hirt has  treated  more
than one hundred cases of locomotor ataxia by suspension, and in no instance
was he able to note any marked or lasting improvement.—H.I


                         Hereditary Ataxia.

  This  rare affection Avas first described by  Friedreich  in 1863, and is some-
times called Friedreich's  disease.   Although several cases 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  Avere IS  cases of ataxia in one family occurring
during three generations.  Dr. W. E. Smith has reported U cases' of hered- 
ACUTE  ANTERIOR POLIOMYELITIS.
691
 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.
   [A  valuable  contribution to the literature of this subject was made in
 1888 2 by Crozer Griffith of  Philadelphia, who published a thorough analysis
 of 113 cases  occurring in 77 •'families of brothers and sisters."   Griffith
 regards  the  affection as  essentially  hereditary, using this  adjective in  its
 broadest sense.  The inheritance may be direct and  similar or polymorphic.
 Under the latter term are included cases in which there existed in the ances-
 tors such predisposing  causes as (1) " other  neuropathies, or  exceedingly
 nervous  disposition in  the parents, grandparents, uncles, or aunts; (2) alco-
 holism ;  (3) tuberculosis;  (A)  syphilis;  (5) consanguinity;  (6) other unclas-
 sified causes."  For  a  complete resume of our existing  knowledge  of  this
 rare disease  the student is  referred to Griffith's admirable paper.—H.]
   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.   [The lesion in  these cases is seated  in the peripheral  nerves, and
 will be described  under the head of Multiple  Neuritis.—H]


 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  haATe 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-
 ease are  not  rare.  At  this  period one or both anterior horns  in a situation
 corresponding to the origin of fhe 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
  1 W.Everett Smith, "Hereditarv or Degenerative  Ataxia," Boston Med. and Surg.
Journ., Oct. 15, 1885. .
  2 Trans.  College of Physicians of Phila., vol. x., 3d series. 
692
DISEASES  OF  THE SPINAL  CORD.
little  beyond  the gray  matter  into the  adjoining  antcro-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.   When  the  paralysis
affects the'lower  extremities  the poliomyelitis is in the  lumbar  enlarge-
ment.   When  the  upper extremity  is  paralyzed  there is  poliomyelitis  of
the cervical enlargement.
  As would naturally be expected (see p.  671), 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 feAV 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  inArolve 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
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. 
ACUTE  ANTERIOR POLIOMYELITIS.
693
   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. 674), 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 Aveeks 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 excita-
bility during the period of increased galvanic excitability.   Aoluntary impulses
can be transmitted through the nerves before the faradic excitability returns.
   Speedy and  notable Avasting 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 wTell as the  touch, and the  skin has a livid
appearance.
   Within a few Aveeks  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 loAver 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
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 Avith
of shortened, flaccid  limbs, club-foot, etc., if not congenital,  are  generally
remote consequences  of this disease. 
694              DISEASES OF THE SPINAL CORD.
   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
ansesthesia;  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.
   AVe 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.


          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 same affection may occur in the adult. The pathological 
       SUBACUTE AND CHRONIC ANTERIOR POLIOMYELITIS.   695

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 Avith 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 positiAre
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
atrophy occurs,  eA7idently 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
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. 
696
DISEASES  OF  THE SPINAL  CORD.
   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 wThole 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.   With 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 palsy.  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).  We  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.  We 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
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.   We may hope  that in the
future their distinctive  characters will be better understood.  In the present
                     1 Archivfur Psychiatrie,  1878, Bd. 8. 
PROGRESSIVE MUSCULAR  ATROPHY.
697
 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 (deuteropathie 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 striae
 until  much reduced  in  size.  Many of the fibres possess  a greatly increased
 number of sarcoleinma  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 eases the latter are first  affected.   The intercostal muscles and  the
diaphragm  may be involved, and death may be  produced by apnoea.  The
muscles of deglutition may  become involved, and  the  aff'ection may  prove
fatal by causing inanition.  The affection is  limited to the  voluntary muscles.
  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 
698
DISEASES  OF  THE SPINAL CORD.
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 were little
more  dense than the strongest  brown  wrapping-paper; the muscles of the
neck,  anterior and posterior, proportionately attenuated; the muscles on  the
scapulae, 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  scapulae 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.   When
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.
   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.
                         1 Dublin Quarterly Journal. 
PROGRESSIVE MUSCULAR  ATROPHY.
699
The  affected parts are notably sensitive to cold,  and their  temperature is
below  that  of other parts.   Defective  capillary  circulation is sometimes
shoAvn 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 Avhich 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 Avhen the affection 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
apnoea  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 Avhich  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-
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 
700               DISEASES OF THE  SPINAL  CORD.
 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 affections, 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 affected 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 affected 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.


    Spastic Spinal Paralysis—Primary  Lateral Sclerosis.

   In 1875, Erb described a group  of  symptoms as a Avell-defined disease  to
 which  he gave  the  name spastic spinal paralysis.   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 aff'ections 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. 
SPASTIC SPINAL PARALYSIS.
701
  The  combination of  locomotor  ataxia  with  lateral  sclerosis has  been
described especially by Westphal.   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-
panied by tAvitchings 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. 673).  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 Avith the skin.
  The tremor, stiffness,  and spasmodic  twitchings  added  to  the  paralysis
increase the difficulty in walking, and  give rise to Avhat 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  poAver, 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.
              1 Vide Ziemssen's Cyc. of Med.,  Am. ed., vol. xiii. p. 97. 
702               DISEASES OF THE SPINAL CORD.
 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 an<1 hed-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 affected 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
 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 deuteropathie forms  of progressive muscular  atrophy,
 that designated by  Charcot in  1874 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, knoAvn
 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. 670.)
 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 cases.  The disease is
in the majority  of cases, accompanied  by the symptoms and lesions of chronic 
                COMPRESSION OF THE SPINAL CORD.            703

 bulbar paralysis.   The primary lesion is to be regarded as degeneration, and
 not inflammation.
   The paralysis begins generally  in the  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. 674.)  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
 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 vertebrae 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 vertebrae, 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.   Dilatation  of  the central canal is called hydromyelus,
 and is  generally congenital.   Cavities of variable size and length and more
 or less centrally located may  be  developed  in  the spinal  cord  in  various
 ways.   The name syringomyelus or syringomyelia is given to these patho-
 logical canals.  (See p.  (i54.)
  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
    1 Vide Charcot, Lecons sur les Maladies du Systeme nerveux, Paris, 1877, tome ii. 
 704              DISEASES  OF  THE SPINAL  CORD.

 tumor (haematoma) 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.  647).
   Of the causes of gradual compression of the cord, the most frequent and
 best studied  is caries of the vertebrre,  or Potfs disease.  Is was formerly sup-
 posed  that compression of the cord Avas 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 vertebrae, but that this displacement
 is not  necessarily or usually the cause is proven by the following facts: Ex-
 treme angular curvature may exist  Avithout 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.    We  OAve  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 vertebras
 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
 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 anasmic 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 ahvays  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 vertebrae, 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 anaesthesia, as described by Brown-Sequard.
  Much more  frequently the paralysis has  the  form of paraplegia affectin«
 the lower limbs. If the spinal affection 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
          1 Sur la Meningite et la Myelite dans le Mai vertebral, Paris 1871. 
COMPRESSION OF THE SPINAL CORD.            705
accompanied by anaesthesia 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 vertebrae extending to the cord.  This  symptom
may be more or less marked, hoAvever, 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  Avhenever  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-
pression sufficient to cause  paralysis for a long period without  disorganizing
changes.  This  is shown by the immediate disappearance  of paralysis from
displacement of vertebr.e,  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 diff'erent  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 vertebrae, 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  Avith  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 vertebrae leading thereto.  As a
means  of securing  rest it  may be found to have a  wider extent of useful
application  tnan  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 may be  due  to syphilis.
  In other  respects the treatment indicated  is essentially the same as in cases
of chronic primary spinal meningitis and myelitis.
                     1 Vide  Clinical Medicine, 1879, p. 560.
       45 
706
DISEASES OF THE SPINAL CORD.
     Pseudo-hypertrophic  (or Myo-sclerotic) Paralysis.

  The characteristics of this affection were first pointed out by Mervon 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 affected.
  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
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 hyperaesthesia  nor anaesthesia.  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 aff'ection  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 be  prevented from
progressing, and there may be more or less  improvement.  The disease rarely
destroys  hAe 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
                  1 New York Journal of Medicine, June, 1875. 
FUNCTIONAL DISEASES OF THE  BRAIN AND SPINAL CORD.  707
                        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.—Spinal
  Irritation.

   FOLLOWING- 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
Avithin 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
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 
708  FUNCTIONAL DISEASES  OF  THE BRAIN AND SPINAL  CORD.

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 Avhich the patient
either cannot be aroused or is aroused Avith 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 Avhich 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, hyperaemia and anaemia  of the  brain, throm-
bosis and embolism, cerebral and meningeal hemorrhage, meningitis, enceph-
alitis, and tumors.   In all these affections, except perhaps active hyperaemia,
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 anaemia (ischaemia)
due to impoverishment of  the blood and enfeebled circulation,  as in the
hydrencephaloid affection first  described by Marshall Hall. (Vide  p. 590.)
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, diabetes  mellitus,  etc.   It may be produced by  such toxic
agents as opium and other narcotics, alcohol, ethers, chloroform, etc.  The
sudden loss of consciousness at the instant of the attack in epilepsy is attrib-
uted to cerebral anaamia 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 in  the general diseases just named and their modus operandi are
not understood.
  There are cases of coma not connected with  any of  the foregoing diseases,
and not clearly  referable to any knoAvn 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 unknoAvn 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 Avere not
determinable during life; examples are—thrombosis of the  basilar artery or
of the longitudinal sinus and meningeal  hemorrhage.  The tAyo  former of
these conditions not many years since Avould have escaped recognition  as
causes of the coma; and  so further  developments in pathological anatomy
may furnish an  explanation, post-mortem,  of cases in Avhich  adequate morbid 
SATURNINE ENCEPHALOPATHY.               709
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-producino-
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 Avhich 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 Avith the continuance of the comatose state. When 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 hyperaemia.
   The  propriety of counter-irritation is doubtful.  Rest, alimentation, nerve-
tonics,  and the judicious employment  of wine or  other  alcoholics  are the
measures Avhich 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 compulsions 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 
710  FUNCTIONAL DISEASES  OF  THE BRAIN AND SPINAL  CORD.

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 Avithout 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 shoivs the  normal  appearances.
  A satisfactory pathological explanation of these effects of lead-poisoning
cannot be given.   They have been attributed to anremia of the brain from
changes in the minute cerebral arteries, to oedema of the brain from increased
arterial pressure, and to the direct  irritation caused by the presence  of lead.
Uramiia 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  uraemia, 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.   It  should  be ascertained, by
examinations of the urine, how far uraemia 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.

  Vertigo 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,
Avhich, 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,  hoAvever, 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  diff'erent  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 
VERTIGO.
711
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 be left alone, and all public assemblages
are avoided,  lest something may happen to him to excite disturbance.   In
a case Avhich 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 Avhich 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  Avith  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  18G1 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
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  aure 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 affection  stomachal vertigo (ver-
tigo a stomacho Iseso).  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 lithaemia (uricaemia).2
  The treatment involves, as the first and most important measure, removal
  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. 
712  FUNCTIONAL DISEASES  OF  THE BRAIN AND SPINAL  CORD.

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.   [In the
same  form of vertigo Ilirt strongly recommends the hypodermic injection of
9 or 10 drops of  a two per cent, solution of pilocarpine.  The injections are
administered  every second day, and should be continued for several  weeks.
This method  of treatment is somewhat debilitating, and  should  only be em-
ployed in comparatively  robust individuals.—H.]


                   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 anesthesia
and analgesia; the first relating to the sensibility to touch, and the second to
the sensibility to  pain.  Analgesia may exist Avithout anaesthesia.   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 ljand, the loss  of sensibility to touch (anaesthesia) car-
ries with  it the loss  of sensibility  to  pain (analgesia).   Cutaneous analgesia
is ascertained, clinically,  by pinching or pricking the  skin.   Anaesthesia 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 aesthesiometer, 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
the  ends  of the fingers.  These normal differences are to be taken into account
in judging of anaesthesia, 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. 
PARALYSIS.
713
 This pathological  condition enters into  the consideration of these  organs in
 other sections of this Avork.
   Under the name erythromclalgia 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 vasomotor spasm.
   Paralysis  is complete Avhen 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, betAveen 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 Avith or Avithout the muscles of  the face.  It is partial when  a portion
 of the muscular system is inA-olved, as in hemiplegia and paraplegia.   It is
 local Avhen a very feAv 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
 betAveen  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 Avill.   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
 betAveen their terminations and their central  connections with either the brain
 or the spinal  cord.   Paralyses are peripheral Avhen  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
 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
 lie 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 poAver 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
                     1 Am. Journ.  Med. Sciences, July, 1878. 
714  FUNCTIONAL DISEASES OF THE BRAIN  AND  SPINAL CORD.

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 Avill be considered in the next
chapter.  The reaction of degeneration, Avhich is of much value in the diag-
nosis of the different kinds of paralysis, has already been described (p. 07*)).
   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, Aveeks, 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 Avaste,
except as an effect purely of disuse.  There may be anaesthesia 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 Avith these  affections  is often of significance Avith 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.
               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.  Anaemia  claims appropriate therapeutic
and hygienic measures.   Cystitis, phimosis, or other local diseases which may

  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 Avriters
embrace cases in Avhich  the affection is due to injurv, but without appreciable lesions
(Vide Eichhorst, Handb. d. Spec. Path, u Therap.)  Cases in which paralvsis  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  PARAL YSIS
715
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 oal-
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 diseases
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 an}" 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.
Whether  or not they have any specially  curative effect, clinical experience
affords eAidence 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
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 
 716  FUNCTIONAL DISEASES  OF  THE BRAIN  AND SPINAL  CORD.

 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  folloAving diphtheria has  been knoAvn  to  involve not
 only the extremities,  together Avith 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 AToluntary manifestations, the patient being in a state of living
 death.  Gleneral 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 affections 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 anaesthesia.  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 be 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 dyspnoea.  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 anaesthesia 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-
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 
HEMIPLEGIA.
Ill
patient at once fell asleep when the eye and the ear in which the perceptions
were preserved Avere 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 Avell 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 affected Avith the choreic movements.  The  paral-
ysis  in  these  cases does  not  extend to the face  or tongue.  The paralysis
Avhich follows diphtheria  is sometimes hemiplegic.  I have  known transient
hemiplegia to  folloAV  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 saAV 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
deAriated 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 Avas in good health.
Thrombosis Avas the probable causative condition in this case.
  A man, aged about seventy, after a long walk in the afternoon retired at
night  feeling Avell, 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,
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 feAV  Aveeks  there remained only a slight diminution  of motor power. 
718 FUNCTIONAL DISEASES OF THE  BRAIN AND  SPINAL CORD.

  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 ceased to recur, and I learned  several  months afterward that he
Avas 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  Avas 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 Avas well  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 Avithout
difficulty, and the following day went out of the hospital on a permit.   Sud-
denly, after the  lapse of a Aveek, 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 anaesthesia.  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.  Hemianaesthesia may be produced
also by cerebral  lesions.  (See p. 615.)  The  loss of sensation may affect all
forms of sensation, including  the special senses.
   Spinal hemiplegia, with motor  paralysis on  one side and anaesthesia on the
opposite side, probably ahvays 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. 615), 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.

   Paraplegia is to be considered as functional when the absence of any ana-
 tomical  change is to be inferred  from the symptoms and course of the affec-
 tion.  As a functional  affection it is much  more frequent in  its  occurrence 
•
                             PARAPLEGIA.                          719

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 folloAvin"-
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 diff'erent 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 Avhen, on the
other hand, it is considered that the various local diseases supposed to have
a causative connection  are not associated Avith 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 anaemia 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 Avhich 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, Weir 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.
  Paraplegia  may be an imagined  disease.   I have met with an instance in
which this self-deception Avas  diagnosticated, the case being analogous to  one
reported by J. Russell Reynolds, and  called by him paralysis " dependent on
idea."  Tl'iese cases are to be distinguished from cases of simulated para-
plegia.  I have met with the  latter in  connection  with hysteria.  Kunze 
720 FUNCTIONAL DISEASES OF THE BRAIN  AND  SPINAL  CORD.

relates the case of a woman who,  having kept the bed  for  a  considerable
time under the  conviction that she bad 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 Avhich
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 dyspnoea
 becomes a  prominent symptom.   Subsequently the  muscles  concerned in
 speech, mastication, and  deglutition  are  involved.   Death takes  place by
 apnoea 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 hyperaesthesia.   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
 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- 
NERVOUS ASTHENIA.
721
nia, and  stimulating tonics, together with sustaining nourishment, are indi-
cated Avith 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 affection.   It occurs without anaemia 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, Avriters 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 Avith  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  Avill 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  teaT
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  Avho 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
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-
       46 
722  FUNCTIONAL DISEASES OF THE BRAIN AND SPINAL  CORD.

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 W. 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.
With 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-
vico-occipital pains, nausea, vomiting, singultus, palpitations, and nervous cough
are associated with tenderness over  the cervical and dorsal vertebrae  whereas
pain in the loAver parts of the body, tympanites, colic, and dysuria are associ-
ated with lumbar tenderness.   Patients generally are mentally depressed  the
poAver of physical or mental endurance is diminished, sleeplessness is common 
DISEASES OF THE NERVES.                  723
general hyperaesthesia 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 hyperaemia or to ischaamia) 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 anaemia.  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 anaemia 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 Avere 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  NERVES.

Neuritis.—Multiple Neuritis.—Peripheral Paralysis—Beri-beri—Kak-ke.—Paralysis of
   the Third Cranial Nerve.—Paralysis of the Fourth Cranial Nerve.—Paralysis of the
   Fifth Crauial 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.
   —Paralysis 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 Neural-
   gia.—Lumbo-abdominal Neuralgia.—Crural Neuralgia.—Sciatic Neuralgia.—Coccygo-
   dyuia.—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
embraced  neuritis, paralytic  affections,  and neuralgia referable to  nervous
trunks or  branches.   Paralysis from lead will be included among the periph-
eral paralyses. 
724                  DISEASES  OF THE  NERVES.
                                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 sivollen, reddened, and more succu-
 lent than normal.   Microscopical  examination shows hyperemia, 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 Avhich  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.   We 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 Avell 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 anaes-
 thesia, either with or without analgesia, but the  anaesthesia 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 oedema,  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-
tion, recovery may take place if the cause be removed and the nerve be notr
too much damaged.  Probably, slight  degrees of neuritis without symptoms
as severe as those described  are not uncommon.   Inflammation of the  nerves 
                          MULTIPLE NEURITIS.                     725

 as Avell  as  affections of the intervertebral ganglia,  has been repeatedly dis-
 covered in cases of herpes zoster intercostalis.
   The differential diagxosis 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
 (Valleix's points), and  the absence of paralysis.
   The  treatment has  reference especially to  causative circumstances.
 Beyond the indications  relating to causation, revulsive and soothing  locai
 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 affected, 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 nenTe-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  [Chronic
 alcoholism is a generally recognized cause of  the  affection.—H.]   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 Avith 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
 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
  ' According to Seheube, the disease which is known as beriberi or kak-ke, and which
prevails in Japan and India, is a multiple neuritis. 
726                  DISEASES  OF  THE NERVES.
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.   A«s  may be  inferred from  what has  been said  on
p. 675,  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 parsesthesias,  sue!
as numbness and formication, are often experienced.   There  usually is some
loss of sensation, but marked  anaesthesia is not generally produced.   On the
other hand, in  acute  cases there often is pronounced hyperesthesia.  The
functions of the bladder  and  of the rectum remain  intact.   Herpetic erup-
tions, oedema,  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 days 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.   [Locomotor ataxia  is  excluded by the absence of  the  Argyll-llobert-
son pupil as well as of bladder disturbances, and by the presence of tender-
ness over the course of the  nerve-trunks.—H.]
  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.


                         [Beri-beri—Kak-ke.
  Beri-beri is an infectious disease Avhich prevails endemically in Northern
Brazil, Japan, India, China, the  Straits settlements, the Malay Archipelago
and other tropical and sub-tropical countries.  Clinically, it manifests itself
chiefly through the signs and symptoms of multiple neuritis.   Up to a quite
recent period there has been great diversity of opinion concerning the cause 
BERI-BERI—KAK-KE.                      727  '  l
of the disease, some  attributing it to a diet composed largely of fish, some
to the habitual consumption of rice, while others have confounded its symp-
toms Avith those produced by the intestinal parasite the anchylostoma duode-
nale.   As a rule, those who have had  the greatest opportunities of observing
the disease  clinically have  been at a disadvantage as concerns the modern
methods  of bacteriological investigation.  Two notable exceptions must, how-
ever, be made to this statement: Drs. Musso and  Morelli haATe studied beri-
beri from a bacteriological standpoint in the pathological institute of Monte-
video,1 and have succeeded in isolating four micro-organisms :  (1) A staphylo-
coccus,  classified as staphylococcus  pyogenes albus;  (2) a micrococcus in
chains ; (3) a small colorless micrococcus;  (4)  a micrococcus which, when
inoculated  in animals (guinea-pigs and dogs), produced a universal degenera-
tive neuritis.  The latter is therefore considered by  these observers  as the
specific organism of beri-beri.  Pekelharing and Winkler2 have also succeeded
in obtaining from the blood of beri-beri patients  micrococci which, inoculated
in animals, produced  polyneuritis.
  Cold and dampness are undoubted predisposing causes,  the disease, accord-
ing to Bentley,3 being most prevalent  during the decline of one monsoon and
the setting in of another.   The affection is said by W. Duncan Scott4 to be
more prevalent among Chinese miners than in any other body of men.  These
miners work  in •'  deep  open pits  with  sloping  sides of sand, often glaring
white, and the heat  at  the bottom  of the  pit is often  very great.   Water
often, if not always, lies  there, in which they  may stand ankle-deep or deeper.
This  itself  may be an  auxiliary influence  in  causing oedema  and nervous
disturbance in the lower  extremities."
   F.  C. Shattuck  and J. -I. Putnam of Boston have  described cases of mul-
tiple neuritis occurring among the fishermen of the Grand Banks, the symp-
toms of  which were remarkably similar  to those of beri-beri.5   As  a  matter
of  course, all affections in which multiple neuritis is  a conspicuous symptom
will present strong points of resemblance,  but, in view of the  observations
of  Pekelharing and  others  above referred  to, the question  of identity can
probably only be  settled  by a bacteriological investigation.
   Those who have had most  experience of beri-beri believe  it to be non-
contagious.  The   virus of the disease becomes concentrated in buildings,
such as barracks, prisons, and the  holds  of  vessels, in  which  people  are
crowded together  under unfavorable hygienic  circumstances.

   Anatomical Characters.—The  chief  anatomical alterations  thus  far
observed consist of cedematous infiltration  of  the connectiA-e tissues, espe-
cially of the lower  extremities, effusion into the serous cavities, dilatation and
flabbiness  of the   heart, oedema of lungs, and  congestion  of spleen, liver,
brain, and  spinal   cord.   The kidneys  are  said by Bentley to  be pale and
enlarged.  Accounts of minute examinations of the organs above mentioned
have "been  absent  from the reports  examined  by the writer.  According to
Leopold, the signs of. multiple neuritis  are constant,  consisting of disappear-
ance of the axis-cylinders of the nerves of the affected region, segmentation
of  the myelin, and small-celled infiltration of the sheath of Schwann.  The
spinal cord  is, as  a  rule, intact, but  in  the  severest cases signs of anterior
poliomyelitis may be detected.

    1 Vide Leopold,  Berliner klinische Wochenschrift. 2-"> January, 1892.
    2 Verhandhinaen  des X. intermitionellen  med. Congresses, Band 5, Abtheilung xvi.
    3 Beri-beri, by Arthur J. M. Bentley, 1893.
    * Practitioner, Mav, 1892.
    5 Journal of Nervous and Mental Disease, August, 1890. 
728
DISEASES  OF  THE NERVES.
   Symptoms.—Two principal forms of beri-beri are encountered—the cedem-
atous and  the  paralytic, or, as they are sometimes  styled, the dry and  the
wet.  The  latter, which is  the  acute  form of the disease, begins  with fever,
usually of  slight intensity and either intermittent or irregular.   This  fever
is sharply  defined from  the  malarial by the absence of rigors.  With  the
subsidence  of the  fever—sometimes during its course—oedema of the lower
extremities  with paresis and numbness  sets in.  The  oedema, at first  most
marked over the dorsum of  the  foot, may extend upward and involve  the
loose  tissues of the scrotum and penis.   Effusion into the serous  cavities
may occur.  According to Leopold, the oedema is due to venous stasis, which,
in its turn, is  caused  by  a  gradual  dilatation of the  right ventricle.   He
bases this opinion  upon the  alleged fact that  coincidently with the  oedema
there develops  a  systolic  cardiac  murmur, loudest at  the   apex,  and  an
increase in  the transverse diameter  of the  heart.  The pulse is full, strong,
and increased in frequency.  The respiration is  embarrassed and there is a
sense of thoracic oppression.   The  tongue is clean, the bowels usually con-
stipated, the urine diminished, though free  from albumin and of high  specific
gravity.  Enlargement of spleen and liver is constant.   The gait is awkward
and stiff and the knee-jerk  diminished or absent.
   Dry beri-beri may either begin  as such or it may be a development of the
acute or wet variety.  In this form the  nervous symptoms are more promi-
nent,  consisting of anaesthesia and paraesthesia (formication,  pricking and
tingling sensations) of the  lower  extremities, paresis, and muscular atrophy.
The gait is  peculiar, the patients  stepping  high on account of the paralytic
dropping of the foot.  The knee-jerk is generally absent,  though sometimes,
according to Duncan Scott, exaggerated, and  the muscles of the calf are
usually tender on  pressure.  In a  certain  number of the cases the muscles
undergo marked atrophy—so much so that Bentley  describes an atrophic
form of the disease.  The  same observer classifies as "acute pernicious" the
cases in which there is a rapid progress from bad to worse.   In cases of this
class the " dyspnoea becomes extreme, sleep becomes  uneasy,  there  is  diffi-
culty in lying down, vomiting is often present, and muscular spasms of dif-
ferent parts  of the body 'occur.  The pulse is increased  in frequency and
feebleness,  there is  fluttering  about  the heart, the lips and countenance
become livid, there is a  scared  aspect, the  extremities become  cold, and the
patient soon  dies nearly suffocated.   In the more sudden  cases these symp-
toms follow one another with  the utmost rapidity, and a few hours suffice to
close  the scene."
   Anaemia   is not  a prominent  symptom  of  the  disease.   According  to
Bentley, anaemia was "entirely absent"  in the great  majority of his cases,
but this statement is not supported by  accounts of examinations  of the
blood.

   Diagnosis and Prognosis.—The  diagnosis  of beri-beri is  readily made
in the countries in which it is  endemic, and  is based upon the  occurrence in
groups of cases presenting the signs  and symptoms of oedema and multiple
neuritis.  The exact status of such  cases as those described by  Shattuck and
Putnam has  yet to be determined.  It is  highly probable that beri-beri is
caused by a specific organism, and that in  future, as is the  case  with diph-
theria, the  diagnosis in doubtful cases will have to  be  determined in the
bacteriological laboratory.
   In  making a  prognosis  the  marked tendency of  the disease  to  relapse
should be  borne in mind,  as well  as the fact that with each relapse the
tendency to  a fatal  termination increases. 
BERI-BERI—KAK-KE.                     709
   The mortality varies in different countries and in different epidemics in the
 same country,  the  lowest estimate (the  epidemic occurring in  the jail at
 Singapore in 1880) being 8.02 per cent., the highest  (epidemic in Mauritius)
 44 per cent.                                                            J

   Treatment.—In the cedematous form of the disease vapor-baths adminis-
 tered daily and diaphoretics have  seemed to be of decided benefit.   Acetate
 of potassium, jaborandi, the compound spirit of juniper, and the compound
 spirit of ether are the  diaphoretics most commonly employed.  In case con-
 stipation is present, purgatives such as calomel, the compound jalap  powder,
 and the compound  rhubarb  pill  may  be  administered.   Frictions of  the
 (edematous extremities with stimulating liniments are  of undoubted service.
 If dyspnoea becomes urgent, a blister should be applied  to the  precordial
 region.   Under these circumstances also a hypodermic injection of 15 drops
 of ether may  be  employed.
   Scott, believing the blood  in beri-beri to  be  hyperacid, prescribes  alkalies
 such as  potassium bicarbonate and the sesquicarbonate of ammonium, and
 claims to have derived  marked  benefit from the tincture of belladonna.'  In
 the paralytic  variety  the  drugs most commonly  employed  are ergot,  nux
 vomica, and nitrate  of  silver.   A  cure in this  form of the disease  may be
 hastened by the judicious employment of electricity.—H.]


                        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
 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. 675).    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 anaesthesia 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 
730
DISEASES  OF THE  NERVES.
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 recoA-ery 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 Avithin
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
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 affectino- this nerve on 
           PARALYSIS OF THE FIFTH  CRANIAL NERVE.        731

the riirht  side occurred without other central  symptoms three Aveeks 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 doAviiAvard. 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 (anaesthesia  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
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—nameh',  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  anaesthesia and analgesia in  these parts  are complete  (anaes-
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
eyes, nose, and mouth was completely  anaesthetic ; 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 
732
DISEASES OF  THE NERVES.
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 Schneiderian 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 Avas 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 anaesthetic 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.  When 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-
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 naso-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.
When 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 eyebroAv is lowered, and the patient is
unable to frown or to wrinkle the forehead on the affected side  from loss of
   1 Transactions of the Royal Medical and Chirurgical Society of London 1869 vol. lii 
          PARALYSIS  OF  THE SEVENTH CRANIAL NERVE.      733

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
the 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  anaemia.  It is sometimes
produced  in new-born  children by the employment  of the  forceps in labor.
Facial paralysis may  proceed  from the  various intracranial affections wdiich
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 aff'ection.   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 poAvder, 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  affected 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
uvulae 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
  1 The fibres of the chorda tympani nerve are probably derived ultimately from the
glossopharyngeal nerve,  although some assign them to the trigeminus. 
731
DISEASES  OF THE  NERVES.
 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 affected 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 affected.   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  aff'ection.
   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 aff'ection.   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.1  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-
 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 apnoea from inability to
 expel, by coughing, matter in the  air-passages.  Paralysis affecting the alas
 nasi  may lead to an amount of depression with 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 "losso-
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 smali
extravasation  of blood into or near the medulla oblongata.   I have met with
  1 For a report of 28 eases of double facial paralysis, see article by Dr Pierreson in
Arehwes generates de Medecine, Aout et Septembre, 1867.               ' 
            PARALYSIS OF THE NINTH CRANIAL NERVE.        735

 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 va°us 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 au
 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-
 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 Avhile 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 speech 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 Avithin and without the neurilemma, and inflammation of the neuri-
lemma or of the nerve-substance. The latter generally occurs either by exten- 
736
DISEASES  OF  THE NERVES.
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 diarrhoea exists and when voluntary
power  over the  muscles  is requisite to prevent  their occurrence.   There is no
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. Weir 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.2  Dr. William  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
      1 Vide article by Dr. Keyes in the New York Medical Journal., Nov.  1870
      2 Vide Injwies of Nerves, by S. Weir Mitchell,  M. D., Philadelphia,'l872. 
PARALYSIS FROM LEAD.
737
 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.1  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 wrist-drop.  This name
 expresses the peculiar appearance of the upper  extremities.   The  patient is
 unable to raise the  hand to a line Avith 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.  Whenever 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
 muscles are usually first affected, and then the extensors on the leg, the anterior
 tibial muscle remaining intact.   The paralysis is shoAvn by inability to raise the
 feet Avith 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. (Vide
 p. IGO.)   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 arc but little if at all affected.
 This fact was illustrated in a striking manner in a case under my observation
at Bellevue Hospital.  Wishing to group  several cases of paralysis for a clin-
ical lecture in the  hospital  amphitheatre,  which is situated at the top of the
       1 Vide Trans. Royal Med. and Chirurg.  Society of London, 1869, vol. Hi.
        47 
738
DISEASES  OF  THE NERVES.
building, I desired to have a patient affected with complete  paraplegia car-
ried up from a Avard 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
affected 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 Avhen this was obtained  he
performed the feat with ease,  and after the lecture brought the patient doAvn
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 vieAv 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.   Voluntary 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 eATident.   Amau-
rosis is one of the occasional effects of lead-poisoning.   Exceptionally, anaes-
thesia and analgesia of the surface have also been observed, affecting  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
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 affected 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. 
NEURALGIA.                           739
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 loAver 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 be said  of its essential
pathological character.  Visceral  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-
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. Valleix was the first to show that, as regards 
740
DISEASES  OF  THE NERVES.
 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 Avay 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.
 97.)  The diagnostic  evidence to be derived from this source in other neur-
 algic affections will be stated  Avhen 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  betAveen paroxysms,
 the patient  being entirely free from  pain, the tenderness on pressure may
 disappear. Exclusive of the tender points, there may be either hyperaesthesia
 or  anaesthesia 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
 nerves are  distributed may not  be notably disturbed.   A neuralgic attack,
 however,  often induces hyperaemia in the site of the  pain, as shown by tem-
 porary redness of the  conjunctiva in cases of neuralgia affecting 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 affecting 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
 W hen  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-
rip\!  V   V^oxj^ms  do  not  exemplify a law of  periodicity.  It  is one
ot 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 
NEURALGIA.                          741
 ous effects of lead are manifested.  Anaemia, by whatever cause induced, favors
 the occurrence of neuralgia.  A large proportion of those who suffer from
 neuralgic affections are anaemic.1  Persons are most likely to suffer from neur-
 algia betAveen the age of twenty and of fifty.  Prior to ten years of age it is
 extremely rare.   Women 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 amomia.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).  Weir Mitchell has observed cases
 in which injury of a nerATe 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, AA'hich is a highly diagnostic feature, the
 nervous  trunks-  successively affected do not ahvays have a common origin; and
 thus the neuralgia maybe 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 Avhich relate  to morbid
 conditions  suspected to  stand in a causative  relation to the neuralgia.   The
 physician in  indi\ridual 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-
  1 With regard to the dependence of neuralgia  on anaemia, Romberg says: "It seems
as if pain Avere the prayer of the nerve for healthy blood."
  z Neuralgia, and the Diseases that Resemble  it, 1872. 
742                  DISEASES OF THE NERVES.
uting to the neuralgic affection, and Avith reference to the cure of  the  latter
these conditions claim appropriate measures of treatment.  Attention is always
to be  directed  to the coexistence of anaemia.  Symptomatic  phenomena,
together with the venous hum in the  neck, may denote the amvmic condition
when it is not manifested  by pallor of the face and the prolabia.  If amvmia
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 amemia is  indicated,  provided the  anaemic condition  con-
tinue, notwithstanding the neuralgia  may cease.  The disappearance of the
venous  hum  is evidence that the anaemic 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 form
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 aff'ection have no intrinsic tendency to  continue ;
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 shoAvn  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 
NEURALGIA.                          743
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." J   During the process of vesication
the neuralgic  pain is frequently increased.   When quickness of vesication is
desirable,  it may be effected  in a feiv moments by  the strong aqua ammoniae,
and still more quickly by means of a hammer heated by hot Avater.   By the
latter means, or by an  instrument devised for the operation known as 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
lias  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
can be 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 Avhich 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 anaemia, 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  anaemia.
The hydrochlorate, nitrate, and  valerianate of ammonium have been found in
                       1 Therapeutics and Materia Medica. 
714
DISEASES  OF  THE NERVES.
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 aff'ections, 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, Watson,
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.  [Among the
latest and most approved  remedies for neuralgia  in general are  antipyrin,
acetanilid, phenacetin,  salol, and  exalgine.—II.]
  Division of a nen^e (neurotomy) and the removal of a section (neurectomy)
are surgical procedures  resorted to chiefly in cases of neuralgia  affecting 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-
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 infraorbital  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, Avith the exception of that portion of the inferior
maxillary  which is contained Avithin 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 affected side, and more or less abundant secretion of  tears.
       1 Aide Practice of Medecine, p. 630.
       ' " De la Nevralgie lombaire, etc.," Archives generates de Medecine 1858. 
TRIFACIAL NEURALGIA.
745
 In this situation the neuralgic affection has sometimes been called migraine,
 hemicrania. and broAvache, 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 elision.   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 affection 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 affected 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 be discriminated from inflammation of the mem-
 brane  lining the supraorbital and the maxillary antrum  and from  syphilitic
 periostitis.  The tAvo 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 feA7er.  Trifacial neuralgia  rarely
 occurs in infancy.   In the majority of cases the age is between  thirty and
 fifty years,  and it  occurs oftener in  Avomen than  in men.
  This neuralgic affection is curable in the majorit}T of cases.  Exceptionally,
 it resists  all the therapeutical measures which have been considered as appli-
 cable to  neuralgic aff'ections in general.   The branches Avhich  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 Avarrants  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 aff'ection 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. 
746
DISEASES  OF THE  NERVES.
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  suflered
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 diff'erent systems  of
practice, the nerve was divided by Valentine Mott, and the patient Avas 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. K. Wood, 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.x
This operation, since that date, has  been  performed by James R. Wood 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
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 anaesthesia of the  face on the affected side.3  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.4


                    Oervico-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: BetAveen the  mastoid
process and the cervical vertebrae, 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 vertebrae  just below the occiput, and
extend over the posterior and superior portion of the cranium.  Dartino- pains
  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 S3. Dennis, M. D., in the New York Med. Journal, June,  1879.
  3 Archives generates de Medecine, 1854.  Vide, also, treatise bv Anstie.
  4 For a report of cases observed  and collected by Prof. Henry D. Xoyes Avith refer-
ence particularly to the effect  upon the eye  of paralysis of this nerve vide New York
Journal of Medicine, vol.  xiv. p. 163. 
                  LUMBO-ABDOMINAL  NEURALGIA.              747

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.


                   k 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 aff'ection.   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
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 affected 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 aff'ection.


                   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.  97).


                  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 affection. 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. 
748
DISEASES  OF  THE NERVES.
   Painful and tender points  are  situated near the upper lumbar vertebrae, 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 by micturition.
   Myalgia affecting the lumbar muscles,  or lumbago, is to be discriminated by
the existence of pain and tenderness on both sides, Avhereas 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
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 
                  LUMBO-ABDOMINAL NEURALGIA.              749

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 laAv 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
pressure upon the great trochanter and  by flexion and extension of the thigh.
Moreover,  febrile movements, general debility, emaciation, etc., in conjunction
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. 
750                 DISEASES OF THE NERVES.


                           [Coccygodynia.
  The term " coccygodynia'' is applied to a variety of neuralgia characterized
by intense paroxysmal pain in the region of the coccyx.  It is more common
in women than in men, and is often  associated with symptoms of hysteria.
It is  often  reflex, as proved  by the relief which sometimes  follows the re-
moval  of sources  of irritation in the genital organs.   In intractable cases
the coccyx  has been removed, and occasionally with permanent relief.—II.]

                             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 Weir 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 aff'ections, is manifestly inappropriate,
and it is desirable  that the name in.this application should become obsolete.
The myalgic affections were  designated by Valleix 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 Avhen the muscles are at rest, and this  may
be aggravated  by  spasmodic pains occurring from  time to  time.  In 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.   Voluntary 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 affected 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
                          1 Vide Clinical Medicine. 
MYALGIA.
751
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 Avith unusual force.   The patient experiences suffering Avhen 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 aff'ection 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 Aveeks.  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 scapuhe—the chronic aff'ection  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 occipito-frontal 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.
   '1. The Muscles  of the JYeck.—In this  situation the  affection, as it com-
monly occurs, has been known by the name rheumatic torticollis.  This name
is applied to the affection 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.  Valleix applied to the affection in the latter
situation the  name cervicodynia.   In this situation the  affection is to be dis-
tinguished from ordinary occipital neuralgia.
   3. The Muscles of the Back.—Valleix called  the affection in this  situation
dorsodynia.   Seated in these muscles, the  pain  is caused especially by move-
ments which approximate the scapulae.
  4. The Muscles of the Loins.— In  this situation  the affection is commonly
known as lumbago.   Valleix  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 
7-12                 DISEASES  OF  THE NERVES.

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.—Valleix 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 aff'ection 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  Avith the palm  of the hand being well borne, as in
cases of cutaneous hyperaesthesia.
   9. The Visceral Muscular Structures.—The tongue and the muscles of the
pharynx  and  oesophagus 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,
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  anaemia 
CEPHALALGIA.                        753
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.   [Fagge regards lumbago as almost invariably the result of irritation
of the kidneys by a hyperacid urine, and states that rapid relief may be fre-
quently given in such cases by alkalies such as the  citrate of potassium  in
full  doses  at  frequent  intervals.—H.]
   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 cerArico-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 Valleix, 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 affection 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 affection 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  tAvelve 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 different cases or in  different attacks in  the same case differs
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 Irequently an  abnormal  sensitiveness  to light and  sounds, and  in
        -is 
754
DISEASES  OF  THE NERVES.
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 aff'ection megrim or
sick headache.  Without 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.  Women 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 different
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
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 anaemia 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 anae-
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 
CHOREA.
755
origin.  In certain cases, migraine is the result of some affection 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, A'inegar, 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.    Warm 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, caffeine, and  the preparations of zinc, especially the
valerianate.   These remedies may be tried in succession.   Hygienic measures
are important.   In  general  terms, the liability  to  attacks is less the more
closely the  laws  of health are observed.   A\'oidance, as far as possible, of
everything Avhich experience shows in  individual  cases  to  act as  exciting
causes is an important part  of  the management.
                       CHAPTER  VII.

                           THE NEUROSES.

  Chorea.—Hereditary Chorea.—Anomalous Muscular Movements.—Local Spasms —
                            Tremor.—Epilepsy.

   CERTAIN 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. 
756
THE NEUROSES.
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  Viti, or St. Vitus''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 Avhich a considerable portion  of  the body is para-
lyzed or several senses are abolished.   Want of ability to direct and harmonize
voluntary movements is a feature of this aff'ection.  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
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 aff'ection.   The appetite is  usually more  or  less
impaired and  the bowels  are constipated.   Anaemia  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
aff'ection 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 
CHOREA.
757
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.  Anaesthesia of the
surface  on one or  both  sides of the body is  sometimes observed; oftener,
however, there is  hyperaesthesia, 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 anaemic  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 Avhich 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 relationship between chorea and rheumatism was investigated by the
collective investigation  committee  of the  British Medical  Association in
1SS7, its report being based upon a study of 439 cases.   Of these, 116 (26
per cent.) were preceded by definite attacks of acute or subacute rheumatism.
There were  26 other cases in  which there was a history  of vague pains
" believed to be rheumatic," and if these cases  are included, the percentage
of antecedent rheumatism amounts to 32.5.   This association is so frequent
as to  warrant  the belief  that there is some etiological relationship between
the two  affections.
  The seasonal relations of chorea and  rheumatism have  been minutely
studied by  Morris J. Lewis of Philadelphia.1   Among the conclusions at
which he  arrived is the following:  " It is more than probable that 'weather'
is one of the most important predisposing causes  of  both the diseases studied
in this paper, although precisely which meteorological factor is  the baneful
one does  not clearly appear.  No  one element  of •weather' explains  fully
the fluctuations of these tracings for chorea, although in the barometer and
storm statistics the relationship appears to  be closer  than to any other etio-
logical factor or factors  that have as  yet been  advanced."  Briefly  stated,
Lewis's tables, based upon  a study of 13S3 cases, show that " chorea  in the
             1 Trans. Association of American Physicians, vol. vii., 1892. 
75s
THE  NEUROSES.
United  States is essentially a disease of the spring,  and that  the  fewest
attacks  occur in the autumn."—II.]
  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 anaemia,
and in most cases patients are anaemic.  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  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 boys, 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 folioavs, 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.
Anaemia in a  large proportion of eases  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 
CHOREA.
759
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 anaemia.  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.
To the efficacy of cannabis  indica testimony is borne  by many.   Cimicifuga
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, asafcetida,
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 anaesthetize 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.

   1 For details  concerning gvmnastic exercises, vide papers by M. See and by M Blache
in Memoires de  I'Acad, de Medecine, Paris,  1855.  For a summary of these details, vide
Meigs on Diseases of Children. 
760
THE NEUROSES.
                        [Hereditary Chorea.
   This disease differs from ordinary chorea in several fundamental particulars.
 In the first place, it is decidedly hereditary, having been traced in five gener-
 ations of the same  family.  Secondly, it rarely manifests  its presence before
 adult life, and often not before the age of forty.   Finally, it is attended with
 decided symptoms of mental inpairment, beginning with loss of memory and
 gradually advancing to childishness and  dementia.  Suicidal proclivities are
 also frequently observed.   The disordered movements of the face and upper
 extremities  are like those of  chorea,  but the distinguishing feature of the
 disease is the gait or walk, which seems to be composed of a series of efforts
 to retain  the equilibrium.   On attempting to walk the patient looks  as if he
 were  about to fall  on his face, but takes a few rapid, stumbling steps  for-
 ward  and thus recovers his balance.  This manoeuvre is then repeated, so
 that, as above stated, the walk consists of repeated efforts to  maintain  the
 balance  of the  body.  Another point  of  distinction  between  hereditary
 chorea and ordinary chorea is  that no association has been observed between
 the former and rheumatism.
   Thus far there have been but  three post-mortem examinations of heredi-
 tary chorea recorded.1  In the first there was a subdural  hemorrhagic cyst;
 in the  second there were pachy- and lepto-meningitis ; and in the third there
 were multiple tumors of  the dura mater.   These  lesions indicate a state of
 continuous irritation of the  cerebral cortex, and  are entirely different from
 any anatomical alterations described  in connection with ordinary chorea.—H.]

 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
rapid pace for several  minutes. These movements have been considered as
denoting  another variety, called  chorea festinans  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 Avhen 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
                1 Annual of the Universal Medical Sciences, 1890. 
               ANOMALOUS  MUSCULAR MOVEMENTS.            761

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 blepharospasmus.
When the angles of the mouth are raised the peculiar expression is signifi-
cantly styled 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
improA'ement 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
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 
762
THE  NEUROSES.
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 Avithout 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  feA^ers, 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
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, Avhereas in  this affection  it  is
secondary.  Moreover,  in  this affection  the associated  symptoms  denotin°-
gravity of disease are  wanting.  The intermissions  sometimes observe the
laws of periodicity governing the diff'erent 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 Aveeks.   Relapses 
               ANOMALOUS MUSCULAR MOVEMENTS.            763

often jiccur.  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 Thoni-
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 Thorn-
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 noteAvorthy 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,
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 withdraAval 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.
                 1 Vide Trade de Pathologie interne, par Jaccoud. 
764                         THE NEUROSES.
   It is an affection of middle or advanced life, the age being very rarely lo>s
 than forty years.  Men much oftener  than Avomen are affected.  These  are
 all the facts at  present knoAvn  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 elboAvs 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
 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. Elliot son claimed  to have  effected a cure by the carbonate of
iron ;  Brown-Sequard, by the chloride of barium ; and Reynolds  and Remak 
ANOMALOUS  MUSCULAR  MOVEMENTS.           765
by galvanization of the spine.   Arsenic, administered hypodermically, has
been found  highly useful  by Kulenburg.   Charcot and  others have given
hyoscyamus with benefit.   Strychnia Ayas  advocated by Trousseau.  The
iodide  of potassium in  large doses proved beneficial in a case observed  by
Villemin.   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.  Among 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 movement* 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 Avhich 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, wTill 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 (ddsroc.  " without fixed position ").  It is character-
ized bv 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).
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 anesthesia 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- 
766
THE  NEUROSES.
ology of this affection.   Athetosis  may occur as a primary affection without
paralysis.  Although bilateral athetosis is  not  associated with  Avell-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 Avith 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.'

  The anomalous movements described by S.  Weir 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 uraemia, 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
writers  le petit vial and epileptic vertigo.  They may be distinguished as epi-
leptoid attacks.  In distinction from epilepsia  mitior, the common form with
general convulsions is called epilepsia gravior, or le grand mid.  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 Avho
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
        1 Vide Real-Eucyclopddie, Wien und Leipzig, 1880, art. "Athetose."
        2 Am. Journ. of Med. Sciences, Oct., 1874.
        3 Lecons sur les Maladies du Systeme nerveux, Paris, 1877. 
EPILEPSY.
767
 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 mu«ele«
 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 the A'iolence 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-
 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 Avith expiration.  The patient remains in this state  for a period
 varying betAveen 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 
768                        THE NEUROSES.
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 Avhich 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.
When 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.  When 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
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 Varolii.
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 wav distinguishable
from epilepsy  inhuman  beings.    In experimental  epilepsy, as well  as  in 
EPILEPSY.
769
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 Avhose cortical centre is destroyed.  Injury
or disease of the motor cortex is very frequently followed by typical epileptic
paroxysms.  In incomplete epilepsy or  petit m'al 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.   With 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  ansomia  resulting  from vaso-motor spasm.
This  view  is  rendered  probable by the  known effects of sudden cerebral
anaemia  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.   While the  efficacy of
cerebral  anaemia  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 toxamiia  analogous to uramiia, 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 uraemia being striking.   If this pathological view be correct, knowledge
of the nature and source  of the  toxical  agent, which may  perhaps be acquired,
will, as Ave  may hope, render  this disease controllable.
   Fpilepsy 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.   While 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
Avould be easy  to collect instances of families in  which the husband or  wife
were subject to epilepsy. Avhose 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
       49 
770
THE  NEUROSES.
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.   Venereal  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, tAventy-three years of age,
unmarried, who had been subject to paroxysms occurring almost nightly for
two  years, stated to me, voluntarily, that she Avas  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 Avas 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 conATiction, 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 taenia, and to cease  after the expul-
sion of the Avorm.
  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 irritatiQn.  A case has fallen under my  observation in which the
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 affected Avith epilepsy Avas in company with another dog
which was subject to this aff'ection.  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. 
EPILEPSY.                           771
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 affection is to be discriminated  from hysterical  convulsions, but these
present points of difference Avhich 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 aff'ections may  be associated.
   If  called to a patient  not  knoAvn to be an epileptic, in the comatose state
which succeeds the convulsions, apoplexy might at  first  be suspected; but
if the con\Tulsions 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, uraemia and epilepsy might easily
be confounded.  Uraemic 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
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 Avell
acquainted Avith 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 fonvard on the face, if the convulsions
be at first tonic  and  afterAvard clonic, if foamy saliva be ejected  from the 
772                         THE  NEUROSES.
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 be 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 Avith 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 Avith 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-
able—namely, as regards the persistence of the malady.  In the vast majority
of cases 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 Avhich
involve their exercise,  and in the cases  in wrhich  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 epibptoid attacks.   It is 
EPILEPSY.
773
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 haul 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 Avhich she happened to be Avhen 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 Avhich 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 Avere able to return  and proceed  with the matter in Avhich they
were  engaged as if  nothing had happened.1  The  following example  came
under my observation  in one of the wards of Bellevue Hospital.  A female
patient quietly standing in the Avard  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 epilepfica.  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 Avhich 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 folloAved  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-
                       1 Vide Clinique medicale,  tome ii. 
774
THE NEUROSES.
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
doAvn for an instant, still without loss of consciousness.  At length, after the
lapse of several Aveeks, 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  feAV seconds.  This
affection had  existed for five years Avithout eArentuating 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 Avrote 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 Avas lost for
a  few seconds.   Sometimes  the  face  was  distorted.   When consciousness
returned, she almost invariably asked, " What 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
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 
EPILEPSY.
■  775
indicated.   If, on the other hand,  the  patient be  anaemic, measures  of an
opposite character are indicated.  Disorders of the digestive system, uterine
aff'ections,  and,  in short,  morbid disturbances anyAvhere  in  the economy,
should  receive appropriate treatment, as they maypossibly be in some way
concerned  in the development or perpetuation of the malady.   The presence
or otherAvise of trenhe is to be ascertained.  Inquiries with respect to syphilis
are not to be forgotten.   Phimosis  calls for appropriate surgical treatment.
[Ocular defects, whether refractive  or muscular, should be corrected.—H.]
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 Avith 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  Avhich
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 Avhich 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
alloAvance 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.
The return of the malady may not be known to the physician, Avho had sup-
posed that a cure  Avas 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 Aveeks  or months  or years without any treatment.
I 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 Avithout
avail; and at length, aftei 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 remain 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 folloAV-
ing:  The nitrate and other  preparations of  silver, preparations of zinc, digi- 
776
THE NEUROSES.
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
rejnedy 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 ATalerianate  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
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 Avas attested by Sharkey, Crampton, 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 Avould
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 obseiwers.  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 
EPILEPSY.
777
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 may be 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 tAvice 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.   Whenever  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, tAvo, or more years ;  that is. pnmded 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
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 lor the
past two years.   I directed him at  once to suspend the remedy.  He did so
                             1 Clinique medicale. 
778
THE  NEUROSES.
 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.
   [Remarkable statements have been recently made concerning the curative
 effect upon epilepsy of  Pasteur's  antirabic inoculations.   Two children who
 had been  bitten by rabid dogs were treated at the Pasteur Institute in Paris,
 with  the  result  of  curing them of epilepsy.  Charcot,  hearing  of this
 accidental discovery,  sent to  the  Pasteur Institute an inveterate epileptic
 aged tAvelve.   After six days' inoculation treatment the attacks ceased entire-
 ly, and had not returned two Aveeks later, at the time the case was reported.
 The beneficial effect is probably  due to the nerve-matter contained in  the
 inoculation fluid, for Babes of Bucharest has  treated  six  cases of epilepsy
 with subcutaneous injections of aseptic, nerve-matter from  the brain of the
 rabbit  and sheep, and with benefit in every case.   This novel addition to the
 therapeutics of epilepsy demands the fullest investigation.1—H.J
   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 Avhen 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  Avere 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-
between one and six  months,  3; between six months and  one  year' 6'
  1 For further details concerning  this method,  vide  Annual of the Universal  Medical
Sciences, vol. ii. A 56. 
EPILEPSY.
779
 betAveen one and five years. 3 ;  set down cured, but lapse of time from date of
 operation to time last seen not given, 7." l
   It remains now to consider the treatment called for during the paroxysms.
 These are rarely Avitnessed  by the physician  save  Avhen  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 bv
 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.
   When 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  fiA'e
 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 Avith 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  Avhole of an afternoon, and when the premonition  was felt
 dashed a little water in the face.   The paroxysm Avas apparently prevented
 for the time, but it occurred as soon as the effort to prevent it was discontinued.
   A highly important point  connected with  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 Avhich  sometimes succeeds epileptic paroxysms, and
 which may  be  incident to epileptoid attacks, violence  to  others, and  even
 homicide, may be committed.  The occasional occurrence of delirium, lasting
 for hours or days, in connection with the  disease, is to be borne in mind in

  1 Vide article on the " Surgical Treatment of Epilepsy," etc., New York Journal of
Medicine, March, 1Sol>.   Prof. Smith in this article uives a summary of facts Avith
respect  to setons,  issues, cauterizations and moxas, operations on  the scalp, trache-
otomy, amputation, operations on the nerves, operations on the arteries, and trephining. 
780
THE  NEUROSES.
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.—Somnambulism.—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, Avhether  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.  Weep-
ing and laughter are physiological acts Avhen they represent emotions which
are natural; that is, excited by adequate causes and not exceeding the bounds
which observation shoAvs 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  vieAV 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 Avithout 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  Avhich  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 knoAvledge 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
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- 
HYSTERIA.
781
gering as well as hysterical  self-deception.  Owing  to  the  facts just stated,
hysteria is  associated in the minds of many.with 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 Avith 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,
knoAvn 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 Avhich constitutes what is commonly called the  hysterical  condition
may be associated also with a host of affections.   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-
esthesia of the surface, either limited to certain situations or diffused over the
body.  Affecting the abdominal walls, this simulates in some cases peritonitis.
3. Anaesthesia, local or general.  This is  sometimes unilateral (hemiansesthe-
sia), and it is generally of the left side.   Not  infrequently the sensibility to
tact  remains Avhile  the  sensibility to pain  is  lost (analgesia).  4.  Different
varieties  of functional  paralysis, especially paraplegia and  nervous aphonia.
[These are often associated with contractures,  which in the  upper extremities
are  usually in the direction of flexion,  while in the  lower extremities the
position assumed  is  usually that  of extension.—H.]  5. The so-called hys-
terical cough.   (Vide p. 220.)   6.  Hyperesthesia 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 dimi-
nution or  suppression of  urine (ischuria).
   What 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- 
782
THE  NEUROSES.
tions ;  they tumble about the bed Avith violence, rolling from the bed to the
floor, and striking with force against solid substances if not prevented;  they
struggle with those who attempt to restrain  them, and .sometimes sIioav 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 Avhat  is known as opistho-
tonos^ occurs in some cases of hysteria.  The jaAvs 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 mauth or for the tongue to be bitten.
The spasm of the larynx and muscles of respiration which characterizes epi-
lepsy is Avanting; 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, hoivever, 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 convulsh^e  move-
ments gradually go off, and  the disappearance of the paroxysm is frequently
accompanied by cries, groans,  sighs, loud Aveeping,  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 moA^ements 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 si»hs.
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                            783
with much difficulty and in  feeble whispers.  The muscles offer  resistance
to efforts  to  separate the jaAvs.  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  Avhat 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 aff'ection.  It is to be discriminated from apoplexy, and  the  diagnostic
points are as  folloAvs :  The attacks do not present the stertor of apoplexy,  and
hemiplegia is Avanting;  the  pupils respond  readily to light;  the  patient is
perhaps knoAvn 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 affection is generally speedily declared by the
efficacy of certain measures of treatment to be presently mentioned.
   Uramiic 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.   Williams  described  these cases in the following
terms: 'A young female becomes anamiic, 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." l  I had met with cases answering to this
 description  many years  ago, before uremia was  as well understood as now.
 The existence  of uremia 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 eA'idence 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 lias not  been preceded  by the  diagnostic symptoms of that disease-
 namely, 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  cive  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. 
784
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, Avas  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
 76  and regular; the skin Avas 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 (Avhich had no effect), enemata
 of  turpentine  and  asafoetida, and fluid nourishment  by the  mouth.   The
 urine was withdrawn with the  catheter.   On the  fourth day there was marked
 improvement.  The eyes Avere 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 Avere passed upon  the floor.  On the seventh day, there
 being no  material change, "firing" Avas  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 Avas 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 Avhat 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.
785
 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 Avas 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 anemia,
 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 poAver  of the will Avhich  enters into  the
       50 
786
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 regards 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 affections.
  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, asafuetida, lactucarium, 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 hygienic.   The  object is to invigorate both body and  mind.   With regard
to bodily vigor, good  diet, abundant  exercise  in the open air, and regular
habits as regards  sleep are important.  With 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.   The
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
get well,  the varied measures of treatment which are adopted prove of course
ineffectual.  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.
787
 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, asafoetida, 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,  asafeetida, 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 anesthetic 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 Burq ; 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 anesthetic part restores sensation in this
 part and  often over a wider district, and  strangely causes a transfer of the
 anesthesia 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.
   [In all  forms of hysteria, but especially in  those associated with paralysis
 and  contractures, a  course of the Weir  Mitchell treatment, consisting of
 isolation from  sympathetic friends and  relatives, absolute rest in bed. mas-
 sage, electricity,  and copious alimentation, is  often  followed  by brilliant
 results.   Hypnotic suggestion is another therapeutic resource which deserves
 a  more  systematic  employment  than  it has  yet  obtained  outside of
 Paris.—H]
                          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- 
788
THE  NEUROSES.
 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.
   [Charcot  and his pupils  have had marked  success in the  treatment  of
 hystero-epilepsy at the Salpetriere by  hypnotic suggestion.   In the  same
 institution continuous pressure is maintained over the ovarian region of the
 hystero-epileptic by means of a belt fitted with pads.   It is  said that so long
 as the truss-like  instrument is  kept in place  the attacks are held in abey-
• ance.—H.]

                              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 Avill, 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 majoritv  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.   With 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 
TETANUS.
789
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.
  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 knoAvn  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 bare 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 aff'ection.
  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
           1 Man. de PAcad, de Med., Paris,  1856. Vide Valleix, op. cit. 
790
THE NEUROSES.
 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.
   [At the present day tetanus is universally regarded as an infectious  disease
 caused by the entry into the organism of the  ,; bacillus of Nicolaier."   Kita-
 sato was, however, the first  to obtain pure cultures of the bacillus  and to
 produce the disease by inoculation in  animals.  It is thoroughly established
 that this micro-organism exists  in  the soil and that it flourishes most abun-
 dantly in  stables and their neighborhood.  In  the  so-called idiopathic tetanus
 it is almost a  foregone conclusion that the germs have gained access to the
 body through wounds or abrasions so slight as to have been unnoticed by the
 patient.—H.]
   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
 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
 backivard 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 pleurosthotonos.  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 o-eneral 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 
TETANUS.
791
is embarrassed  in  proportion as  the  respiratory muscles are affected.   The
embarrassment is  usually great during the paroxysms, and fatal apnea 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 apnea or by asthenia.
The danger of  apnea is  in proportion to the amount of  embarrassment of
respiration.   Death by asthenia is  caused by the exhaustion incident to long
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, hoAvever, 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.  Within  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 someAvhat 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.
                    1 Clinical Lectures  on the Nervous System. 
792
THE  NEUROSES.
  !£ .Is 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
less 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,   c. Deglutition  slow and difficiilt^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.  With 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.
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 amy!
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  :
When  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 
DELIRIUM  TREMENS.                     793
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.
   [Behring and Kitasato have succeeded in conferring upon rabbits immunity
from tetanus.  The blood-serum of these immune animals will, when injected
subcutaneously,  not only  confer immunity  upon others,  but  will actually
cure the disease  when produced by inoculation.  From the blood-serum  of
immune  animals Tizzoni and Centanni have succeeded in  isolating an albu-
minoid substance, an " antitoxin," which is believed to be the prophylactic and
curative  principle to which the  virtues of the serum are due.   Several cases
of tetanus which were apparently cured by antitoxin injections have  been
already reported, and our  hope of a  specific remedy for  this fatal  disease
undoubtedly  lies  in  the  direction indicated  by these remarkable  experi-
ments.—H.]
                        CHAPTER  IX.

                   THE  NEUROSES (Continued).

        Delirium Tremens.—Alcoholism.—Hypochondriasis.—Pathophobia.

                 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-
enino-  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. 
794
THE NEUROSES.
 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 comes 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
 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.  Wilks 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, Avho  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
 folloAvs  paroxysms of.  intemperance in periodical drinkers Avhen 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
Avishes to go out, and requires to be constantly watched.  To these manifesta-
tions  of  mental disorder are added  illusions of the sense*  phantasms  and 
DELIRIUM  TREMENS.
795
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 windows and are
dashed  in pieces, believing  that they are pursued  by wild beasts or by men
Avho 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 Avas overtaken by men  on horses who  followed in pursuit.   The
degree of terror must he  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.  Vigilance  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.   When  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, but 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 
796'
THE  NEUROSES.
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 (juantity of serum.   The substance of the brain may be
cedematous.  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
the fact that the delirium generally ceases after sleep has continued for sev-
eral  hours.  Inability to sleep is an essential feature of the aff'ection 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  affection  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 drinking
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 circum-
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 
DELIRIUM  TREMENS
797
inflammation or cerebral congestion.   These measures are noiv 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
in 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 any particular  method of treatment,  but
that a large proportion of  fatal cases  favors1 the presumption that the treat-
ment was injurious.  Excluding cases in Avhich the affection occurs in con-
nection  with wounds, surgical operations, and accidents, or with other affec-
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 Ware
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 indiscriminately  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.
  Cases 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 affection 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
Avhich  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  Avhich  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 
798
THE NEUROSES.
Dr. G. M. Jones of  Jersey, England,  who  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 doses which experience has abundantly shown may be given Avithout 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
cases, in  one of which it appeared  to  act like  a charm, but  in the others no
curative effect was apparent.
  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 large majority of the great number of cases treated  at Bellevue Hospital.
Ilyoscyamin  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.  Visitors, 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 
HYPOCHONDRIASIS.
799
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 Avithdrawal 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.
  [An  important contribution  to   the  treatment of alcoholism  has been
recently  made  by Dr. T.  S.  Latimer  of Baltimore.   His cases, 2012 in
number, were treated at the Baltimore city jail.  " They were cases  of almost
continuous drunkenness, culminating at  short intervals in a severe debauch,
leading  to some act of violence or to a condition of drunken stupor in which
they were picked up on the streets  quite helpless and almost or quite uncon-
scious."  Of these " 2012 cases of  chronic alcoholism with acute explosions,
87 of Avhich were  maniacal,  under circumstances  of  the most depressing
character all  did  well  without the  use of alcoholic stimulants ". . .  . " All
were  treated with  potassium  bromide—the  maniacal  cases with 30-grain
doses every two hours, and the non-maniacal with the same drug and  dose at
intervals of four  hours.  No addition  was made to this treatment  except in
three or four cases in  which 10 drops of tincture of digitalis and 5  grains of
carbonate of ammonia at  intervals of  three hours were also given ;  all
recovered."
  Latimer's patients were immediately  and absolutely deprived of alcohol,
the result being in no instance  injurious.   He therefore  logically concludes
that  the  symptoms of delirium tremens are the result  of over-stimulation.
and that they are not due to the abrupt Avithdrawal of stimulants.  None of
the patients were bound or subjected to any physical restraint beyond that
attendant upon their being locked  in  their cells.  They  spent their  time in
incessant walking, and the physical fatigue thus excited appeared  to  induce
sleep earlier  than would  otherwise  have occurred.  Another  advantage  of
non-restraint is that patients  who  are  bound  and at  the  same  time left
entirely alone experience  a  degree of terror far greater than is the  case with
those whose  limbs  are unconfined.—11.]

                 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 affection 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 
800
THE  NEUROSES.
cases represent gradations between these extremes.  The mental depression
or despair Avhich may be produced by a knowledge of the fact that a serious
or fatal  disease actually exists  doe's  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 be 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 raligious 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 well  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.
   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.  With cases of bedridden patients Avho 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 hypochrondriasis  are physical  and mental.  Some  persons
are constitutionally liable to morbid  apprehensions in this direction   When
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 
HYPOCHONDRIASIS.          '            801
to exaggerate the permanent consequences of dissipated habits in  early life,
especially abuses  of  the sexual function.   Delusions  with respect  to  the
hitter 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.   Want of mental  occupation contributes indi-
rectly to  the  affection.   Persons  Avho  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 Avant 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
Avho 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
and sio-ns: and it is  obvious  that the accuracy of the diagnosis will depend
on the'ability of the  phvsican to exclude the affections to which the different
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
specially those who  are dependent  for the  means of living upon a  certain 
 802           VASO-MOTOR  AND  TROPHIC NEUROSES.

 measure of health ;  and a decided opinion, in Avhich 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.  With 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.
                         CHAPTER  X.

             VASO-MOTOR  AND  TROPHIC NEUROSES.

Progressive Unilateral Facial Atrophy.-Sclerodenna, or Sclerema.-Myxcedema-Aero
              megaly.—Kaynaud's Disease.—Symmetrical Gangrene.

            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 oTvCaZI
are atrophied   The atrophy may extend to the tongue orThesame  SUI  anl
also to the palate and uvula.                                        e tina 
SCLERODERMA.
803
   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
:he 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 affected 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 be 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
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.   [One of the  rare autopsies in cases
of hemiatrophia facialis  was recently (1888)  made by Mendel, who found
atrophic changes in the  descending root of the trigeminus.—H.]
   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 does
not endanger life, but the conspicuous deformity is not a small calamity.

                     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 o-xArjpos (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. Walter 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
examination after death.    The affection is not to  be  confounded Ayith that
called  by some writers acute sclerema,  which  is  peculiar to infants.  The
latter is a variety of oedema.  The affection 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. 
SOI            VASO-MOTOR AND TROPHIC NEUROSES.

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.
  Various measures of treatment were employed in the cases which have
been reported.   It remains to be ascertained Avhat 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.


                            Myxoedema.
  This  remarkable  affection,  which was first  described  in  1873  by Gull,
received the name  myxoedema 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  caisation.  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 folloAved
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 oedema begins generally in the face, producing a characteristic
physiognomy.   The eyelids, the lips, the alae nasi, the cheeks—in fact, all of
the features—are SAVollen. The oedema which causes  the swelling differs from
ordinary oedema in  its firmness and resiliency.   It does not pit on pressure
and does not gravitate.  The  face acquires a dull, expressionless appearance,
Avith an absence of  all the finer lines of the  features.  The cedematous skin
has an  anaemic, 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 Avith the mucous
•edema.  They become swollen and shapeless, an appearance  Avhich has been
described by C J nil as ''spade-like.'' 
MYNCEDEMA.
80o
  The same  condition as that affecting the face and  the  hands may extend
over the whole  body,  so that the  skin  everyAvhere is sAyollen.
  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 oedema. 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 sloAvness  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
anaemia, 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 uraemia, 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 myxedema  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 myxoedema  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 oedema.  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 anaemia and an  oedema similar to myxoedema.  The
affection known  as  cretinism bears  some  resemblance, particularly in  the
mental  symptoms, to myxedema, and cretinism seems to  be in some  way
connected with  disease of the thyroid gland.  Finally, myxoedema  is often
associated with  atrophy of  the  thyroid  gland.
  PThe  fullest investigation of  the subject of myxoedema was made by the
Clinical  Society  of London in 1888.  Their report, which is  based upon an
analysis of 109  cases, concludes as  follows :  " Finally, it may  be stated  that
there is strong  evidence that myxoedema, sporadic cretinism, endemic  cre-
tinism, cachexra strumipriva,  and the operative myxoedema of animals are 
806
VASO-MOTOR  AND  TROPHIC NEUROSES.
severally species of one genus ;  that such clinical differences as exist between
them are due to causes already sufficiently set forth ; and that the one path-
ological fact common  to all these  conditions is the occurrence of morbid
processes or of operations involving the annihilation of the  function  of the
thyroid body."
   It is not yet settled exactly  how atrophy or ablation of the thyroid gives
rise  to  myxoedema.  In explanation  of  the pathogeny of  the  disease tivo
theories have been advanced.  In accordance with the first, the thyroid gland
elaborates some material which is essential to the healthy metabolism  of the
tissues, and especially  to those  of  the nervous system ;  according  to  the
second, the gland  eliminates from the blood  one or more substances which
are noxious to the organism, and especially  to  the nerve-tissues.

   Treatment.—It is  of the utmost importance  to protect the patient from
cold.  With  this  object in view, removal to  a tropical climate should be
recommended.  The influence  of cold  in  accelerating and  that of heat in
retarding the development of myxoedema is well shown by the results  of two
series of experiments (total excision of thyroid)  upon  monkeys by  Victor
Horsley.  " In the first series no special after-treatment was  carried out, and
the average duration  of life after the  operation was twenty-four days.  In
this series the symptoms characteristic of acute myxoedema  developed.  In
the second series of experiments  special precautions Avere taken  to keep the
animals warm:  after excision of the gland they were kept at a temperature
averaging 90° F.   The average duration of life in the second series was 125
days.  In this series the symptoms characteristic of chronic myxoedema were
developed."
   Hot baths, friction, and general massage have been  of marked benefit in
several  carefully-observed  cases.  A  remarkable  case  is reported by Dr.
John Thomson1 of Edinburgh, in which recovery from an apparently hopeless
condition  was brought about by the  systematic employment of hot  baths,
friction, and prolonged exposure of the  body to the heat  of an open fire.
Jaborandi and its alkaloid pilocarpine are the only drugs from which benefit
seems to have been derived.  The committee of the London  Clinical Society
speak of their beneficial influence in  myxoedema as  undoubted, and attribute
it  to  their action  on the functions  of the skin.
   In  1890, Prof. Victor Horsley suggested that myxoedema be treated by
transplantation  of the  thyroid of a  healthy  sheep into the  subcutaneous
tissues of  the patient.   This suggestion was first carried out by Lannelongue
of Paris;  later  by  Walther of the  same city, and  by Fenwick, Collins,
Harris, Wright, and Macpherson of Great Britain.   In Fenwick's case death
occurred five days after the operation, the disease  haATing  been too  far ad-
vanced for a fair  trial of  any kind  of treatment.   Of the remaining  six
cases, there are but four in which the  progress of the patient after the oper-
ation was recorded.  Of these four, in two there was a more or less prolonged
period of  improvement, while in the  other two the improvement was only
temporary.
   The treatment of myxoedema with  hypodermic injections of thyroid extract
was  first employed by Dr. George  Murray, a pupil of Horsley.  Murray,
observing  the rapid improvement which follows the transplantation  of the
thyroid, concluded that it  must be  due to the  absorption of thyroid juice
remaining in  the  gland, rather  than to a secretion  of  the latter "in its new
and abnormal situation.
   Up to May 18, 1893, according to  Beadles,2  100  cases of myxoedema had
           1 Trans. Medico-Chirurgical Society of Edinburgh, vol. A-'ii. p. 50.
           2 Journal of Mental Science, July and October, 1893. 
ACROMEGALY.                         807
been treated by Murray's method or some modification of it. and, with the
exception of two cases, they have all been  followed by remarkable improve-
ment.
  The  next step in the therapeutics of this disease was the administration of
the thyroid per os, and it appears to have been first taken by Prof.  Howitz of
Copenhagen, Avho, in March, 1892, fed a myxedematous patient with the thy-
roid glands of calves.   Four months later,  Dr.  Hector Mackenzie employed
this method of thyroid feeding, with the result that in less than three months
the patient subjected to it had improved to such an extent as to be " scarcely
recognizable."   The  thyroids in the last-mentioned case were pounded and
given in  a  little brandy.   An extract of the thyroid and a substance called
thyroidin, obtained by precipitation with alcohol  from the glycerin extract
of the finely-minced gland, have also been administered, and apparently with
results equalling those obtained by the  ingestion of the crude gland itself.
  This treatment, successful  though it  be, has one drawback :  it must be
kept up indefinitely.   No sooner is the thyroid treatment withheld than the
patient shows  signs  of relapse.   As remarked by Beadles, hoAvever,  " the
taking of an occasional dose is surely a hardship not hard to bear, even were
it necessary for the remainder of the patient's life."
  The various methods  thus  far employed  in the treatment of myxoedema
are the following :
  1. Thyroid grafting.
  2. Subcutaneous injection of an extract of the thyroid gland.
  3. Ingestion of an extract (aqueous or glycerin) of the thyroid  gland.
  4. Ingestion of thyroid gland, raw or slightly cooked.
  5. Ingestion of a  dry extract obtained from the thyroid gland, in the form
of a powder, tabloid or capsule, or pill.
  G. Ingestion of thyroidin.
  In this country the treatment of myxoedema with thyroid preparations has
been carried out by F. P. Kinnicutt,  J. J. Putnam,  M. Allen  Starr, and
doubtless by many  others.1—II.]

                             [Acromegaly.
  Acromegaly (derived from  iixpov, extremity, and fiiya,  large), first mi-
nutely described and named by Marie in  1886, is a dystrophic affection cha-
racterized  by enlargement  of  peripheral  portions of the body.   The  parts
chiefly affected  are the feet, hands, and face, and the enlargement is princi-
pally caused by hypertrophy of  the osseous tissues.   The  facial  alterations
are so  characteristic that patients affected with this disease, no matter what
their  nationality, come to bear an extraordinary resemblance to each other.
The alterations consist, for the most part, of  hypertrophy of the nose and infe-
rior maxilla.  The former is enlarged in all its dimensions, and each constitu-
ent of  the organ—the bones, the cartilages, and the derma—takes  part  in the
hypertrophy.   Even  the  Avails of the blood-vessels are thickened, the lym-
phatics dilated, and  the  mucous membrane  (edematous and  infiltrated with
leucocytes.   It is the hypertrophy of the inferior maxilla which is chiefly
concerned  in giving  the  face its characteristic  expression.   The bone  is
enlarged in all its dimensions, sometimes to  such an extent as to entitle it  to
be called colossal. The distance from the  angle to the symphysis is increased
(in  a case reported by C. L.  Dana it measured 5| inches), so that in well-
marked cases the lower lip and teeth project beyond the upper—prognathous
type.   The downward slope of the ramus is also greater than normal;  or,  in
other words, the angle formed  by the body  and ramus is more than normally
obtuse.
          1 Vide Trans. Association of American Physicians, vol. viii.,  1893. 
808           VASO-MOTOR  AND  TROPHIC  NEUROSES.

   Macroglossia  is a condition common  to all well-marked  cases, the enlarge-
ment of the tongue being chiefly due  to hypertrophy of  the  interfascicular
connective tissue.
   The first signs of acromegaly generally appear  in the hands, Avhich become
hypertrophied  in the  directions  of breadth and  thickness rather than in
length.   All the tissues of the hand—the bones, muscles, connective tissue,
and  skin—participate  in the enlargement, but there  is no deformity of the
phalangeal joints.  The nails  do  not enlarge correspondingly, and  therefore
appear abnormally small.  They are flattened and widened and often marked
with longitudinal striations.   The feet  are affected  in  the  same manner as
the  hands—that is to say,  they are enlarged chiefly  in the directions of
breadth and thickness.   Cases  are now and then met with in Avbich the feet
and hands are enlarged as  to length also.   The enlargement of the hands is
perhaps the  most striking feature of the disease, and is often so great as to
cause them  to  be  compared  to spades and  " battledores."   Dorso-cervical
kyphosis  is  a constant symptom, and is sometimes so great as to cause the
chin to project forward  and downAvard so as to approach the sternum or e\*en
to rest upon it.  There is generally combined with this antero-posterior curv-
ature a certain  degree  of scoliosis, as well as a compensatory lordosis in  the
lower dorsal and upper  lumbar regions.
   The bones of the chest, clavicles, scapulae, ribs, and sternum are all hyper-
trophied, and the same  is true  of the costal cartilages.  The antero-posterior
diameter of the thorax is enlarged, apparently at the expense of its transverse
diameter,  and the downward slant of the ribs is increased, so  that when  the
patient  is sitting with  the  head bent forward the lowermost of these bones
may rest  upon  the crest of the ileum.
   In most cases the thyroid  gland is diminished in size, but has also been
found  enlarged.  The  thymus is sometimes persistent or enlarged, and in
either case gives rise  to percussion-dulness in the upper sternal region.
   A long list of symptoms is  referable to  the nervous system, and may be
classified  as cerebral, vaso-motor, and  sensory.   Among them may be men-
tioned  polydipsia, polyuria, glycosuria,  hyperidrosis.  cutaneous anaesthesia,
and loss of the senses of taste  and smell.  Disturbances of vision, especially
in the form  of  hemianopsia, have  been frequently observed.   In women  the
menses are suppressed at an early period of the disease, and sterility is abso-
lute.  Duchesneau * queries whether this may not explain  why heredity is so
little  concerned  in the  etiology of the affection.   In males  diminution  or
extinction of sexual desire is the  rule.  Trophic disturbances of  the skin in
the form  of keloid  growths or molluscum  fibrosum  have been observed too
frequently to be regarded  as  mere coincidences.   The  appetite is generally
preserved and is sometimes voracious.   One of Dana's patients2 " ate twenty-
seven plates  of ice-cream at one  sitting, thereby winning a wager  that he
could eat more  than two men."
   Of the  subjective symptoms above  mentioned, cephalalgia is undoubtedly
the most  constant, and  is often the sole thing complained of.   In a typical
case reported by Marie3 the patient travelled  from Spain  to Charcot's clinic
on account of persistent headache.   He appeared to attach no importance to
the abnormal increase  in size  of  his hands and  feet, the  deformities of his
spine and  thorax, and  the  marked alterations in  his physiognomy.   In this
case the cephalalgia which was  the sole complaint came on  two or three hours
after the  patient had  fallen asleep in the recumbent position, but did not
supervene when he slept in the sitting posture.
               1 Contribution & VEtude de VAcromegalic, Paris, 1892.
               2 Journal of Nervous and Mental Disease, Nov.' 1893!
               3 Noueelle Iconographie de la Salpetritre, tome 'i., 1888. 
ACROMEGALY.
809
  The changes  in  the  muscular system  are worthy of notice.   It is highly
diagnostic  of the  disease  that, with enormous hands, deep chest, and other
signs usually indicative of strength, the patient  is  decidedly feeble.  This
muscular feebleness increases  until, in late stages of the disease, he may be
compelled  to remain in  bed from this cause alone.  This muscular inability
is caused by  progressive  atrophy.

  Anatomical Alterations.—Besides  the  enlargement of the bones and
overlying parts  above mentioned, the  persistence  of the  thymus, the altera-
tions of the  thyroid, the macroglossia,  and  the deformities of the spine.
there remains to be mentioned  a lesion which is believed by Marie and others
to be concerned in the pathogenesis  of the disease.   The lesion referred to is
hypertrophy of the pituitary body, or, as some prefer to call it, the hypophy-
sis  cerebri.  This so-called gland, which normally weighs  but  a few grains
(from five  to ten), has been found in cases of acromegaly as large as a hen's
egg, and even larger.  Enlargement of this body occurs far too frequently to
be regarded as fortuitous.   Souza-Leite in his classical thesis speaks of it as
constant, but in rare cases it has been  absent.   On the other hand, hypertro-
phy of the hypophysis has been observed without  coincident acromegaly.  On
the whole, it must be admitted that there is an intimate  connection between
enlargement of  the hypophysis cerebri and acromegaly, and the question, as
yet undetermined, is whether the  former is a cause or a consequence of the
latter.  Marie draws a parallel between disease of the hypophysis and acro-
megaly on the one hand and  disease  of the thyroid and myxoedema on the
other.

  Diagnosis.—The only  affection  with  which acromegaly is  likely to be
confounded is  that to which Marie has given the  name of  hypertrophic pul-
monary osteo-arthropathy (" osteo-arthropathie hypertrophiante pneumique ").
James Ross1 does not recognize the distinction drawn by Marie between them,
but to the  writer they seem to be separate conditions.  In  pulmonary osteo-
arthropathy the jaw is not enlarged; kyphosis is not constant; the finger-
tips  are swollen and bulbous, and the nails curved like the beak of a parrot;
and, finally, the articular ends  of the  long bones are enlarged  to such an
extent as to impede the moArements of the extremities.  As implied by the
adjective ''pulmonary," these  deformities  are  associated with lesions of the
respiratory organs—the lungs and pleura.  The points of distinction between
osteitis  deformans (Paget's disease), leontiasis ossea, and gigantism are obvi-
ous.  Until quite recently acromegaly was unrecognized.  The present tend-
ency is  to include  under this head  affections which bear to it  but a partial
resemblance, such as circumscribed osseous hyperplasias and gigantism.  The
former are  congenital and generally unilateral, while in the latter the different
parts of the body preserve their relations to each other.

  Prognosis.—The prospect of recovery from the outward manifestations of
the disease is hopeless.   The  osseous changes  are irremediable.   Life may,
however, be prolonged  for years, the patient eventually succumbing to pro-
gressive asthenia or dying  more suddenly with  signs of cerebral compression.
The  poivers of  resistance  to intercurrent acute disease are, as a matter of
course,  greatly  impaired.

  Treatment.—Little  is  to be said under this head.   Antipyrin, exalgine,
and caffeine have been used with more or less  success to relieve  cephalalgia.
The  strength is to be maintained  by a nourishing diet—in some cases, per-
                      1  International Clinics, April, 1891. 
810
VASO-MOTOR  AND  TROPHIC NEUROSES.
haps, by restraining the tendency to boulimia.   Duchesneau, acting on  the
hypothesis that the disease may be due to suppression of the function of the
hypophysis cerebri,  suggests  the  hypodermic injection  of extracts  of  this
" gland.'—H.]


         [Raynaud's  Disease—Symmetrical  Gangrene.

   This affection is characterized by extreme pallor and coldness of peripheral
portions of the body—fingers, toes, nose, ears—on exposure to cold, followed
by intense venous congestion of the same parts, and eventually, if the circu-
latory disturbances continue,  by well-defined areas of dry gangrene.   The
above are the essential clinical features of the disease, but, in addition, haemo-
globinuria and scleroderma have been observed in a few cases.  The affection
was  first  described by Maurice Raynaud in 1862 in a thesis containing a
report of  25  cases, of which 20 were of the female sex.  The disease  is most
prevalent in early life, the great majority of Raynaud's cases occurring betAveen
the ages of eighteen and thirty.  The same observer also  noted 5 cases of the
affection in children between three and nine years of  age.  He has therefore
suggested the term "juvenile gangrene" as an appropriate name for the dis-
ease,  but  it Avill doubtless continue to be called by  the name of him who first
accurately described it.  The term juvenile  gangrene is further inapplicable
because it might  be supposed  to  imply that the affection is limited to the
young.   This,  however,  is far from being  true.  In two typical cases now
under the Avriter's observation the  ages of the patients are fifty-five and sev-
enty-seven respectively.  The chief theories of  the cause of Raynaud's dis-
ease  are (1)  that is due to an  endarteritis obliterans ; (2) that  it is  due to
peripheral neuritis ; (3) that it is the result of vascular  spasm.   The  last is
the theory of Raynaud himself.
   The early  age  of many of  the  cases,  the intermittent character of the
symptoms, and the great rarity of the  disease as compared with endarteri-
tis suffice to exclude the latter as a causative  factor in  its  production.
   There is little  to support  the theory that peripheral neuritis is the cause
of Raynaud's disease.  In the first place, the rarity of the  latter and the fre-
quency of the  former  militate  strongly against it.   Secondly, the cases in
Avhich neuritis has been found  post  mortem  may be examples of mere coin-
cidence, or, more  probably, the neuritis is secondary to the local circulatory
disturbance.   A  degree of asphyxia sufficient, in  its  severer forms,  to pro-
duce  gangrene  might, in its lighter grades, readily lead  to degenerative and
inflammatory  changes  in  the nerves of the  affected  part.
   The theory of arteriole spasm is  certainly  the one which  is most in  accord-
ance with the clinical phenomena.   The disease  is most  frequently observed
in females and in the young—i. e. in those whose vaso-motor system is most
impressible.  It occurs in paroxysms,  and is excited by exposure  to  the
surest exciter of  vascular spasm—cold.  Finally,  in  several cases,  during
the paroxysm  there has  been  dimness of  \ision' which was shown  by the
ophthalmoscope to depend upon  a contraction of the  central  retinal artery
and its branches.   This, more  than any other observation, tends  to corrobo-
rate Raynaud's view that the disease known by his name is due to an  1; enor-
mous exaggeration of the excito-motor energy of the gray parts  of  the
spinal cord  which control  the vaso-motor  innervation."   The  symptom
hamioglobinuria is in all  probability due to a " local asphyxia " of the renal
vessels.

   The symptoms  consist of pallor and  coldness, both subjective and objec-
tive, of the affected  parts, constituting  the  stage of local  syncope.   This is 
RA YNA UD 'S DISEASE.
811
immediately followed by the stage of local asphyxia, characterized by lividity
and  cyanosis  of  the  same parts  accompanied  with parsesthesiae. such as
numbness and tingling, or with severe pain.  Ecchymotic spots and vesicles
may appear  and  may  become the  starting-points of dry  gangrene.   The
auricle is a favorite site of the latter, but it may also attack the'fingers and
toes and cause  the loss of one or more phalanges.   The  lesions, whether
vascular or gangrenous,  are  remarkable  for  their  symmetry.   Haemoglo-
bin uria has been  already mentioned as  a symptom of the disease, and it
must be  acknowledged that it is difficult, if not impossible, to draw a line of
demarcation betAveen certain cases  that have been described as examples of
paroxysmal haemoglobinuria and genuine cases  of Raynaud's disease.

   Diagnosis.—Genuine cases are  distinguished by the presence of the two
stages above mentioned—" local syncope " and local asphyxia—followed sooner
or later  by gangrene.  The latter may be limited to  a  sphacelus  scarcely
larger than a  pin-head  on one  or both ears.  Large areas  of spreading gan-
grene dependent  upon  endarteritis obliterans or  following an injury are not
to be included in  the category of Raynaud's disease.   Neither are  cases of
mere local syncope of  the hands—the  so-called digiti mortal  As is well
known, the latter  symptom  is occasionally seen in Bright's disease, and is
caused by a vascular spasm which  is trivial when  compared with the tonic
contraction of the vessels in Raynaud's  disease.

   Prognosis.—NotAvithstanding the  apparent  gravity of its symptoms, the
affection  is not per se a dangerous one.  As remarked by Raynaud, the system
in the course of time seems to  acquire a species of tolerance (accoutumance)
of the disease.

   Treatment.—Exposed  parts of the body should  be protected from cold
and woollen underclothing should be  worn the year round.   If the patient's
means  permit, the winters should be  spent in a warm climate.   Exposure to
the morning air before breakfast should be carefully  avoided in all climates.
Raynaud in his later researches1  reports good results from the continuous
electrical current  applied  to the spine and  extremities.   " The action exer-
cised by  the current on  the cord appears to consist in an enfeeblement of the
excito-motor power, Avbence  there results a corresponding relaxation of the
reflex vascular contractions."—H.]

                   1 Archives generates de Medecine,  Jan., 1874. 
             SECTION  SIXTH.

DISEASES AFFECTING THE  GEXITO-URIXARY SYSTEM.
                         CHAPTER  I.

   CONGESTION  OF  THE KIDNEYS.—ACUTE  AND CHRONIC
                         BRIGHT'S DISEASE.

Active Cougestion of the Kidneys.—PassiAeCongestion 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 affections 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 due, 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 dru"-s are
cantharides, turpentine, oil  of mustard,  cubebs, copaiba, nitrate of potash,
chlorate  of  potash,  and  carbolic acid.    Of these  drugs, cantharides taken
        S12                                                    ' "' 
             PASSIVE CONGESTION  OF  THE KIDNEYS.           813

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 Avith 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 cf 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.   Vie 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.   We 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.   Hyperamiia   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
 bv 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 
814             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. (Edema 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 
ACUTE BRIGHT'S DISEASE.
815
 Excluding inflammation of the kidney, the  most important causes of paren-
 chymatous  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 irritating
 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 anaemia and leucocy-
 thaemia ; cachexia, especially chronic pulmonary tuberculosis ; chronic alco-
 holism ;  and,  according to Wilks 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 casts  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.  We do not include
under this name the renal changes which have already been considered in this
section—namely, simple  parenchymatous  degeneration,  fatty  degeneration, 
 816             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 betiveen 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.
  When 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.
817
 The capillaries  of  the glomerulus frequently contain in their  meshes des-
 quamated  and proliferating  endothelial cells minded  with  white and some
 red blood-corpuscles^  Both  the epithelium of the glomerulus and that lin-
 ing the capsule  of Bowman swells up, proliferates, and, often with an admix-
 ture of white blood-corpuscles, forms a crescentic mass of cells fillino- up the
 space between the compressed glomerulus  and the capsule.  These'changes
 constitute  the  affection  called  glomerulonephritis,  which  is an  important
 element  in  many, and almost  the sole alteration in  some, cases of  acute
 Bright s disease.  A similar  accumulation  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  disintegrating epithelial cells are found  in
 some of  the  convoluted tubes.   Hyaline 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 caATities 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 eedema, 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.  Aomiting  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
        52 
818            CONGESTION OF THE KIDNEYS, ETC.

the pleural  cavity.   Hydrothorax sometimes occurs to such  an extent as
to occasion  great'suffering from dyspnu-a 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  «-anty.
Suppression sometimes occurs.  The specific gravity generally exceeds that
of the urine in health.   The total  quantity of urea  excreted  in  tw-enty-
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 shoAvs 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 TqVo" an(^
5^-5-  of an  inch in diameter.  A number of varieties are distinguished.  Those
Avhich  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 suf-
ficient for the manifestations of their toxical effects upon the brain.  Vomiting
and  purging may precede, or occur without the cerebral symptoms of uraemia,
being due to a vicarious  elimination of  urea and  other  excrementitious sub-
stances through  the  gastro-intestinal mucous membrane.   Epistaxis and
 _ * Both serum-albumen and glohulin 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.                              v 
ACUTE BRIGHT'S DISEASE.
819
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 generally sudden ;  but it is
often  of temporary duration, and recovery is complete.  The ophthalmo-
scope, 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  Avith
changes appreciable Avith 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, but 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 different 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.
acute
  Pathological  Character.—As both kidneys  are  diffusely inflamed in
„,v,ute Bright's disease, it is to be inferred that the  irritant Avhich 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.  [Compression
of the vessels of  the glomerulus by the products of inflammation  within
Bowman's capsule also  tends to diminish the excretion of water.—H.J   the
red  and  white corpuscles found in  the kidney and in the urine are the natural
products of inflammation.  The red corpuscles  doubtless  escape, at least in
part by diapedesis.   The albuminuria  may be  referred partly to innamma- 
S20             CONGESTION OF THE KIDNEYS, ETC.

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
blood pressure may also be concerned in the  causation of albuminuria.   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 Avhich  results from the withdrawal  of albumen  from the blood
and the diminished  excretion  of water.  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.

   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 Avhich 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. Eune-
berg has advocated the vieAv that the cause is in all eases 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 adATocated 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 Avhy 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 bv  Cohnheim in the
second volume of his Allgemeine Pathologic, Berlin, 1882. 
                     ACUTE BRIGHT'S DISEASE.                  82J

eases of typhoid and typhus fever, yellow fever, erysipelas, relapsino- 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 affec-
tion, but  in many of these cases changes  in  the  kidney are very slight or
entirely absent.   As  a primary affection it occurs especially  in persons
addicted to intemperance.  In these cases it is sometimes difficult to say bow
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  Avanting.   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.
(Edema 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 N Y. Med. Record, March, 1879. 
82:2            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 and other  excrementitious  substances elim-
inated by the kidneys is  small.  Suppression 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 convulsions 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 urinary con-
stituents through the skin and gastro-intestinal mucous  membrane if  uraemia
exist  or be threatened.
   With reference to the first of these objects, Avarmth and rest of the surface
are important.  The patient should keep the bed in  order to maintain both
warmth and rest.   The diet should be unstimulating.  Water 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 moist-
ened  cloths covered with  oiled muslin and several thicknesses  of flannel or the
spongio-piline are useful.   Saline laxatiyes 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 Avhich 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 dyspncea.  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.
823
are urgently indicated ay hen symptoms denoting uramiic poisoning  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 compulsions have  occurred.
If the indication be  not urgent, salines  and sudorific  remedies may 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.  They 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.   With  reference to a diuretic effect pure or distilled water
should  be taken  as  a drink  as  freely  as  possible Avithout 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.
   I raemic coma and  convulsions call  for measures of treatment  in addition
to those  which  are  eliminative. in their operation.   Venesection 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 Avhen 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
kidnevs present a  great variety of morbid appearances as  regards size, color,
character of the surface, etc.   Kidneys  affected Avith chronic Bright's disease
may be small, of  normal size, or enlarged;  they may be  red. yelloAv, 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; 
824            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 ,>asis
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-
ber&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 Avithout doubt more generally accepted at the pres-
ent time than any other classification.   The distinct affections 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 affections 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 Avell 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.  Waxy 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.  Whether 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 cases 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 lar°-e and the
small kidneys.  There are large kidneys with the clinical history of the small,
and  vice versd; 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.                 825

 ent manifestations or varieties of the  same disease—namely, chronic  diffuse
 nephritis.                                                J
   The tAvo 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   When
 the disease has lasted for several years, it is  almost  certain that the small
 granular kidneys will be found after death.   When the aff'ection 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-
  onged 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 defener-
 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 Avith
 red and Avhite (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 yelloAV parts, or may be almost
 uniformly  of a pale yelloAvish-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.  816).   There is  often  a
groAvth of new connective tissue in  the  Avails of  the arteries, presenting itself
frequently in the form of an obliterating endarteritis.  In addition to this  devel- 
 826            CONGESTION OF THE KIDNEYS,  ETC.

 opment of new connective tissue combined Avith 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 cither in the tubes or in
 the interstitial tissue.  The lumina of the tubes contain  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.   Whether 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 Avhich  will appear  in  the course of this article render it  clear that,
 important as it is to distinguish certain general  types or ATarieties 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-Avaxy 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 Avith such
 wasting diseases that the greatest number of the large  Avhite 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   Waxy degeneration of the kidneys  is, with  very few  exceptions,

  ' Some writers regard the large  white kidney as  characterized  especially bv fattv
 degeneration of the epithelium, as free from waxy defeneration, and as unattended by
 hypertrophy ot the heart.  This constitutes onlv one variety of large Avhite kidnev   \
 part of the confusion arises from the fact that there are different forms of diffuse nephri-
 tis Avhich may present the appearances of the large white kidnevs—namely  1 The pale
 kidney of acute Bright's disease, especially of scarlatinal nephritis.  2 The lar«-e pale
 kidney without Avaxy degeneration and with hypertrophy of the heart  3 The lar^e
 pale kidney of chronic Bright's disease without waxy degeneration  and'without hyper-
 rophy ot the heart.   4. The large pale kidney with waxv degeneration   Most of the
 large white  kidneys of chronic Bright's disease without hypertrophy of the  left ventricle
are attected  with Avaxy degeneration. 
CHRONIC BRIGHT'S  DISEASE.
827
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 change in the kidney may be so slight as to be recogniz-
able 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.
For microscopical examination iodine and sulphuric  acid and methyl-violet
are to be preferred. A slight or moderate Avaxy 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.  Waxy  degen-
eration of the kidney, Avhen of clinical importance, may be considered  practi-
cally as  associated always with diffuse nephritis.  Whether 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 Avaxy 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, Avhich then presents
some one of the forms of chronic  diffuse nephritis.  Usually, hoAvever, careful
inspection will reveal in the glomeruli, and perhaps elsewhere, the  character-
istic translucent appearance of the Avaxy material.   When a large amount of
the waxy deposit  exists, we have  the characteristic appearance of the Avaxy
kidney.   The organ is then enlarged, pale, and  anaemic.  The consistence is
•firm.   The surface is smooth and glistening.  The capsule  is  not  adherent.
Upon  section the  cortex is found to  be the part  chiefly SAVollen.   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 Avaxy kidney is the appearance.  The
more the yelloAvish 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
membranse propria? 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
degeneration   Fatty degeneration of the  epithelium and anaemia of  the kid-
neys  are prominent features.   The  waxy glomeruli  present a  more  homo-
geneous  appearance, feAver nuclei, and less shrinkage  than those involved in
the other forms of chronic diffuse nephritis.  There is nothing characteristic
of Avaxv degeneration in the casts found in the tubes.1
  1 These casts, often called waxv, may stain red with methyl-violet, but they  do not
give the characteristic reaction with iodine and sulphuric add   Formless clumps pre-
senting this reaction have, however, been  found in the  tubes (Kyber). 
 828            CONGESTION OF THE KIDNEYS,  ETC.

   Waxy  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.  Waxy kid-
 neys  are  very  rarely accompanied  by hypertrophy of the heart.   The coin-
 cidence of waxy spleen and of Avaxy liver with  this form  of kidney disease
 is an  importantdement 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 Avaxy
 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 Avaxy 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
 vieiv  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  Avaxy  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    White 
CHRONIC BRIGHT'S DISEASE.                 829
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 are
often placed abnormally  close to  each other in consequence of  atrophy of the
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 BoAvmau.
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 m 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 ot
 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 
 830            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  Weigert 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 followed 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 waxv
 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 £scape 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 snia 1 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
tacts respecting dropsy were noticed it existed in 74, and was absent in  15
cases.  The dropsy was slight or  moderate in 21, and considerable in 36 cases 
CHRONIC BRIGHT'S DISEASE.
831
In 17 cases the degree and the extent of the dropsy were not noted.1 Of 430
cases collected from diff'erent authors and analyzed by Frerichs, general dropsy
existed  in 370 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.   When  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.  With  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.  When used
in a different  sense, it refers to broad homogeneous casts of a yelloAvish 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 Vide "A Clinical  Report  on  an  Analvsis  of  One Hundred and  Two  Cases  of
Bright's  Disease," bv Austin Flint, M. D., one of the  Attending Physicians^of Belle-
vue Ilospital, etc., published in the Bellevue and Charity Hospital Reports, 1870, p. 226. 
832            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 change.  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.  We
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 was
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.  With 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  Avaxy 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 Avith 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.
833
 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.  (Edema

 BrighifSI^isTse1     glV6 ^    ^^ ^  aPPearance high]y characteristic of
    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
 vio ently  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.  (Edema 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.  (Edema of the  glottis is  of rare occurrence (according to the  sta-
 tistics of Frerichs and of Rosenstein, 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
 haA-e  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
53 
834            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 dyspncea 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.  When
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.
835
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, weeks, 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 20.
   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 26 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 Vide Bourneville, Etudes cliniques et therrrwmetriques sur les Maladies du Systemeuer-
re,n; 1*72; also, article by McBride in the Archives of Medicine, Sew York, beb., 1881,;
also' Bartels in Ziemssen's Cyclopaedia, vol. xv
  * For  eases illustrating the latency of renal disease, vide Bellevue and Chanty Hospital
Reports, 1870, p. 256. 
836             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.   Cseteris 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.  With 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.   Waxy 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.
837
 of renal disease.   The researches of Fenwick and Wilson 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 infreauent
 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"*
 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.  Reference 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 of 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  e\Tident
 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 
838            CONGESTION OF THE KIDNEYS.  ETC.

these events were  preceded bv 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 healtli 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 betAveen 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 shoAV 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 shoAV that the exposures, hardships, and deprivations incident to the
lives of those Avho  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 those 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 Avas  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 be 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.
839
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.  [It
does so, in all probability, in an indirect manner through the medium of the
gout to which it gives rise.   Garrod  found that thirty per cent, of his gouty
patients  in  hospital practice  had been exposed to  the  poisonous action of
lead.—H.]
   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 Avith 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
defeneration.  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 feAV 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

 m0WhenCacutgeediffuse nephritis supervenes upon chronic  Bright's disease, it
 may be difficult to determine the prior existence of the chronic affection, and
 Tuch  cases may lead to the  erroneous  supposition that the chronic  is a sequel
 of the  acute disease. 
840
CONGESTION  OF  THE KIDNEYS,  ETC.
  A difficulty in the way of determining the particular forms of chronic dis-
ease represented  in  individual cases is the fact that  the  different formsare
not infrequently combined.  In typical cases of each form, however, the diag-
nostic points are sufficient for  the differential diagnosis, but even then  mis-
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.
Ursemic 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.  Diarrhoea 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 
CHRONIC .BRIGHT'S DISEASE.
841
 degeneration, and much less frequent than in cases of the small granular kid-
 ney. _ ihis form  of disease may occur at any age, but it is rare in very early
 and  in  advanced hfe.  The diagnostic  points  which have  been mentioned
 apply to the typical waxy kidney.  In cases in which parenchymatous changes
 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 defen-
 eration.                                                          J   b

   Uraemic 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 lrfe 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  uraemic  coma,  hydrothorax,  pulmonary
 oedema, 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 
842
CONGESTION  OF  THE KIDNEYS,  ETC.
 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
 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.   Whatever 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
 (Friedrichshall, 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- 
CHRONIC BRIGHT'S DISEASE.
843
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 §xx, applied to  the  abdo-
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 obse'rvations
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.  Bemoval 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.
   Hydrao-ogue 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.   We 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- 
 844             CONGESTION OF THE  KIDNEYS, ETC

 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
 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.  Bemedies, 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
 Avhich 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.
   [Nitro-glycerin has been much employed of late in the treatment of Bright's
 disease, and is a valuable  addition to our  therapeutic resources.  It often
 increases the secretion  of urine  when other diuretics fail.  It is most effective
 in cases of contracted kidney,  and may be  given in doses of i minim of a
 1 per cent, solution  every  hour for  three or four doses ;  later in the same
 dose at longer  intervals.   It probably exerts its effect by reducing excessive
 arterial tension.—H.]
   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-
                          1 Vide Dickinson, op. cit. 
CHRONIC BRIGHT'S  DISEASE.
845
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.   With 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
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 opium to be taken habit-
ually  in 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.
  Vomiting 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 eliminatory 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  vieAV 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  Avhich 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 
846  ACUTE  INTERSTITIAL  OR SUPPURATIVE  NEPHRITIS, ETC.

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.   Ihe 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.
                       CHAPTEE  II.

ACUTE  INTERSTITIAL  OR  SUPPURATIVE  NEPHRITIS.—DIS-
  EASES  OF   THE   URINARY   PASSAGES. — PERINEPHRITIC
  ABSCESS.

Acute Interstitial or Suppurative  Nephritis.—Pyelo-nephritis:  Anatomical Characters;
  Clinical History; Causation ;  Diagnosis ;  Prognosis ;  Treatment.—Pyelitis.—Pyo- .
  nephrosis.—Hydronephrosis.—Renal   Colic   and  Nephrolithiasis.—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 remoA'ing 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 
       ACUTE INTERSTITIAL  OR SUPPURATIVE NEPHRITIS.   817

the process colonies of micrococci can he 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 pyelonephri-
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.
   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 ammoniamiia,
and by  some  to septicaemia or pyaemia.  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 Avhich 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 Avith-
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
pyonephrosis 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. 
848   ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS,  ETC.

   Causation.—Suppurative  nephritis caused by infectious emboli occurs in
many cases of pyaamia 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.
   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 laro-e 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- 
PYELITIS.
849
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 tlm 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
atrophy from pressure.  In extreme cases a large sac containing pus is formed,
the Avails 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
become 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 be  developed.
   When 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
cause.
     I.
       54 
850  ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS,
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.
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 aff'ections 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  but if 
PYELITIS.
851
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
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 knoAvn 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,
Ouietude is to  be enjoined, especially in cases in which the  affection depends
on  calculi.   Soothing  applications to  the lo}ns 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 bone 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. 
852   ACUTE INTERSTITIAL  OR SUPPURATIVE NEPHRITIS,  ET(
  When 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 kmney.
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,
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 Avasting 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  hydronephrptic 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.  With 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 
H YDR ONEPHR OSIS.
853
congenital  find, acquired.  Of 52 cases of hydronephrosis  collected by  Sir
William 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 witli  malformations of other organs, as
imperforate  anus,  hare-lip, etc.
   The  causes of acquired hydronephrosis may be  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.
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 folloAv 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.  (!. In not a few cases no cause of
the hydronephrosis has  been found.   With  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.

  Clintcal  History.—With 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
symptoms.    One kidney may be destroyed by the  development of a hydro-
nephrotic sac Avithout  any symptoms referable to this condition.  In  this
case  the other kidney,  Avhich' 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
unvrnia.  lii  cases of double hydronephrosis the condition  is manifestly grave
if the  renal  tissue be sufficiently impaired to interfere with its functions. 
854  ACUTE INTERSTITIAL OR SUPPURATIVE NEPHRITIS, ETC.

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 Avhen 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  Avanting,  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 Avhen the obstacle  to the flow
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 (juantity.  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. 530.   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. 526 et seq.)   Hydro-
nephrosis may be confounded with pyonephrosis.  With 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- 
               RENAL  COLIC AND NEPHROLITHIASIS.           855

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 sae 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
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
bv the local and  general  symptoms in each case.   Free opening of  the sac
aiid 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, they are
 either discharged Avith 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 aloim-  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
 passao-e more  or  less pain and constitutional  disturbance.   The amount and
 duratfon 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 rena  colic are produced by
 the oassle of coagulated fibrin and of an hydatid vesicle through the ureter.
   A^aXsm  of renal colic is usually developed suddenly.   The attack,
 however may be preceded  by more  or less pain or a sense of uneasiness
 dulto imitation  o'perhaps  inflammation  caused .^v the presence of caWh
 in the pelvis  of the kidney.   The paroxysm  quickly attains its maximum
 of  ntensity   The pain  in'some  cases becomes  exceedingly intense.   It is
 referredUo\he  situation of  the kidney on one side   that  - ^ the side of
 the  last dorsal  and the first lumbar vertebra.  ^f^™™1*^™™*
 point in different diction., btrt -jecg jdoog the^sorf tii   -ter

 ^tle^Zlet^irZ^t ngot always,  drawn upward by the 
 856   ACUTE  INTERSTITIAL OR SUPPURATIVE NEPHRITIS, ETC.

 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, Ayalks
 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 bladder.   Not infrequently the urine is bloody.   If  it contain pus or
 muco-pus, either pyelitis or cystitis coexists.
   With 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
 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 wThich  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 suffering 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.  747.)   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 
               RENAL  COLIC AND NEPHROLITHIASIS.           857

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 Avarm  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 litliiasis or gravel.  The terra
" gravel" is properly applied only to concretions formed within the body, not
to those Avhich 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
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 calculi.   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 Avas
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 litliiasis, 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 nephro-lithiasis, 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
potassa?, in half-drachm doses thrice daily,  maybe given, but either the  bicar-
bonate  or  the citrate of potassa, a  drachm tAvice daily, is preferable.   The
Vichy 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 closes 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 be 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 
858   ACUTE INTERSTITIAL  OR  SUPPURATIVE NEPHRITIS,  ETC.

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-
ment. Abstinence from articles  of diet containing oxalic acid is to be enjoined
if the  concretions consist of the oxalate of lime.  [Piperazin has been re-
cently lauded as  a solvent of uric-acid calculi.  There  is no question as to
its solvent action upon these concretions outside of the body, but the  reports
concerning its  poAver to accomplish this within the organism are conflicting.
It may be given in daily  doses of  15  grains..—II.]
  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 pliosplioruria, 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 majorityof 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
  1 Thudichum  on the Pathology of the Urine, and Roberts on Urinary and Renal Dis-
eases, may be especially mentioned. 
PERINEPHRITIC ABSCESS.
859
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.  When 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.
  Of 1GG  cases of perinephritis collected  by Nieden,1 70 per cent, were in
males and  30  per cent, in females; 2(i cases  were in children.   From an eti-
ological point of view it  is important to distinguish betAveen 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 Avounds in  or  about the kidney), muscular strain,
exposure to cold, and severe acute general  diseases.   Wounds of the kidney
are by no  means necessarily followed by  suppurative  inflammation.   Peri-
nephritis has been known to develop in  the  course of py;emia, 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 feAv 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.  Rigors 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.   With  reference to the local symptoms and  the  diag-
nosis the liability  of the  purulent collection to descend below Poupart's liga-
    1 " Ueber Perinephritis," Deutsches Archivfur klin. Med., Bd. 22, p. 451, 1878. 
860          STRUCTURAL  DISEASES OF THE KIDNEY.
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 Avith 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, Avith 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-
ery.  A considerable hemorrhage followed the opening in 1 of the cases.   In
2 of the cases the kidney Avas felt by the finger at the bottom of the  abscess.1
Gibney has reported 28  cases of perinephritis in children, suppuration more
or less  extensive occurring in  10.   In  14  of these cases the abscess Avas
opened by incision, and in  2 cases the opening was spontaneous.  With 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 affection  is in reality a perinephritis.2
                       CHAPTER   III.

STRUCTURAL  DISEASES  OF  THE  KIDNEY.—H FAI \TURI \ —
  HEMOGLOBINURIA.—DIABETES INSIPIDUS  AND DIABETES
  MELLITUS.—SEXUAL  DISORDERS.

Eenal Cysts.—Cystic Degeneration  of the Kidneys.—Hydatids of the Kidney.—Eenal
  Tuberculosis.—Carcinoma of the Kidney.—Movable Kidney.—Eenal Hematuria —
  Endemic Hematuria.— Hemoglobinuria.— Malarial  Hematuria.— Chyluria — Dia-
  betes Insipidus.-Diabetes Mellitus: Clinical History; Causation; Diagnosis'- Prog-
  nose;  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

   Boston Medical and Surgical Journal, July 9, 1868.
   Vide articles by Dr. Y
  the American Journal i
  icaqo Medical Journal,
liography of this disease. 
          ECHINOCOCCUS OR HYDATIDS  OF THE KIDNEY.      861

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 cystic degeneration of the kidney.  Sometimes only one, but 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.
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  degree of cystic degenera-
tion is sometimes found at autopsies of  persons who had presented no symp-
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.   Without this symptom the
diagnosis is impossible, and with it the existence of cystic degeneration 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. 557  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  feAV 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 
862          STRUCTURAL DISEASES OF  THE KIDNEY
 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
 place  and an abscess forms  in the  lumbar region, Avhich when opened  or
 allowed to open spontaneously gives exit to echinococci together Avith 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.  561.)
 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 canulaa, 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
               1  Die Echinococcuscysten der Nieren, Stuttgart  1877. 
RENAL  TUBERCULOSIS.
863
 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, nephrophthisis, 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
 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 hematuria 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 
864          STRUCTURAL DISEASES OF THE KIDNE
are
that employed in examining the sputum (p.  ll<i)-   When  they
ered the  diagnosis of tuberculosis  involving some part of  the  genito-un-
narv tract is established, but the exact  location of  the  tuberculosis remains
to be determined bv symptoms.  Inoculation in the anterior chamber ot  a
rabbit's eve  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
gland 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.   Waxy 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-
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
Avhen  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 draAving  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

  1 Rohrer, Das primare Nierencarcinom, Inaug.  Diss.,  Zurich,  1874.  Of 107 cases in
which the age of the patient was stated, 37 were less than ten years,  4 Avere between ten
and twenty, 5  between tAventy and thirty, 10 between thirty and forty, 10 betAveen 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 (Eohrer). 
                    CARCINOMA  OF  THE KIDNEY.                865

a primary affection in both  kidneys.1  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 William  Roberts, the average weight in children is
8J pounds and in adults 9i pounds.   The maximum weight Avas 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
softened masses renal cancer has often been punctured during life  under the
supposition that a cyst or an abscess was present.   The color is 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.  When  their number is large the
red patches give a hemorrhagic aspect to the tumor, Avhence 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 glands
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 eives rise to metastases less readily than cancer in other situations.2  The
secondary deposits are met with  most frequently in  the retro-peritoneal glands,
the lungs, and the liver. The frequency with which 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
vertebne 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-

  1 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
C>| : 2).   In adults, the right oftener than the left (5 : 4).  Bilateral cancer was of
equal frequency in children and in adults (Rohrer).
  2 According to Kuhn, secondary  growths are found in 28 per cent, of the cases in
children, and in 44 per cent,  in adults (loc. cit.).
55 
860          STRUCTURAL DISEASES OF THE  KIDNEY.
 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  characteristic
 arrangement of cells in alveoli with intervening  stroma.   The microscopical
 appearances as regards the size of  the  alveoli, the shape of the cancer-cells,
 the  amount and character of the stroma, and the degree  of vascularity vary
 in different cases.  The designation  of the tumor as medullary or as scirrhous
 depends upon  these  variations.  In the  soft renal cancers,  which  is  the
 most frequent  form, the  ahreoli 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 interstitial  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 re-
 semble  the  epithelium of the  convoluted tubes, being  very  granular and
 indistinctly  separated from each other.   They are, however, always irregular
 in shape.  Cylindrical-celled epithelioma of the kidney has been described by
 Wagner.  Waldeyer, 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
 doAvn 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 
CARCINOMA OF THE KIDNEY.                867
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-
nosis.  A cancerous kidney usually oecomes 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. 442).
   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.  With 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, hamiaturia  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 -i!)
cases by Sir William 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 m
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

  ' With reference  to these two diagnostic events-namely, tumor and  hsematuria-
Rohrer divides his 115 cases into four classes,  as follows: 1,  in 3b eases there waa
neither tumor nor  hematuria, and  the disease was therefore  unsuspected;  2, in 12
cases  there was hematuria  without  tumor;  3, in 25 cases there were both  tumor and
hematuria;  4, in 42 cases there was  tumor  without haematuria. 
S68          STRUCTURAL DISEASES OF THE  KIDNEY.

ureter and give 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, hut 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 he 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
AVilliam  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.
Wbarry 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-
  1 The Lancet, Feb. 10, 1877.                            ' Ihid^ April ^ 187?< 
MOVABLE KIDNEY.
869
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.
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 symptoms.  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-

  1  Glasqow Medical Journal, Aug., 1883.                             .
  2 Of 65  cases  collected by Roberts, in 42 the  right alone was movable, in 9 the leit
alone, and in 14 both kidneys. 
870         STRUCTURAL DISEASES OF THE KIDNEY.

toms of incarceration " was applied by Diet!   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
kidney.  According to  Roberts, epigastric pulsation is in  some cases a promi
nent phenomenon in connection Avith movable kidney.   Aarious 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.   The  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 be 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  which 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 (nephror-
rhaphy), but this also is open  to  many objections.  [The indications for
operation in cases of movable kidney are thus formulated by  M. H.  Rich-
ardson : " If  the  symptoms  are  unendurable, then nephrorrhaphy can be
done with  little danger to  life  and with a  very good chance of permanent
recovery, or, at least, enough lasting  benefit to justify the operation.  Finally.
if fixation has not followed, nephrectomy can be resorted to as  a remedy for
unbearable pain and distress."1—H.]

                    1 Annual Univ. Med. Sci., 1889, vol. iii. 
RENAL  HEMATURIA.                     871
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.  When it takes place from the bladder or the urethra,
it comes within the province of surgery; hut 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.
   When the bleeding is from the kidney the  blood is thoroughly mixed with
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.
   Bioody urine  should not  be 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-

  1 Teiehmann's blood-test is convenient.  Some of the urinary sediment or a portion
<,f 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 i the  characteristic brownish rhombic hsemin  crystals appear if blood  be
present. 
872          STRUCTURAL  DISEASES OF THE  KIDNEY.
 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  Haematuria.

   This name  is  applied to a form of haematuria occurring in Brazil, Eyypt.
 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
 length, and is found especially in  the portal and other abdominal veins.   The
 parasite is  thought to  be  ingested with the drinking-water.  It produces a
 multitude of eggs,  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
 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 Tl7 to y1^ 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 filaria 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.


                 Haemoglobinuria—Haematinuria.
   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
ot  blood thus  produced is  called haemoglobinaemia, and that  of the urine
hemoglobinuria.   The  urine in haemoglobinuria contains, therefore, dissolved
biood-colonng matter, but usually no  red  blood-corpuscles.   The urine ha* a 
HJEMOGL OBIN URIA.
873
reddish-brown color, which  in extreme cases  is compared to the color of
porter.
  Hamioglobinaemia and  the consequent haemoglobinuria may be 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 at ell 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-broAvn
pigment, and casts  of which  the most characteristic are  those containing or
composed of similar pigment.  The urine  is always albuminous.   Of course
care must  he  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-
in^ 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- 
874          STRUCTURAL DISEASES  OF  THE KIDNEY.

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 due  to the latter, the usual health of the patient is restored.
  With 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, hut 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
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, and  woollen underclothing should be constantly worn.   Only
in a few cases, in which a syphilitic history has existed,  has mercurial treat-
ment  been  found effective.   Even  in non-malarial cases quinine is  often
beneficial.  Chalybeates  and other tonics, with good alimentation and  the
moderate use of wine, are to  be prescribed according  to  the indications in
individual cases.
  1 This view is supported by the experiment of Ehrlich  and  of Boas, Avho, in a case
of paroxysmal haemoglobinuria, after applying an elastic  ligature around the root of
one of the fingers, plunged this finger into iee-Avater 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 
MALARIAL  HEMATURIA.                  875
      Malarial  Haematuria—Malarial  Haemoglobinuria.
  Both haematuria and hemoglobinuria 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  milder cases  the affection may he either haematuria or haemo-
globinuria.  The diagnosis is based upon  the history of malaria.  The attacks
of hematuria may occur with the regularity of malarial paroxysms, but more
frequently they are variable in the  time  of  their appearance.  In  some
instances  the hematuria 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
tAventy-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
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  Avith  quinine in the  treatment of this affection.
  The milder forms of malarial hematuria are often relieved or cured by qui-
nine.  The ordinary astringent remedies may be employed in conjunction with
quinine.   All severe muscular exertion should he avoided.   For  cases which
are rebellious to  treatment—and such cases are not very rare—Tyson recom- 
876          STRUCTURAL DISEASES  OF  THE KIDNEY.
 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 which 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
 this country and Canada, as well  as in  England and  Germany,  who  have
 never visited  tropical regions.2
   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 intermittingiy, the intervals in different
 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 filaria
 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.3  These  embryos are from T^  to  Y\  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 he detected with  a low
 power of the  microscope by the  motion which their lashing  imparts to the
  1 James Tyson, article "Malarial Hematuria and Hemoglobinuria," in Pepper's Sys-
tem of Practical Medicine, by American Authors, Philadelphia, 1886, vol. iv. p. 111.
  2 Dr. Guiteras has found the filaria 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 Avith the  excep-
tion of five years in Augusta Ga   One was a case of chyluria, the other one of  chvlo-
cele (John Guiteras, The Medical Neivs, Apr. 10, 1886).
  3 Stephen  Mackenzie estimated that there were from 36,000,000 to 40 000 000 embrvo
filarise in the blood of a patient whom he observed.                '   ' 
DIABETES INSIPIDUS.
877
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.  What 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.1  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 filaria san-
guinis hominis.  This parasite may be the cause also of haematuria,  chylous
hydrocele, chylous  ascites, elephantiasis, milk scrotum, and naevus-like dilata-
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 filaria  disease  by  mosquitos,  in
Avhich 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  health y
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 feAv  cases.   Special virtue has been claimed  for the decoction
of mangrove-bark (Rhizophora racemosa) 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.
  1 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 beins found at the autopsy.  In the few other reported autopsies no changes have
been found in the urinarv organs or lymphatics to explain the chyluria. 
878           STRUCTURAL DISEASES OF THE KIDNEY.

The term  is applied  to two affections which differ essentially each from tla-
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 Avater 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.
  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.  When 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 Avith
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

  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 Avhether
this existed or not.  This affection existed throughout life without impairment of the
general health  ( Virchouis Archiv, Bd. 95, p. 70). 
DIABETES MELLITUS.                     879
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 cerebrafdisease,  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.  (Aide p. 813.)   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
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
affections.

                          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 aff'ec-
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- 
880          STRUCTURAL DISEASES OF THE KIDNEY.

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 Avhen the
affection 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 glycohaemia: Glycohremia 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
pathology of diabetes mellitus.  The pathology of glycohaemia is the pathol-
ogy of the diabetic disease.

  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.
  [Dickinson l believes  diabetes to be always  dependent upon changes in the
central  nervous system, the most  important  of which are dilatation of the
arteries and perivascular spaces, minute  hemorrhages, and disintegration of
nerve-elements.   Such  changes, however, are  not  constant in diabetes,  and
have been found in other diseases.—II.]  Frerichs also found dilatation of the
vessels, capillary hemorrhages, and minute myelitic foci 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
Avords, 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 coeliac plexus be involved  in the pancreatic  disease is not
knoAvn.  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.
  [Extirpation of the pancreas in the dog is invariably followed by diabetes
       1 Med. Times and Gazette, March 9, 1870,  and Treatise on Diabetes, 187-">. 
DIABETES MELLITUS.                     881
mellitus, the animal developing also polydipsia and polyphagia and becoming
greatly emaciated.   To produce diabetes  experimentally the entire pancreas
must be removed.   It is  said that if a  portion amounting to no more than
one-tenth of the  gland be  left behind, it  will suffice to carry on its function
so far as the suppression of diabetes is concerned.  In explanation of these
facts the theory has been  advanced that  the pancreas elaborates a glycolitic
ferment—i. e. a ferment which destroys glucose.   If  so, it is  manifest that]
this  ferment does not pass into the intestine through the pancreatic duct, for
diabetes is not produced by ligaturing this duct.  The supposititious ferment is
formed in the gland and absorbed by the  blood-vessels and lymphatics.1—H.]
  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 Ilenle 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  be 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.
Xot  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-
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
invested   This  may be true for a limited  period, but examinations  extend-

  1 Vide  Nommes, " Etude sur  le Pancreas et sur le Diabete Pancrdatique," These  de
 Paris. 1889.
56 
8S2          STRUCTURAL DISEASES  OF  THE KIDNEY.
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 (juantity 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  i and 10  per cent., in extreme cases  being 15  per
cent.  Usually from  2  to I 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).   Albu-
minuria,  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 Tom la- cerevisise, 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-
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 
DIABETES MELLITUS.
883
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 in  some 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 someAvhat 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.
I  have known of several instances in which  this occurred. The gangrene
resembles  gangraena  senilis.   Ulcerations of the lower  limbs without  gan-
grene  have been  observed.   Wounds and surgical  operations often  take an
unfavorable  course in diabetic patients.  In  protracted cases oedema of the
leas 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 
881          STRUCTURAL DISEASES  OF  THE KIDNEY.
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
Avonien 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, affecting  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
Avhich 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.  With  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
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.  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 aff'ection.  The existence of diabetes  notably  impairs 
DIABETES MELLITUS.
885
the tolerance of other diseases.  Griesinger 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
86 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.
 [Prof.  Cantani of Naples, whose  experience  of diabetes was based on the
 study of more  than one thousand  cases, believed the principal cause of this
 disease to be the abuse of farinaceous and saccharine substances.  In support
 of this view  he adduces  the following facts: In Naples, where the diet of
 the people is  largely farinaceous, diabetes is so prevalent that a physician in
 large practice may have twenty or thirty cases of the disease under observa-
 tion at the same time.   On the other hand, in  Genoa, where the  amount of
 meat consumed by  the inhabitants  is large, it is difficult to obtain a case of
 diabetes for clinical purposes.
   According  to  Cantani, diabetes begins with non-combustion of a fraction
 of the ingested carbohydrates, and therefore there appears in the urine—
 which, as a rule, is not increased in quantity at this early stage—only the
non-assimilated sugar.  By degrees less and less sugar is consumed, until at
last there comes a  stage when  the amount of sugar  excreted corresponds
exactly  with  that  ingested.   It is therefore, according to  Cantani, no real
privation to eliminate  carbohydrates from the diet of a diabetic, at least in
late stages of  the -disease, for they serve  no nutritive purpose.   They are
excreted practically unchanged, and are  the chief cause of the polyuria and
its evil consequences.                                    .
   The other principal theory of  the etiology of diabetes is that of Ebstein.
This observer, having determined by a series of ingenious  experiments  that
   1 Jonmal of the American Medical Association, April 17, 1886.   The " son of one of the
sisters" developed diabetes since  the note appeared in the Journal. 
880
STRUCTURAL  DISEASES OF  THE KIDNEY.
carbon dioxide  retards the conversion of  glycogen into sugar outside of the
body  employs  this  fact to explain  the  non-combustion  of sugar  m the
diabetic   He believes diabetes to have its source in  a general alteration of
the protoplasm of the body, as a result of which  it  produces less than the
normal amount of CO,.   In consequence an excessive quantity of glycogen
is converted into sugar, giving rise to the glycamna  and  glycosuria  of dia-
betes.—II.]

   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
ao-ed 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.  [A convenient  instrument  for  the  estimation of the
quantity of sugar in the urine has been recently  devised by  Dr.  Charles W.
Purdy of Chicago.—H.]

   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
          1 Vide Roberts, Urinary and Renal Diseases, Philadelphia, 1879. 
DIABETES MELLITUS.
887
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.
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 vulv;e. 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 which 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                                .....      ,   ....        v .,
   In respect of  prognosis much depends on the ability and  willingness ot 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.

   i Of 250 fatal cases observed and analyzed by Frerichs the following^^ causes

 bral hemorrhage  10; cerebral  sc^^S^^dgs) eomadiabeticum (Frerichs,

 phthisical eases;  for instance,  43 per cent, in Gnesingers analws. 
 S88          STRUCTURAL DISEASES OF THE KIDNEY.

 In proportion as this object is effected the glycohannia 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.
 I have known instances, for example, of diabetic patients eating freely of rye
 and  corn-meal bread under the belief that  only Avheat 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 he 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.
 H. Y. 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 2i 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 de'scrip!
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 youncr
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 
DIABETES MELLITUS.
889
 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
 sugar.   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
 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

  1 A. Flint, Jr., " On the Treatment of Diabetes Mellitus," Journal of the Am. Med.
Association, July 12, 1884. 
890         STRUCTURAL DISEASES OF THE KIDNEY.
instances, however, it has been  not only nugatory, hut hurtful and even
destructive.
  As regards the employment of  drugs, if there  he 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  Yichy  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
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.
  ()ther 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, hut 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.   [Favorable reports concerning
the treatment of diabetes with jambul or jambol have been recently made by
several writers, while with others the results have been negative.  Possibly
the discrepant results are due  to the  fact that in  India different plants are
included under the term jambul.   The powdered seeds may be  used in daily
doses of 150 to 320 grains.   It is highly significant that the drug is recom-
mended  to  be  always given  in  connection  with a  carefully regulated
diet,—H]
  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.  Yarious symptoms  may require palliative  treatment,
   An important part of  the treatment of  diabetes pertains to hygienic obser-
vances.  The body should he 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 he  recommended.   The
hydropathic pack has been found  serviceable.  A change from a climate Avhich
is cold and variable to one uniform and warm is often highly advantageous.  A 
INVOLUNTARY SEMINAL EMISSIONS,  ETC.          891
long sea-voyage in a Avarm 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.   [By  means of  muscular exercise sugar  may
be made to  disappear from the urine  in the early stages of the disease in
mild cases, even though  the use of carbohydrates be continued in modera-
tion ;  and in  the severer forms  the affection  may by the same  means be
diverted into a more benign course.—H.]  Last, but not least in importance,
mental relaxation and recreation are to be enumerated in the list of  regim-
inal 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 within 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.
Thev do not imply  a morbid condition  nor do they lead to any morbid  effects.
Thev occur especially when habitual sexual intercourse is interrupted  from
any cause.   Under  these  circumstances they  are manifestations  Of  health
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 AA-hich is to excite fears for a merce-
nary purpose.
   Occurring more  frequently, the  emissions denote a  morbid erethism  and
Aveakness 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 
892          STRUCTURAL  DISEASES OF THE KIDNEY.
diurnal as well as nocturnal.  They are produced by anything which pro-
yokes the sexual passion, and may take place with little or no excitement of
the external organs.
   Spermatorrhea means, strictly, the discharge of semen Ayithout 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.  Were 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.  Yeritable  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
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, hut 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 he  <>iVen
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 
             INVOLUNTARY SEMINAL  EMISSIONS,  ETC.          893

to me to be distinctly efficacious.   Marriage is ahvays  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 he  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 folloAV 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, may involve absence of sexual  desire.   Different persons in  health
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.                       ,  .  .        n         ^  i
   \s 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  lar<?e 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 
891          STRUCTURAL DISEASES OF THE  KIDNEY.
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-
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-
nal 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. 
             INVOLUNTARY SEMINAL EMISSIONS, ETC.          895

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  FEYER.—FEBRICULA
                      —CONTINUED  FEVERS.

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, hut  is primary or idiopathic.   Local  affections may exist
in essential fevers, but  they cannot he 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, conta-
gious, and miasmatic-contagious fevers.  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,  rotheln, 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 he regarded as
miasmatic contagious diseases.
  The foregoing list of fevers  does not comprehend all  that exist.  It com-
       896 
                  GENERAL PATHOLOGY OF FEVER.             897

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.
   There 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 four.  Fevers have been said  to be
ataxic when symptoms referable to the nervous system, such as delirium, etc.,
are prominent.   Fevers of unusually long duration have  been  called slow]
and when  the febrile  phenomena—especially the temperature—are intense,
the 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.
When the decline is rapid, occupying only a few hours or a day  or two, the
fever is said to terminate by crisis.  When the decline is protracted the ter-
mination is by lysis.   These different 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.   The general
causes and the theory of fever  are among the most difficult and least under-
stood  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 he 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 he 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. Wood—.Fewer:  A  Study
in Morbid and Normal Physiology, Washington, Smithsonian Institution, 1880.
        57 
898     CLASSIFICATION AND PATHOLOGY OF FEVER, ETC

they cannot be 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.  When 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  beat-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.  We 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.                          399

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.  When  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 feyer have been  found in cases  in which, owing to complications, death
has taken place.
   The  invasion in cases of febricula  is generally abrupt, but in a certain
proportion of  cases lassitude, loss of appetite, and general malaise exist for
two or three days 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 bleuatres), 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
through  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, Was  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 be added absence of diagnostic traits belong-
ing to the clinical  history  of either typhoid or typhus fever.  Cases, however, 
900    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,
hygienic 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. Wood 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 chamres
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 ; ?>. the stage
of retrograde  metamorphosis and ulceration ; 4, the stage of repair.   These 
TYPHOID FEVER.
901
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 hypersemia
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
calls 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.
   • Untersuchungen Sber  die Path, anatom.  Veranderungen der Organe beim Abdominal-
typhus, Leipzig. 1869. 
902    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  due 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 yelloAvish  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, hut  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.
903
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 rarely
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 tha^ a pin's point.   With
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.  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 Avhole 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 friable  mass  without
trace  of  the normal  transverse  striation.  This change may lead to rupture
of the muscular fibres with  hemorrhage.   This  metamorphosis is not con-
fined to typhoid  fever, but it may occur in other diseases,  and may  be pro-
duced in animals by  injuries to the muscles.   Regeneration  of muscular
fibres destroyed by parenchymatous or by hyaline metamorphosis takes place
during convalescence. 
904     CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

  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.   Writers 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  oT 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.  [The red blood-corpuscles are also relatively increased in
number.   The writer counted the corpuscles  in  five cases  of  typhoid fever
during the height  of the  disease, the result being  an average of  5,176.000
per cubic millimetre.   In two of the same series  of cases an examination of
the blood during convalescence showed  a  marked diminution in the  number
of the  red corpuscles,  in  one amounting to 804,000 per cubic millimetre, in
the other to 1,306,000.  These facts are only explicable on  the theory of an
abnormal loss of water during the  febrile period and its absorption during
convalescence.—H.]
  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, 
TYPHOID FEVER.
905
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.
   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, hut 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 he 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.
When  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 dves   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 I  negative.  Gaffky found  the colonies in 27 out of 28 cases,  and in the
  i Eberth Virchouis Archiv, 1880, Bd. 81; Gaffky, Mittheil. aus d. Raised. Gesundheit-
0^r Berlin  1884; Fraenkel  u. Simmonds, Die aetwlogische Bedeutung d. lyphus-

^kh^Ze^L nave'fSd detect spores.  Vacuoles in the ends and sides of the
samte.
bacillus are common. 
906    CLASSIFICATION AND PATHOLOGY OF FEVER,  ETC

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.1  The culture  method is a much  more delicate
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
typhoid 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  haye  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

  -1 The greater  certainty 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-
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 Avith 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.
907
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
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,  Avith 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, Avho 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, hut, 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.                       .
  Nerrous 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 
908    CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

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-
fusion on awakening from sleep, the patient being unable to  recall where he
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 change 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, but 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- 
TYPHOID FEVER.
909
portion to the intensity of the disease.   Frequently there is dilatation of the
pupils.
   Wakefulness 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-
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 tendons of the wrist  perceptible to  the  touch (the latter called subsultus
fendinum), 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 he simply
furred or frosted, but it is oftener covered with a coating more or less thick,
Avhich 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 
 910     CLASSIFICATION AND PATHOLOGY OF FEVER,  ETC.

 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.
 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 1S40-50.   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.  Gurgling on pressure in the
iliac region  as a sound and as a  tactile  sensation is a frequent symptom
 ihese three symptoms—namely,  meteorism or tympanites, iliac tenderne- 
TYPHOID FEVER.
911
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
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 he 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- 
912     CLASSIFICATION  AND PATHOLOGY OF FEVER, ETC.

tion is observed in various affections in which perspiration occurs.   Petechia
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 bleuatres) 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.
  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;  hut,  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.   While  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, hut 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 aAT'erage 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 Avhen menstruation
should take  place. 
TYPHOID FEVER.
913
  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 Aeries considerably in different oases, 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
have  analyzed was 93; and in the  fatal  cases, 110.  In some mild cases the
average  frequency during the Avhole 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 bv 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°—
        5S 
914    CLASSIFICATION AND PATHOLOGY OF FEVER, ETC.

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
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 tAvelve
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 he found to he 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, and
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 Avhich will answer equally well 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 he based on
the ensemble of symptoms.  Of 42 cases ending in recovery, analyzed with ret
erence to the duration of the fever, dating from the time of taking to the bed
  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 Avith a solu-
tion of sulfo-diazo-benzol, and then adding ammonia, when, if the reaction is present, the
urine acquires a red color Avhich 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. Woehen-
schrift, 1883, No. 38). 
TYPHOID FEVER.
915
to the time Avhen 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
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 appetite, 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, hut 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 SAvelling 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
 enfeebled for a considerable period. 
916
CONTINUED FEVERS.
                         CHAPTEK  II.

                 CONTINUED FEARERS  (Continued).

Causation of Typhoid Fever; Diagnosis; Prognosis—Typhus FeA-er: 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-
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
Avere  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,  it 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
folloAving 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 tAventy-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 Avomen when attacked Avith 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 Avhich 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
Avho have long resided there.   As of those who are exposed to the  typhoid-
  1 Of 5988 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 Avinter 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.
917
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 S5° 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.  We 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, but  rarely if ever  in the same  way as
the strictly  contagious diseases, such as typhus fever, smallpox, scarlet fever,
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.  Washerwomen  not  infrequently contract the disease from
washing linen soiled with typhoid excreta, and it is  easy to understand Iioav
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 feAV  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 different 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
  i For fuller details concerning these cases, vide A Flint, Clinical Reports on Continued
Fever etc. 1852, and American Journal of the Med,eal Sciences, July,  1845. 
 918                      CONTINUED FEVERS.

 of  oro-anic  matter not likely to be present in any water Avhich 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
 way, 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.1   Here it is probable that  the vehicle  of infection  is the
 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 Avhich 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.2
   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 a-priori 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.3
  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, it is not necessary
 to suppose  that  the  infection is through the  respiratory  organs,  for  after
 reaching the mouth  or throat the organisms  could he swalloAved.
  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

  1 Dr. F. C. Curtis, in the Fourth Annual Report of  the State Board of Health of Xnr
 ,ZrFVeS .a,n accou."t of an  outbreak of typhoid fever at Port Jervis in the autumn of
 188d, traceable to milK-supply.  (See, also, The Lancet, Feb. 7, 1885.)
 • * Xu Svvitzerland  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 eases is not free from doubt.
  3 According to bacteriological nomenclatures, the typhoid bacillus mav 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 saprophvte.  It
occasionally makes incursions into the human body, where it becomes a parasite 
TYPHOID FEVER.
919
is complete, and the disinfection and speedy removal of the excreta of patients
affected Avith the disease.1
  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, hut probably never several
months, as has been supposed.   On  the other hand, the duration sometimes
does not  exceed one or two days.2  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-
ential  diagnosis cannot he fully considered without  anticipating  the diag-
nostic events which belong to the  clinical history of  these fevers.   The dis-
crimination is to he 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
Avith 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 he 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 be 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, hut 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 he
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

  i V 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 artiee on this disease in
Pnoe/s System of Practical Medicine, by American ^^Philadelphia, 188o, vol.i.
  » Vide Murchison, in St.  Thomas's Hospital Reports, vol. 11. 
920
CONTINUED FEVERS.
as a complication.  The existence of pneumonitis  is shown by its physical
signs.  The differential diagnosis  is to be  based on facts Avhich  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
typhoid 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
symptoms are  unusually prominent from the beginning.   The liability to this
error is chiefly in cases occurring in children.  Events other than the abdom-
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  Avanting.
Hence typhoid fever in children is not infrequently  called enteritis.   With
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 hear 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 days, 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.   Various
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  diarrlnea.
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-
  1 Henry D. Chapin, Am. Journ. of Obstetrics and of Diseases of Women and Children.
July, 1883. 
TYPHOID FEVER.
921
ZILl   T^  °^ *}lG. dlSease  is often ^regular,  pulmonary  and cerebral
symptoms frequently being most marked. The occurrence of cases of typhoid
lever 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.b- 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 i cases, or a fraction less than 13 per cent.  Of the 73 cases which I have
analyzed, li>  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
is  in  successive
years in the Massachusetts General Hospital.1   In 182S, of 22 cases, 2 died ■
in 1829,  of 25 cases, 1 died; in 1830,  of 14  cases, 4 died; in 1831, of 29
cases, 2 died;  in 1832, of 23  cases, 4 died; in 1833, 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 different 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 betAveen ten and  fifteen years, and the next lowest betAveen 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  Avhenever  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
               1 Report on Typhoid Fever, by James Jackson, M. D. 
922                     CONTINUED FEVERS.
 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  faATorable 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 ;  hut 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 he hoped for in
 cases in which the symptoms denote the utmost gravity.


                            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 1759,
 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  ro<pa<;, 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 slip 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 oedema
 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, hut 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 
TYPHUS FEVER.
923
 common in typhus 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 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 freemently and more deeply congested.
 A besotted or expressionless countenance is earlier and more strongly marked.
   Nii-rvous 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 Avhenever  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 — \ characteristic eruption occurs in a larger proportion ot  cases ot
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 65 cases which I have  analyzed, it existed in  57. It is
oftener wantino in children than in adults.   The eruption appears  earlier in 
924
CONTINUED  FEVERS
typhus.  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 ot 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;
they 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 gravity  of disease.  This  statement does not hold good with respect to
the eruption in typhoid fever.
  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.                                    #
  Petechias are observed in some cases of typhus, as m cases ot 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.  Petechia  are spots
caused by minute extravasations of blood; that is, they are ecchymoses, and
these  are not  distinctive of typhus.   Aibices 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, hut 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 
-  TYPHUS FEVER.
925
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 defen^escence 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 5S
cases ending in recovery gave, as the  average temperature in the morning, a
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 entirely.
   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 !»  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 oh fever for the further  evidence of the con- 
926
CONTINUED FEVERS.
tao-iousness 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 Avere admitted into Bellevue Hospi-
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, 1863,  to
June, 1864, 26  patients, admitted into the hospital for various  affections, con-
tracted the fever.  In May, 1864, the fever patients Avere 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 Avho
are  much  exposed escape.   There is  no 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 he  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  he about
twelve 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 
TYPHUS FEVER.
927
exposure.   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.           ,                                        r      J  J
   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
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 want of ventilation
seemed to be important elements in causation.3  No cases of typhus occurred
out of the almshouse, and the disease  was not imported.
 _  Overcrowding, deficient ventilation, especially  if conjoined Avith 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 likely 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.  (Vide
p.  918.)  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 diff'erent 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
             1 Vide St. Thomas's Hospital Reports, vol. ii.
             2 For facts bearing on this point, vide Murchison, op. cit.
             3 Vide Boston  Med. and Surg. Journal, June, 1841. 
928                     CONTINUED  FEVERS.

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 typhoid, 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.
   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. 
TREATMENT  OF  TYPHUS  AND  TYPHOID FEVERS.     929
                       CHAPTER   III.

                 CONTINUED  FEVERS  (Continued).

Treatment of Typhus and Typhoid Fevers.—Eelapsiug 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
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 Hospital 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 7'* cases  treated from  January 1 to July 1, 1863, without acid, the
death-rate Avas  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
  1 Vide report  by Dr. Irving W. Lyon, then one  of the house-physicians of Bellevue
Hospital, in  American Medical Times^ Feb., 1864.
       59 
930
CONTINUED  FEVERS.
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, Jurgensen, 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 wet 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 he drawn
up beside the bed.   The patient should  he lifted and placed in the bath by
attendants without any exertion on his part and with as little disturbance
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.   When 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.
   [It cannot be denied that the statistics of the Brand method of treatment
are far more favorable than those of any other.  In fact, Brand declares,
after an experience of thirty years in the treatment of typhoid fever with
cold baths, that every  case treated  according to his method will recover,
provided the baths are begun before the fifth day.  In support of this state-
ment he gives the  following figures :

    Jurgensen (Tubingen)..............217 cases,    1 death.
    Vogl (Munich).................221   "      6 deaths.
    Military Hospital (Stralsund)...........257   "      1 death.
                   (Stettin)............186   "      3 deaths.
    Brand (private practice).............342   "      1 death.
                                                1223   "     12 deaths.

And not one of these  twelve deaths occurred in a case that came under treat-
ment before the fifth  day.—H.]
  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 
         TREATMENT OF TYPHUS AND  TYPHOID FEVERS.     931

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 different 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 102£°.   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.
   We  possess  a  considerable list of drugs  which  have  antipyretic effects.
The  most  important  of these  are  quinia,  salicylic  acid,  kairin,  resorcin,
hydrochinon, antipyrine, and thallin.  Of antipyretic  drugs,  quinia, admin-
istered  in  doses  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 fall 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.
   Valuable as  are the antipyretic remedies in typhoid fever, there is no proof 
932
CONTINUED  FEVERS.
 that they exert any specific effect upon the special poison of the disease or that
 they shorten the duration of the disease.  The injurious effects of pyrexia per
 se have undoubtedly been much exaggerated.  Some late A^riters 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.
   [Intestinal antiseptics are of undoubted value in the treatment of  typhoid.
 In fact, considering that the disease  has its  origin in the gastro-intestinal
 tract, it is a question whether intestinal antisepsis be not the primary indica-
 tion.   The best drugs  of this class  are thymol and naphthalin.  Under the
 use of the former the  writer has repeatedly observed a steady descent of the
 temperature, a  gradual diminution in the daily number of stools, and a speedy
 cleansing of the tongue—in  short, a diversion of the disease into a  progres-
 sively favorable  course.   There can  be  no doubt  concerning the powerful
 antiseptic action  of thymol, for during its  administration phenol, which is a
 constant product of intestinal  putrefaction, disappears from the urine.
   OAving to its insolubility, a property upon  which  its value as an intestinal
 antiseptic  largely depends, thymol must  be administered  in pill  or  capsule.
 As to the dose, I have given from 30  to 40 grains in twenty-four hours—
 two 2 J-grain pills every three or  four  hours—although much  larger .quanti-
 ties may  be given  with  safety, and perhaps with  still better  results.
   Many other  drugs  recommended as  intestinal antiseptics are not worthy
 of this title.  According to Bouchard—and there is no better authority—an
 intestinal antiseptic must be  more or less insoluble and exert no toxic action
 on the organism.—H.]
  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 he
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.                                                              tl
  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
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  tine- 
         TREATMENT OF TYPHUS AND  TYPHOID FEVERS.      933

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 Avith 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, giATen 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 folloAved
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 wellas
other serious complications, contraindicates depressing  measures.   The  posi-
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  uramiia by saline hydragogues if they be not contraindicated
bv the  abdominal  symptoms.    If contraindicated  reliance must be had on
nie'Kure* to  produce'copious perspiration.  For the latter object the pilocar- 
934
CONTINUED  FEVERS.
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 good  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.  When 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  5.97 ; 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  H. Griscom, an account  is given of 82  cases  of typhus
transferred from an emigrant ship at Perth Amboy, 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.
()n 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,
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 thev
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
        1 Transactions of the New York Academy of Medicine, 1853, vol. i. part ii. 
         TREATMENT OF TYPHUS AND TYPHOID FEVERS.     935

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 it 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 he disturbed and a reluctance to make any exertion.
   The supporting diet  should be in a liquid form,  embracing the necessary
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-
ferent articles of  food  just named, milk is by far the most valuable as enter-
in^ 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 
936
CONTINUED FEVERS.
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 he 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 typhus 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
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 
         TREATMENT OF TYPHUS AND TYPHOID FEVERS.     937

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
tor 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.   While  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.                                                    J         *  J
   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 saited 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 Avalk
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
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 be any ground for suspecting its 
938
CONTINUED FEVERS.
purity   In order to prevent diffusion of the disease the intestinal dejections
should be disinfected bv adding a solution of the sulphate of iron  and car-
bolic "acid  or. better still, slaked lime, and they should  not he 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 dejections  should he at once plunged in boiling
water or disinfected.

                          Relapsing  Fever.
   A form  of continued fever  heretofore  known  by a variety of names, hut
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  Clvmer, 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?  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
1S69-70 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 1865 there was a great epidemic  in  St. Petersburg.  Since this date
 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

   1 Fevers,  their Diagnosis, Pathology, and Treatment, by Meredith  Clvmer, M. D., Phila-
 delphia,  1846, p. 99.'
   2 Vide Transactions of American Medical Association, vol. ii.
   3 Vide Clinical Reports on Continued Fever, based on Analyses of 161j. Cases, by Austin
 Flint, M.D., 1852.
   4 Vide New  York Medical Journal, March,  1870. 
RELAPSING  FEVER.
939
appellations.  The disease described by Griesinger 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.   When  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
chsete Obermeieri, or the spirochete of relapsing fever.   It belongs to the
group called spiro-bacteria.  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  motionless.
These  spiral  organisms are extremely delicate, and are  readily seen only
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.   Ihe 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
  »  The spirochete Obermeieri resembles the Spirochete plicatalis discovered by Cohn in
mucuffiom the mouth, and a spirochete previously  discovered by Ehrenberg in water.
Similar spiral-shaped bacteria have been found elsewhere. 
940
CONTINUED FEVERS.
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.   We are ignorant as to
the life-history of this  organism.   Attempts to cultivate it artificially have
failed.  We do  not  know  hoAy 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 fehrile 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 95°.   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.
   During 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
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 may exceed  that of the first paroxysm  but in the 
RELAPSING  FEVER.
941
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 Avhich  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 someAvhat  distinctive of this disease.  The tongue
may, however, become  dry and fissured.  Herpes labialis sometimes occurs.
Vomiting of blood presenting the  character of " black vomit" has been ob-
served, but it is a very rare  symptom.   It  is generally associated Avith 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 cases,
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  he 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.                                                          •  i •  i i
   \ 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 
942
CONTINUED FEVERS.
not cease with the ending of the paroxysm, hut 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
AA-hich 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-
tery, pneumonia, and acute diffuse nephritis.  Relapsing fever, when it attacks
pregnant women, always leads to miscarriage or abortion.   The mother almosi
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. 
RELAPSING  FEVER.
943
   Diagnosis.—The diagnosis of relapsing fever is made certain by the dis-
 covery ot 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 preATiously exist,
   Facts, however, go to show that it is not a highly contagious disease.   Con-
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 Ayhen  the miasm
is  derived  from a number of patients in the Avards of a hospital or  in  close
apartments.   The disease is not likely to be contracted  from single  patients 
944
CON TIN UED FEI rERS.
in well-ventilated rooms.  The investigations of the Metropolitan  Board of
Health in New York during  the prevalence of the disease shoAved 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 eA'idence.   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 immediate^ 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 spirochsete 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 spirochaetae.  Their existence terminates in about a week,
 as a  rule,  and the first febrile paroxysm then ends.   In a small proportion  of
 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 instauces a third and a fourth brood
 are produced, but in most persons the conditions therefor are extinguished after
              1 Vide Murchison, .S7. Thomas's Hospital Reports, vol. ii. 
RELAPSING FEVER.
945
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 spirochaete
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.   What 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 compulsions 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 be  relied upon for
cutting   short  this  disease.   With  our present  knowledge there  are  no
remedies which,  employed in  the intermission, will  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
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
         60 
946
CONTINUED FEVERS.
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.   When 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-
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 aff'ection and accompanied Avith 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 
ERYSIPELATOUS FEVER.
947
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 danger, is  affected
materially by the degree of intensity, the extent, and the local results of the
erysipelas.  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,  Western, 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
Aermont,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 Avithout 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 different 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
death was due to either laryngitis or oedema of  the glottis.  The lymphatic
"lands of the neck became more or less swollen, the  swelling in some cases
bein«- 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
          1 Vide American Journal of the  Medical Sciences, January, 1844.
          2 Vide New York Journal 'of Medicine, July, 1853. 
948
CONTIN UED  FEITERS.
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 danger 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.   Petechiae 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
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 :i7 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 Avithout rigor.  The febrile movement
              1 For both reports,  vide Buffalo Med. Journal, 1857. 
INTERMITTENT  FEVER.                    949
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 days.   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.

                     PEBIODICAL  FEVERS.

Intermittent Fever: Anatomical Characters; Clinical  History; Causation; Diagnosis;
             Prognosis; Treatment.—Pernicious Intermittent Fever.

   TH E  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  diyisjon   Ihe
intermittent and remittent fevers are often distinguished as malarial fevers.
These fevers will be found  to present many striking points of difference as
contrasted  with the fevers which have been considered in the preceding chap-
ters  They diff'er 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. 
950
PERIODICAL  FEVERS.
                        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
ao-ue,'" " chill fever," " the shakes," and by names expressiA'e 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 Bemittent
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,
yawnings, 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  shiverings, 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 " goo'se-skin," are  often observed.   NotAyithstanding
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.
   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 
INTERMITTENT FEVER.
951
 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.   With 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
 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 
952
PERIODICAL  FEVERS.
from the intermission.  The duration of the interval is the basis of a division
into varieties commonly known as the  different 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 inter-
mittent  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,<i23 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
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
   1 Vide Woodward, Camp Diseases of the  United States Army, Philadelphia, 1863. 
INTERMITTENT FEVER.
953
 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.  Gleneral 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, hut 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 diminished  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, th«r-
 mometric observations  may show more or less increase of the heat of the
 body at the time when the paroxysm was  to he expected.   So long as these
 fluctations of temperature  exist the  disease has  not completely  diappeared
 and relapses are liable to  occur.
  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 
954
PERIODICAL  FEVERS.
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 aff'ections 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
being 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
may after a time become  free from  malaria.  On the other hand, the area
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
\ork has extended far upward on the banks of the Hudson River  eastward
into the State of Connecticut, and along the  hanks of the Connecticut River
into Massachusetts, periodical fevers  until lately not having been endemic in
these situations for  a long period. 
INTERMITTENT FEVER.
955
   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 affected.  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
palmellne, 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 Avhich Klebs and  Tommasi-Crudeli found in
the  ground of malarial regions, and Avhich they supposed to be the  special
cause of malaria.  There is  no proof whatever that either the palmelbe of
Salisbury or the alleged bacillus malarke of Klebs and Tommasi-Crudeli are
in any  way concerned  in the production of malaria.  Bodies which were  dis-
covered in  1S81  by Laveran in malarial blood, and which have been more
carefully studied since 1883 by Marchiafava and Colli 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.   When 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
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.2 They consider these bodies to be parasitic organisms
which penetrate the red blood-corpuscles, which they partly or wholly destroy.
  1 Laveran, Traite des Fiewes palustres,  Paris, 1884; Marchiafava and Celli,  several
articles in Fortschritte d. Medicin in 188.°) and 1885. The latter authors call this supposed
parasitic organism, Plasmodium malarise.                        #
  Councilman and Abbot in 1883 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.  (See 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.
  '.Gerhardt had previously produced intermittent fever by the injection into human
beincs of malarial blood. 
956                     PERIODICAL FEVERS.
and in which they elaborate the characteristic malarial pigment. If these bodies
be parasitic  organisms, they are entirely different 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 amccbae
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.1
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 he very  strong.2
  [Since the  last edition  of this work conclusive evidence has been adduced
in favor of the view  that these bodies are  the cause of the malarial fevers
and that their different forms are  dependent upon the  rate  of development
of the parasite.   The organism may be described in  general terms as a poly-
morphous haematozoon.   It has  been  studied  more  particularly  in  this
country by  Councilman, Osier, and Dock.—H.]
  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 he 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 Unless such an analogy exist in the " AViirmchen" found bv Gaule in frog's blood.
  2 Laveran's corpuscles have been demonstrated  in malarial blood in Algiers in Italy
and in this country. 
                         INTERMITTENT FEVER.                    957

 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.   Whenever  the disease involves  immediate
 danger, it is to he 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 affection 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 Avhich 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 cases
 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.
   With 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  Vide  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 tAyenty to
forty grains    \t that time this treatment was  novel and bold.  The author  believes
that he was  the first in this  countrv 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. 
958
PERIODICAL  FEVERS.
 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  paroxjsm  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.
 Asa 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
 degree.    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 aff'ections, the primary object of treat-
 ment is to interrupt the paroxysm  as speedily as possible.  In  children and
 infants the doses  are to he less than  in adults  in proportion to the age.   In
young children, owing  to  the difficulty of administration by the mouth, the
remedy may be  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 be 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 
INTERMITTENT FEVER.
959
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 hydrochhorate
of quinia is especially well adapted for subcutaneous injectiqn, 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 Ayhich 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 s.
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    T.i the  foregoing are to be  added the eucalyptus  globulus and
hvdrastia   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 he 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   Thev mav  sometimes come into play where the preparations ot
I 
960
PERIODICAL FEVERS.
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 Ayhen
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, hut 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 Avard 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 Vide N  Y.  Med. Journal, Aug., 1880. 
PERNICIOUS  INTERMITTENT FEVER.            961
                  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-
ease are to be considered apart from simple or ordinary intermittent fever, and
collectively they constitute a variety of the disease called pernicious, malignant,
and congestive. Of these names  the first is commonly adopted by writers.  The
term congestive, although much used in the Southern and Western 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 Western 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 be 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 be 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.  Vomiting
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
          61 
962
PERIODICAL  FEVERS.
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. ^
  Heematuric malarial fever, which is  one of the most  important forms of
pernicious fever, has already been considered  (p. 875).
  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.  When 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.
   With 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 
PERNICIOUS INTERMITTENT FEVER.            963
when the symptoms denote active cerebral congestion.  Coldness of the  sur-
face is an indication for tiie  external application of heat by means of warm
blankets, bottles  of hot  water, etc., and for internal stimulants.   Vomiting
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.    With 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 he 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, hut 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  betAveen 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 doses 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 risk 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 untoAvard  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.  [A more
efficacious  method  of administering quinine in pernicious intermittent fever
is by intravenous injection.   Bacelli has treated 30 cases in this manner with-
out a death whereas  in 16 cases which  he  treated  with subcutaneous injec-
tions there  were  5 deaths.1  Bacelli employs the  following solution for in-
travenous injection :
       1 Verhandlungen des N. international medicin. Concjresses, Band ii. S. 143. 
964
PERIODICAL  FEVERS.
          R.  Quiniae hydrochlor.,                    gr. xv ;
              Sodii chlorid.,                      #  gr. xiss :
              Aquae dest.,                           giiss.—M.
The injections are made by thrusting a syringe with a hollow needle attached
directly into one of the veins of the  forearm.—H.]
   The nostrum called Warburg'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 be known, and on
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.

                PERIODICAL  FEVERS (Concluded).

Simple Eemittent 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 remittent 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
superfoetation " !  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 long 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 affections, and  the term  typho-malarial fever has been introduced  by Dr.
  1 Vide The Principal Diseases  of the Interior  Valley of North America  Second Series
Philadelphia, 1854, p. 557.                                     '           ''
  2 Vide article by the author, in the Buffalo Med. Journal, 1857. 
       SIMPLE REMITTENT AND  TYPHO-MALARIAL FEVER.    965

Joseph J  Woodward.1  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.                                          b

        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.   When 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  mcfanmmia.
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 afebrile 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. 955.
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 be
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
  1 Vide Outlines of the Chief Camp Diseases of the United States Army, etc., by Joseph
Janvier Woodward, M.  D., Assistant Surgeon U. S. Army, etc., 1863. 
966
PERIODICAL  FEVERS.
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
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-At;ssels.   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.   When  the  change is
intense the  Avhite matter also  has  a dirty grayish tint and presents many
puncta 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 melanaemic
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.
   After death from remittent fever more or less congestion and inflammation of
the stomach and of the intestine are frequently found.  The mucous membrane
of these parts may present ecchymoses.  The solitary glands and Peyer's patches
may be swollen.   The latter often present the shaven-beard appearance.
  The same parenchymatous and  hyaline degenerations  which  have  been
described under  the  head of  Typhoid  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
  1 Woodward 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. 
       SIMPLE REMITTENT AND TYPHO-MALARIAL FEVER.   967

forty-eight hours, and then notably subsides ;  the  pulse falls in frequency,
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 different 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
 hi-h  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

 ^In t^oWarial  fever  the  symptoms distinctive of  typhoid  fever are
 intermingled with  those of periodical fever.   The symptoms  referred to aie
  hose connected with the abdominal lesions of typhoid fever-namely, diar-
  W Tympanites,  and  iliac  tenderness.  These symptoms become more or
 fesTmarked during the  second  week of the career of the disease.  The cha-



 f "col  tion"1th rin.pl. rliuent fcve,  *^7^XS
 one or both parotids are sometimes observed m cases of typbo-malanal 
968
PERIODICAL  FEVERS.
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  diff'erent 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 1862,
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 typhoid fever are wanting, in  simple remittent
  l Vide article by Woodward  on " Typho-malarial Fever," in the  Transactions of the
International Medical Congress, Philadelphia, 1877, p. 305. 
        SIMPLE  REMITTENT  AND  TYPHO-MALARIAL FEVER.    969

 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 Ayhen  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 aA'ailable, 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 be 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 Ayhen
 these  manifestations of cinchonism appear.   If other preparations of cinchona
 be used  thev 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. 
970
PERIODICAL  FEVERS.
 If cinchonism be not produced during the remission, the remedy may be con-
 tinued during  the  exacerbation of fever.   This  is preferable to  Ayaiting for
 another  remission.   In a case in Avhich  the  practitioner  is satisfied  that  a
 remission has already occurred—in  other words, Avhenever  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 
YELLOW  FEVER.
971
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 diff'erent
parts  of the world  a variety of names denoting its geographical relations,
such as Walcheren 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 the 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-
  1 The presence of large oil-drops is not a sufficient criterion of fatty infiltration in
distinction from fatty degeneration.  (Consult the article on Fatty Liver p. 550.)  It
is  incorrect to regard the hepatic changes  in yellow fever as comparable  in> degree
or extent with  those  in acute yellow  atrophy of  the  liver   There is still  less
-round for the assumption that the essential symptoms of yellow fever  are referable
to an  acute  parenchymatous  or  fatty  degeneration of  the  liver (Liebermeister,

&!!lSchmeidnt,)'"The Pathology of Yellow Fever," New  York Medical  Journal, 1879, vol.
xxix. p. 128. 
972
PERIODICAL  FEVERS.
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.   Bed 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  Avho 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 different
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.  Vomiting 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
region, 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. 
YELLOW FEVER.
973
 has  been called «the  state of calm."   This is reckoned  as the second sta-e
 ot 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 afte<-
 this stage.                                                         J
    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 I 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.  Vomiting 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 recoATery 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.   Barely  it has a greenish or
 yelloAvish 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, Avhich 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,
hoAvever, in its passage through the intestinal  canal that its morphological
characters are not demonstrable. Uric acid and the triple phosphates may be 
974                     PERIODICAL FEVERS.
found in the evacuations from the bowels.  Sometimes blood but little altered
is passed from the bowels.  Diarrhoea in this as in the first stage 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.   Uncmia
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 uramiia.   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 cases."   Bush  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 Boche, in which the patient fancies himself well or but little
ill.
  The physiognomy of patients is described by  different  Avriters Avith 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 he difficult to
convey  by language a clear idea of the characteristic appearance.
  The  duration of  the  disease after  the febrile paroxysm varies  between
  1 Vide "The Urine in Yellow Fever," by Prof. J. AV. Holland, in the London Prac-
titioner, July, 1879, and the American Practitioner, Sept., 1879. 
YELLOW FEVER.
975
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
   W riters 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.
When  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.   Belapses sometimes occur after
convalescence appears to be declared.
   In mild cases the disease ends in convalescence immediately following  the
paroxysm of fever.  Whenever an epidemic  prevails  there  is a certain  pro-
portion of cases devoid of any gravity.   In these cases a slight chill occurs,
folloAved  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.   When 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 Boche,  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.  Volumes 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 Boche.)  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 collusion 
976
PERIODICAL  FEVERS.
by contagion.   For example, Fenner, with great zeal and fidelity, traced the
first 30 or 40 cases in the epidemic at  Nenv 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 communicability.  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  Ncav 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.  When 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.  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, rail-
roads, and other conveyances.  The fact of the  disease being portable ren-
ders judicious  quarantine restrictions of  vital importance,  but  in  view of
its non-contagiousness  the  restrictions  need not include the detention of
persons.

 „' Vide  article  on "Epidemiological Conclusions and  Suggestions," in Brit,  and For.
Medico-Clururg.  Review, Oct., 1870, p. 484. 
YELLOW FEVER.
977
   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 V estern Hemisphere, and in certain  parts of Europe and
 America than in Africa.   In  the Western World it prevails especially in the
 commercial  towns on  the  Atlantic  coast  south  of Charleston, S. C, on the
 Gulf of Mexico, and  in  the West 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 Avith 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.
   Unacclimation 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 Avho 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 he 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 among 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 tAvo hard frosts.   Epidemics,
 however, have a self-limited duration.  Fenner  noted  that at Ncav Orleans
 repeatedly the  disease  disappeared before the occurrence of frost.   An  epi-
 demic  rarely continues longer than  b'O 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
         62 
978
PERIODICAL FEVERS.
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
issue  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 Boche, 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.   Bemiss
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.
  2 DaCosta, Medical Diagnosis, Philadelphia, 1881, p. 828.
  3 S.  M. Bemiss, article on " Yellow Fever " in Peppers Svslem of Practical Medicine, by
American Authors, Philadelphia, 1885, vol. i. 
                            YELLOW FEVER.                       (,;<)

 diminution or suppression of urine, abundant hemorrhage  in  any situation

 coma^Of th   ^r^'J-t,Ution, hicC0U^ d^™> convulsmm™i
 coma.   Of these symptoms, black vomit and suppression of urine are almost
 invariably forerunners of death.   Coma and convulsions  are fata  sa mptoni
 dependent on uraemia.                                           "  ^
   A favorable prognosis cannot be confidently  entertained in any case of this
 d.sease.  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 different 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
 tendon e}- 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 Avell borne, it is difficult to  see
what indication they fulfil which may not be equally met by mild laxatives 
980
PERIODICAL  FEVERS.
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 he 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 he 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.  With 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.

  Pretention.—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 
ERUPTIVE FEVERS.
981
disease  prevails  or  all articles of merchandise, clothing, etc. brought there-
from  mus   be thoroughly  d.sinfected.   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 danger 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.

                       EBUPTIVE  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  fob 
982
ERUPTIVE  FEVERS.
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 eio-hteenth 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 aff'ections destructive  of human life.   It is not, however, so rare, even
in its unmodified  form, at the present day but 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 papilhe of the corium are dilated, tortuous, and elongated.  The connect-
ive tissue of the papillae is slightly cedematous.   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  the middle  layers of  the  rete  Malpighii.   Weigert1 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 Wagner  as occurring  in the epithelium of mucous membranes
in diphtheria.   The metamorphosis belongs  to the group of the coagulation
necroses.  Weigert 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 which 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-
rating 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-
ing to this view, in the papule a large  number of the epithelial  cells  in the
upper Malpighian layers become swollen and transformed into cavities, the
        1 Anatomische Beitrage zur Lehre  von den Pocken, Breslau, 1874, Theil i. 
VARIOLA,  OR  SMALLPOX.
983
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 We
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.  Weigert
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 
984
ERUPTIVE  FEVERS.
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  netAVork
of fibrin.
  Pus-cells are found  in the connective tissue of the corium, especially around
the vessels of the papilla*.  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 Weigert 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 haemorrhagica, 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  different 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.    Without 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 ot 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- 
VARIOLA, OR SMALLPOX.
985
 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 P"mary lever   It is often intense, the thermometer sometimes showing a
 rise to 1U4  or lOo  .  Nausea and vomiting  are  often prominent symptoms
 in  this stage.   The tongue becomes coated.  Pain is referred to the eph-a,-
 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 he mild, the eruption will probably be 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 petechias  and ecchymoses.   These
 may he 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 
986
ERUPTIVE  FEVERS.
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 papulae are smaller, rounder,
and harder, and lack the crescentic  or curvilinear arrangement Avhich 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—i. 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  be 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 he 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 he 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 Avords, suppuration
takes place.  With 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 diff'erent forms of cutaneous eruption, all except the squamae and tuber-
culx are represented in the successive changes in  the eruption of smallpox—
namely, enumerating them in the order  of their sequence, maculae, papulae,
vesiculse, pustular, 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, the  formation  of typical vesicles  and of pustules does  not  take
place.   Little  erosions and ulcers rapidly form in the site of the eruption
lhe membrane surrounding the  spots is swollen and inflamed   The spots 
                       VARIOLA, OR SMALLPOX.                   987

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 auditonus, 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.—With 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, ami 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 SAvelling 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
*eab   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 
988
ERUPTIVE FEVERS.
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, which  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 days ; 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
tAventy-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.
  Various complications and  anomalous events are liable to  occur in the
several stagesof 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.  (Edema 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!
Furuncuh, 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!
hpistaxis is  an  occasional  early symptom, but  does  not betoken unusual
gravity of the disease.  Haematuria is sometimes an early and always a grave

nSThrn?1"0? ^  °Tmn,g  at My period 0f the  disease  from the
mouth, throat, air-tubes, or bowels, accompanied  by petechia* 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 
VARIOLA, OR SMALLPOX.
989
  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 J" "
  pura  vanoosa   Death may take  place  in these cases before  any eruption
  characteristic of smallpox has appeared, and then a diagnosis is possible oil
  from a knowledge of the etiology of the  case.   In females meosS-uation may
  occur, and if not irregular or profuse it  is not an untoward event.   Metror-
  rhagia  often occurs in  hemorrhagic cases                         -^cioi
    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  Westphal, 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
  diseased 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,  but 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 Avere informed.  The
 coffin was taken home  to a Xew 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 Whether
 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 Aide Nonveau Diet., art. "Contagion."
  2 Vide article by Dickson  in the American Journal of the Medical Sciences, for July,
1862. 
990
ERUPTIVE FEVERS.
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 Avhich
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 vtero.
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 betAyeen
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 avIio 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
Weigert and by Cohn 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 the eruption  are fully manifested; but it is not so easy at  an early 
VARIOLA,  OR  SMALLPOX.
991
 period of the stage of the eruption before the vesicles are distinct,   In seek.
 mg 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  loAver extremities is to he  recollected.
   The diagnosis cannot be made  with positiveness prior to the stage of the
 eruption.  Pain  in the loins Avith 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 be 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 Janewav 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.                 frr„lth
  2 For an example vide Report  of the Proceedings of the Illinois  State Board of Health,
Springfield, 111., June 29, 1«83. 
992
ERUPTIVE  FEVERS.
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
uramiia.  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 ot 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  lessened 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 
VARIOLA,  OR  SMALLPOX.
993
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 Avith 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 Avhich 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 Bayer.  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 Aelpeau,  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 hut 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.                                                ,  >.\. -L   \*
   5 The application  of  a mild mercurial ointment spread on  cloth has been
hio-hly recommended by authors in different 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 §yj).  .Niemeyer pre-
ferred a weaker solution (gr. j to gvj).                             .
   (j 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.
   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., I860.
         63 
994
ERUPTIVE  FEVERS.
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
Wallace.  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.
   With 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  be
left at the hospital, or in cases in  private practice destroyed.  Fumigations
as a means of  destroying the contagium should not  he  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  he 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 Vide Buffalo Medical Journal, vol. vi., 1851. 
MODIFIED  SMALLPOX, OR  VARIOLOID.
995
 vicinity were inoculated by Zabdiel Boylston. P Boylston was  the  first  o
 no e this important fact relating to variola" produced b'y inoculation: namel
 that the average period of incubation is  shorter by several days than in case
 of natural smallpox.  Hence the production of natural smallpox may be anti-
 cipated  and  prevented  by inoculation after known exposure to the miasm of
 tllG CllSC(ISC
    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, Avhen inoculation was largely practised the disease was severe.  The
 *?? Lb  mortallty was exceedingly small, varying,  according  to Shattuck, in
 23,000 cases in Boston  between 5 and 30 deaths in 1000.  Transferrin^  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  AVho 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.  Aaccination 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 Avithout 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 Vide Trousseau, Ctinique medicate, tome i.
                  2 Am. Journ. of Medical Sciences, July, 1862. 
996
ERUPTIVE  FEVERS.
  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 differential 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  Oowpox.

  Aaccinia 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 Avhich  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 179S,
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 Avould  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  worlds  The practice was  introduced  into  this
country  m 1799,  notwithstanding a  bitter popular  prejudice, by Benjamin
 Waterhouse of Boston, the first professor  of medicine in Harvard'University 
VACCINIA, OR COWPOX.
997
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
day 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 ot
vaccination.   Incomplete vaceima-va ccinoid, 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  andI 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- 
998                      ERUPTIVE FEVERS.
tion to those Avho suppose themselves to be protected  against  smallpox, the
responsibility of 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 the 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 Avhich
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
Avith  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 si a' 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,  the  importance of which is obvious, are, What degree of
protection against smallpox is afforded by cowpox ? and, What 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 Boyal Military Asylum  at Chel-
sea, England, in forty-eight years, 1950 had, on  admission, marks of small-
pox, and 3821 either had marks of vaccination or they were at once vaccinated.
Of the former, 6.15 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.

tlisUnrt/r^n  °fue °ynfcoi°TC[d Society of Boston, April and June, 1872, report of
uibcourse by  JJr. Henry A. Martin.
  2 Vide Reynolds's System of Medicine. 
VACCINIA,  OR COWPOX.
999
    Another reason for the increase of  varioloid amon°- those who havp T™
 vaccinated is, that the protective influence of vaccination diminishes afei   he
  apse of a certain number of years.   Varioloid occurs much oftener am on'
  hose 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
 ing into the  etiology of varioloid.   The importance of revaccTnation  ests
 upon this fact   Bevaccination after the  lapse of a greater or less number  of
 yearsis 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
 vanes widely in different 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.   With our  present knowledge the propriety, if  no't
 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.  Bevaccination, 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 f per cent. ;  among those who had one cicatrix, 7?  per cent.;
 among those who had two cicatrices, 41 per cent.;  among those who had three
 cicatrices, If per cent.; and  among those who had four or more  cicatrices,
 f 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.
  Within the  past few years an important practical question relating to vac-
                              1 Aitken, op. cit. 
1000
ERUPTIVE FEVERS.
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 Avith 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
Avhether 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. With respect
to these points of difference, the disease as now produced by the animal virus
corresponds with the disease as described and delineated by the earliest vac-
cinographers—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 boA'ine 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.   Whether cowpox be ever in a broader  sense spontaneous is an open
qxiestion.
  2 Vide Discourse by Dr. Martin in Journal of the Gynecological Society of Boston : also,
  Practical Eemarks on \ accination," by Dr. Frank P. Foster, in Neumann's Hand-book
of Skm Diseases, translated by Bulkley, and in article on " Vaccination " in Pepper's Sys-
Um of Practical Medicine, by  American Authors, Philadelphia, 1885, vol. i -also. Sur
le Coupoz decouvert cL Passy, par Bousquet, Paris. 
VACCINIA,  OR COWPOX.
1001
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.  Ihe
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.   With 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 fm'l retains its activity for a considerable  period.
   tr"ad  the mode & vaccinating, if dried lymph be used or lymph con-
tained in capillary tubes it ma, be inserted  by means of slmht punctures  or
bv s^rapin-way the epidermis,or by minute scarifications; the latter method
K preferable   Having  made, with a common lancet, a number of linear
^stse scratches^deep "^^ M^meTs^

17  s°hou,d tfitt^ r„Pumbert0and nTlarger than ha,f a dime.   If 
1002
ERUPTIVE  FEVERS.
 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 C4. 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.
 Ihe 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.
 Me had never been vaccinated, and vaccination was at  once performed   The
 lg;2Vide «**» by Dr. Piffard in the New York Med. Journal, Nos. for  June and Julv, 
                    VARICELLA,  OR  CHICKEN-POX.               1003

vaccine disease was deferred until the measles had run its course   It then
became deve oped 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 bulbe of greater or less size form instead of vesicles.  Ncav
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.   Writers  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 o-ive 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.   Varicella is very rarely  communicated
to adults   This is not true of varioloid.  Varicella affords no protection against
variola  and  conversely, persons who  have  had smallpox contract varicella.
Vaccination  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 
1004
ERUPTIVE  FEVERS.
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 differential diagnosis  promptly  and  positively, the
folloAving 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.
  Varicella 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.

                  EBUPTIVE  FEVEBS (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 regards symptoms and fatality.  In its mildest form it is a
trivial aff'ection, but in its severest form  there  are few diseases more appro- 
                   SCARLATINA,  OR  SCARLET FEVER.            1005

 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  angtnosa, and scarlatina maligna.   Widely different as are the^e
 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 cedematous 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 Avhich 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, hut it is produced  by the  scarlatinal poison ; according  to
 a  second view, the disease, both  anatomically  and etiologically, is  identical
 Avith 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.  Ileubner has attempted to prove,
 from an anatomical point of view, the  non-identity of scarlatinal  diphtherh
 and primary diphtheria, but the differential criteria to which he calls attention
 are  not sufficient  to distinguish  anatomically  one disease from the other.1
 [According to  Wurtz and  Bourges,  Avho have  lately studied  the  characters
 of the pseudo-membrane of scarlatinous angina,  it would appear that the
 membrane  which appears at an early stage of the disease is non-diphtheritic.
  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 m scarlatinal
diphtheria and those of primary diphtheria j" Eeobaehtungen uber Scharlach-Diph-
therie," Jahrbuch der Kinderheilkunde, 1S79, xiv. p.  1). 
1006
ERUPTIVE FEVERS
Their observations  are based upon a study of eleven cases, in nine of which
the membrane appeared at an early period, while in two it was a late manifes-
tation—seven days after the eruption  in one case, thirty-six days after it in
the other.  In the  first series the infectious agent of diphtheria—the Klebs-
Loffler bacillus—was never detected, Avhile in the second series it was found.
In  the  first series a streptococcus  identical  in all respects Avith the strepto-
coccus of Fehleisen—the infectious agent of erysipelas—was always present.
—H.]
  The inflammatory process may be propagated from the pharynx along the
Eustachian tubes to the mucous membrane lining the cavity of the middle ear.
Suppurative median otitis, Avith perforation of the tympanum, and sometimes
with consecutive caries of bone, may thus be produced.  Swelling and inflam-
mation of the lymphatic glands of the neck not infrequently accompany scar-
latinal angina.   The glands may suppurate.   The mucous membrane of the
larynx, trachea, and bronchi is sometimes inflamed.  The inflammation in this
situation 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 SAVollen.  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.  SAvelling 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 Acute  Bright's Disease
(p.  S15).  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.  Bedness 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 aff'ection of the throat is due to the
efflorescence Avhich 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,  diff'erent 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  he
delayed one, tAvo, three, or more days after the time when it usually appears.
A considerable delay in  the appearance of the eruption is generally  attribut-
able to some complication. 
SCARLATINA,  OR  SCARLET FEVER.
1007
   Stage of Eruption.—This stage in children  is sometimes ushered in bv 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
 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  Avhich 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 
1008
ERUPTIVE  FEVERS.
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.
  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—betAveen 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  poAver 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 very 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.   Bestlessness, 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. 
                  SCARLATINA, OR SCARLET FEVER.            1009

   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  be 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-
 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 be  developed as  effects of uraemia.
 Disease of the kidneys is an important complication  in a certain proportion
 of  cases.   Generally, but not ahvays, 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
 Avith. 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,
 (edema  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.   Uramn'a, taking place either as a concomitant
        64 
1010
ERUPTIVE  FEVERS.
or a sequel of scarlet fever, may occur without albuminuria and  without
dropsy.  Hence the importance  of examinations of the urine in all  cases,
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
breath emits  an intolerable fetor in some cases.  Sometimes,  but rarely, the
inflammation  extends into the larynx and bronchial tubes.  (Edema of the
glottis is  an  occasional accident in adults.  The structures of the 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 he
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 affection may be
sufficient to lead to a fatal result.
  Hemorrhages in various situations, together with. petechias 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 
                  SCARLATINA,  OR  SCARLET FEVER.             1011

 affection when exposed  to the contagium.   In cases of scarlatina sine erup-
 ttone 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 Avith 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
 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 Avhich 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 <edema 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 Avas  held by Graves and others that the kidneys 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
                               1 Vide p. Si5. 
1012
ERUPTIVE FEVERS.
 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.

   Causation.—The 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 long 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 different
 cases.   Trousseau cites a case in which the attack took place AA'ithin 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 attacked  a  few  days
 after confinement.   Cases have  been reported in which the disease was con-
 tracted in  vtero.
   As a rule, this disease is  experienced only once ;  but, making due allow- 
SCARLATINA,  OR  SCARLET FEVER.             101:3
 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 eruptive fevers,
 micrococci have repeatedly been found in various organs of the body in scar-
 latina,  particularly when  these are  the  seat  of  complications,  but  it is  not
 believed that these micrococci are concerned in the production of the disease.

   Diagnosis.—Attention to the following  diagnostic points renders the  dis-
 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 body 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 he 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.  Whether 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, 
1014
ERUPTIVE FEVERS.
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. Uramiic
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
of 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.  With 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; hut 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 words, 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, hoAvever, 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 
SCARLATINA,  OR  SCARLET  FEVER.
1015
hygienic 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
aff'ection 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,
but care in this respect should not lead to error in the way of ventilation 01
of oppressing the patient Avith an overplus of clothing. Vigilance 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 cases  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 effectually accomplished by the use of
water.   It  Avas 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 Aviped 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.                                                .    .
   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
strikino- 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 o-iyen without discrimination, and the physician is to be  guided  in their
use by watching their immediate apparent effects,  precisely as  in other essen- 
1016
ERUPTIVE  FEVERS.
tial fevers.   In children, wine-whey, milk-punch, and  egg-nog are eligible
forms for the administration 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 best of these
is frequent spraying with a 20 per cent,  solution of boracic  acid, a  2 per
cent,  solution  of  carbolic  acid, a  saturated  solution  of salicylic acid or
thymol, or with peroxide of hydrogen.  The latter, provided a reliable prep-
aration  be employed, is  a remedy of undoubted efficacy.   In  addition, the
atmosphere of the room  should be charged with steam.  It is undoubtedly
difficult to induce young  children  to co-operate in the employment of the
atomizer, but with gentleness and firmness it can in most cases  be accom-
plished.— H.]  The chlorine mixture is highly recommended by Watson and
others.   Stimulating or  caustic applications to the pharynx are of doubtful
utility.  The difficulty of making them' in children, and the perturbation occa-
sioned by making them forcibly in spite of their resistance, are not small ob-
jections ; 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.  Whether  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 
SCARLATINA,  OR  SCARLET  FEVER.
1017
 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  best  of these is the hydrate
 of chloral   This drug is highly recommended by J. C.  Wilson,  who employs
 it  habitually in the treatment of scarlatina, in  doses of 1 or 2 grains every
 three  hours to children of two or  three  years of age.—H.]  With reference
 to the liability to heart-clot, Bichardson  advises the carbonate of ammonia
 given in small doses frequently repeated.  Several  writers  have advocated
 this remedy  as having a special  salutary influence  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
 been considered in a former part of this work, to which the reader 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 conAralescence.   Begarding,
 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  Avhich there have  been cases, and
everything that may prove  to he fomites.  Cases occurring in hospitals and
private houses should be at once isolated, and  all articles  in the apartment
                               1 istille, op. cit. 
1018
ERUPTIVE  FEVERS.
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.
                      CHAPTER   VIII.

                  EBUPTIVE  FEVEBS  (Continued).

Eubeola, or Measles:  Clinical History; Causation; Diagnosis; Prognosis;  Treatment.—
                        Eoseola.—Kotheln.—Dengue.

                        Rubeola, or Measles.

    EUBEOLA—so called from the red color of the eruption, called also mof-
     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 Botheln, and  in  this country
distinguished as German measles.
   Bubeola 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,
Avith 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 Avhich takes
place on the mucous  membrane of the  air-passages prior to its appearance on
the skin.  With these local affections, which vary much in intensity in differ- 
RUBEOLA, OR MEASLES.                  1019
 ent cases, there is associated moderate pyrexia, the axillary temperature rarely
 exceeding 102   R, 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.
    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 be  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 Avith 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  sIioavs 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 Avhole 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,  Avhich 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 stage of 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 
1020
ERUPTIVE FEVERS.
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
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
variety, 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 rubeolous 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  petechia  varying
betAveen the size of a pin's head  and that of a split pea.   There was hemor-
rhage 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, 
RUBEOLA, OR MEASLES.
1021
lungs, 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 eleemosynary 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-
ity 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
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 Avhich  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
 measfes 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.

   C-UJSation.__Bubeola, 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, but 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  froin 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
 desouamative  stages.                           ,                         ,
   The duration of the period of incubation  varies within  widely separated 
1022
ERUPTIVE  FEVERS.
ses
limits—namely, between one day and thirty days.  In  the majority of ca
the attack occurs between six and ten days after exposure.  The duration an as
within these limits in a dozen cases under my observation in which the time ot
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.  When produced by inoculation the period ot
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-
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.  Well-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 different epidemics
of rubeola, as  of other epidemics, is by no means  uniform,  but varies much
in  different 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 Avhich 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 aff'ections 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  knoAvn 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 eyes, and bronchitis, with  pyrexia, in persons who  have never had
 measles at a time Avhen 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 
RUBEOLA,  OR  MEASLES.
1023
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."

   PnoGNOSis.—In the majority of cases, as this disease is ordinarily presented
in civil practice, it is either mild or unattended with  dancer;  but in a cer-
tain proportion of  cases the disease is severe and dangerous.   The severity
and danger 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
prove a serious disease in camps.  Woodward states that  of the 38.021 cases
contained in the official returns from the armies of the United States  in the
first two years of the late civil war, there were 1S64 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  5.1
   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-
ing 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 mortalitj* 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 but 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  Avidely-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, hut 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 decree of pyrexia  call for antipyretic treatment, the wet sheet may be
resorted to.   Befrigeration 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.
               1 Sanitary Memoirs of the War, XeAV York, 1SG7-69. 
1024
ERUPTIVE  FEVERS.
  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 bath,  and
overloading the body with clothing, are not to be employed.   This general
rule  may be adopted—namely, measures should not be employed for  this
object if, aside from the object, they are likely to  he hurtful.   The tepid bath,
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 symptoms,  either Avith 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 he 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  he suspected.  There is
ground for the opinion that the communicability is greater during this stage.
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 
ROTHELN.
1025
 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.   \ 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
 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  Xew  York in ISTd, 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, hut 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.
 Rotheln, like roseola, is  devoid of danger, and  rarely calls  for more than
hyedenic treatment,1
  [A valuable contribution to the study of rubella was made by Dr. J. P.
  1 A  valuable article on  this disease by Dr. W. A.  Edwards was published in the Am.
Journ. of  the Med. Sciences, October, 18S4.
         65 
1026
ERUPTIVE  FEVERS.
Crozer  Griffith of Philadelphia in 1SST.1  Of  the  150 cases on which his
report was based, only 1 was an adult.  The great  majority of cases  occur
betAveen the ages of five  and fifteen.   The contagious nature of the disease
is shown  by its prevalance  in " homes "  and other public institutions.
   The characters of the eruption of rubella are  far  from uniform, for which
reason it has been  described as a  polymorphous  exanthem.   The only two
varieties of the eruption which are of practical importance are those known
as rubella  morbilliforme and rubella scarlatiniforme.   These terms indicate
the remarkable  resemblance which the  exanthem  of rubella may bear  to
either  measles  or  scarlatina.  From  these affections rubella may be distin-
guished by the shortness and mildness of  the prodromal symptoms, the com-
parative mildness  of the catarrh  of throat, nose, and  conjunctiva, and the
brief duration of the fever.  In sporadic cases, as well  as at the commence-
ment  of an epidemic, mistakes  in  diagnosis  are liable  to occur, but may be
avoided by observing the  rapidity with which the exanthem  develops,  often
in the midst of apparent health, as  well as the subsidence of the fever  while
the eruption is at its  height.  Enlargement and  tenderness of the cervical
glands  are also important diagnostic signs  of rubella.  In  doubtful  cases
inquiry should always  be  made as  to whether the patient has been recently
taking drugs such  as antipyrin, quinia, and  chloral, which may give rise to
an eruption remarkably like  that  of rubella.
   As this  disease tends intrinsically to recovery and is  attended with few or
no distressing symptoms, there  is  little to be said concerning its treatment.
Confinement to bed  during the febrile period, and a mild, non-stimulating diet
composed mostly of farinaceous substances and  milk, are all that are needed
as a rule.   An occasional warm bath  will, while serving  the purposes of
cleanliness, promote  the development of the eruption,  allay  pruritus,  and
tranquillize the nervous system.   The pharyngitis, if severe, is to be treated
with emollient and astringent gargles and  applications,  precisely as in mild
cases of scarlatina.—H.]

                              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 West  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
1780, and  was described by Bush.   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.
It prevails especially in tropical  and subtropical  countries.   An extensive
epidemic occurred along the southern coast of this country in 1880.2
   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 folloAvs a febrile stage or a paroxysm of
fever.  The duration of the pyrexia varies between nine hours and three or four
             ] Medical Record, July 2 and 9, 1887.
             2 J. Forrest, Am. Journ. of the Med. Sciences, April, 1881. 
DENG UE.
1027
 days, the average duration being about thirty-six hours.   Durin- thi.  sta-e
 and sometimes during the access, acute, often excruciating, pains'in the head
 ^""t80^^  neck>7l0in^and ex^mities 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 affectecL  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.
 Coryza  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. Belapses 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.  Wragg 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. W. McLaughlin of Austin, Texas, has
 cultivated from the blood of  dengue patients a micrococcus which he regards
 as the special agent of infection.1  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 toAvns 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
 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  tbose  who had it  in
 1828 he accounts  for by  supposing that  after an  interval  of  twenty-two
 years the susceptibility was renewed.2   It is an aff'ection chiefly occurring  in
 Avarm  climates, and it prevails  especially in cities and large toAviis.   To the
 latter  rule there are, however, striking exceptions.
  This affection, although  extremely  distressing, and presenting not infre-
  l"Kesearches into the Etiology of Dengue," Journ. of  the  Am. Med. Association,
June 19,  1886.
  2 Elements of Medicine, 2d ed., p. 748. 
1028
ERUPTIVE  FEVERS.
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.   Bubefacients 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.
                          [Leprosy—Lepra.

  Etiology.—Leprosy is a chronic  infectious disease of which the principal
lesions are cutaneous.  It is now universally  believed  to be caused by a
micro-organism—a bacillus—discovered  by Hansen in 1880, and hence often
called  " Hansen's bacillus."   Morphologically the bacillus  leprae is remark-
ably like  the  bacillus tuberculosis.   In  fact,  the two  can scarcely  be  dis-
tinguished except by their different  reactions  to certain dyes.  Unlike the
bacillus of tubercle, the bacillus  leprae is stained by the ordinary anilin dyes
as well as by Gram's method, by neither of which can the bacillus tuber-
culosis be  colored.
  There has been much discussion  concerning the heredity of leprosy, but
the weight of  authority is against the a dew that it is transmitted from parent
to child.  " In syphilis, the type of  a hereditary disease, we find all grades
of direct hereditary transmission, from the foetus dead in utero or the infant
born  with, or  showing shortly after  birth, manifestations of the disease, up
to those where parental disease causes only more  or  less lowering of health
in the children.  There is nothing  of  the kind  in  leprosy.  There is  no
disease of the foetus, and  rarely any of  the infant, and there are  no charac-
teristic signs,  as  in syphilis,  to   distinguish  hereditary  from  acquired
leprosy."1  A  strong  argument against the hereditary  transmission of leprosy
is afforded  by  the fact that the disease is  rare in childhood.  On the other
hand,  the  advocates  of heredity  refer to cases in which  the affection has
manifested itself many years—twenty-seven in one case (Bidenkap), thirty-
two in another (Hallopeau)—after removal from all possible sources of infec-
tion.   They claim that a  period  of  incubation  so  protracted is scarcely con-
ceivable, assuming as  a matter of course that  the disease is more apt to be
latent for  a protracted period when transmitted by inheritance.    To the
writer it seems quite  as likely to  remain dormant in the one  case as in the
other.   Leprosy is most prevalent between the ages of twenty and forty, and
attacks both sexes in about equal degree.  It occurs in all latitudes ;  in fact.
it prevails most extensively in regions the climatic conditions of  which are
diametrically  opposite. For example, lepers are numerous  in Norway  and
Sweden, and equally  so in India.   In the latter country there were in I860
174,21)4 cases.   In  America there are colonies of lepers in  the province of
~Sew  Brunswick, in Minnesota, Louisiana, Key West, and Mexico.   It  is a
singular fact, to which attention was first  called by Bidenkap,2 that leprosy
is rare in  large  cities, even though  it be prevalent in the country districts
around them.   Mr. Jonathan Hutchinson attributes the origin of leprosy  to
the use  of salted  fish, and asserts  that the " real  influence in spreading
leprosy over  Europe in  the Middle Ages  was  probably not  the returning
Crusaders, but the advance of Christianity, Avhich enforced frequent fast-
      1 Van Harlingen, Annual  Univ. Med. Sci., vol. iv., 1892.
      2 An Abstract of Lectures on Leprosy, by J. L. Bidenkap. Christiania, 1886. 
LEPROSY.
1029
days on which salt fish was largely consumed."  In accordance with this vieAv,
he holds that leprosy may be extinguished by the substitution  of other kinds
of food for fish, more especially for salt fish.1  The last-mentioned hypothesis
is referred to  on  account of the eminence  of its advocate, but those whose
acquaintance with leprosy is most intimate  regard it as having little basis of
fact to rest upon.

   Symptoms.—Leprosy is universally  divided  by systematic writers into
two forms : the anaesthetic or  nervous—lepra nervosa—and the tuberculous
—lepra tuberosa—in  accordance with  the predominance of  the  disease  in
the integument or peripheral  nerves.   It is  probable, however,  that  in all
cases both the skin (and  mucous  membranes) and the nerves are the seat of
the specific  infiltration.

   Lepra Nervosa.—Decreased cutaneous sensibility, either  with or with-
out obvious  change  of the skin, is the first  symptom  of the  anaesthetic
variety.   When gross changes  are present, they assume the form of erythem-
atous spots from two to  three centimetres in diameter, sharply defined, and
but slightly  elevated.    They persist  usually for months, and  then fade
slowly from  the  centre  outward.   They  generally reappear  in  the  same
regions, and  occupy a larger space and  are more prominent than during the
first outbreak.  They may  also  be attended with desquamation, so  as  to
resemble  psoriasis  vulgaris.   The affected regions are more  or  less  anaes-
thetic, and areas of anaesthesia may be detected on careful  examination in
regions which present  no gross appearances of disease.
   The next symptom is an outbreak of  vesicles resembling those  of pemphi-
gus.   The vesicles burst, and  leave a raw surface which may heal with more
or less loss of substance  and leave  behind a shining white anaesthetic cica-
trix.   The vesicular  eruption  is often attributed by the patients to scalding,
frost-bite, or pressure, and doubtless  such traumatisms are concerned in their
production, for, on account  of the anaesthesia, the hands and feet are some-
times  unconsciously  injured to such an extent as to impair  their vitality.
Muscular atrophy  and  contractures of  the muscles of the  extremities,
especially those  of the  hand, supervene,  and  examples of  the  claw-hand
(main-en-griffe) are  not uncommon.   Paralysis, especially of the orbicularis
palpebrarum  muscles, develops, and  may, through the resulting  inability to
close the  eye, lead to  destructive inflammation  of the cornea.
   The ulcers resulting  from the vesicular  eruption may,  instead of healing,
extend in depth and involve the  periosteum.  In this way the phalanges of
the fingers and toes may  be  gradually destroyed and cast  off spontaneously.
The nerves of special  sense and the lymphatic glands are seldom involved
in  this variety of the disease.   Amyloid  degeneration of  the kidney and
other glandular organs  is not uncommon.   The disease is  to a certain extent
paroxysmal,  each vesicular  outbreak being attended with fever,  and  some-
times  with delirium and coma.  As the disease progresses the patient be-
comes more and more emaciated and falls into  a state  of  profound cachexia.
Death is due  to intercurrent disease or  may  occur in one  of the  febrile par-
oxysms    The average duration of  lepra nervosa is  variously estimated  at
from  ten  to twenty years.  Sometimes the disease appears to be arrested, the
eruptions disappearing  and the general health improving in a marked degree.
It is even stated  that sensation may return to the anaesthetic spots    Lepra
nervosa may become converted into lepra tuberosa, in which event it is gen-
erally  rapidly fatal.
1 Trans. X. intermit, med. Congress., vol. v. 
1030
ERUPTIVE FEVERS.
  Lepra Tuberosa.—Tuberculous leprosy may begin somewhat abruptly,
with fever and cutaneous  eruption, or insidiously.   Ill-defined  spots  upon
the surface, especially of the face (cheeks  and eyebrows), are  generally the
first symptoms  to  excite suspicions of the disease.   They are of a livid or
brownish hue.  At a later period these spots become infiltrated, so as to form
distinct projections or marked tuberosities.   The integument of the face,
especially  of the superciliary region,  becomes  greatly  thickened, and the
countenance acquires  the characteristic  leonine  expression.  The  hair and
even the down (lanugo) of  the affected parts entirely disappear.  The sensi-
bility is not impaired  unless the nerves  are affected, and the case, therefore,
one of the mixed variety.  By degrees the entire skin of the face, including
that of the ears, is involved  in this  species of pachydermatous  thickening.
At  a  later stage distinct rounded  tubercles of the size of a  pea or larger,
and deeply pigmented, project from  the  thickened  base.   The parts chiefly
affected are the face and extremities.  The hairy scalp is never attacked, and
the neck, breast, and back may remain free from the infiltration  throughout
the course of the  disease.
  In  the  acute form  of tuberculous leprosy there  are  febrile  paroxysms
followed by eruptions  which often  resemble  patches of erythema nodosum
or erysipelas,   they may fade, leaving behind some thickening  or pigmen-
tation, or  in late  stages they may suppurate.   In  the course of time the
mucous membranes of  the  mouth, nose, and throat are attacked,  causing
hoarseness and  increased secretion of nasal mucus.   Swelling of  the lymph-
glands is an early and  prominent symptom.  The tuberosities upon the skin
have  been observed to disappear during the course of an intercurrent erup-
tive fever, and general* tuberculosis, to which many lepers succumb,  seems
to cause a recession of the  leprous deposit.
  The usual course of  lepra  tuberosa is  the  following:  The tubers eventu-
ally become depressed  in the centre  and disappear  by slow absorption  from
centre to  circumference.  This  may occur without ulceration.   In  other
cases  the  epidermis disappears from the depressed portion of the tuber and
a slow process of ulceration begins, which  may extend in depth and destroy
the underlying cartilages and bones.   In this  manner—by  softening  and
ulceration of the  leprous deposit—the cartilaginous framework of the nose,
the laryngeal cartilages, and  the cornea and other tissues of the eye may be
entirely destroyed.  In  this stage of the disease the cachexia is decided and
febrile paroxysms are  frequent,  The latter may be as regular in occurrence
as the paroxysms of intermittent fever.  The  symptoms now point  to an
involvement of internal organs.   This is not necessarily of a leprous cha-
racter, for, as already stated, amyloid degeneration of the kidneys and other
glandular  organs is a frequent complication.  A  persistent diarrhoea may be
due to amyloid  degeneration of the mucous membrane of the  intestine or to
the specific leprous deposit.

  Anatomical Characters.—The  leprous  tubercles  (" lepromata") are
classified by Virchow among the granulomata.   They  are  composed  essen-
tially  of round  cells the most of which are believed  to have emigrated from
the vessels.  There  has been considerable  discussion  as  to whether the
bacillus leprae is within or  outside of the cells of which the specific deposit
is composed.  Late researches indicate that during the early stages of the
process the bacillus is intracellular.   At  a later period many of the cells are
disintegrated and the  contained bacilli  set free.

  The diagnosis presents no difficulty except in the early stages and even
then  suspicions of the  disease should be excited by the spots of' erythema 
LEPROSY.
1031
succeeded by bullae, especially if  such symptoms were observed in one who
had  formerly resided in a country in which leprosy was endemic.   In doubt-
ful cases of  the tuberculous form  a fragment  of the  diseased integument
should be excised  and examined for Hansen's  bacillus.

   Prognosis.—The prognosis is always unfavorable, but  long  periods of
improvement  may occur during  the course of the disease, and in some few
it  appears to  come to a  standstill.   Of  the  two varieties,  lepra  nervosa
offers the better prognosis.

   Treatment.—It is customary  to  attribute the  rapid decrease of leprosy
in central Europe during the  Middle Ages to the strict measures of isolation
at that time enforced,  and  there  is scarcely any authority who questions the
advisability of a separation of the  infected from  the non-infected.   Never-
theless, it cannot be denied that leprosy has declined in places where the
isolation of  the infected  was but  partial.   This  is  true, for example, of
Norway, the  Faroe Islands, and  Iceland.  The  conclusion seems, therefore,
inevitable that there have  been other causes, apart from mere isolation, tend-
ing to the extinction of the disease.   As suggested by Bidenkap, these may
possibly be found in the improved social conditions, the greater comfort and
cleanliness, and the better  food coincident with the progress of civilization.
   The curative  treatment  is both hygienic and medicinal.  If possible, the
patient  should be removed to a mild, equable climate where the greater por-
tion of  his time may be spent in  the open air.   Frequent baths (both warm-
water and steam) are beneficial both  generally and  locally.  Tonics, especially
iron and quinia, are applicable to most cases, and  during the febrile parox-
ysms the latter  drug may be given in larger, antipyretic dose.   Cod-liA^er oil,
arsenic,  iodine, and  phosphorus  have  also  been   employed.   Among  local
remedies there are  two—gurjun  oil  and chaulmoogra oil—which have been
regarded as curative in early stages  of the disease.  The first mentioned is
made into a  liniment  by mingling it with equal parts  of lard oil and lime-
water, and rubbed into the  affected parts under  moderate pressure.   It is
also giyen  internally in doses of  5  to  15 minims  in emulsion in lime-water.
This drug is  largely employed by the physicians of India.   Chaulmoogra oil
mingled with twice its quantity of  lard  or lanolin is  also  used both locally
and  internally.   The  affected areas  are  rubbed with this ointment several
times daily, and during the intervals the skin  is  covered with a cloth satu-
rated Avith it.  Internally, it is given in doses of 5 minims three times a day,
which may be gradually increased up to the point  of  tolerance.   Intolerance
of  the  drug  is manifested by diarrhoea and vomiting.  Instead of  the oil
itself its active principle, gynocardic acid,  may  be given in 1-grain pills
thrice daily after meals.   Unna  has reported good results in one case from
the employment, both local  and internal, of  ammonium  sulphichthyolate.
Internally, this substance is given in pill form in daily doses of from 5 to 15
o-rains.   Koch's tuberculin has been employed in the  treatment of leprosy,
but  as might have been anticipated, with negative results.   In cases compli-
cated with tuberculosis the effect  of this remedy might be positively in-
jurious    Leprous ulcerations are  to be treated on general surgical principles. 
1032      DIPHTHERIA.—MILK SICKNESS.—INFLUENZA.
                        CHAPTER   IX.

         DIPHTHERIA.—MILK  SICKNESS—INFLUENZA.

Diphtheria:  Anatomical Characters; Clinical History; Pathological Character; Causa-
        tion; Diagnosis; Prognosis; Treatment.—Milk Sickness.—Influenza.

                             Diphtheria.

   OF the general  diseases which remain to be considered, one of the most
     important is the affection  now  commonly known as diphtheria.   This
affection  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 gangrenosa,
morbus suffocans vel  strangulators, 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—namely, the
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
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 be involved in  cases 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
ATesicated surfaces, wounds, ulcers, and leech-bites—in short, wherever the skin
is deprived  of epidermis.  Exceptionally it  may  he 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 
DIPHTHERIA.
1033
  the  tonsils or the soft palate.   The pseudo-membranous exudation is often
  al hough not necessarily, preceded by a simple (catarrhal) inflammation   The
  false membrane  is observed first as a grayish-white, slightly elevated natch
  which cannot be detached from  the  mucous  membra/e without leading a
  bleeding surface.  The white patches  may remain distinct, or they may coa-
  esce 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-
  ciation is sometimes soft  and pulpy in consistence ; hut 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
  tour 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
  sAvollen from cedematous infiltration and  the presence of inflammatory prod-
  ucts.   The tonsils especially are often  greatly enlarged.   The uvula may be
  sAvollen 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.
   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. (Vide p. 208.)  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, hut 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, Ayhereas 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 deri\red 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  Avhite blood-corpuscles.  Upon mucous
membranes covered Avith laminated flat  epithelium, as upon  the tonsils, 
1034       DIPHTHERIA.—MILK SICKNESS.—INFLUENZA.

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 well 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 closety adherent to  the
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 Weigert
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 organism
that is now generally recognized as the specific infectious agent of diphtheria
was first thoroughly described and studied by Loftier.2 although  it had been
preyiously observed by Klebs.3  It is  therefore commonly  snoken  of as  the
Klebs-Lbffler bacillus.   Loftier  found this bacillus to be a constant accom-
paniment of diphtheria, but at first  expressed himself with reserve as to its
specific  nature,  because  he  had once found it in the mouth of a healthy
child.  Later researches  by  Loftier himself, by Boux and Yersin, Escherich
Bneger, and others have removed all  doubts concerning the  specific nature

thlrP^nn!lfPeam0frdi^hthe-rltiC inflararaa£0ns of the intestine or of the bladder when
there is no thought of the existence of the disease known as diphtheria
   lUifthedimgen aus d. Kais. Ges-Amte, Bd. 2, 1884
  3 2 Cong, fur inn. Med., Wiesbaden, 1883. 
DIPHTHERIA.
1035
of this organism.  The confusion in which  the  etiology of diphtheria has
been involved is  due to the fact that  all cases  of membranous pharyngitis
are not diphtheritic.   It  is now well recognized that  a distinction is to be
draAvn between  diphtheria  and pseudo-diphtheria.  For example, the  mem-
branous  angina so frequently observed  in  scarlatina  is generally pseudo-
diphthentic, although genuine diphtheria may occur under the same circum-
stances.  ^ The only certain method of establishing the diagnosis of diphtheria
in doubtful cases  is a bacteriological examination, including cultures  of the
organisms of the fibrinous  deposit.  The presence  of the Klebs-Loffler
bacillus  stamps the case as one  of  genuine  diphtheria.—H.]
   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
loAver jaA\r, 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 lungs 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  invoh7ement of the air-passages,  the anterior and upper parts of
the lungs 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  degeneration of the  heart  and  acute myocarditis have been found  in
certain cases which terminated suddenly with  signs of paralysis of the heart.
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.   Without 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 
 1036       DIPHTHERIA.—MILK  SICKNESS —INFLUENZA.

 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,  fhe  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 may be increased paroxysm-
 ally, as in  simple laryngitis or in true croup, by the addition of spasm  of
 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 diff'er  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.                                              r
  In cases of greater or less severity  the clinical history embraces symptoms
                              1 Vide p. 209. 
DIPHTHERIA.
1037
 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 ansemic 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 aff'ections
 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.  Vomiting  is  a frequent,  and in some cases  a prominent, symptom
 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 aff'ection 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. 
1038       DIPHTHERIA.—MILK SICKNESS.—INFLUENZA.

Hematuria 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 Aveeks. 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-
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 
DIPHTHERIA.
1039
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 Avhich 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,
giving 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.   Xotable impairment or loss of virile  power may be mentioned as  one
of the rare sequels of dipththeria.
   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 in 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. 725) 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.

   Pithological  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, [but
•ire largely due to the  entry into the blood of toxic products secreted by  the
specific' organism  of the disease,  the Klebs-Lbffler bacillus.   At the same
time symptoms of septicemia  may be produced by the absorption of putrid
products of the local  inflammation.—II.]                        _
   A question  which has occasioned  much discussion and concerning which 
1040       DIPHTHERIA.—MILK SICKNESS—INFLUENZA.

opinions differ is, whether diphtheria and membranous croup  be distinct dis-
eases.   [This has been settled by the discovery of the Klebs-Lbffler bacillus,
although in practice the application of bacteriological tests to fibrinous exu-
dations is  often  difficult or impossible.   The clinical points of distinction
between diphtheria and certain forms of pseudo-membranous  laryngitis have
already been discussed under  the  head of Membranous Croup.—H.]
   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
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 Avhat 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 amo,ng 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 disease has been repeatedly communicated
to the  lower animals by inoculations with the Klebs-Lbffler bacillus.—H.]
Further evidence of the contagiousness of diphtheria is afforded by the intro-
duction of the disease into  situations where it had not previously existed
by patients coming from places in which it was  prevailing.  There are  some
instances recorded of the special poison being transported by individuals who
did not themselves become infected with the disease, but such cases are rare.
The contagium of diphtheria 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  had been  a  patient affected
with diphtheria.  Observations have been reported Avhich show the possibility
of the transmission of the diphtheritic poison by means of  milk.1
   [Certain  of the  lower  animals, such  as the  calf, the turkey, and the cat,
are subject to  a  disease which closely resembles  diphtheria  and is believed
by some to be identical with it.   The facts  appear to the  writer to  be in
favor of the view  that the disease  may be transmitted by these animals to
man.—H.]
   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.
        1 Vide article by Hart in Proc.  of International Med. Congress of  1381. 
DIPHTHERIA.
1041
  siWe thnt 5hpa8eS °TUr Und^ CjrCUnistances whkh  seem to render it  impos-
  butV^il     PeClaI igei'm °f dlPhthe™ had been introduced from without-
  occur^^ " SCr  J,SPOntane°US devel°P—t of other contagious diseas s
  SC„!  tjiese instances cannot overthrow the  general belief in the con-
  rag Hie source  Pf/^-  ^ * ^^ tTUe that [t is often  ^possible to
  trace the source  of  infection  in cases of diphtheria.
  suscentibilb?^   % tt(\d!Phtheria is ^ equal at all periods of life.   This
  susceptibility is  greatest  between two and seven years of age.  After this
  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  Avith  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.

   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
 special 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
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
         66 
1042       DIPHTHERIA .—MILK SICKNESS.—INFL UENZA.

for a time for puerperal fever.   When 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  be 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.  [The  only positive criterion of the nature of the false membrane—
and hence of the disease—is  afforded by a bacteriological examination of the
exudate.—H.]

   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.   Without  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 be 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 week.
   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-
cope in this disease.   It may occur in  cases  which,  as regards  the general 
DIPHTHERIA.
1043
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  eases 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.-—With 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 poison the system with the
products of their activity, it is a reasonable supposition that local treatment is
first in importance.  According to  this view, the object is to destroy the para-
sites  as early, quickly, and effectually as possible.  There is sufficient  prob-
ability 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,  Bational 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 data 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 bv some practitioners,  and their use is sanctioned by some
standard authors.  Thev 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
 kin in which there is abrasion ; as. for example, after the application of a
blUter   Manv physicians have testified to the apparent hurtfulness of  these
applications  "On the other hand, testimony of their usefulness is not want- 
1044       DIPHTHERIA .—MILK SICKNESS.—INFL UENZA.

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 Avith 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.  Whatever  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.   Various
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.   When 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 haATe
weight in proportion  to  their  opportunities for observation and  the  confi-
dence placed in their opinions.
  [Dr. J. LeAvis Smith of New York recommends the following treatment of
diphtheria, Avhich has  been used  with success  at the New York Foundling
Asylum : " Trypsin, when  well prepared  and fresh, is an active solvent of
pseudo-membranes,  but it requires an alkaline medium for its activity.   Sul-
phur, as  shown by  E. B. Squibb of Brooklyn  and others, requires moisture
in order  to obtain its full activity  and efficiency  as an  antiseptic  agent.
Therefore, by means of a steam  atomizer,  the  vapor  of the following pre-
scription is constantly directed toward  the face  of the patient:

            R. Sodii bicarbonat.,
                Aquae calcis,
3ij;
Oil.—M. 
DIPHTHERIA.
1045
Or this:
             R. 01. eucalypti,                        ^ij ;
                Sodii benzoat.,                       sj •
                Sodii bicarbonat.,                     ^ij ;
                Glycerini,                            ii •
                Aquae calcis,                         Oij.—M.

While this spray is being used the following powder is blown by the insuffla-
tor over the  fauces and into the nostrils every hour or two hours:

             R. Trypsin,
                Sodii bicarbonat.,                  da. §ss ;
                Pulv. sulphuris,                      gij.—M."

   Of late years peroxide of hydrogen has been largely employed as a topical
remedy in diphtheria, but, it must be  confessed, with discrepant  results.
These are, in all probability, due to  variations in the strength and quality of
the preparation.   When  it gives rise to decided smarting, it is either too
strong or too acid.   Smith  recommends for spraying the fauces a 15-volume
solution  diluted  with  ten  times  its bulk of water, and for the  nares the
same solution  diluted  twelve or  fifteen  times.  He advises that the mother
or nurse  first  apply the  spray to her own throat, and  dilute it if it causes
pain.  The writer believes  in the efficacy of  the peroxide of hydrogen when
employed with the above-mentioned precautions.   It is a powerful  germicide
and  disinfectant, and, being free from  taste  and  odor  and non-poisonous, is
especially applicable to the treatment of diphtheria in  children.—H.]
   With 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
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 Dr.X E. W. 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 haA-e
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.  We
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
   Uide 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 
 ] 046       DIPHTHERIA .—MILK SICKNESS. —1NFL UENZA.

 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,
 Avithout 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 ; but,  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-
 radic or primary so-called  true croup.   The  most efficient of the measures for
 this  end is the inhalation of Avarm vapor or steam.   With  reference  to this
 measure and other points relating to the treatment directed to the laryno-eal
 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.   With 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 liyes 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
                              1 Vide p. 210. 
MILK SICKNESS.
1047
  (intubation) has been practised with considerable success by Dr O'Dwver of

  in  Utai Imd le" ^""S"^ ^^ * W  °^ Factitioneifw
  obtained  b^^  O'llw      r^8"1'8 "\ emPlo?ing ^is method than those
  thTsubiectof Vli,l J     Cnhe rGUiai'ks °n intu^tion  in connection with
  the suoject  of Membranous Croup  are equally applicable here —H 1
    The  propriety of precautions against co\tagLnhL been a read,  referred
  to.  Patients affected  with the disease should be at once isolated   When
  ever practicable, the  removal, especially of children between thee and I Ive"
  years  of  age from an  infected house or district is  advisable.   Thorough  dJ!

  PatentTand o?  tt^T °* *l iv^  whichW been in  contact wih
  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
  strychnine       CUrreDt'       J h^odermic injections of small doses  of


                             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 West-
  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
  Western 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
  World.   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.
   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 eAxidence 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 Avriters  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 
DIPHTHERIA—MILK SICKNESS—INFLUENZA.
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 oniy 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.  Wild 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  arc
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 Umhelliferae,
the Eupatorium  ageratoides,  the  Bhus  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-
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 
MILK SICKNESS.
1049
 more pronounced, extreme  nausea and vomiting supervene  accomnanied bv
 mtense thirst, obstinate constipation, and a ^L^ivJ^^°^^2
 The temperature of the surface, particularly of the extremities LTlow 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 pre"
 sure.  The pulsations of the abdominal aorta are prominent,  IntestinalCe  -
 istole seems to be wholly suspended.   The tongue is swollen and flabby  pre-
 senting the impressions of the teeth, and when protruded is tremulous7' ? \t
 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  eyes 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.   Vomiting 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-
 ing 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.  Becovery is slow.
   Nothing  is positively known concerning  the pathology of milk sickness.
 The symptoms suggest an intense gastritis, but in the few recorded autopsies
 mention is  made only of redness of the mucous  membrane  and  contraction
 of  the stomach.   The intestinal canal  has been found markedly contracted.
 With 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 
1050       DIPHTHERIA .-MILK SICKNESS.—INFL UENZA.

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

                         [Influenza—Grippe.
  Definition  and Etiology.—The term  " influenza " is of Italian origin,
and was introduced " at a time when less was understood of its  nature  and
origin than at present, if indeed this  be  possible."2   It is evidently derived
from the belief that the prevalence of  the  disease was due  to some  peculiar
influence of the stars, and, although the days  of " stellar pathology " have
gone by, the term  survives, and is undoubtedly the  best for  the disease in
question.   This is  chiefly because it is universally understood  and  is at the
same  time  absolutely  non-committal.   The terms  into  which  the word
" catarrh "  enters,  such  as epidemic catarrh and  epidemic catarrhal  fever,
are objectionable  because  catarrh  is  not  necessarily present.  The  term
" grippe " has been recently introduced into this country from France, where
it has long been applied to attacks of ordinary  coryza.  It seems  to  have
taken hold  of  the  popular fancy, and  it  is possible  that it may eventually
supplant the older and, as I believe,  the  better  name for  the disease.
  Influenza is pre-eminently an epidemic disease, and frequently pandemic.
In the rapidity of  its extension over the globe it surpasses  cholera, and the
same  is true  with regard to the number  of individuals infected.   In the
great epidemic of  1889-90 it is  said  that one-third of the inhabitants of
Bussia  suffered from the disease.  The march of the disease is so rapid that
it has been  attributed to a miasm which is  conveyed  by the  atmosphere, but
closer study has demonstrated  that its progress  is  not  faster than that of
human  beings on their travels.  For example, it is said that in 1780 the  dis-
ease took six months to travel from St. Petersburg to Paris, while in 1837 it
traversed the same distance in six weeks.  In 1889 it never travelled  faster
than  an express-train.   Another  fact which  militates  decidedly  against the
idea that the poison is conveyed by the atmosphere is that in 1889, while the
disease  Avas travelling rapidly from east to west  and from north to south, the
prevailing winds were in the opposite directions.
  Attempts have been made to connect the prevalence of influenza  with cer-
tain meteorological  conditions, but thus  far  they have  been unsatisfactory,
not to  say contradictory.  For  example, in Bussia, during the epidemic of
1889, the barometer is said by Teissier to have  been  continuously low, while
the atmosphere was almost saturated with moisture and the temperature decid-
edly above the average for the same period  of the year.   On the other hand,
Masson states that during the epidemic in Paris the barometer was unusually
high  and the temperature lower than usual.  The  only point of agreement in
the atmospheric conditions is found in the fact that both in Bussia and France
the air  contained an unusual amount of moisture.
  The  disease has been attributed to  an  excess of ozone in the atmosphere,
but on  no other ground than that ozone is irritating to  the bronchial mucous
  1 The  following are among the articles which describe  this disease: Hirsch, Handb d
Histonsch-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 West," 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 3Ied
and Surg. Reporter. Apr. 12, 1884.  A thorough monographic treatment of the subject is
much to be desired.                                                    J
  * Influenza, by Symes Thompson, London, 1890. 
                                INFLUENZA.                         1051





  micro-organism to which influenza is probably due are favored b/certain
  conditions of the atmosphere.   This  would appear  to follow from what we
  know of the cultivation of microbes in the laboratory, where the s^ate of the
  soil and the  temperature must be adjusted to habits  of aclvariety
  Ihus far, however, nothing definite has been  learned concerning the S
  spheric conditions most  favorable to the propagation  of influenza
    Every epidemic the course of which has been accurately traced has trav-
  elled from east to west.  The disease is said to be endemi/in S  Petersburg
  and Moscow as well as in Central Asia.                                  g
    The question whether  or not influenza is contagious  has  been keenly dis-
  cussed, and at present the weight of opinion  is in  favor of an  affirmative
  ansAver.   The facts upon which is  based the opinion that the  disease  is com-
  municable directly from  the  sick  to the well are very numerous and in my
  opinion, most convincing.  In the  first place, the proportion of cases is much
  arger among individuals living together than in those who  occupy separate
  houses  or  apartments.   If contagious, we  would naturally expect to find a
  number of cases in large industrial establishments,  and such is actually the
  case.  For example, it is said that influenza appeared  first in Paris in 1889
  on the  26th of November, in the  Magasin du  Louvre, and  that 670 of the
  employes were speedily attacked.2   Now, it is scarcely reasonable to suppose
  that this epidemic outbreak  was  due to  certain germs  wafted by the atmo-
  sphere through the doors and windows of this  particular building, to the
  exclusion of those adjoining.  It  is much more likely that  the contagion
  spread from  one  to another  until all of the large number  mentioned were
  infected.
    In general terms, the proportion  of cases is very large in schools, factories,
  and municipal buildings—i. e. in communities  which have free access to the
  outside world, and therefore abundant opportunity for acquiring any kind of
  contagion and conveying  it to their associates ;  while, on the other hand, the
  proportion  of  cases is  small in prisons and insane asylums—i. e. in communi-
  ties debarred  from intercourse with the  outside world.  One of the best
  proofs of the doctrine of contagion, although a negative one, is afforded by
  the immunity from influenza  which was enjoyed by the lighthouse-keepers
  of England during the epidemic of 1889-90.   At this time  there were on
  the coasts  of England and  Wales and  in the  Channel Islands about 415
  " keepers" distributed  among 51 lightships and  16 lighthouses on detached
 rocks or piles.  Among these persons, who were, in  virtue of their occupa-
 tion, peculiarly exposed to the  vicissitudes of the weather, there were only
 eight cases of influenza, each  one of which  had  been  exposed to contagion in
 places on shore where  the disease was prevalent.3  It was observed in certain
 parts of England  that the  epidemic of  1889 was preceded  by an  epizootic
 disease among horses to which the  name of influenza was applied, and it was
•supposed that the  disease in  man  might have  been  derived from the horse.
 Parsons, however calls attention to the fact that the so-called horse-influenza
 has prevailed at times when  there has  been no human epidemic,  and that
 persons having the care of horses  were not observed to suffer particularly
 from the  disease or to be first  attacked by it.   Finally, influenza  has been

        1 Loc. cit., p. 414.
        2 Widal, Traite de Medecine, tome i. p. 805.
        3Dr Parsons' "Report to the Local Government Board," 1891, p. 95. 
1052      DIPHTHERIA.—MILK  SICKNESS.—INFLUENZA.

observed to prevail  in  places  where there was  no similar  disease  among
horses.
  The fact that the source of infection or contagion is not always discover-
able does not in the least disprove the infectious or contagious nature of the
disease,  for the  same  obscurity  often  surrounds  the  origin  of  smallpox,
measles,  and  scarlatina.   As  Parsons  remarks:  "The  botanist  who is
acquainted with the flora of a particular locality will sometimes observe by
the wayside or in cultivated ground a plant of a kind never previously found
there by him, but he does not therefore suppose  that  it has originated de
novo, but concludes  that  the seed or root has somehow  been introduced,
although he may  not be  able to trace in  what way."

  Bacteriology.—As yet, notwithstanding the researches  of the most com-
petent investigators, no micro-organism  bearing  a constant relation  to  the
symptoms of influenza has been detected.  In the bronchial mucus, in serous
effusions, and in pulmonary consolidations the microbes so commonly present
in such  pathological products have  been frequently  found.   Among them
may be mentioned the diplococcus of Fraenkel, the pneumococcus of Fried-
lander, the streptococcus pyogenes, and the staphylococcus  pyogenes aureus.
The different organisms are the causes of the various secondary infections or
complications of  influenza, but are in no  way to be regarded as  the cause of
the  disease itself.  Chantemesse  and  Widal examined the blood in eight
cases of influenza, and never succeeded in detecting any  organisms  Avhatever,
either by direct inspection  or by culture.

  Anatomical Alterations.—Lesions  peculiar to influenza are unknown.
A fatal  result is almost invariably due  to  complications, and  especially to
pneumonia, either fibrinous or catarrhal.  Eichhorst mentions having seen two
cases proceed to a fatal issue with no symptoms other than those of profound
prostration, and finding at  the autopsy nothing abnormal except an enlarged
and softened spleen.  In most cases there are signs of catarrhal  inflammation
in the larynx, trachea, and bronchi,  together with congestion  of the lungs
and enlargement of the spleen.  These  may be regarded as the characteristic
anatomical alterations of influenza, but there is nothing by which  they may
be distinguished  from ordinary congestions and catarrhs.  The  complicating
pneumonia seems  to have a  special  tendency to terminate in  suppuration.

  Symptoms.—The symptoms of influenza are remarkable for their variety,
and can scarcely be made to conform  to any single  type.  This is particularly
observable when different epidemics are compared, although  even in the same
epidemic the disease is remarkable for the diversity  of its manifestations.
For example, the epidemic of 1837 is said to have been  chiefly  characterized
by coryza, and hence the  term influenza  came to be misapplied to ordinary
cases of sporadic  catarrh.  In  1889  coryzal  symptoms were comparatively
rare, being well  marked in not more than from one-third to one-half of all
cases.   Nevertheless, there are certain features common to all cases which
may serve as starting-points in the description of  the clinical course  of  the"
disease.
  Incubation.—The difficulties in  the way of determining the  length of  the
stage of incubation are unusually great,  because of the  almost  universal
prevalence of the disease.   This makes it very difficult to determine whether
the known exposure of an individual  to infection is  the only  one to which
he may  have been subjected.   Probably the  best  opportunity for  determin-
ing the length of this stage is afforded  by those  instances in which the ar-
rival of  a person suffering from influenza in a place previously  free  from it 
INFLUENZA.
1053
  has been followed by an outbreak of the  disease, the first cases occurring in
  those who first came in contact with  the  new-comer.  Instances of  h^!ort
  are numerous, and those who have observed them  agree  n fixmethemeuod
  of incubation  at  from two to three  days.   It is, however va  abe  S
  exceptional cases may be  protracted to a week  or more          '      1D
    Invasion— The attack generally begins abruptly with a well-marked chill
  or repeated  slight shivering, pain in the head, back,  and muscular  system
  general y, and a rapid rise of temperature-sometimes to 104° or 105° F
  Ihe aching in the back  and limbs is often most distressing.  As remarked
  by Thompson, « the  patients are unable to be still on accoimt of theTchino
  and umvilling  to move on account of  the  pain."  The prostration  is extreme
  and attended with great depression of spirits, insomnia, and sometimes deTr
  urn.  Catarrhal  symptoms, manifested  by conjunctival injection,  lachryma-
  tion, sneezing  and sore throat, are prominent in some epidemics and observed
  more or  less frequently in  all.  Added to  these may be a  hard  dry cou-h
  of a paroxysmal character, somewhat like that of  whooping cough, and at-
  tended with little or no expectoration.  As a rule, the symptoms in  individual
  cases are  chiefly referable to the nervous,  the respiratory, or  the digestive
  system.   In the nervous form the attack begins with severe throbbing head-
  ache, a sense  of constriction in  the forehead and temples, and pain  in the
  eyeballs.   It may be accompanied with photophobia, vomiting, and a tend-
  ency to somnolence.   During the first night of the  attack  the  drowsiness is
  apt to be replaced by insomnia attended with great restlessness and jactitation
  and sometimes by violent  delirium.   Toward morning  the  patient becomes
  more tranquil  and is perfectly able to recall the  disagreeable events  of the
  past night.  The temperature, which may  have been as high as  104° or 105°
  during the night, undergoes a marked remission, or falls to the normal point-
  in  the course  of the day  and there  continues.   On the  other hand, there
  may be a recurrence  of  the fever on  the  second  night, but never  in uncom-
  plicated cases does it reach the maximum  observed  during the first night of
  the disease.  Although the temperature  may be normal, the patient is by no
 means well, but is kept in bed by a sense of profound prostration, both  bodily
 and mental, which hinders  him from attempting any  species  of  exertion.
 Convalescence  in  cases  of this  sort  may be protracted  for weeks, or the
 attack  passes  off completely and  the  patient resumes  his  ordinary occupa-
 tions, to  be prostrated  again in  the  course  of a few days by a genuine re-
 lapse.  Trigeminal  neuralgia,  sciatica, and  intercostal  neuralgia  are often
 observed in this  form of the  disease, and may be its chief, or even its sole.
 manifestation.   Hyperaesthesia, either diffuse or in distinctly circumscribed
 areas, has also been described.   The  principal  seat  of pain  is in  the
 lumbar region  of the  spine, and  this rhachialgia may  be so intense  as to
 create suspicions  of an impending attack  of smallpox.   From the back it
 usually radiates to the  neck and the  extremities.  Fortunately, it  is not, as
 a rule, of  long continuance, generally subsiding in the course of from twelve
 to  twenty-four  hours.
   The rhachialgia  has been  regarded  as due to congestion of the spinal me-
 dulla, and this Ariew of its origin is corroborated by the  frequent coincidence
 of  paresis, or even paralysis, of the lower extremities, and occasionally also
 of  paralysis of  the  bladder.   These different forms of paralysis, when due
 to  acute' congestion of the  spinal medulla, are of very  transient  duration.
 When they persist during convalescence, they are generally due to peripheral
 neuritis.   In rare  instances  paralysis of the  extremities  has been dependent
 upon anterior poliomyelitis.
  Syncope, vertigo, dyspnoea, slowness, irregularity, and intermittence of the
pulse, and  attacks of praecordial pain  resembling angina pectoris have been 
 1054       DIPHTHERIA .—MILK SICKNESS.—INFL UENZA.

 observed, either singly  or  combined, in the nervous  form of influenza, and
 are believed to be due to an involvement of the medulla oblongata.  They
 are all comprehended under the designation of u bulbar phenomena.''   The
 exact nature of the  bulbar lesion  which gives rise  to these symptoms is un-
 known, but  it is probably congestive.  Symptoms  identical with  those  of
 cerebral  meningitis  are  sometimes present, and because of their usually
 rapid subsidence are  believed to  be due to vascular  disturbance alone.   Sup-
 purative  meningitis  has,  however, occurred in cases of  influenza,  and is
 generally secondary to otitis or pneumonia.  It arises  by secondary infection
 with one or other of the micro-organisms mentioned  under the  head  of
 Bacteriology.
   In  the thoracic or respiratory form of influenza the  attack begins  with
 coryza like that of an ordinary endemic attack.   The inflammation,  however,
 does not remain localized in the nasal mucous membrane, but extends upward
 to the conjunctiva and downward  to the larynx, trachea, and bronchi.   On
 auscultation  a few sibilant rales are heard on both sides of the chest.  Cough
 is not usually present until the second or third day of the disease,  this  time
 being apparently required for the downAvard descent of the catarrhal process.
 It  is dry and convulsive; later it  becomes looser, and the  expectoration is
 often nummular, like  that of phthisis.   The most serious  pulmonary mani-
 festation of influenza is pneumonia, which may occur either at the beginning
 or at the end of the  attack.   In the first form—that which occurs at the
 onset—the pneumonia is a primary manifestation of influenza, and  differs in
 several important respects from the ordinary non-epidemic fibrinous  pneumo-
 nia.  The initial chill  is generally absent, the pain in the side slight or want-
 ing, and the crepitant rale  rarely heard.  The  rales of this  form  of pneu-
 monia are subcrepitant rather  than crepitant, and the expectoration resem-
 bles  that of  bronchitis rather  than that of fibrinous  pneumonia, being less
 viscid than the latter  and only exceptionally tinged  with blood.   The dysp-
 noea is usually greater than would  seem to be warranted by  the amount of
 lung involved.   The  pulse is less frequent and  also less resistant than that
 of ordinary pneumonia.  The general condition  is marked by great prostra-
 tion, and recovery, when it occurs, is by lysis rather than by crisis.  A lung
 affected with this disease  may present microscopically  the  appearance  of
 lobar or  fibrinous pneumonia,  but  the  exudation, when  examined with the
 microscope,  is found  to  contain an unusual quantity  of  leucocytes.
  The pneumonia which occurs  at the close of an attack  of influenza or
 during the period of convalescence is a  complication  rather than a  manifesta-
 tion of the primary infection.   Under such circumstances the type  is either
 that of ordinary broncho-pneumonia or of fibrinous pneumonia.
  Pleurisy, either dry, sero-fibrinous, or purulent, may occur, either in asso-
 ciation with pneumonia or independently of the  latter.  It is said  that the
 streptococcus is the organism most often found in  the pus of that  form of
 empyema  which  complicates influenza.   The digestive  system is more or less
 disordered in all cases of influenza,  the tongue being, as a rule  heavily
 coated the appetite completely absent, and the patient complaining of a
 sense of epigastric uneasiness which may be temporarily relieved by vomit-
 ing.   Occasionally, however, the  gastro-intestinal symptoms are  so promi-
 nent as to give  the attack  a special character and cause it to  be classified as
 an abdominal variety of the disease.   Obstinate vomiting, severe diarrhoea,
gastralgia, and intestinal colic  are  the  principal  symptoms of this  form  of
influenza^  Sometimes the  intestinal  symptoms predominate,  and  when
accompanied with  a heightened temperature  are apt to excite suspicions of
typhoid fever.  This mistake is by no  means rare, and may be made by the
best diagnosticians.   The resemblance  between  certain abdominal forms of 
INFLUENZA.
1055
influenza and typhoid fever is  often great.  In the former the patient may
he in a  stupid apathetic state  with frequent diarrhoea, enlarged and tender
spleen, tenderness in the right iliac fossa, slight  bronchitis, and even  epis-
taxis.   Under such circumstances the diagnosis must be held in reserve  until
the differential points are brought  out more prominently  by the progress of
DUG  CcLSG.
   The action of the heart is depressed in all cases of influenza, and probably
as already  intimated, through  an  involvement of  the   medulla oblongata.'
Ihe pulse is often slow, irregular, and  intermittent, and these manifestations
of cardiac weakness may persist for a  considerable period after the cessation
of the attack   On account of its depressant action upon the heart,  influenza
is a serious disease  in the aged, as well as in all individuals who are the
victims  of  any  kind of cardiac disease.
   Certain eruptions  resembling those  of measles and scarlatina have  been
described by most writers as  occasionally occurring  in  the course of  in-
fluenza.   They appear on the second or third day,  are most prominent on the
face, neck, trunk, and inner aspect of the lower extremities, and are followed
by desquamation.  They rarely last longer than forty-eight hours.   It seems
to me  that  undue importance has  been attached by certain  writers to these
erythematous rashes, which all must acknowledge are quite rare.   Out of
1000 cases examined particularly with reference to  this  point  by Dr. H. P.
HaAykins of St.  Thomas's Hospital, London, only 7 had the eruption.
   Numerous disorders of the  eye  and ear have'been described as compli-
cating the course of influenza.   Among them are oedema  and abscess of the
eyelids,  paralysis of the  ciliary muscle and of the  recti  muscles,  keratitis,
iritis,  ciliary neuralgia,  xanthopsia, hemeralopia, etc.  The most common
affections of the  organs  of special sense  are  purulent inflammation of the
middle ear  and acute pain in the eyeballs, supposed to be caused by inflam-
mation of the capsule of  Tenon.

   Duration.—There is  no fixed rule  as to the duration  of an attack of  in-
fluenza.   In the  mildest cases it may consist of nothing more than headache
and  neuralgia of one or  more nerve-trunks,  or of  coryza,  hoarseness, and
cough, or of what seems to be nothing more than an  attack of severe indiges-
tion.   Fever  in  these slight forms  of  the disease may not  be  present, and
never  lasts  more than  twenty-four hours.  The  patient, although feeling
far from  well, may be able to  attend  to  his  usual  occupations, and  in the
course of two or three days is  well.  In the severe  cases the fever and the
nervous  phenomena may persist for four or five days, at  the end of which
time  the attack  terminates with profuse sweating, diarrhoea, polyuria,  or
herpes.  Belapses are quite common, occurring in nearly ten per cent,  of the
cases, and a second relapse has been observed.  The  period of the relapse
is usually betAyeen one  and two weeks after the primary attack, and  it is
generally traceable to exposure  to cold or resumption of work before recovery
was complete.  The relapse is  usually more severe than the  primary attack,
with which  it generally corresponds in type.   A primary attack of nervous
type may, however, be  succeeded by a relapse  in which catarrhal symptoms
are predominant.
   \s previously  remarked, convalescence is  protracted  and marked by a
degree of lassitude apparently  out  of all proportion to the  severity  of the
primary  attack.   The nature  of the symptoms of  the convalescent  period is
determined  by the type of the  attack and the constitution of the individual.
In neurotic  individuals cephalalgia,  insomnia, and  a general  state of neuras-
thenia may  persist for many weeks  or months.  In fact, there are individuals
at this  date (1894) who  refer  the  origin of muscular and  neuralgic pains 
 1056       DIPHTHERIA .—MILK SICKNESS.—INFL UENZA.

 and other symptoms from which they habitually suffer to an attack of influ-
 enza in  the  winter  of  1889-90.
   One attack of influenza is not protective against another, the disease in
 this respect resembling diphtheria, erysipelas, and cholera, rather than mea-
 sles, smallpox, scarlatina, and whooping cough.

   Diagnosis.—In times  of epidemic, when physicians are on the alert,  the
 diagnosis of influenza presents no difficulty.   The tendency at such times is
 rather to attribute every  affection of  the muscular, nervous, and respiratory
 systems  to influenza than to overlook individual cases of the latter.
   In the nervous form  attended with severe rhachialgia and a scarlatiniform
 eruption smallpox may be at first suspected, and in  children with marked
 catarrhal symptoms it may be difficult or even impossible to distinguish  the
 onset of  influenza from that of measles.  A little time will settle the diag-
 nostic  difficulty in both instances.  The  muscular and articular pains may
 simulate rheumatism very closely, but are more evanescent and unattended
 with the local articular  phenomena, redness, heat, and swelling, so character-
 istic of rheumatic inflammation of the joints.
   The abdominal form  may closely simulate typhoid  fever at its origin, but
 the distinction soon becomes manifest by the decline of fever and the absence
 of the lenticular  rose-colored spots upon the abdomen and elsewhere.
   The nervous form  of  influenza bears a certain resemblance to dengue, and,
 since the latter disease was  prevalent in Syria when the epidemic reached
 Paris in  1889, many  physicians were at first inclined  to regard it not as influ-
 enza, but as  dengue. This mistake was the more natural  as  the catarrhal
 symptoms which were so prominent in previous epidemics of influenza were
 at first conspicuous  by  their  absence.  With  the progress of the epidemic,
 however, the catarrhal  symptoms came to  the  front  and doubts as  to the
 nature of the epidemic were generally dissipated.   There are, however, those
 who continue to regard  influenza as the dengue of northern latitudes.
   The question may not  be  definitely settled until, with the progress  of
 bacteriology, micro-organisms peculiar to each of these affections  are dis-
 covered.  It seems, however, to the writer that the diversities in their clinical
 course are amply sufficient  to  warrant their separate classification.  The
 phenomena presented by  dengue  in  different epidemics  are  comparatively
 uniform.  Catarrhal  manifestations are exceptional  instead of forming the
 rule, as in  influenza. The pain  in dengue is  articular rather than muscular
 or neuralgic, more intense than the neuralgic pains of influenza, is especially
 apt to attack the knees, and causes a characteristic limpin^  o-ait   The
 temperature-curve of dengue  is, as a  rule, higher than that  of Influenza and
 marked by remissions.   Dengue, instead of running its course in a few days
 lasts from one to  three weeks;  and, finally, among its symptoms is an erup-
 tion which makes  its appearance  in the great majority of  cases.   This erup-
 tion is, it is true, variable, being sometimes  erythematous or even vascular •
 but  cutaneous lesions  are the rule,  instead of being, as in influenza, rare
 coincidences.

   Prognosis—Influenza  is in itself a benign affection, and  is rarely fatal
 except in the aged  and those debilitated  by previous illness.   In marked
 contrast to  cholera, it is  said to be sometimes less fatal at the beginning than
 at the height of an epidemic,   « Vires acquirit eundo."  This was particularly
marked in the epidemic  of 1889-90.   According to  Parsons, « the mortality
 n London in  1890 ascribed directly to influenza  has been 648 deaths, or at
 he Tj      *?* S-LT °f th6J estimated population."   Of these deaths,
the great majority (5o8)  occurred in the  first  quarter of the year 
INFLUENZA.
1057
 of 'PeT^ '? *f*'- thT Were  i'120'000  ca«es of influenza  in the  State
 «JrJ.S   T a      g thG re°ent ePidemic> of which number  78S0, or 1 in
 C\ciy 14_i.  0.10(1.
   The above figures, supposing them to be correct, by no means represent the
 mortality  of influenza,  for, as is  well  known, this  disease is distinguished
 perhaps above all others  by the prolonged debility  and consequent suscepth
 bihty to other diseases which it leaves behind.  It also has the property of
 bringing to light affections, especially of the lungs and heart,  which other-
 wise might have remained latent for an  indefinite period
   Probably the best method of ascertaining the mortality of influenza is
 that of comparing the number of deaths from all causes during its epidemic
 prevalence  with that of the same period in  ordinary non-epidemic  seasons.
 lhis has been done in London, and  with the following results:2 During the
 four weeks ending  Jan.  25,  1890, which  comprise  the  period  of the
 epidemic, there were 2258  deaths above the average for the corresponding
 weeks in the  previous ten  years.   This  is at the rate of 6638 per million
 inhabitants  per  annum.   The  affections  which contributed most  largely to
 swell the  mortality during the four  weeks mentioned were diseases of the
 lungs and  heart.
   The prognosis in individual cases  depends largely upon the  condition of
 the patient at the time  of the  attack.   Previous  affections of the lungs,
 kidneys, and especially of the heart, add greatly to the gravity of the disease.'
 In pregnant women an attack  of influenza is apt to give rise to abortion, and
 under such circumstances  this accident  is  liable  to be followed  by  sep-
 ticaemia.

   Treatment.—The patient should be put to bed and kept there during the
 attack.  The severe pains may be mitigated by  a  warm bath and  by the
 internal administration of quinine, opium, or  one  of the coal-tar analgesics.
 The disease being invariably depressing in its action on the heart, it is safer
 to relieve pain with  small, frequently-repeated doses of an opiate than with
 antipyrin, phenacetin, and similar preparations.  The latter drugs have, how-
 ever, been largely employed, and if their dose is  small and their effect care-
 fully watched  they  may be used not only with safety, but with speedy relief
 of the  muscular  and  neuralgic  pains.   Their  careless  use  is certainly
 attended with danger, as  is shown by the fact that seventeen  deaths  were
 directly  attributed to overdoses of antipyrin  during the epidemic in  Vienna.
   Maclagan reports good results from  salicin in  doses of 20 to  40 grains
 every tAvo hours for several hours ; later, the same  dose every  two or three
 hours.   This drug,  on account of its insolubility,  its large dose, and to  most
 persons  its unpleasant taste, is not likely to come into general use.   The
 same is true of the  salicylate of sodium, which, although decidedly beneficial
 in those forms of influenza attended with  severe  muscular and articular
 pains, is strongly objected to by many patients on account of the nausea to
 which it gives rise.  Among  other  remedies employed  may be mentioned
 benzoate of sodium, caffeine,  strychnia, and  ammonium  chloride.
   Probably the best and safest mode of  treatment consists in the continued
 use  of quinine sulphate  (about 3 grains every three  hours) and the occa-
 sional use  of analgesics, among which the best are opium and  its alkaloid
 morphia, phenacetin, salol, and antipyrin.  Complications  are to be  treated
 as under other circumstances, bearing in  mind, however, the importance of
abstaining  from  debilitating measures of any kind.
   Food consisting chiefly of milk and eggs should be administered at regular
                     1 Annual Unir. Med. Sci., vol. i., 1892.
                     2 Parsons, loc. cit. 
1058
ARTICULAR RHEUMATISM.
intervals, and in most  cases, especially in elderly individuals, alcoholic stim-
ulants should be prescribed.  When the stomach  is irritable and  the pulse
frequent and  soft, champagne  will  be  found to  be a  most  serviceable
remedy.—H.]
                         CHAPTER  X.

ACUTE, SUBACUTE, AND  CHBONIC ABTICULAR BHEUMATISM.

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
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 aff'ection 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 
ACUTE ARTICULAR RHEUMATISM.           1059
affections, but it is most convenient to consider  them in the light of comnli-
cations
  Clinical History.—Acute articular rheumatism, in the majority of cases
begins 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  days; 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
jarring the bed or room occasions suffering.   Pressure  over the joints  is
painful.   Owing 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.  The 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 over
the hip and shoulder, hut only over joints that are comparatively  superficial.
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 (monarthritis).   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  local 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

m Tkltai 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 pathologica
hw-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 
1060
ARTICULAR RHEUM A TISM.
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
SAveating, 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 saliATa 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
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

Medi^J^at^X;^. ^ °f ArtiCUkr Rheumati->" b7 the author, Buffalo 
                    ACUTE ARTICULAR RHEUMATISM.           1061


 ;eonioendto ™e^zft^z:jz1^ bec°rinmUei«■"•■
 any time in the eourse  of the dhsease   but tlll^™" inv°'«d a'
 early and middle periods.   They aro more Ik W to  '  7 '*  Sreatest in ">*
 patient.   They oeLr rarely in p^n^re ttn fo^arfof llT^t

 mlrked delil U   71™* T ** iD  °th« ^rile'dlealeS attfnded ^
 marked debility   A murmur of temporary duration, referable to aeute dili

 *—"^^^^
 some cases  a notable  diminution  of red blood-corpuscles
    In a small number of cases of acute articular rheumatism important svmn
 toms develop which are described under the names of cerebral 7eZ™ism7d
 rheumatic hyperpyrexia.   Under the name  cerebral  rheumatism cases have
 been described which  present symptoms referable  to different patho o^ica
 conditions, some without  and some with  demonstrable lesions of the br  n
 The most important group of  cerebral symptoms, and the  one commonly
 understood as cerebral  rheumatism, is that which is generally associated aa-i h
 Ttself iXt temperaVUI?   Tt ls ^ no mean« ^^ain 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. °,n8et °f tlle dlsease> but  more  frequently they develop  at some later
 period,   b hey are  ushered in by rise of temperature, restlessness, disturbed
 sleep and headache.  Delirium, often violent, but sometimes of a low, mutter-
 ing 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-
 ing sometimes an elevation of 110° or even higher.  In the majority of cases
 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, and has been already referred to in the article on the former disease.
   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 haemor-
 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, moArable  nodosities  during 
1062
A R TIC ULAR RHE UMA TISM.
 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, 1863, entitling my article "A Contribution toward  the Natural
 History of Articular Rheumatism."  In making an analysis, in 1854, 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.  With reference to this point in my
 report of the analysis I used the following words : "At the present moment
 Ave cannot answer the question, What are the intrinsic tendencies of  articular
 rheumatism as respects its continuance, its complications, and its remote con-
 sequences in the  organism ?  Were we able  to  answer this question by an
 appeal  to facts, we 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." 2  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
 ot course  paramount to any other object.   The cases thus treated progressed
 so satisfactorily that I  found no ground for  a discontinuance of the plan
 Ihe 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-
  1 Barlow  and Warner, Trans. International Med. Conqr., London, vol. iy   1881 ■  Troi-
 'Vi68^,08^                        Uuionmedic'mi'      '
   \ ide Buffalo Medical. Journal, March,  1854, vol. ix. p. 557. 
ACUTE  ARTICULAR  RHEUMATISM.           1063
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 but 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.1
   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,
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.2
   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.
    V 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.
   i Vide " A Contribution toward the  Natural History of Articular Rheumatism," by
the author American, Journal of the Medical Sciences, July, 18M.
   »S Di? Sutton's communications there is no reference to my report in the Amer.
Journ. of the Med. Sciences, 1863. 
1064
ARTICULAR RHEUMATISM.
   Pathological Character.—There have been various theories as to the
pathological  character of  rheumatism, none of Avhich 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  be 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 tofo ;
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
the 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 troD-
lcal  and frigid latitudes.                                    J          v
  Accepting  the  parasitic doctrine, an essential causative factor, acting in
conjunction with a special predisposition, is a specific micro-organism    This
obtainef0   conclusion> but  the demonstrative proof has  not as yet been

  The predisposition or susceptibility is not destroyed after the disease has 
ACUTE  ARTICULAR  RHEUMATISM.
1065
 once occurred, as in cases of certain other infectious diseases.  In a consider
 able proportion of cases recurrences take place                    consxder-
   Acute articular rheumatism  may occur  as  a  complication of various dis
 eases ;  but it is not probable that the articular affections which occurSome-
 times as complications or sequels of scarlatina, gonorrhoea, syphilis, diphtheria
 puerperal fever, dysentery purpura, and some other diseases are in most cases
 etiological^ 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 4ich 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
 mobihtyof the disease is not to  some  extent manifested; the existence of
 pyrexia in some cases of articular rheumatism prior to the  affection of the
 joint;  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-
 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 category.   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.   When 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- 
1066
ARTICULAR  RHEUMATISM.
 pears.  Ulcerative endocarditis is  an occasional  event, giving rise  to  fatal
 py;emia.
   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.  Want
 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 less
 degree of liability to  complications than  have been hitherto generally  sup-
 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 feAv 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 Wright in 1847, and afterward, on a larger scale, by Garrod
and Fuller.   The bicarbonate  of potassa, the bicarbonate of soda, the  tar-
trate of petassa 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-ei°Iit 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.  With refer- 
ACUTE  ARTICULAR  RHEUMATISM.            1067
 in1R& tfe I'   '       1S mTfestly the g^at object of treatment, he stated
 no 111' W   exPenenc\emb™ced, up to that- time, 194 cases, and that « in
 unZfreZ  Tp  ? ^ h|a* fQCt[°n 0ccurred after the pa^nt has been
 treated wir^r" twenpfm hours''  The analysis by Dickinson of cases
 !l'« !    ■? alkahes  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  affections the
 alkali selected  should he 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,   io render it more grateful to the palate and stomach, citric  acid or
 lemon-juice may be added to each dose, which is to be taken during efferves-
 cence.  Ihis 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 should 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
 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, Avhich
 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
 onty  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.
  1 Vide article by Dr. Wm. H. Dickinson in Trans. Med. and Chirurg. Society, 1862. 
1068
ARTICULAR  RHEUMATISM.
  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 Avith 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 adATantages 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-
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
                   1 Neic  York Medical Record, Nov. 4, 1882. 
ACUTE  ARTICULAR  RHEUMATISM.            1069
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
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
 mav hi  assTcLed-namely,  hyperpyrexia,  cerebral meningitis, or uraemia.
    I^aCosUhs reported SO^trEted 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 2'> cases was any cardiac  complication  subsequently developed.   The
 of  the -,-> ca^b      J          2> I d    i  Senator has made some obser-
 mean duration ot  the disease  was-.-.<; udj     p:w:no. o\  t0  Q drachms of
 vations on the  treatment  with benzoic acid.   Giving -•>  to  6 dracnms oi
                 1 Vide Pennsylvania Hospital Reports, 1S(><), vol. n. 
 1070                 ARTICULAR  RHEUMATISM.

 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 Arvcna-
 rius of St. Petersburg  a  quarter of  a  century ago, has more recently been
 employed Avith success by Lagrange  and Dujardin-Beaumetz in France.1


        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 Avhen  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
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  with 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 be  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
                      1 Vide National Dispensatory, 1879. 
SUBACUTE AND CHRONIC ARTICULAR  RHEUMATISM.  1071
 chronic rheumatism.   Subacute or chronic  synovitis, not rheumatic, is to be
 excluded.   ihe  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.  Whenever 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  sar.saparilla into which guaiacum enters—the bichloride of mer-
 cury, iodide of potassium in large doses, colchicum  in small or moderate doses,
 the hydrochlorate 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
 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 certair
 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, Avith 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 Avhich 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, hoAvever, much  of the benefit  derived from watering-places is due
to the various incidental hygienic influences. 
1072   LITHAEMIA.—GOUT—RHEUMATOID ARTHRITIS,  ETC.
                        CHAPTER  XI.

 LITHJEMIA; URHLEMIA.—GOUT.—RHKUMATOID ARTHRITIS.—
                             RHACHITIS.

 Lithaemia; Uricaemia.—Gout: Anatomical  Characters; Clinical History;  Pathological
  Character;  Causation;  Diagnosis; Prognosis; Treatment.—Eheumatoid Arthritis —
  Rhachitis:  Anatomical  Characters; Diagnosis; Prognosis; Treatment.

                       [Lithsemia;  Uricaemia.
    THE term  lithaemia was  first  employed  by Murchison  to  designate a
     diathetic condition believed by him to be due to disordered function of
 the liver.   This view of the  pathogenesis  of the  affection  was based on the
 theory that  uric acid represents  a  stage in the formation of urea, and conse-
 quently accumulates in cases in which the apparatus chiefly concerned in the
 formation of urea (the liver) is deranged in its mechanism.   Although there
 is little or nothing in the way of fact to support Murchison's theory concern-
 ing the relations of uric acid to  urea, there is no  question concerning the
 existence of " lithaemia," and little doubt that it is dependent upon an accu-
 mulation of uric acid  in the system.
  The relation  of lithaemia to gout is most intimate.  In  fact, it has been
 called by DaCosta, who has drawn its  outlines  and filled them up with con-
 summate skill, " American gout."   In this  country, where typical  gout is
 seldom seen, it is  of special  importance that lithaemia should be recognized,
 and for such recognition we are chiefly indebted to the teacher just men-
 tioned.  Like most  American products, lithaemia is acquired rather than
 inherited.
  The lithaemic  state  is  characterized by  multifarious symptoms chiefly
 referable to  the nervous system  and by certain  deviations of the  urine from
 the standard of health.   The  latter  will first be considered, since it is upon
 them that the  diagnosis must be based.
  The urine of lithaemia is, as  a rule, high-colored, scanty, very acid, and
 deposits on standing pink or  brick-dust  sediments of urates, and  sometimes
 crystals of uric acid.   Its specific gravity is  increased, ranging from  1020 to
 1030, and has been found as  high  as 1035.   Crystals of  oxalate  of  calcium
 may also be  found in the urinary  sediment.   The normal proportion of uric
acid to urea—which, according to Haig, is as 1 to 33—will generally  be
found by chemical analysis to be preserved.   An excess of uric acid may  not
manifest itself by a urinary precipitate, and therefore, in cases of suspected
lithaemia in  which  the  urine, though  highly acid, remains  free from brick-
dust sediment, the only method  of determining such excess is by chemical
analysis.
  Lithaemia  may he  a temporary condition in the healthiest after  over-indul-
gence in rich food or alcoholic stimulants, " but what in  most persons is an
occasional result of an  extraordinary cause is in  some almost a daily occur-
rence,  either from  the  food  being always excessive in amount  or'unduly
stimulating,  or from some innate  defect of  power,  often hereditary, in  the
liver, in virtue  of which its healthy functions are liable to  be deranged by
 the most ordinary articles of diet.   Most persons appear to have  more liver,
 just as they have more lung, than is absolutely necessary for  the  due per-
 formance of its functions.   But in others, not unfrequently the offspring of
 gouty parents, the organ in its natural condition seems only just  capable of
 performing  its  healthy  functions  under  the most favorable circumstances, 
LITHJSMIA.
1073
 ne rlnnT*     ^"^nm^ W *' °nCG induCed h? articles of ^ which most
 hse ? bv  gG   Wlth  faClhty-   This  functional derangement may manifest
 and of nth^T  Sr?t°1mS  °f indiSestio"> by disturbances of circulation
  "?* oth*r Penological systems, but especially by deposits of lithic acid,
  vi intom's' nfP fTntS 1D the  Urine" '  In this Country, as above stated, the
 s}  ptoms of lithaemia  are  predominantly  nervous, and  consist of  mental
 fiXSn'  J6f g°' lnS0™ma' neuralgia, muscular twitchings  and cramps,
 irritability of temper, and occasional headache which may assume  the type
 of hemicrama.   Persistent severe headache is, however, not often  observed.
 ♦i, .  n°       g^atest practical importance  to be conversant  with the fact
 that albuminuria may be a symptom of lithaemia, because the  prognosis of
 albuminuria from this cause is vastly more favorable  than that of albumin-
 uria dependent upon  structural lesions of the kidney.   The lithaemic origin
 ot albuminuria may be  suspected in cases in which the amount of albumin
 in the urine is  small  and variable, but the crucial  test of the matter is the
 response to treatment.  As  a rule, in cases of  the kind referred to. this is
 prompt and decided.   Casts, in the proper sense of the term, are generally
 absent,  but it is by no means  uncommon to find that peculiar modification of
 the cast known as the «  cylindroid."   The frequent association of cylindroids
 with the lithaemic  diathesis has been commented  upon  by Alfred  St.m°-el2
 As suggested by DaCosta, who has recently studied the subject of  lithaemic
 albuminuria, it is  highly  probable  that various forms  of albuminuria de-
 scribed as " intermittent," « post-cibal," " albuminuria of adolescents " etc. are
 in reality  dependent upon lithaemia.3
   Our knowledge of  this entire subject is yet in its infancy, but the existing
 facts warrant the statement that the condition of the kidney associated with
 lithieinic  albuminuria is not  organic and has little tendency  to  result in
 structural change.

   The DlAGNosrs of lithaemia is based chiefly upon symptoms of disorder of
 the nervous system   occurring  independently of  organic disease of  the
 cerebro-spinal axis  or of the  peripheral nerves and associated with a urine
 presenting the  above-described deviations  from the healthy standard.  In
 addition, gastro-intestinal disturbances are  frequent, and  the pulse is often
 weak  and intermittent.
   XotAvithstanding the apparent gravity of its symptoms, lithaemia does not
 tend, per se, to a fatal issue.   It does, however, lessen the general powers of
 resistance, and  therefore renders the system an easier prey  to  intercurrent
 acute  disease.

   The treatment of lithaemia is for the most part dietetic, and therefore
 its success depends  upon the  degree  of self-Control possessed by the patient.
 Alcoholic  stimulants  of  every kind are  harmful, but especially champagne,
 Port wine, Burgundy, and  Madeira.  It is  generally conceded that  the least
 injurious form of stimulant is  whiskey, and some lithaemic patients  can take
 a moderate amount  of whiskey and water at dinner with apparent impunity.
   There are different  opinions  concerning the  proper diet for this condition,
 some recognized authorities recommending a diet  largely  nitrogenous, com-
 posed  of every  kind  of  digestible  meat with  a  scanty  allowance of carbo-
 hydrates, while  others, equally experienced, proscribe such meats as  beef and

  1 Murchison, Croonian Lectures,  1874, p. 66.
  2 " Cylindroids in the Trine, and their Significance," Medical Nevs, July 15, 1893.
  3 For a full discussion of this  important subject, see  "The Albuminuria and the
Bright's Disease  of Uric Acid and of Oxaluria," by J. M.  DaCosta,  MD.,  LL.D.,
American Journal  of the  Medical Sciences, Jan., 1893. 
1071   LITILEMIA.—GOUT-RHEUMATOID  ARTHRITIS, ETC.

mutton, and  limit the nitrogenous food to fish,  the  white  meat of chicken
and game, eggs, and oysters.  The latter plan is believed by the writer to be
preferable, at least at the beginning of treatment,  Later,  when the patient
is able to  take considerable out-door exercise, beef and mutton  once a day
and in small  amount may be permitted.  The most important point in the
dietetic treatment of lithaemia  is  to limit the amount of the food.  The con-
dition  is one of hepatic  inadequacy, precisely analogous to the renal inade-
quacy  described by Sir Andrew Clark.   Excess is a relative term, and what
seems like privation to the robust  may be excess  to the lithaemic.   The prin-
cipal meal should be taken  early—at one or two o'clock—for in the majority
of cases the digestion is  at  its  best at that time.   Late dinners and suppers
are notoriously injurious.  Green vegetables, with the exception of asparagus
and rhubarb, may be freely allowed, but the amount of potatoes and bread
should be  restricted.   Sugar should be discarded, with the exception  of a
small amount in the tea, coffee, or cocoa, which beverages may be  permitted
in moderation.  Fat, except as it exists in good butter and bacon, is  gen-
erally digested with difficulty.   There are idiosyncrasies  regarding the use
of  milk  which should always  be respected.    In most  cases milk to the
amount of one pint daily is beneficial.   The patient should  be encouraged to
drink abundantly of pure water: the urine is thereby rendered less irritating
to kidneys and bladder and regular evacuations of the bowels are promoted.
The latter effect is  more certain when  a  glass or two of water is swallowed
before breakfast.   It is probable that the various mineral waters  employed
in this condition  owe their undoubtedly beneficial effects to the H20 which
they contain.
   Daily  warm or tepid  baths  followed by  vigorous friction and out-door
exercise, of  which  the  best form is riding,  are hygienic  measures of the
utmost importance.   In the opinion of  the writer, lithaemia would  be a com-
paratively rare affection  if every adult  of average strength were to exercise
daily  to the  extent of  inducing free perspiration.
   The drugs employed in  the  treatment of lithaemia belong  chiefly to the
class of laxatives.  In case  of constipation, half an  ounce of the Rochelle
salt or the sulphate of magnesia or  a  drachm of the Sprudel salt dissolved
in a glass  of  water should be taken before breakfast.   An occasional dose of
blue mass (2 or 3 grains)  or a grain or two  of  calomel at bed-time is often
of decided benefit.  Anaemia is not  a prominent symptom of lithaemia, and
if present is mostly due to  digestive disorder.   In such cases it is  most suc-
cessfully treated by the administration of dilute hydrochloric acid—10 to 20
drops in an ounce  of water—after each  meal.—H.]


                                 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 gutta, 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.  "Writers 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 
GOUT.
1075
cases in
 considered as chronic.   Persistent or chronic gout will embrace all
 winch  the disease  is protracted.

   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 except
 tions the  urates are deposited first in the joints, and in the majority of cases
 nrst 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.   I he  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
 articular 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 com-
 pared 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 the  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 
 1076    LITHAEMIA.—GOUT—RHEUMATOID  ARTHRITIS, ETC.

 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
 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.  828).  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  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.  Aarious 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,   (iouty 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 Historv.—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.
1077
TbiecK of tl  ^e  n0tieen alre/dy exPerienced, but in persons who are
have shown that f^'  1TJ d&n°te ™ imPe«ding seizure.   Observations
ble^diminurion  of    ?eve^.day? P«<*ding a gouty paroxysm there is a nota-
Die  aiminution  of uric acid in the urine
The
   1 he seizure  is marked by  pain, which  in the great majority of cases is
  eated in the metatarsophalangeal joint of one of the greaJ toes.   The pa n
 soon becomes more or less intense, and frequently it is excruciating, being com-
 of'the U at'entSlr CaUSGd^ the S^S of - animal,ga disbcaSon
 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 feve? subside.
 1 he 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.  Ihese  appearances are observed after the  severe  pain  has
 3*03X6(1.
   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 Avhich 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,
 high-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
 night; in other  words, remissions occur  instead of intermissions.  The local
 symptoms gradually  decline  as the fit or  attack passes off.   Oedema 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 
1078   LITH.EMIA.-GOUT.-RHEUMATOID ARTHRITIS,  ETC.

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 Aveeks 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.   When 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
Avithin  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 be 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 mav
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
changes in 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.
1079
t^o^L^t^T^ def°med and cHPPled after a comparatively short
   Lr"9^raud 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 affection 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 Avhich constitutes the disease in cases of gout may determine
disorders, sometimes of  a grave  character, in  organs more  important to  life
than those in Avhich 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, but it may be doubted if a purely func-
tional disturbance occurring in this  connection  eATer 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
symptoms 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
mav 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- 
 1080   LITHAEMIA.—GOUT—RHEUMATOID  ARTHRITIS, ETC.

 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 be 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 (lithse-
 mia).   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. (iar-
 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;  but 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 
GOUT.
1081
 £:?[ ^ntraf **» be Presented under the head of Causation.  The  indi-
 Aiduahty of each disease is therefore sufficiently established.

 nortinnSnf I0N'~G°Ut " * di,athetic dise^e, and the diathesis in a certain pro-
 va  on that r^in ?*^ *"* ^^  U Ls a matter of common °^-
 transm tted  s,        /^l "*  PredlSP°Sed t0 this disease> and * * sometimes
 tics Showed *™*™7*}l*™g* *  series of generations.  Scudamore's statis-
 tics showed that of  o2J patients affected with gout, in 309  the disease had
 ™-"  "f fh %* Pa[e"tS  °r SrandP-ents.  Of  80 cases  reported  to  a
 and T rrnd  t ♦  !w^ A?demy' ^ 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!
 Ihere 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
 IIS 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-
 tiAre 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  Avhich
 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, Russia, 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 
 1082    LITHAJMIA.-GOUT-RHEUMATOID ARTHRITIS, ETC.

 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 anion- laborers accustomed to a plain diet  and neither wine-drinkers  nor
 beer-drinkers   .My clinical records contain notes of  several such oases,  bout
 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 occnr 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.
 CEdema, 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.
10S:l
of performing this experiment, as described by Garrod, is as follows :  " Take
one  or  tAvo 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.   When the  fluids  are well mixed intro-
duce one  or tAvo 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.   Rheu-
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 disease, 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  fy^persia  with  a scanty
 secretion of urine which deposits  the urates, and  the  liability to gravel or
 a t:  kfof renal colic.  If with these symptoms an examination of the blood-
 serum show a morbid excess of uric acid, the development of - attack of
 gout  may be predicted with  considerable eonfidence.   Th ed g -is of^
 orders of internal organs -^ ^    !^ ^mainly on their occur-
 ^ eln prtimi J to attack^  gott,  either preceding,  accompanying, or
 XwingPthe sudden cessation  of well-marked gouty  manifestations.

    poorxosn—The immediate danger to life from  gout is  slight.  If it ever
    Froonosis_   ine          irre(riflar or s0-called misplaced manifestations;
  per se, prove fatal, it is by its ™««la        .  h d  ^ im  ted  to gouty




           i This account from Garrod's work has been somewhat condensed. 
1084    LITILEMIA.—GOUT—RHEUMATOID ARTHRITIS, ETC

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 laAV 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.—Various 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  patients 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 ;  but its severity  may he
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 oAve 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.
1085
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 be 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. 
 1086    LITHAEMIA.—GOUT—RHEUMATOID  ARTHRITIS, ETC.

 combined.  Chloroform as a local application has been recommended.  Trous-
 seau highly recommended  tobacco  fumigations,  not during the  paroxysms,
 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 unstim-
 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.  With 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.   Wine 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  Avith 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.
  [Piperazin has been  recently highly recommended in the  treatment both of
 acute and persistent gout and as a solvent of uric acid and  urates.   It should
 be administered highly diluted  with water, and  may be  given to  the extent
 of 15 grains per diem.  Its continued use does not appear to be attended
 with unpleasant effects.—H.]
  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  qud 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-
 ent 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 
GOUT.
1087
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 aiter they have been continued for a short time.   This injunction is also
applicable to the carbonate of lithia  and other diuretic remedies.   Exacerba-
tions  ot  the disease, which  are liable to occur from  time to time,  may be
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 mainly 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, caulifloAver, 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 be  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  Avhich  do not admit of removal.
   Different mineral waters have  been much resorted to in the treatment of
gout, particularly  the Yichy  water.   Of the utility of the latter and of other
springs there is much difference of opinion  among those who have given more

    1 National Dispensatory, 1879.
    2 Article "Gout" in System  of Practical Medicine, by American Authors, vol. n. 
 1088    LITHAEMIA.—GOUT-RHEUMATOID ARTHRITIS, ETC.

 or less attention to an investigation of their effects.  The Vichy water is Va-
 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
 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-art/iritis,  arthritis pauperum, and malum senile  articulorum.  When the
 affection attacks the hip-joint  it has  been called malum coxae, senile.   When
 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 be 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 Avriters.
  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 the disease, and  as a rule upon post-mortem examination the cavities of the

  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 Gout  and PA*,,"
matic Gout, London,  1859.                                                neu~ 
RHEUMATOID ARTHRITIS.
1089
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
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 affected, 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 Ranvier, 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
       69 
 1090   LITHAEMIA.—GOUT.—RHEUMATOID  ARTHRITIS,  ETC.

 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
 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 but 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,  Weir  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 patholo^
 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.
   [Other symptoms, frequently observed, which favor the neuropathic  theory

  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
 resulting in enlargement  of the medullary spaces and absorption of the bony trab   1 '
 Ziegler observed changes which he interprets as  proliferation of the hnnpr^iwir-86'
 chow's Archiv, 1877, Bd. 70).                                     uone-ceils ( Vir- 
RHEUMATOID ARTHRITIS.                 1091
of this disease are a persistently rapid pulse, pigmentations of the skin some-
times resembling freckles, at others occurring as a more diffusa melasma, and
excessive perspiration.—H.]
  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-
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.  Whether 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 healtli.
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.  Remedies  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.   Warm 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. 
1092   LITHJEMIA.-GOUT.-RHEUMATOID  ARTHRITIS, ETC.
             [Rhachitis—Rickets—Morbus Anglicus.

  Rickets is a disease  of infancy characterized  by imperfect and  irregular
ossification,  and more particularly  by excessive  and perverted development
of the epiphyseal  cartilages.  It is  too much the custom to consider rickets
as nothing more than a disease of the osseous  system, whereas, as insisted
upon  by  Cheadle,1 it  affects not only bones, but muscles  and ligaments,
mucous membrane, the  skin, blood, and  nervous system.  The muscles are
enfeebled, sometimes to  such an extent  as to simulate paralysis.   The liga-
ments are relaxed  so as  to  permit  of deformities of spinal and other joints.
The involvement of the  mucous membranes is often indicated by persistent
diarrhoea and  other signs of gastro-intestinal disturbance; that of the skin
by excessive sweating ;  that of  the  blood by more or less anaemia;  and that
of  the  nervous system  by  laryngismus  stridulus,  convulsions, and  other
manifestations of exaggerated reflex  excitability.  It appears evident, there-
fore, that the  cause of rickets is  general  or constitutional, and  that the
theories which account  solely for its most conspicuous manifestations—those
of the osseous system—are  altogether too narrow.
  All authorities are  agreed that faulty  nutrition is at  the root of rickets,
but there are different opinions concerning the nature and mode of action of
the nutritive defect.  For example, some contend that rickets may be pro-
duced  at  will by  withholding certain elements  from the diet, while others
insist that a constitutional predisposition  is necessary to the development of
the disease.   The  latter opinion seems to me to be correct.   Special defects
in the food, to be presently alluded  to, are  undoubtedly the exciting cause
of rickets, but they only become operative in certain constitutions and under
certain hygienic conditions.
  The view  held  and ably maintained by Parrot that  rickets is only  a form
of congenital syphilis has been generally abandoned.  In the first place, in
the majority of cases of rickets  there is neither a history of syphilis nor any
of  its  signs or symptoms in child or parent.    Again, a large proportion
of syphilitic children never show  the characteristic signs of rickets.  The
signs  of congenital syphilis  are patent at birth  or a few weeks thereafter,
while those of rickets do not appear, as a rule, until the period of dentition.
Notwithstanding  these  essential differences  between  syphilis and rickets,
there can, I  think, be  little  doubt that the general debility consequent upon
congenital   syphilis  may  indirectly  favor  the  development  of  rickets.
Although  the  two  diseases are fundamentally distinct, there is no antagonism
between them.
  Rickets is not directly transmitted  from parent to child.   Individuals free
from rickets may have rickety children, and, conversely, rickety parents may
have  healthy  children.   When  both parent and  child  are rickety, it is
because they  have been  exposed  to  the same hygienic influences.  These
generally-admitted facts with reference to heredity furnish additional proof
of the distinction between rickets and syphilis.   Bad hygienic surroundings
such as want of light, the absence of pure  air, deficient clothing, dampness.
and insufficient food, have been regarded as the sole causes of rickets.  They
are  undoubtedly  powerful predisposing factors, but  rickets  may develop in
children whose hygienic environment leaves nothing to be  desired.  The
weight of  evidence is in favor of the view that the principal, if not the sole
cause of rickets is some  special  defect in  the food.  As a rule, the disease is
limited  to ': hand-fed"  children.  Exceptionally, it  may occur in children
who are at the breast, but under such circumstances the milk will be  invari-
ably found to be  of poor quality, either  because the mother is enfeebled by
                      1 Brit. Med. Journ., Nov. 24, 
RHACHITIS.
1093
previous  disease or other cause  or  because the lactation is  too prolonged.
Uieadle states  that he has  seen but one  instance of  rickets in a  child
suciuett by a healthy mother, and  on investigation  it was found that the
woman had continued to  nurse  her child  while pregnant.   Admitting the
tact ol the almost  exclusive limitation of  rickets  to hand-fed  children, the
question arises as to  the nature  of  the dietetic defect.   At one time it was
believed to consist  in the  administration of farinaceous substances.    The
lactic acid generated in excess  by the fermentation of  starch was supposed
to unite with the lime of the bones  and  remove it from the system in the
form of a soluble salt.  This would  account for the well-known fragility of
the  bones of rickety  children.   There are, however,  formative  lesions in
rickets at the points of junction  of  epiphysis and  diaphysis, and these were
supposed to be due  to an irritation  of the  cartilaginous tissue  by  the lactic
acid.  This theory  seems  very plausible, especially as digestive  disturbances
are  exceedingly  common in  rickets  and lactic  acid has  been found in the
urine  of rickety children.   It  is, however,  inadequate,  because  rickets may
be cured in children who are kept upon  a farinaceous diet, provided other
substances, such as  milk  and  cream, are  also freely  administered.   It is
evident, therefore, that the effect of a farinaceous diet in producing rickets
is negative rather than positive; in  other  words, a child upon such a diet
acquires rickets not because it  is  given certain  articles of food, but because
it has  been deprived of others.
   Rickets has been  attributed to want of  lime in the food, and the  disease is
said to have been produced in  animals by depriving them of this substance.
The bones may certainly  be rendered brittle  in  this  manner, but rickets
which is chiefly distinguished  by formative cartilaginous  lesions does not
arise.   Rhachitis is  by no means unknown in limestone districts, and Cheadle
states  that in his native town, where the  water is  highly charged  with lime
and goitre is common, the disease is especially rife among the children.
   Certain  facts  with  reference  to   particular  animals—bears, lions,  and
monkeys—in  the Zoological Gardens of London  tend strongly to support the
ATiew that a deficiency of animal fats and earthy salts  is the chief dietetic
cause of rickets.  Up to within a few years it has been  found next to impos-
sible to rear young lions in the London Gardens, these animals almost invari-
ably dying with all  the  symptoms  of rickets.  More than  twenty litters
perished from this  disease.  But one litter was raised  during the period
referred to, and in this solitary instance the cubs were suckled by the dam.
As a rule, the lioness in captivity cannot be  trusted to suckle her young, and
they have to  be  fed " by hand."   Their food until quite recently consisted
of the flesh of old horses, which  is almost destitute of fat, and the bones of
these animals are said to be proof against  the  teeth of adult  lions.   As a
consequence the  cubs were inadequately supplied with fat  and  earthy phos-
phates.  A short time  ago, at the suggestion of Mr. Bland Sutton, the diet
was changed, the meat being continued while the bones were  crushed and
mingled with  cod-liver-oil.  In addition, the  animals were supplied with milk.
The consequence was that a litter of young lions in  whom  the signs of rickets
were well marked recovered entirely from the disease and  became in every
respect strong and healthy.  The raising of this litter is  said to be a " unique
event in the history of the society," and  is undoubtedly to be attributed to
the  improved diet.
  If further proof is needed that a deficiency of fat is an important element
in the etiology  of rickets, it may be  found in  the fact that this  disease is
often preceded by intestinal  disturbances which are chiefly  manifested by
diarrbea.   While this affection  lasts the  system  is inadequately supplied
with fat, even though an  abundance of the latter be ingested,  for  it is 
1094   LITHJEMIA.-GOUT- RHEUMATOID ARTHRITIS,  ETC.
hurried through the intestine before it  can be prepared for absorption by
being emulsified.

  Symptoms and  Anatomical Characters.—A  child that has learned to
walk ceases  to do  so or  complains of being tired on slight exertion,   lhe
teeth fail to  appear at.the proper time, or, if dentition has begun, the process
is interrupted.   Coincident with these symptoms there are often well-marked
digestive disturbances,  manifested by a coated tongue, a distended abdomen,
frequent eructations, vomiting and obstinate diarrhoea.  The general  nutri-
tion suffers and  the subcutaneous fat  disappears.   The  first striking altera-
tions are observed  in the skull, which assumes  a characteristic square shape
known as the caput quadratum.   The fontanelles remain patulous at a time
when they are usually closed  (middle of the second year and later), and are
much larger than  normal; the sutures also remain open, and the edges of
the bones which form their boundaries are thickened.  The term craniofabes
is  applied to a  condition of the bones  of the  skull sometimes observed in
rhachitis.  It is  most marked in the occipital bone, which  becomes thin and
yielding in  spots  and  crackles on pressure like parchment.
  The jaws undergo changes of shape on account of their yielding too readily
to muscular traction.  The inferior maxilla is flattened anteriorly,  so that
the incisor teeth form a  straight line instead of a curve, and in consequence
the body of the  bone acquires a  rectangular  outline.  The  upper jaw is
narrowed laterally at the  point corresponding to  the zygomatic process.
  The thoracic alterations  are highly characteristic.  At the junction  of the
ribs and costal cartilages  a series of small nodular tumors  (ecchondromata)
develop, which  in thin  infants are  plainly visible, and  in  those with a
thicker layer of fat may be distinctly palpable.   They form a chain extend-
ing in a curved  manner  from  above downward, and outward, and constitute
Avhat is commonly known  as  the rickety rosary.  In addition, the sides of
the thorax are depressed, so that the sternum projects forward like that of a
chicken or like the keel  of a  boat; hence the  terms pectus gallinaceum and
pectus carinafum applied  to this deformity.  The lower  ribs are bulged out-
ward, partly by  way of compensation for the depression of the  lateral  por-
tions of the chest  and partly  because of the pressure exerted upon them by
the distended abdomen.  On transverse section a rhachitic chest is generally
pear-shaped, instead of circular as in health.  The vertebral column may be
deformed in every possible manner.   Kyphosis, lordosis, and scoliosis may
coexist in the same case.  The pelvis undergoes changes which, in  females,
may be the  cause  of serious dystocia in after-life.   Under the weight  of the
body the yielding  bones  which bound this cavity give way and permit the
sacrum to  approach abnormally near  the  symphysis.
   In the extremities the  epiphyses are  seen  to be abnormally prominent,
especially those  at the inferior extremities of the  ulna and radius, tibia and
fibula.   In  the  lower  extremities  curvatures in all  directions, hut usually
with the convexity outward, develop.  These are most marked in the hones
of the  leg, but  the femur may also  be decidedly  distorted.   Characteristic
deformities  in infants  are produced by strain  and pressure on the yielding
bones  during the  act of crawling.   It  is in this way that  the curvatures of
the arms are produced, as well as an angular bend above the ankles, to which
attention has been called by Fagge, who suggests  that  it is due to  pressure
transmitted to the tibiae from the insteps and feet.
   The  clavicles and scapulae are bones in  which marked charges are fre-
quently observed, and the former may be fractured by suddenly lifting  a
rhachitic child.
   Pain in  the bones,  either spontaneous  or evoked by handling the little 
RHACHITIS.
1095
 I the mornin. and a t g f ^ ^ &t "^ S° that the PiIlow is d™ched
  oms of the dL    a1te°den«y to cast off the bed-clothing, are three symp-
 drgnostic!       G WlUCh' takGn t0Sether> are regard*d by  Jenner as highly

 bufthaeChbonvPchSUeS " ° uT°. C°UrSe-   An acute variefcy  has been de«^bed,
 e^Dhvses JttTS  +^Ch lt  pr6SentS are in the diapVses instead «f the
 theS   P     AGhthe J°mtS are  imPlicated, and there is bleeding from
 navgbrcom^lfee?I   -!i!0rt r6 Pr°bably °f a SCorbutic  nature"  Rbachiti«
 arvn^mrP   1?  ^\^f  mesenteric*, pulmonary tuberculosis, and
 cHidST-nd     uus-  •  Thi  latter'  indeed'  is so  ofte»  seen in rickety
 children, and so seldom in others, that it is rather a symptom than a compli-

 hZ^T^f^  iDt°  mi,nUte h»tologioal details,'it will suffice to  state
 here that the developmental  processes in  rhachitic bones, and  especially in
 the  epiphyseal  cartilages,  are  extensively  disorganized.   Normally, the
 epiphyseal cartilage is separated from the shaft of the corresponding bone bv
 two well-defined layers: first, an outer  one, one to two millimetres thick, nex"t
 the  epiphyseal cartilage, of a dull-bluish color, and known  as the proliferative
 zone ; secondly an  inner, thinner layer, of a yellow  hue, called the zone of
 calcification.   In rickets there is excessive formation  of cartilage-cells in the
 proliferative  zone, together with  diminution of its  hyaline matrix and its
 partial conversion into fibrous tissue.   The zone of calcification is abnormally
 vascular  and contains an unusual quantity of marrow.  Both zones encroach
 upon each other by irregular projections of their hyperplastic tissues, so that
 the  boundary between them is very ill  defined.
   Rhachitic bones are diminished in  weight, and  the proportion  of  their
 organic to their mineral constituents is decidedly increased.  They have been
 shown experimentally to fracture with abnormal readiness.

   Diagnosis.—The  physiognomy of  well-pronounced  rickets is unmistak-
 able.  The square head  and  distorted limbs are highly  diagnostic, and on
 closer investigation  the epiphyses,  especially those of the lower extremities
 of the ulna and radius, are found  protuberant.  The chest  should  be care-
 fully examined for the prominences at the junction  of rib and cartilage, as
 well as for the more conspicuous projection  of the sternum, forming the so-
 called pigeon-breast.   It  must be borne in mind, however,  that the latter is
 frequently seen in individuals entirely free from rickets, being due in such
 cases to  obstruction to respiration in infancy from  enlarged  tonsils, bron-
 chitis, or other cause.   The  more  latent forms of the disease may be recog-
 nized, or  at least suspicions  of their existence should  be excited, by retarded
 dentition,  profuse sweating  of the scalp  at  night, obstinate diarrhoea, and
 pain  excited  by suddenly lifting  the  child.

  Prognosis.—The prognosis of rickets in itself is favorable.  Even decided
deformities, such as bowing of the legs and enlargement of the epiphyses,
may disappear in time.   When, however, the disease  is not  recognized at an
early stage, and the child in  consequence placed upon proper treatment, it
may  lead  to  dwarfing of the body and irretrievable deformities  of  head,
thorax, vertebral column, extremities, and  pelvis.  The latter, in the case of
females, may  be, as previously stated,  of the gravest import as concerns the
act of parturition.

  Treatment.—In the treatment of rickets diet is of paramount importance.
The  disease can be prevented with absolute certainty by giving children food
which contains  an  abundance of animal fat, proteids, and salts.   The total 
1096   LITILEMIA.—GOUT.-RHEUMATOID ARTHRITIS,  ETC.

(juantity of animal fat should  amount  to  at least one-fourth of all the total
solids, the proteids  to about one-third, the carbohydrates to a little more than
one-third, and the salts  to  about one-tenth.1  The fat is best administered in
the form  of cream or rich milk,  but if these  cannot be obtained the best
substitute is cod-liver oil;  " but raw  meat is better than iron, cream or fresh
milk than  cod-liver oil."   The hygienic  environment should  be  carefully
selected, the patient occupying a  room in which the sunshine enters freely
and spending the greater portion of the day in the open air.   A residence at
the seashore and warm  sea-water  baths  are highly  beneficial.   The latter
may be administered at home by dissolving sea-salt in  the  bath-water.
  Among drugs, phosphorus is  pre-eminent.  There  is a general consensus
of opinion  in  favor of the view that its administration  in rickets exerts a
favorable action  upon the  nutrition of  the bones.  It may be given in doses
of y£7  to y^-jj- grain  twice or  thrice daily.
  The following formulas may be employed with advantage:
Thompson's Solution. . Phosphori. Alcohol, absolut.,	gr-j; n^cccl;
Spt. menth. pip., Glycerinae,	"Lx; §ij—M
Of  the above  mixture, 6 minims may be given thrice daily to a child from
two to four years old, increasing the dose by  1  drop every week until  10
drops are given.
  Or the following formula of Dembitz may be  used:

           R. Phosphori,                            gr. I;
               Carb. bisulph.,                        gtt. vj ;
               Aquae destillat.,                       giv.—M.
    S. A teaspoonful daily, or half as much twice daily, after eating.

  The  phosphorated oil  of the U. S. P.  is an excellent vehicle for  phos-
phorus, and may be given with cod-liver oil:

           R. Olei phosphorati,                      rrl^',
               Olei morrhuae,                     ad. §vj.—M.
    One teaspoonful for a  child one year old, to be given after food.

  Intercurrent maladies  such  as bronchitis and  diarrhoea  should receive
appropriate treatment.   Unless the latter is checked neither  medication  nor
diet will be of  any  avail.—H.]
1 Vide Cheadle, loc. cit. 
                              SCORBUTUS.                         1097




                       CHAPTER   XII.

             SCORBUTUS—PURPURA.—HEMOPHILIA.

Scorbutus, or Scurvy: Anatomical Characters; Clinical History; Pathological Character;
   Causation; Diagnosis; Prognosis; Prevention;  Treatment,—Purpura Simplex, Pur-
   pura Eheumatica, and Purpura Hsemorrhagica—Haemophilia.

    THIS concluding  chapter  will be.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 known 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 Wars 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
War.  The  inconsistency between these facts and the existing state of know-
ledge is in  part to be explained by the 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 Wales,2  in
1881, out of 82,629 cases of disease in the chief naval services of the world,
there' were only 34 cases of scurvy.   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

  i "Report on Scurvy," United States Sanitary Commission,  by William A. Hammond,

Mi Artide2'" Scurvy," in A  System of Practiced Medicine, by American  Authors, vol. ii.
p. 16S. 
 1098          SCORBUTUS.—PURPURA— HAEMOPHILIA.

 coagulated.   The  blood-corpuscles  have been considered by some observers
 diminished in number, and by others  unaffected in this regard^.   [In eight
 cases in Avhich  the blood-corpuscles Avere counted by the Avriter,1 the highest
 number per cubic millimetre  Avas 5,320,000; the lowest 1,980,000.  These
 wide differences are  due to the varying  severity of the disease.   Examina-
 tions of the blood, so far as the enumeration of its corpuscles is concerned,
 possess no absolute significance, but are of great practical interest in individual
 cases.—H.]  No uniform  changes in the form or constituents  have been
 determined.  It is not established that a deficiency of  potassa is a constant
 feature.  Contradictory results have been obtained respecting  the white cor-
 puscles, the quantity of fibrin,  and the  proportion of  albumen.   In short,
 quoting Immerman,  " If we take a general survey of the total analyses made
 of the blood of scurvy patients  up to this  time, we can hardly avoid a feel-
 ing 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 be 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
                  1  Philadelphia Hospital Reports, vol. i., 1890. 
SCORBUTUS.                        1099
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
body.  They occur sometimes beneath the conjunctiva and within the globe
of the«eyes ; 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.
   The skin is dry and rough, compared by Larrey to that of a plucked fowl.
The ankles are often cedematous, 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.
 Weakness 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-
riders that tiie special deficiency relates to  the salts of potassa    That this
deficiency enters  into the pathological condition is probable, but that it con- 
1100         SCORB UTUS—PURPURA .-HAEMOPHILIA.
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. _ V\ lth
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
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  due 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 shoAvn 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 he marked.   In
isolated cases  the diagnosis  involves discrimination from purpura  hsemor-
rhagica.  This  differential  diagnosis  will be  considered  in  treating of  the
latter  affection. 
SCORBUTUS
1101
  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,   finder these circumstances'the disease may be
overlooked.   Thus, Hammond,  Woodward, 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
and muscles  of  the lower  limbs  may  lead the  practitioner  for  a  time to
consider the disease as muscular rheumatism or myalgia.   When  associated
Avith  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 scurATy.  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 Avith 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.   With 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 long 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 alimentarv  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. 
1102         SCORBUTUS.—PURPURA.—HAEMOPHILIA.

  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 very
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
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-
podium 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 (Leoutodon
taraxacum).
  Wales 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, but 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.   Remedies  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.   Wine, 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 hath.   Pain in the back
and limbs may be alleAnated by friction with anodyne and mildly-stimulating
                                 1 Loc. cit. 
PURPURA.
1103
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 collutones.   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.
  • IS" hairdl,y  necessai7  to  add  that the  scorbutic  condition,  when asso-
ciated with  dysentery, typhus or typhoid fever, or with  any disease, claims
the same dietetic and other measures of treatment as does scorbutus exist-
ing alone.


  Purpura  Simplex,  Purpura  Rheumatica, and  Purpura
        Hemorrhagica (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 Werlhofii.   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 
1104         SCORB UTUS.—PURPURA.—HAEMOPHILIA.

slight fever, or there  may he 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  place in
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
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, peliosis 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 Aveeks, but 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 hsemorrhagica 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 Werlhof'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 Werlhofii 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- 
HEMOPHILIA.
1105
terns of anaemia, such as vertigo, weakness, functional cardiac disorders, and
X?  A!' rv?l0P ln P^portion to the loss of  blood.  Hemorrhage may occur
into the brain or its meninges.  Death may result from loss of blood or from
S^com  licati°na  dlSOrder> marked especially by typhoid symptoms or from

   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.
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 positiveness 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.   With 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.   Hemostatics  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  strikin- 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
m 
1106         SCORB UTUS.—PURPURA.—HEMOPHILIA.

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
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 (Wachs-
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.2  The affection has been
repeatedly observed in  Jews.  It seems  to be more common  in cold, moist
climates than in  Avarm climates.   Although a  large  proportion of bleeders
have been blondes, Avith 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 wholly 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

   1 Of  780 cases collected by Dunn, 717 were males and 63 females {American Journ.
of Med. Sciences, Jan., 1883).
   2 A full account of the American literature on this subject will be found in the article
by Dunn above cited, and in the article on " Haemophilia," by Osier, in A System of
Practical Medicine,  by American Authors, Philadelphia, 1885, vol. iii. 
HEMOPHILIA.
1107
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,   lhe swelling seems to be due to hemorrhage into the joint.   Neur-
algia, especially of the trigeminus, is not infrequent.
  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.  Vaccination 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.   When 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.  [The fluid extract of
Hydrastis canadensis has been used successfully in haemophilia by Fiirth, the
dose being  30  drops  daily.  Hayem believes the best haemostatic in this
affection to  be the transfusion of entire blood, of which but a small quantity
will sometimes put an end to an otherwise  uncontrollable hemorrhage.   He
believes that it  acts  by supplying to  the  blood the elements—the haemato-
blasts  or  blood-plaques—which  are  so active in the formation of throm-
bi.—H.] 
              -[SECTION  EIGHTH.

THE  ZOONOSES, OR  DISEASES  TRANSMITTED FROM  ANIMALS
                            TO  MAN.
                         CHAPTER  I.

      ACTINOMYCOSIS.—ANTHRAX.—GLANDERS.—RABIES.

  Actinomycosis: Diagnosis; Prognosis; Treatment.— Anthrax: Diagnosis; Prognosis;
   Treatment.—Glanders: Symptoms; Diagnosis; Prognosis; Treatment.—Eabies.

                          Actinomycosis.
 ACTINOMYCOSIS is an affection which prevails  extensively in cattle
XX  and is occasionally observed in horses, swine, and dogs.  Its  constant
association with  a parasite belonging  to the species Cladothrix and commonly
known as the ray-fungus was  first demonstrated  by Bollinger in 1876.   In
cattle the disease manifests itself, for the most part, as a tumor of the jaw
which  involves  both the bone  and  the soft parts investing it.   The  skin
covering the tumor is for  a time intact, but eventually ulcerates and gives
exit  to  a purulent material in  which are  suspended numbers of yellowish
granules which, when  examined under  the microscope, are found to be com-
posed of the specific fungus of  the  disease.  Besides the jaw, the neck and
tongue of the animal are frequently invohTed in the morbid process, and the
disease  may have its  primary seat  in  the stomach, lungs,  or integument.
The predilection  of the affection for  the maxillary bones is  attested  by the
term "big-jaw"  popularly applied to it.  In this situation it bears  a close
resemblance to  osteo-sarcoma.
  Infection in man  may occur  directly by  inoculation  with the discharges
of animals suffering from the disease or  by eating their flesh.   A not uncom-
mon  mode of infection is perforation of  the mucous membrane of the  mouth
or other parts with vegetable substances to which the ray-fungi are adherent.
A number  of cases  are  on record  in  which  the disease  had its starting-
point in an  abrasion of the buccal mucous membrane caused by chewing ears
of wheat, barley, or rye, and it is undoubtedly in this manner that cattle are,
as a rule, infected.
  In actinomycosis of the lung the  disease has  been traced to a bristle of
barley  imbedded in the  parenchyma of the organ, and  in  abdominal  actino-
mycosis the morbid process has had its origin in  a bristle of grain lodged in
the vermiform appendix.   A  relation has  been supposed by some observers
to exist between dental  caries and  actinomycosis.   Doubtless  infection
through the mouth might more  readily  occur in cases in which the gums are
loosened around one or more carious teeth, but, in view of the frequency  of
decayed teeth and the great  rarity  of  actinomycosis, the relation  between
them must be regarded as accidental.
  Four avenues of infection  are generally recognized :  (1) The mouth and
       1108 
ACTINOMYCOSIS.
1109
throat ; (2) the  respiratory tract; (3) the utestinal canal; (I) the  integu-
ment.
  Secondary infection  may occur through the medium  of the  blood, the
fungus being  swept  along by  the  current, either free  or in the  interior
of  leucocytes.    Secondary infection  via the  lymph-vessels is rare:  as a
rule,  therefore,  the  lymphatic  glands do  not participate  in the  morbid
process.
  Actinomycosis in man is distinguished from actinomycosis  in animals by
the much slighter tendency in the former to the formation  of a circumscribed
tumor and the  much greater tendency to extension by fistulous burrowing in
all  directions.    From  the throat,' for example, the  process  may  extend
beneath  the skin  of the  neck  externally and downward along the spinal
column to the  thorax, involving  the  lungs; it may perforate the diaphragm
and invade the abdominal  organs; in a word, by continued  extension in the
manner just mentioned  and by secondary embolic deposits all the organs of
the body may  be ultimately involved in the morbid  process.
   On the  other  hand,  exceptionally, the disease  may,  as  in animals, remain
more  or less circumscribed, without  presenting  the abscess-like characters
above described.  This is  more  frequently  the case, however, with the
secondary embolic deposits.
   The seat of  the  primary manifestations of actinomycosis depends upon  the
point of infection, the disease in  the  great majority of cases developing at
or  in the neighborhood  of the latter.  Among 421 cases  analyzed by Illich,
the disease was seated  in the head and neck 218 times; in the  tongue, 16 ; in
 the lungs, 58 ; in the abdominal region, 89; in the stomach,  11.  In  29 cases
 the point of infection could not be determined.

   The course of actinomycosis is, as a rule, chronic. In exceptional  cases, in
 which it seems to  be acute, it is probable that the affection has been latent
 for some time  before the advent of symptoms.  This statement is particularly
 applicable to intestinal  actinomycosis,  in  which the first overt manifestation
 of the disease  may be caused by a perforative peritonitis the result of a long-
 standing invasion  of the intestine.

    The symptoms  of actinomycosis depend largely upon its  seat.  In  the
 head and neck it appears  as a hard, indistinctly circumscribed, painless swell-
 ing of the soft  parts, the bones in man  being seldom involved.  Softening
 gradually takes place in one or more portions of the growth, and pus  is event-
 ually discharged,  in the  absence  of surgical interference,  either externally
 through  the integument  or into the mouth alongside of a carious tooth
   When seated  in the  lungs the disease runs a course very similar to that ot
 chronic  tuberculosis, being attended  with cough  and expectoration, often
 copious, and sometimes fetid or hemorrhagic.   There are also pains in the
 chest and  back, irregular fever,  and  progressive  emaciatiom   Pulmonary
 actinomycosis  may last many years, its course being  diversified by marked
 remissions  The physical signs are those of consolidation and cavity-forma-
tion   In  one  important  particular the  course of  pulmonary  actinomycosis
differs from tuberculosis-namely, in its tendency to perforate the chest-wall
 and form a fistulous communication with  the exterior.
   The intestinal form of  actinomycosis may begin  as  a pseudo-membranous
inflammation  of the intestinal  mucosa, but,  as  a  rule  is  not recognizable
Sini°aUy until it  has  involved  the  abdominal walls, the  tissues around the
anu(periproctitis actinomycotica), or  the lumbar region.  It may also extend
^L hbVdder and lead to perforation of that viscus,  or,  as above stated, ts
firsfmanfftstetion  may be an acute perforative peritonitis.  Metastatic deposits 
1110   A CTINO MYCOSIS.—A XTHRA X.—GLA NDERS.—RA BIES.

in the liver with consecutive abscess are liable to occur in this variety of the
disease.
   When seated in  the  integument actinomycosis  may assume the form of a
fungous ulceration, or it may consist of nodules which cicatrize in the centre
and invade the  integument in all directions.  The latter variety may be mis-
taken for lupus on superficial examination.

   The diagnosis  is made by microscopic  examination, although suspicions
of the disease should be excited by the characteristic grayish or yellowish
granulations contained  in the purulent discharge of  the open ulcers or fistu-
lous  tracts.  When these are examined microscopically, they are found to be
composed, for the  most part, of the pathognomonic organism of the disease,
the so-called  ray-fungus.   This term  is derived from the  peculiar arrange-
ment of the fungus, which is in the form  of rods or rays with  rounded or
club-chaped extremities converging to a common  centre.

   The prognosis  is  most favorable when  the disease is seated in the head
and neck, doubtless because in  this situation it is more amenable to surgical
treatment.  Of  100  cases  in this  situation,  13 were  fatal,1  whereas of  34
cases of pulmonary  actinomycosis  analyzed  by  Hodenpyl,  32  died.  The
prognosis  of  intestinal actinomycosis is undoubtedly more  favorable than
that  of the pulmonary form of the disease, although, as remarked by Ulich
in his  valuable  monograph, it is a disease of the gravest significance.2

   The treatment of  actinomycosis is  altogether surgical, and consists  of
incision, curetting, drainage, and injections of solutions of corrosive subli-
mate, boric acid, tincture of iodine, and other antiseptic substances.   When
superficially situated the disease is quite amenable to  the treatment just out-
lined.  In fact, the  process has been cured by simple incision.   It is  an interest-
ing fact that  several cases treated with  hypodermic injections  of Koch's
tuberculin have  reacted in the  same manner as cases of tuberculosis.—H.]

   [Anthrax (Malignant Pustule; Charbon; Splenic Fever;
                      Wool-sorters'  Disease).
   Anthrax attacks by  preference the herbivora, especially cows, sheep, and
horses, and is usually transmitted to man  by inoculation—i. e. by the secre-
tions of the diseased animal coming in  contact with an abraded or wounded
surface.  It may,  however, be  conveyed  in other  ways:  by  the bites  of
insects, by inhalation,  and by eating the  flesh of infected animals.

   The symptoms  vary in  accordance  with the mode of infection.   When
acquired by inoculation, they are at first exclusively  local.  At the point  of
inoculation, in  which  a  burning pain is  felt, a  papule speedily develops.
This  soon becomes vesicular at the summit, the contents of the vesicle being
either serous or bloody. The neighboring parts become extensively indurated
and  cedematous and  assume  a red  or  purple tint.  The  vesicle  rapidly
enlarges and  ruptures, leaAring behind  a dark-brown  scab which  conceals a
gangrenous base.   Streaks of  redness indicative  of lymphangitis may  be
traced  from the primary lesion  to  the nearest lymphatic glands, which  are
enlarged and  tender.
   On the second or third day constitutional symptoms set in.   These  consist
of severe pyrexia, rapid  pulse and dry tongue, great prostration, delirium,

               1 Birch-Hirschfeld, Real-Encyclopadie, vol.  i., 1894.
               2 "  Eine  hochst gefahrdende Krankheit." 
ANTHRAX.
1111
  fs dS^H7ail085?' ^T^' aid C°llapr-   Enlargement of spleen and liver
  dayTaZXTfi  ?     V-^  CaseS.death  maJ occur in from five to eight
  aay s after the first signs of inflammation
    In favorable cases both the local and general symptoms are milder; the
  gangrenous patch sloughs  out,  and the ulcer gradually heals.
    Instead of proceeding to the formation of a distinct papule and vesicle, the
  local lesion may be  limited to an cedematous infiltration of the affected part.
  Ihis anthrax  <*dema, to which attention was called by Bollinger, is most apt
  to be seated in the eyelid, but may occur in other parts
    Two other forms  of  anthrax  are recognized—the gastro-intestinal and the
  tforaac    In  the  former the infection  has its starting-point  in  the gastro-
  intestinal tract.   In this variety the constitutional  symptoms  are the first to
  attract attention, doubtless  because the local process is concealed from view
  Ihey may be  ushered in  with a chill, but  this is not constant.  The leading
  characters of this form  of infection are—great prostration; headache ; nausea
  and vomiting; diarrhoea, the evacuations generally containing blood; colicky
  pains ; and tenderness  over  the  liver.   Dyspnoea  is often  prominent.   The
  patient rapidly falls into a state of collapse, the surface  becomes  cyanotic,
 and death is the  inevitable result  in the course of from two  to seven days.
  Phlegmonous  areas  may appear  on the surface, but the papule, vesicle, and
 eschar above  described are not  seen.
    The thoracic variety of  anthrax has received the name of wool-sorters'
 disease because of its prevalence among those whose business  it is to handle
 wool.  Previous to  its recognition  and description  by Dr. Bell of Bradford,
 England, fatal cases of  this disease were habitually registered  as pneumonia,
 congestion of  the lungs, and bronchitis.  A chill or slight chilly sensations
 followed  by great prostration, dyspnoea, rapid  pulse, and vomiting  are the
 earliest symptoms.   The face becomes congested or  cyanotic and the extrem-
 ities cold or livid.   There may be a copious hemorrhagic sputum, but expec-
 toration is sometimes wanting.   Mucous rales  are often  heard on ausculta-
 tion, but the signs of pulmonary consolidation are wanting.  The latter fact,
 taken in connection with the gravity of the general  symptoms, should excite
 suspicions of the  true nature of  the disease.  The thermometer in the axilla
 may register a normal or subnormal temperature, but placed in the rectum it
 will  show the existence of decided fever—102° to 103°.  The  mind may
 remain clear to the  last, or  death  may be  preceded by delirium, coma, and
 convulsions.
   The external  post-mortem  appearances  consist  of the above-described
 cutaneous lesions  and  of swelling  and hemorrhagic  infiltration  of  lymph-
 glands.  The blood remains fluid and contains an abnormal number of white
 cells—leucocytosis.  In addition, there  are sub-serous ecchymoses, cloudy
 SAvelling of the cells of the liver and kidney, granular degeneration of the
 muscular fibres of  the heart, swelling and softening of the spleen, intumes-
 cence of  the intestinal  follicles  and of  the mesenteric and retro-peritoneal
 glands, and localized oedema, ecchymosis, and  loss of substance of the intes-
 tinal mucosa.  The last-mentioned  signs are the analogues of the cutaneous
 lesions, and may indicate the point of infection in cases of the gastro-intesti-
 nal variety.
   The bacillus anthracis is found in the smaller  blood-vessels throughout the
 body.

   Diagnosis.—The diagnosis is  based  upon  known exposure  to contagion,
the detection of the anthrax  bacillus in  the contents  of the pustule and in
the oedema  of  infiltrated parts, and upon  the  results of inoculations in the
lower  animals—rabbits, guinea-pigs, and mice. 
 1112    A CTINOM YCOSIS.—ANTIIRA N— GLA NDERS—RABIES.

   The prognosis, ahyays grave, is most favorable Ayhen the point of inocula-
 tion is accessible to surgical treatment.

   Treatment.—The treatment of anthrax is mostly surgical.   A crucial
 incision should be  made in  the pustule and pure carbolic acid applied to the
 wounded surface;  or  carbolic acid in solution (50 centigrammes of the acid
 to 10 grammes of  glycerin and water) may be injected around the  point of
 inoculation.   The  actual  cautery is  preferred  by others.  Out of  40  cases
 treated in Buenos  Ayres with the cautery, only 1 died.1  Internally, carbolic
 acid,  quinine, calomel,  sodium salicylate, and other  antiseptic  drugs have
 been  administered, and, it is claimed, with  benefit.
   Prophylaxis is  of the utmost importance.   The sad death of Hoffmann,
 pathologist to the  General Hospital of Aienna, should serve  as a warning to
 those engaged in  experiments with  the  anthrax  bacillus.  " After using a
 hypodermic  syringe for  an experiment on animals, he sterilized it through a
 spirit flame  and administered to  himself an  injection of morphia.   Blood-
 poisoning followed,  and  numerous  gangrenous  spots developed  over his
 body."—H.]
                         [Glanders (Farcy).
   Glanders is a  contagious and inoculable disease which prevails among the
 equidae—horses, asses, and mules—but may be transmitted  accidentally to
 other animals, excepting  the  bovidae, and to  man.   Clinically, it  presents
 itself under  two forms, according to  whether or not it attacks the  nasal
 cavities.   When the latter are involved the affection is known as glanders,
 whereas when the  lesions are chiefly cutaneous  it is called " farcy."  It is an
 interesting fact that the contagiousness of this disease, which at the present
 day  appears  so  manifest and so  pronounced, has been  contested from the
 beginning of  the  eighteenth century up  to  a comparatively recent period.
 Elliotson of  England (1833) and Bayer of France  (1837) were probably
 most  instrumental  in  determining its contagious  character.
   The specific infectious agent of glanders is a bacillus which was isolated
 and cultivated at about  the same time by  Bouchard, Capitan, and Charrin in
 France and by Loffler and Schiitz in  Germany.  It  is from 2 to 5//. long by
from 0.5/jt to  1.4// in width, and is readily stained  by aniline dyes in  alkaline
 solution.   It is  destroyed in two minutes by a temperature of 100° C, and
 in fifteen minutes  by a solution of corrosive  sublimate  of the  strength of
 1 : 1000.   In  a  word, it offers  little  resistance to the ordinary microbicides,
 such as aeration, insolation, heat, and putrefaction.  It invades by preference
 the lymphatic system, being  present in very scanty numbers, and therefore
found  with  great  difficulty,  in the blood,  saliva,  and urine.  It  has  never
 been found  in  either  the bile or the milk.
   Man is generally  infected by  the  horse,  and  therefore those most fre-
quently attacked with glanders are  grooms, coachmen,  farmers,  veterinary
surgeons, cavalry soldiers, and others  whose occupation brings them in  close
 contact with this animal.  Glanders has  been communicated by the bite of
an animal suffering from the  disease, but infection does not invariably occur
after such an injury.  As is well known, Claude Bernard escaped the disease
after being bitten by a glandered  horse.   As a general rule, infection occurs
through inoculation of  a wound  or  minute abrasion of the integument or
mucous membrane, although an experiment of Babes tends to prove  that the
virus may penetrate the sound skin.  This well-known bacteriologist  induced
glanders in guinea-pigs by rubbing their skins with a pomade containing the
specific organism of the disease.   Glanders has been  acquired  by  drinking
             1 Annual of the Universal Medical Sciences, vol. iii. 1890. 
GLANDERS.
1113
water from the bucket used  by a diseased horse and  by blowing the nose
with the  cloth used to  clean the  animal's nostrils.   The disease  may  be
caused by the ingestion  of meat  contaminated with  the  secretions  of  an
infected animal;  this has been established experimentally, and is not refuted
by the fact that such meat has been eaten with impunity.  Experiments are
opposed to the  view that glanders may be acquired  by inhalation of the
infectious  agent.  As already stated, in  the  great  majority of cases the
disease is  acquired by man from  the horse, but a number of instances of  its
transmission from man to man are recorded.

  Symptoms.—When acquired by inoculation, the incubation stage lasts, as
a rule, from three to five days; when acquired by infection—as,  for example,
by the ingestion of contaminated meat or water—this stage is  longer, lasting,
according  to Boger,1 from fourteen to twenty-five days.  The  disease may
assume the form of glanders or farcy, and may be either  acute or chronic.
  Acute  Glanders.—This variety may  begin acutely,  or the  acute  symp-
toms may be  engrafted  upon  a  chronic  process.  Profound prostration,
chilly sensations  or well-marked chills,  headache, and  anorexia  are  the first
general symptoms.   To  them may soon he added pains in  the  limbs and
joints, either vague and ill-defined or so  localized as to  resemble  the  pains  of
articular rheumatism.  Before the onset of the above-mentioned symptoms
the wound of inoculation may have cicatrized, or, on the other  hand, it may
be in an ulcerated condition.  The face, hands, and feet  are swollen, and often
streaked with lines of redness corresponding to inflamed lymphatic vessels
(lymphangitis), while the glands to which they lead are swollen and painful.
The face is sometimes the seat  of an  erysipelatous inflammation which may
extend to the scalp.  The nose and cheeks are swollen,  and from between the
closed eyelids there  exudes a puriform  fluid.  About  the sixth day a puru-
lent eruption generally appears.   It is seated in the integument of the face
and  extremities and in the  mucous membranes of the  eyelids, nose, tongue,
and  fauces.  The pustules  are acuminated, surrounded by a  red areola, and
often rest upon an indurated base.   They may be the starting-points of more
or less extensive patches of  gangrene.
  Simultaneously with the  eruption the characteristic symptoms of  glanders
make their appearance.  They are chiefly referable to  the  nasal cavity, and
consist of  a sense of obstruction in this region accompanied with  a muco-
purulent  discharge, generally blood-streaked,  which,  by contact  with the
nostrils and lips, gives rise  to excoriations of these parts.  When examined
with the nasal speculum  the mucous membrane of the nares is seen to  be
reddened,  swollen, excoriated, and ulcerated.   The ulcerations  may involve
the perichondrium,  attack the bone, and lead to perforation of the nasal sep-
tum.   The gums are swollen and ulcerated.   The salivary glands  and the
lymphatic ganglia of the  neck are  tumefied and tender, and the latter may
suppurate.  The  patient is annoyed with a frequent cough attended with a
muco-purulent,  fetid secretion,  and  signs of  broncho-pneumonia  may  be
detected in the bases of the  lungs.   The fever, at first  slight, now rises to
104° or even  higher, and its type is continuous.  The pulse is small, weak,
and frequent—from 100  to 150—and  may be irregular.  Nervous symptoms
are now prominent ; there  are great restlessness and insomnia, and delirium,
previously nocturnal, is now  continuous.   The urine  is albuminous and
contains leucine and tyrosine.  Diarrhoea and vomiting are often prominent
symptoms  at  this stage.
  The duration  of  acute  glanders  depends upon whether the disease begins
  i Traite de Medecine publie sous la  direction de MM. Charcot, Bouchard et  Brissaud,
vol. i. 
1114   ACTINOMYCOSIS.—A NTHRA X—GLANDERS.—RABIES.

as such or is  engrafted upon the chronic form.  In the  former case it may
last for three or four weeks; in the latter death occurs in  three or four days.
   Chronic Glanders.—The symptoms resemble those  of  the acute variety,
but are less  intense and  are  subject to frequent remissions.   The lesions
are limited  for  the most  part  to  the mucous membranes  of the  nose,
pharynx, and larynx, in which, on  proper  examination,  ulceration may be
detected. There runs from the nose a thick, blood-streaked, mucous discharge
which  dries  in blackish crusts about the nostrils.   The  nasal  passages are
obstructed, and the voice in consequence acquires a nasal  twang.   It may be
rendered faint and hoarse or be completely extinguished by ulceration of the
larynx.  Cough is a frequent  symptom, and may be  due to pulmonary con-
gestion or to broncho-pneumonia.   In  cases  in  which this variety of the
disease has succeeded to farcy the lesions of the latter may persist on the
integument.   The  general symptoms are identical with those of chronic farcy.
The duration of chronic glanders is sometimes greatly prolonged.   Cases are
reported in which  it has persisted for many years.  It is doubtful whether
recovery ever takes place.
   Acute Farcy.—The constitutional symptoms of this variety are  identical
with those of acute glanders.   On  the  sixth  or seventh day multiple sub-
cutaneous abscesses appear, of which the contents are sanguinolent rather
than purulent.  Their  course is  either  indolent—that is, unattended with
redness and other signs of active inflammation—or acute,  the abscesses being
surrounded with a zone of redness and streaks of angeioleucitis.   They may
be transformed, either  by  their spontaneous  rupture or  by operation, into
open ulcers.   In the second or third week, or even  later, a pustular eruption
appears, and, as  in  acute glanders,  may be the  starting-point of gangrene.
Delirium eventually sets  in, and  death  takes place in a state of coma.  The
duration of farcy is longer than that of glanders,  extending sometimes to six
or more weeks.  Doubtful cures have been reported.
   Chronic Farcy.—This form  of the  disease is  characterized by  muscular
and  articular pains, stiffness  of the joints, swelling and lymphangitis  of
the inoculated part, and  enlargement  of the corresponding lymph-glands.
The chief symptom  of chronic farcy is abscess.  At  the  end of a month or
six weeks from  the date  of inoculation numerous abscesses appear in the
subcutaneous tissues, especially  in  those  of  the lower  extremities.   They
rarely  appear on the face,  and still more rarely on the trunk.  The abscesses
are ill  defined, though large, and the skin investing them is of a livid hue.
They may undergo resolution, but, as a rule, they open spontaneously.  This
event,  rupture, is  of slow  development, sometimes  not occurring until eight
or ten  months after the first signs of suppuration.  The abscess may contain
pus alone  or  a mixture of pus  and blood.   After its discharge the abscess
may cicatrize, or it may be converted into a fistulous tract, or, finally, it may
result in an obstinate ulcer  which by its extension inward may lay bare the
tendons and bones of the  affected part.   At this  stage of the disease a pain-
ful swelling of the testicle is often observed.   Chronic farcy is not attended
with the pustular eruption characteristic of the acute varieties of the disease.
The fever runs no regular course until  toward the end, when it assumes the
hectic  type.   At this period the  prostration is great; the patient falls into  a
state of mental hebetude  or mild delirium ; the  emaciation is  extreme, the
skin dry and sallow; diarrhoea and  vomiting are  common, and  there is  a
frequent dry cough, not accounted for  by any physical signs of pulmonary
disease.  Death  is the  usual  result, although  recovery is  possible.   The
disease continues, as a rule, for from twelve to fifteen months.  When it runs
a  shorter  course  the fatal  event is  usually  caused  by some intercurrent
disease or by purulent  infection. 
RABIES.                            1115
   Diagnosis.—The occupation of the patient and known exposure to conta-
gion are important factors in the diagnosis.  Cases, however, are occasionally
encountered in which  a history of contact with infected animals is wanting.1
The cutaneous lesions, as well as those of the nasal cavities, may be mistaken
for manifestations of syphilis.   In doubtful cases the  secretions from the
diseased parts should  be tested by inoculation  in rabbits or guinea-pigs, and
should  be examined both microscopically  and by culture methods.

   Prognosis.—The prognosis  varies  in accordance with the course of the
affection.  Acute glanders is almost  inevitably fatal.   Chronic farcy is the
most favorable  form that the disease can assume, one-fourth, or, it  is said,
even one-third, of the cases recovering under proper  treatment.

   Treatment.—In case  of direct contagion by  inoculation,  the wounded
part  should be excised  or cauterized.  For the  latter purpose the actual
cautery or the  galvano-cautery is  preferable to the mineral caustics.   AVhen
the  disease is  fully developed,  precautions  should be taken to prevent the
infection  of others.  Linen soiled with the  secretions  or  discharges of the
patient should  be burned, and  those in  attendance upon the sick should
make sure  that there are no abrasions upon their skin through  which the
system might  be  infected.  Abscesses and ulcers are  to  be treated  upon
general  surgical principles,  with the  addition of measures to destroy the
germs in situ.   For example, after the opening of an  abscess the resulting
cavity should  be thoroughly mopped with  cotton saturated with creosote,
iodine, or a strong solution of carbolic acid.   Obstinate ulcers may be lightly
touched with the actual cautery.   The nasal cavities and the fauces should
be sprayed  with weak solutions of carbolic acid, sulphocarbolate of  zinc, or
nitrate  of silver.   Internally,  phosphorus,  arsenic, mercury, sulphur, and
iodine have been  administered with  a view  to a specific action upon the
morbid process.  Good results  are claimed from the employment internally
of the binarseniate of strychnia.  In the chronic forms of the disease the
strength is to  be  maintained by nutritious  food, tonics, and  stimulants.]


                                 Rabies.

   The affection called rabies canina,  and more commonly known as hydro-
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.
   1 As in a case reported by Pepper, Trans. Association American Physicians, vol. vii. 
1116    A CTINOM YCOSIS.-ANTHRAX.-GLANDERS.-RABIES.

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
and vomiting.  Two or three days elapse before the distinctive characters of
the disease are fully declared.
  When 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 swalloAV 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
expuition, 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 
RABIES.
1117
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 Avithin  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-
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 Aveeks, 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 
 1118    A CTINOMYCOSIS.—A NTHRAX.—GLA NDERS.—RA BIES.

 other  than the cases  in which hydrophobic phenomena have been incidental
 to  other diseases.
   Of  the  great number and variety of remedies Avhich 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 Wickrath (Bhein-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
 gramme (gr. $) 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.2   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.   When rabies  is suspected the
 animal should  be confined, and not killed until the character of the  disease
 is fully declared.   Babies 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.  When 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 hark 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
  1 Vide report of this case by Dr. B. A. Watson in Am. Journ. of Med.  Sciences, July
 1876.
  2 For a translation of the history of this case, by Dr. S. W. Williams, with full  details,
vide New York Med. Record, Aug. 9, 1879. 
RABIES.                            1119
 affected 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  Benault of persons bitten by the wolf, 164, about two-
 thirds, became affected by rabies.1
   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
 period  of incubation, which after  forty to  fifty inoculations  becomes  only
 seven  days,  where  it  seems  to  remain Avithout 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 subeutaneously 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,  1886) 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
 dogs a large  number, probably at least two-thirds, never  develop hydrophobia,
 even Ayhen no preventive treatment has been adopted.  At the present writing
 the period of time alloAved for incubation has not elapsed.2
   [From  1886 to 1891, 9465 persons  were inoculated at Pasteur's labora-
 tory, of whom 90 died  of  hydrophobia,  making a mortality of  0.95 per cent.
 These  figures include all the deaths after the inoculation treatment.   If from
 them there be subtracted the cases  which died a few days after treatment—
 i. e. before the inoculations could have taken effect—the mortality amounts to
  1 Jaccoud, op. cit.
  2 There is not a strict analogy betAveen 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 article  by H. M. P>i<rgs 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.) 
 1120    ACTINOMYCOSIS.—ANTHRAX.—GLANDERS—RABIES.

only 0.61 per cent.   A still further proof of the efficacy of these inocula-
tions is afforded by the following facts :  It is well known that the bite of a
rabid dog is most serious when the head is the part injured.   Of persons
thus wounded, 80 per cent, perish, Avhereas  of 710 such cases treated at the
Pasteur Institute only 24 died, making a mortality of 3.38 per cent.  In this
estimate are included all the cases of  head-wounds treated, not excepting
those in which  the  symptoms  broke  out immediately after  inoculation.1
   An  extraordinary  case has been  recently reported by  Muni of Bologna.
The patient, a man set. 22, developed  well-marked symptoms  of paralytic
rabies  while undergoing the usual inoculation treatment.   Murri, finding this
ineffectual, adopted the heroic expedient of injecting the emulsified  nerve-
tissue directly into  the Areins, the result  being that the  paralysis gradually
disappeared and  the  patient recovered after  a protracted convalescence.
   Tizzoni has isolated from the  blood  of animals  rendered immune from
hydrophobia an antitoxin which  appears  to possess the protective properties
of Pasteur's inoculation fluid, and which may be kept indefinitely so as to be
available for immediate use.   If Tizzoni's experiments  are confirmed, the
importance of his discovery can scarcely be over-estimated.—II.]

  1 " Prevention de la rage apres morsure," etc., par le Dr. E. Roux, Transactions of the
International Congress of Hygiene and Demography, 7th Congress, 1891. 
INDEX.
Abscess, fecal, 417, 419
    of brain, 657 (vide Encephalitis).
    of heart, 247
    of kidnev, 846
    of liver, 346, 405, 415
    of lungs, 94
    of spleen, 579
    of stomach, 345
    perinephritic, 858
    perityphlitic, 418
    retro-pharyngeal, 327
    subphrenic, 57
    tropical, 532
Abscesses in heart, 246
    metastatic, 93, 243-246.
    pyemic, in lungs, 93
Acephalocysts, 196, 558
Acetone in diabetic urine, SS'2
Acetonuria, 7
Acholia, 548
Achroiocythaemia, 296, 297
Acromegaly, 807
    anatomical alterations, 809
    diagnosis, 809
    prognosis, 809
    treatment, 809
Actinomycosis, 1108
    course, 1109
    diagnosis, 1110
    prognosis, 1110
    symptoms, 1109
    treatment, 1110
Addison's disease, 317
         anatomical characters, 317
         causation, 323
         clinical history, 320
         diagnosis, 322
         pathological characters, 319
         prognosis, 322
         treatment, 323
         \V.  Gilman Thompson's  views,
             320
Ague and fever, 950
    cake, 953, 965
    dumb, 954
Akinesia. 712
Akinesia, 712
Alalia, 594
Albuminuria, acute,  818
    after scarlatina, 1008-11
    in acute Bright's disease, 818, *19
    in acute interstitial nephritis, 847
        71
Albuminuria  in  chronic  Bright's disease,
       831, 832, 837, 839,  840
    in congestion of kidney, 813, 814
Alcoholism or alcoholismus, 793
    causation, 794
    clinical history, 794
    diagnosis, 796
    prognosis, 795
    treatment, 796
Amoeba coli, 404
Amyotrophic  affections, spinal. 697, 701,
       702
Anaematosis, 292
Anaemia, benign,  292
    cerebral, 589
    idiopathic or essential, 311
    lymphatic, 307
    of spinal cord and its meninges, 628
    pernicious or idiopathic, 311
         anatomical characters, 312-314
         causation, 311
         clinical  history, 314
         diagnosis, 315
         facts in  favor of defective haenio-
          genesis in, 314
         facts in favor of increased haemo-
          lysis in, 314
         iron in the liver, 313
         pathological urobilin, 314
         prognosis, 316
         treatment, 316
    simple or benign, 292
         clinical  history, 293
         diagnosis, 293
         prognosis, 294
         treatment, 294
    splenic, 307
Anaesthesia,  712
Analgesia, 712
Anasarca, 62, 820
Anatomy, morbid, 19
Anchylostoma duodenale, 312, 509
Aneurism, cardiac, acute,  247
    of heart-valves, 239, 243, 249
    partial, of heart, 246
    thoracic, 286
         anatomical characters, 286
         clinical  history, 286
         diagnosis, 288
         prognosis, 289
         "tracheal tugging" in, 288
         treatment, 289
Aneurisms,  miliary,  in cerebral   hemor-
          rhage, 600, 602, 606
                            1121 
1122
INDEX.
Aneurisms,  miliary, in  tuberculous cavi-
      ties, 103
Angina, 199
    Ludovici, 333
    pectoris, 282
        clinical history, 2*2
        diagnosis, 284
        pathological characters, 283
        prognosis, 284
        treatment, 285
Ankle-clonus, 675, 701
Anthracosis of lung, 94
Anthrax, 1110
    diagnosis, 1111
    post-mortem appearances, 1111
    prognosis, 1112
    symptoms, 1110
    treatment, 1112
    varieties, 1111
Antidotes to corrosive and acrid  poisons,
      339
Antiscorbutics, 1102
Aorta, aneurism  of. 286
Aphasia, 221, 594, 621
    amnesic, 595, 621
    ataxic, 595,  621
    in cerebral  embolism and thrombosis,
      594
    in cerebral hemorrhage, 608
    in cerebritis, 658
    in hemiplegia, 654
    sensory, 622
Aphemia, 654
Aphonia,  199, 221, 654,  616, 662
Apnoea, 142, 144, 145
Apoplexy,  congestive, 587, 625
    from cerebral hemorrhage, 603
    from embolism and thrombosis, 593
    meningeal, 623,  632
    prevention of, 612
    pulmonary,  186
    spinal, 629
Appendicitis, indications for operation  in,
      421
    opium in the treatment of, 421
Appendix  vermiformis,  inflammation  and
      perforation of, 417
Argyll-Robertson pupil, 686
Arterio-capillary fibrosis, 830
Arteritis, 600
Arthritis deformans, 1088
    pauperum, 1088
    proliferating, 1088
    rheumatic, acute, 1058
    rheumatoid, 1088
    simple acute, 1065
Ascaris alata, 502
    lumbricoides, 499, 562
    vermicularis, 500
Ascites, 525, 526 (vide Hydroperitoneum).
Aspiration in empyema, 53
    in thoracentesis, 47, 48
Aspirator,  Dieulafoy's, 48
    Flint's, 48
Asthenia, nervous, 721,  858
Asthma, 163
Asthma, causation.  166
    clinical history, 163
    diagnosis, 169
    hay, 165, 167
    pathological character, 163, 165
    prognosis, 170
    thymic, 218
    treatment, 170
Ataxia, locomotor, 685
         anatomical characters, 685
         causation.  689
         clinical history, 686
         diagnosis,  688
         pathological character, 685
         prognosis,  688
         treatment, 689
Atelectasis, 88
    acquired, 89, 144, 151
    congenital, 89,  93
Atheroma of arteries, 600
Athetosis, 619, 765
Atrophy, acute yellow, of liver, 545
    brown, of liver, 563
    facial, progressive unilateral, 802
    granular, of kidney, 828, 832
    of lungs, 156
    ot stomach, 370
    progressive muscular, 696
            anatomical characters, 697
            causation, 699
            clinical history, 697
            pathological character, 696
            treatment, 700
    red, of liver, 252, 565
Aura epileptica, 766, 773


                   B.

Bacillus malaria?, 955
    tuberculosis,  111
         lesions due to, 99, 103, 104
         staining of, 115
Bacteria in acute ulcerative endocarditis,
       244
    in variola, 984
Basedow's disease, 279
Basilar  meningitis, 639 (vide  Meningitis,
       tuberculous),
Beri-beri, 726
     anatomical characters, 727
     causes, 727
     diagnosis and prognosis, 728
     symptoms, 728
     treatment, 729
Bile-passages, diseases affecting, 567
Black tongue, 201
Blood, transfusion of, 980
Bloodletting in pleuritis and other acute
       inflammations, 33, 80, 142, 147
Blue line on gums  in lead-poisoning, 463,
       737
Bothriocephalus  latus, anaemia caused by,
       504
Bradycardia, 277
Brain, abscess of, 657 (vide hmcephalitis).
     anaemia of, 589 
INDEX.
1123
Brain, carcinoma of, 665
    congestion of, 585
    embolism and thrombosis of, 591
    functional diseases of, 707.
    hemorrhage in, 600
    induration of, 659
    inflammation and abscess of, 657 (vide
       Encephalitis).
    inflammatory and  structural diseases
       of, 657
    sclerosis, diffuse, of, 659
    softening of, 659
    tubercle of, 665
    tumors of, 664
 Break-bone fever, 1026 (vide Dengue).
 Bright's  disease of  the  kidneys, acute,
                815
             anatomical characters, 816
             causation,  821
             clinical history, 817
              diagnosis,  821
             pathological character, 819
              prognosis, 821
             treatment, 822
          chronic forms of, 823
              anatomical characters, 825
              causation, 837
              classification,  823
              clinical history, 830
              diagnosis, 839
              pathological character, 837
              prognosis, *41
              treatment, 842
 Bronchiectasis, 133,  150, 157, 158
 Bronchitis,  138
     acute,  affecting  the large  bronchial
            tubes, 138, 139
          anatomical  characters,  138
          causation, 140
          clinical history, 139
          diagnosis, 141
          in young children, 143
          pathological character, 140
          prognosis, 141
          treatment, 142
     affecting  the  small bronchial tubes,
       138, 145
     chronic, 138, 149
          anatomical  characters, 149
          causation, 151
          clinical history, 150
          diagnosis, 151
          prognosis, 151
          treatment, 152
     circumscribed, 138, 149
     fetid, 149, 150
          Dittrich's plugs in, 151
     fibrinous,  its  association  Avith  skin
       disease, 148
     subacute,  138, 143
 I >roncho-pneumonitis,
 Bronchorrhagia, 181
 Bronchorrhcea, 150,  193
 Bronzed-skin disease, 317
 Brown induration of lungs, 96, 2a2, 253
 Buboes, scarlatinous, 1010
145, 176
Bulbar  paralysis, acute or  apoplectiform,
           636, 646, 703
        chronic, 616, 661 (ride Paralysis,
           glosso-labio-larvngeal).
Bulimia, 386


                   C.
Cachexia, carcinomatous, 362
    malarial, 953
Caecitis, 417
Caecum, inflammation and  perforation of,
           417
         anatomical characters, 417
         causes, 418
         treatment, 418
     inflammation and  perforation of ver-
       miform appendix of, 419
     painful tumor of, 419
     perforation of,  419
Calcareous degeneration, 118, 133.
Calcification or cretefaction, 118, 133
Calculi, biliary, 466
         passage of, 467
     intestinal, 432
     pancreatic, 584
     pulmonary, 118
     renal, composition of, 856
         passage of, along ureter, 855
Capsules,  suprarenal, disease of, 317  (vide
       Addison's disease).
Caput Medusae, 541
Carcinoma, gastric, 359  (vide Cancer of
       stomach).
     laryngeal, 223
     of brain, 665
     of intestine, 431
     of kidney,  864
         anatomical characters, 864
         clinical history, 866
         diagnosis, 867
         prognosis, 867
         treatment, 868
     of larynx,  223
     of liver, 555
     of lung,  194
     of oesophagus, 331
     of pancreas, 583
     of peritoneum, 526
     of spleen, 582
     of stomach, 359
         anacidity in, 362
         anatomical characters, 359
         causation, 361
         clinical history, 361, 393
         diagnosis, 361
         prognosis, 364
         treatment, 364
     within the chest, 194
     within the cranium, 665
 Cardialgia, 286
 Carnification of lungs, 25
 Carotids,  ligation  of, in epileptic convul-
        sion, 778
 Carphololgia, 909, 921, 923
I Carus, 708 
1124
INDEX.
Casts of renal tubes in renal congestion,
      813. 814
    in acute nephritis, 817, 818, 820
    in  chronic nephritis, 826, 829,  831,
      832, 839
    in diphtheria, 1037
    in haemoglobinuria, 872, 873, 875
    in relapsing  fever, 942
    in scarlet fever, 1010, 1011
    in suppurative nephritis, 847
    in typhus fever, 925
    in variola, 985, 992
    in yellow fever, 974
Catalepsy, 788
Catarrh, 138
    autumnal, 167
    dry, 150
    intestinal,  426
    senile, 145
    suffocative, 145
    summer, 167
Catarrhus aestivus, 167
    autumnalis, 167
Causes of disease, 19
Cells, serous  infiltration of. in variola, 982
    vesicular or dropsical transformation
      of, in variola, 982
Cephalalgia, 753
    treatment of, 755
Cerebellum, diseases of, 614
Cerebral diseases, 585
         topical diagnosis of, 613 (vide Lo-
           calization of cerebral disease).
Cerebritis, 657  (vide Encephalitis).
    diffused interstitial, 682
Cervicodynia, 751
Cestoda, 502
Chalicosis pulmonum, 95
Charbon, 1110
Chest, new growths within the, 194
Chicken-pox, 1003 (ride Varicella).
Chlorosis, 295
    Egyptian,  311, 510
    Sir Andrew Clark's theory of, 296
    tropical 312, 510
Choked   disk  in  tuberculous  meningitis,
      642
Cholaemia, 570
    hepatogenous, 570, 571
Cholecystitis, 569
Cholera asphyxia, 484
    cyanosis, 484
    dry, 462
    epidemic or Asiatic, 479
         anatomical characters. 481
         bacteria in, 481, 483, 486, 489,
           490
         clinical history, 482
         diagnosis, 490
         enteroclysis in, 496
         hypodermoclysis in, 497
         pathological character, 486
         prognosis, 491
         prophylaxis, 491
         treatment, 493
     infantum,  448, 471, 475
Cholera infantum, intestinal antiseptics in,
       478
     morbus, 471
     nostras, 472
     sicca, 462, 483
     spasmodic,  484
     sporadic, 471
         causation, 473
         clinical history, 472
         diagnosis, 473
         pathological character, 473
         prognosis, 472,  474
         treatment, 474
Cholerine, 483
Cholesteatoma within cranium, 665
Cholesteraemia, 529,  548
Chorea, 756
     causation, 757
     clinical history, 756, 757
     festinans vel procursiva, 760
     gravidarum, 757
     hereditary,  760
     major, 756
     oscillatoria, 760
     pathological character, 1061
     relation between rheumatism and, 757
     saltatorea, 760
     scriptorum, 761
     seasonal relations of rheumatism and,
       757
     treatment, 758
Chthonophagia, 387
Chylopoietic system, diseases of, 324
Chylous ascites,  528
Chyluria, 876
Circulation, cerebral and spinal, 585
Circulatory system, diseases of, 225
Cirrhosis, biliary, 544, 573
     of kidney, 828, 832
     of liver, 538 (vide Hepatitis).
        hypertrophic, 544
        infantile, 542
     of lung, 102, 133
     of stomach, 347
Clergyman's sore throat,  328
Clinical history  of disease, 19
Coagula, ante-mortem, 273
     post-mortem, 273
Coagulation  necrosis  in  acute   Bright's
           disease, 817
        in diphtheria, 1034
        in dysentery, 401
        in gout, 1075
        in laryngitis, 209
        in pneumorrhagia, 186
        in relapsing fever, 938
        in tubercle, 102
        in ulcerative endocarditis, 243
        in variola, 982
     of blood in cavities  of the heart, 29,
       246, 249, 274
Coccygodynia, 750
Colic from copper, 466
     from lead, 710
         causation, 461
         clinical history, 460 
INDEX.
1125
 Colic from lead, diagnosis, 463
         prognosis, 461
         treatment, 463
     hepatic, 457,  530
     intestinal, 457
         causation, 458
         clinical history, 457
         diagnosis, 457
         pathological character, 458
         prognosis, 459
         treatment, 459
     painter's, 460
     renal, and nephro-lithiasis, 457, 855
 Colica pictonum, 460
 Colitis, 421
 Collapse of pulmonary lobules, 88, 89, 92
 Colotomy in intestinal obstruction, 441
 Columns, posterior, sclerosis of, 684
 Coma, 708
     in acute yellow atrophy, 547
     in alcoholism, 794
     in catalepsy,  788
     in cerebellar  disease, 614
     in cerebral hemorrhage, 603
     in cerebral hvperaemia,  587
     in diabetes, 609,  884, 887
     in diphtheria, 1037
     in delirium tremens, 793
     in embolism and thrombosis,  593, 594,
       598, 600
     in encephalitis, 658
     in epilepsy, 768
     in hysteria, 781, 782
     in insolation, 624
     in intermittent  fever, 951, 961
     in meningeal hemorrhage,  623
     in meningitis, 636, 639,  642, 649
     in pachymeningitis, 633
     in poliomyelitis, acute anterior,  692
     in scarlatina, 1009, 1016
     in tumors, intracranial,  668
     in typhoid  fever, 909, 912, 914,  934
     in typhus fever,  923, 934
     in uraemia,  783, 818, 834, 839, 840, 942
         treatment of, 843
     in variola, 987, 992
     in vellow fever,  974, 975, 979
     vigil, 909, 923, 987
 Comma bacillus in cholera, 481, 483, 486
 Congestion of brain,  585
     of cord, 628
     of liver, 564,  578
     of lungs, 96
     renal, active,  812
         passive, 813
 Conjugate deviation,  604
 Constipation, 452
     causation, 453
     clinical history,  453
     pathological character, 452
     treatment, 454
 Consumption, galloping, 102, 110
     pulmonary, 99 (vide Phthisis, pulmon-
      ary).
Convulsions (vide references  under Coma).
 Cor bovinum, 266
Cor villosum, 226
Cord, spinal (vide Spinal cord).
Corpora amylacea, 662, 677, 682, 686
Coryza, 139, 143, 167
Costiveness, 452
Cough, nervous, 219
CoAV-pox, 996  (vide Vaccinia).
Cramp, 761
     writer's, 761 (vide Chorea scriptorum).
Cranium, tumors within, 664
Croup, false, 199, 204, 208
     membranous, 207  (vide    Laryngitis
       with exudation).
     spasmodic, 218
     true, 199, 204,  208  (vide  Laryngitis
       with exudation).
Cry, cephalic, 641
Cyanosis, 145, 157, 158, 164
Cynanche, 199
     contagiosa, 1032
     maligna, 1032
Cysticerci, 502
     cellulosae, 503
Cystinuria, 857
Cysts, apoplectic, of brain, 602
     renal, 828, 829, 861


                   D.

Dance, St. Vitus's 756 (ride Chorea).
Degeneration, cheesy, in tubercle, 133
     cystic, of  kidney, 860
     fatty, in emphysema,  155
         of heart, 269
     fibroid, in tubercles, 133, 134
     hyaline, 1034
         in tubercle, 133
     parenchymatous, in diphtheria, 1035
         in malarial fevers, 966
         in scarlatina, 1006
         in variola, 984
         of gastric tubules, 370
         of heart, 270, 272
     reaction of, 672, 676
     secondary to cerebral hemorrhage, 602
     spinal, 671, 677
     waxy, in malarial fevers, 966
         of gastric tubules, 372
         of intestines, 431
         of kidneys, 826, 840
         of liver, 545, 553
         of spleen, 581
         of stomach, 370
Delirium ebriosum, 796 (vide Alcoholism).
     hysterical, 781
     in Bright's disease, 835
     in typhoid fever, 908
     tremens, 793
     vigilans, 795
Dementia paralytica, 715  (vide Paralysis,
       general cerebral).
Dengue, 1026
Dermalgia, 750
Diabetes acutus and acutissimus, 885
    insipidus, 812, 877
    mellitus, 812, 879 
1126

Diabetes mellitus, causation, 880, 885
         clinical history, 879
         coma in, 884, 887
         diagnosis, 885
         pathological character, 880
         prognosis, 886
         treatment,  887
Diagnosis, definition of, 19
Diarrhoea, 445
    acute, 422
    bilious, 445
    causation, 445, 447
    choleraic, 483
    clinical history, 445
    colliquative, 449
    crapulous, 447
    dysenteric, 445
    fatty, 445, 583
    lienteric, 445
    serous, 445
    stercoraceous, 445
    treatment, 447,  449
    tubular, 422
    typhoid, 445, 907, 909
Diathesis, hemorrhagic, 1099
    tuberculous, 111, 114, 122
Diazo-reaction in typhoid fever, 914
Digestive or chylopoietic system, diseases
      of, 324
    ulcer of stomach, 351
Dilatation of stomach, 349, 352, 365
         lavage in, 369
         prophylaxis, 370
Diphtheria, 1032
    anatomical characters, 1032
    causation, 1040
    clinical history, 1035
    cloudy SAvelling  in, 1034
    coagulation necrosis in,  1034
    diagnosis, 1041
    paralysis following, 331, 1038
    pathological character,  1039
    prognosis, 1041, 1042
    treatment, 1043
Diplegia facialis, 734
Dipsomania, 386, 388. 794
Dirt-eating, 387
Disease, Basedow's or Graves's, 279
    bronzed-skin, 317
    clinical and natural history of, 19
    diagnosis of, 19
    Duchenne's, 685
    duration of, 21
    elementary forms of, 22
    Hodgkin's,  309 (vide  Pseudo-leuco-
      cythaemia).
    individuality of, how determined, 20
    laws of, 21
    Meniere's, 710
    pathology of, 19
    prevention of, 20
    self-limitation of, 21
    Thomsen's 763
    treatment of, 20
    trichina], 507
    vagabond's 322
INDEX.

     Disease, Werlhof's, 1104
     Diseases, acute, definition of, 20
         anatomical characters of, 19
         aspects, different, under which they
           are to be considered,  19
         causation of, 19
         cerebral, localization of, 613
         chronic, definition of, 24
         classification of, 21
         functional, 19
         general, 21, 896
         local, 21, 22
         pathology of, 19
         self-limited, 21
         surgical, 22
     Dissociation symptom, 656
     Distoma hepaticum, 562
         lanceolatum, 562
     Dorsodynia, 98
     Dropsy, 21
         cardiac, 254
         general, 134
         in acute Bright's disease, 820
         in chronic Bright's disease, 830, 840
         peritoneal, 526
         renal, 820, 830, 837
         scarlatinous, 1009
     Duchenne's disease, 685  (ride Ataxia, loco-
           motor).
     Ductus communis choledochus, inflamma-
           tion of, 567
     Duodenitis, 334, 349, 423
     Duodenum, ulceration of, 349, 429
     Dura mater, haematoma of, 622-632
   |  Dysentery, acute, 397
         acute sporadic, clinical   history, 401
             causation, 404
             diagnosis, 405
             pathological character, 398, 403
             prognosis, 401, 405
             treatment, 405
         amoebic, 404
         anatomical characters of acute >imple,
                   398
                 of diphtheritic, 400
         catarrhal, 398
         chronic, 412
             anatomical characters, 413
             clinical history, 414
             diagnosis, 415
             prognosis, 415
             treatment, 416
         croupous, 400
         diphtheritic, 398, 399
         epidemic, 398, 408
             anatomical characters, 409
             causation. 410
             clinical history, 409
             treatment, 411
         fibrinous, 400
         follicular,  398 413
         malignant,  410
         pylephlebitis from, 566
   |      scorbutic, 410, 412
         stools in, 402, 415
         ulcers of, 414 
 Dyspepsia, acute, 339, 341
     nervous, 390
         diagnosis, 391
         prognosis, 392
         symptoms, 391
         treatment, 392


                   JE.

 Echinococcus, 502
     multilocular, 562
     of kidney,  861
     of liver, 557, 558
         anatomical characters. 557, 558
         clinical history, 559
         diagnosis, 559
         pathological  character, 558
         prognosis, 561
         treatment, 561
     of lung, 196
 Ecstasy, 789
 Ectopia renis, 869
 Electricity in Addison's disease,  323
     in angina pectoris, 285
     in cephalalgia, 754
     in chorea, 760
     in diagnosis of paralyses, 675
     in exophthalmic goitre, 282
     in functional paralysis, 714
     in lead  paralysis, 738
     in myalgia, 755
     in neuralgia, 743
     in neuritis, 725, 726
     in neuroses, 761
     in paralysis, 611
     in paralysis agitans, 765
     in peripheral paralysis, 729
     in poliomyelitis anterior, 694, 696
     in progressive muscular atrophy, 802
 Electro-muscular sensibibtv  and  contrac-
       tility, 712-714
 Embolism, 591
     of brain, 600
 Embolism and thrombosis, cerebral, 591
         anatomical characters, 601
         clinical history, 593
         diagnosis, 596
         pathological character, 592
         prognosis, 598
         treatment, 599
     in  ulcerative endocarditis,  242, 244,
       252
     of  mesenteric arteries, 430, 431
     of  pulmonary artery, 93, 122,  273
Embolus, 591
     infectious, 93
Emissions, involuntary seminal, 891
Emphysema, 154
     acute, 155
     idiopathic, 154
     interlobular or interstitial, 154
     of  lungs, 154
         anatomical characters, 155
         causation, 158
         clinical history, 156
         diagnosis, 160
EX.                                1127


 Emphysema of lungs, pathological charac-
           ter, 157
          prognosis,  162
          treatment,  162
     senile, 156,  162
     vesicular, 154  (eide  Emphysema of
       lungs).
 Emprosthotonos, 790
 Empyema, 20, 25, 50
     causation, 50
     cystidis felleae,  569
     diagnosis, 51
     prognosis, 52
     treatment, 52
 Encephalitis, 657
     anatomical characters, 657
     causation, 657
     clinical history, 658
     prognosis, 658
     treatment, 658
 Encephalopathy, saturnine, 461. 709
 Endarteritis, 102
     deformans, 600
     in chronic Bright's  disease. 825
     obliterans, 102, 601
 Endocarditis, 225, 229, 237
     anatomical characters. 238
     bacteritic, 243
     causation, 239
     clinical history, 239
     diagnosis, 240
     diphtheritic, 243
     embolism, cerebral,  in. 591
     malignant, 238, 243
     mycotic, in pyaemia, 243
     papillary, 238
     pathological character, 239
     prognosis, 241
     puerperal, 243
     pvaemic, 243
     rheumatic, 229, 1058,  1060
     septic, 243
     simple, 23.*.
     treatment, 242
     ulcerative, acute, 238, 243
         anatomical characters. 243
         causation, 244
         clinical history, 244
         diagnosis, 245
         pathological character, 245
         petechial spots in, 245
         prognosis, 245
         retinal hemorrhage in, 245
         treatment, 245
Endopericarditis, 240
Enteralgia, 460
     from lead, 460 (vide Colic from lead).
Enteritis, acute, 423
         anatomical characters, 423
         causation, 424
         clinical  history, 423
         diagnosis, 424
         pathological character, 424
         prognosis, 425
         treatment, 425
     chronic, 425 
1128
INDEX.
Enteritis, membranous. 422
    polyposa, 413
    subacute, 425
    varieties of, 423
Enteroliths, 432
    obstruction of intestine bv, 442
Enterorrhagia,  450, 541, 909, 933
    clinical history, 452
    etiology, 451
    prognosis, 452
    treatment,  452
Enterorrhcea, 445, 473
Ependymitis, granular or chronic, 655
Epilepsia gravior, 766
    mitior, 766
Epilepsy, 766
    antirabic inoculation  in the treatment
      of, 778
    causation, 769
    clinical history, 766
    diagnosis, 770
    hemiplegia in,  787
    in cortical  lesions, 621
    pathological character, 769
    prognosis, 772
    spinal, 680
    treatment, 774
Epileptiform convulsions,  766
Epileptoid  attacks,  766, 773
Fpithelioma of stomach, 359
Eructation, nervous, 380
Erysipelas, 946
    epidemic, 201
Erythromelalgia, 713
Etiology, 19
Exophthalmic goitre. 280
        cerebral symptoms in, 281
        diminished electrical resistance of
           skin in,  281
        tremor in,  280
Exudation, catarrhal, 1033
    croupous, 1032
    diphtheritic, 1032
    pseudo-diphtheritic, 1034
Eyeballs, prominence of, and enlargement
      of thyroid  body,  associated with
      functional disorder of  the heart,
      279

                   F.
Farcy, 1112
    acute, 1114
    chronic, 1114
Febricula, 896,  899
Fecal abscess, 417
Fever, abdominal typhus,  900
    African, 971
    and ague, 950
    bilious, or bilious remittent. 964
    break-bone, 1026
    camp, 968
    causes  of, 898
    cerebro-spinal,  648
    Chagres, 950
    Chickahominy, 968
    congestive, 961
Fever, continued, common, 896, 899, 900
        simple, 899
    dandy,1026
    definition of, 897
    enteric, 900
    ephemeral, 899
    epidemic, characterized  by  pharyn-
      gitis, 948
    erysipelatous, 946
        epidemic, 947
    famine, 938, 944
    five-day,  938
    gastric, 340
    heat, 624
    hectic, in phthisis pulmonalis, 106
        in pyelitis, 849
    Hungarian,  971
    ileo-typhus,  900
    intermittent, 950
        anatomical characters, 950
        causation, 954
        clinical history, 950
        diagnosis, 956
        prognosis, 957
        relapses of, 953
        stages of, 950
       " treatment, 957
    intermittent, compound types  of, 952
        bilious,  954
        cAigestive, 961
        latent, 954
        malignant, 961
        masked, 954
        pernicious, 961
             algid, 961
             apoplectic, 961
             asthenic,  962
             comatose 961
             haematuric, 962
             icteric, 961
             quinia in, 957, 963
             soporose,  961
             treatment of. 962
        prophylaxis of, 960
        quartan, 952
        quotidian, 952
        tertian,  952
             types of, 952, 956
    jungle, 971
    lake, 971
    lung, 77
    Panama, 950
    pathology of, 897
    pneumonic, 64, 77
    pythogenic, 900
    relapsing, 938
        anatomical characters, 939
        causation, 943
        clinical history, 940
        coagulation necrosis in,  939
        diagnosis, 943
        prognosis, 945
        spirochazte Obermeieri in, 939, 942
        treatment, 945
    remittent, bilious,  964
        pernicious, 970 
INDEX.
1129
Fever,  remitient, simple and  typho-mala-
               rial, 965
             anatomical characters, 965
             causation, 968
             clinical history, 966
             diagnosis, 968
             pathological character, 968
             prognosis, 969
             quinia, use of, in, 969
             treatment, 969
     rheumatic, 1058
     scarlet, 1004
     seven-day, 938
     ship, 922
     short, 938
     simple, 899
     spotted, 648
     suppurative  or secondary, in  variola,
       987
     swamp, 950
     symptoms of, 898
     thermal, 624
     typhoid, 900
         abortive, 920
        , anatomical characters, 900
         bacillus of, 902, 905, 917
         bacteria in, 902, 906
         blood in, 904
         causation, 916
         clinical history, 906   •
         complications, 904,  915
         diagnosis, 919
         latent, 920
         prevention of, 918,  937
         prognosis, 921
         treatment, 929
     typhoid and tvphus,  non-identity  of,
       922
     typho-malarial, 915,  964  (vide Fever,
       remittent typho-malarial).
     typhus, 922
         anatomical characters, 922
         causation, 925
         clinical  history, 923
         diagnosis, 927
         prevention of, 937
         prognosis, 928
         recurrens, 938
         treatment, 929
     Walcheren, 971
     worm, 499
     yellow, 971
         anatomical characters, 971
         causation, 975
         clinical  history, 972
         diagnosis, 978
         prevention of, 980
         prognosis, 975, 978
         treatment, 979
Fevers and other general diseases, 896
Fevers, adynamic, 897
    asthenic, 897
    ataxic, 897
    causes of, 898
    classification of, 896
    contagious, 896
Fevers, continued, 890
    eruptive, 20, 896, 981
    essential, 21, 896
    exanthematous, 896
    fastigium of, 897
    high, 897
    low, 897
    lysis of, 897
    malarial,  950
    miasmatic, 896
        contagious, 896
    micro-organisms in, 897
    pathology, general, of, 897
    periodical, 896,.898
    slow,  897
Filaria sanguinis hominis, 528, 872, 876
Fingers, bulbous or clubbed, 109
Flux, bloody,  409
Fomites, 926, 989, 1012
Foot-clonus, 674
Friedreich's disease, 690
Functional morbid changes, 19


                   G.
Gall-bladder, cancer of, 570
    dilatation of, 569
    inflammation of, 569
Gall-stones, passage of, 466
        clinical  history, 467
        diagnosis, 468
        prognosis, 469
        treatment, 469
Gangrene of lungs, 150, 188
        anatomical characters, 188
        causation, 188
        clinical history, 189
        diagnosis, 189
        prognosis, 190
        treatment, 190
    symmetrical, 810
Gastralgia, acute, 383
    chronic, 384
Gastrectasia, 365
    anatomical characters, 365
    clinical history, 367
    diagnosis, 368
    prognosis, 368
Gastric carcinoma, 359
        anatomical characters, 359, 366
        diagnosis, 361
        etiology, 361
        prognosis, 364
        symptoms, 361, 393
        treatment, 364
    tubules, degeneration of, 370
             anatomical characters, 370
             causation, 370
            clinical history, 371
    ulcer, 351 (vide Ulcer, gastric).
Gastritis, acute, 334
        anatomical characters, 334
        causation, 337
        clinical history, 336
        diagnosis, 337
        pathological character, 336 
1130
INDEX.
Gastritis, acute, prognosis, 337
        treatment, 338
    chronic, 342
        interstitial, 347
            anatomical characters, 347
            causation, 349
             clinical history, 348
            diagnosis, 349
            treatment, 349
        lavage in, 345
    phlegmonous, 345
        anatomical characters, 345
        causation, 346
        clinical history, 346
        diagnosis, 347
        metastatic, 346
        prognosis, 347
        treatment, 347
    polyposa,  343
    subacute, 339
    toxic, 336, 339
    uraemic, 341
Gastro-duodenitis, 349, 568, 573
Gastrodynia, 383
Gastro-enteralgia, 460
Gastromalacia, 350
Gastrorrhagia, 392, 541
Gastrorrhoea, 473
(ienito-urinary system, diseases of, 812
Germ, how supported by effects of quinia,
       959
Glanders, 1112
    acute, 1113
    chronic, 1114
    diagnosis, 1115
    etiology, 1112
    prognosis, 1115
    symptoms, 1113
    treatment, 1115
Globus hystericus, 781
Glomerulo-nephritis, 816, 825
Glosso-pharyngeal nerve, paralysis of, 734
Glottis, oedema of, 215, 333
        anatomical character, 215
        causation, 216
        clinical historv, 216
    spasm of, 218, 288*
Glycohamiia, 880
Glycosuria, 879 (vide Diabetes mellitus).
    causes of,  584, 885
Goitre, exophthalmic,  279
Gout, 21, 1074
    anatomical characters, 1075
    anomalous, 1079
    causation, 1081
    chronic or persistent, 1078
    clinical history, 1076
    diagnosis, 1065, 1082
    irregular or misplaced, 1079
    kidneys in, 828, 837
    latent, 1079
    pathological  characters, 1080
    prognosis, 1083
    retrocedent, 1079
    rheumatic, 1088
Gout, tophi in, 1075
    transient, 1076
    treatment, 1084
    uric acid in blood in, 1076, 1080
Graphospasmus, 761               •
Gravel, 857
Graves's disease, 279
Grippe, 1050
Growths, morbid (vide Tumors).
Gumma in brain, 665
    in cord, 703
    in heart-wall, 247, 272
    in intestine, 428
    in liver, 545
    in lungs, 197
    in pharynx, 329
Gums, blue discoloration of, in lead-poison-
       ing, 463
    in scorbutus, 1098


                   H.

Haematemesis, 392
Haematinuria, 812, 872
Haematoma of dura mater, 622, 632
    of the peritoneum,  524
Haemato-myelitis, 630, 677, 679
Haemato-myelus, 629
Haematophilia, 1105
Haematopoietic system, diseases of, 291
Hsematorrhachis, 629
Haematuria, endemic, 872
    renal, 849, 850, 862, 863, 867, 871
Plaemoglobinamia,  873
    malarial, 875
Haemoglobinuria, 812, 875
    paroxysmal, 873
Hsemopericardium, 235
Ffaemophilia, 1105
Hazmophthms, 292, 312
Haemoptysis, 181, 187
    in bronchitis, 148
    in miliary tuberculosis, 136
    in phthisis pulmonalis, 105. 108, 118,
       121, 134
    in pneumorrhagia,  187
    with cardiac valvular lesions, 253
Hay asthma, 165, 167
    fever, 167
Headache, 753
    in unemia, 834, 839
    sick, 754
Heart, abscess in, in infarction, 246
         in myocarditis, 246
    aneurism of, in myocarditis, 246
    atrophy of, 269
    dilatation of, 247, 252, 263, 265, 1060
    enlargement of, with valvular lesions,
           248, 260
         without valvular lesions, 267, 829
    fatty degeneration of, 269,  318
    functional disorder of, 275
             causation, 277
             diagnosis,  278
             treatment, 278 
INDEX.
1131
Heart,  functional  disorder  of, associated
               with  enlargement of thy-
               roid body and  prominence
               of eyeballs, 279
             pathological character, 281
             treatment, 282
    gummata in, 272
    hvpertrophv and dilatation of, in  ne-
           phritis,  826, 836, 837, 840
         clinical history of, 265, 268
    infarctions in,  246
    murmurs, 257 et seq.
    new growths and parasites in, 272
    obesity of, 269
    parasites in, 272
    parenchymatous  degeneration of, 270,
       272
    partial aneurism of, 246
    rupture of, 246, 247, 273
    syphilitic disease of, 247
    thrombosis of,  246. 249, 273
    tubercles  in, 135, 272
    valvular  lesions of, Avith enlargement,
               248, 260
             anatomical characters, 248
             causation, 257
             clinical  history, 253, 261
             diagnosis, 257
             pathological character, 256
             prognosis, 261
             treatment, 262
Heart-beats, diminished frequency of, 277
Heart-clot, 238,  243, 244, 246
Heart-sounds, reduplication of, 276
Helminthi, intestinal,  498  (vide Worms,
       intestinal).
Hematoma of dura mater, 622, 632
Hemianaesthesia, crossed, 615
    from lesions of corpora striata, 618
Hemianopsia  from cortical  lesions, 622,
       658
    from  disease  of the  corpora striata,
       618
    from disease of the optic thalami, 617
Hemiathetosis, 765
Hemichorea, 617, 756, 766
Hemicrania, 745, 753
Hemiopia, 619, 622
Hemiplegia, 717, 718
    double, 610, 715
    emotional, 717, 718
    in cerebral  embolism  and thrombosis,
       594
    in cerebral hemorrhage, 603,  605
    in epilepsy, 768
    infantile spastic, 660
    in insolation, 717
    in lesions of cortex, 620
    in meningeal hemorrhage, 623
Hemoptysis (vide Haemoptysis).
Hemorrhage, cerebral, 600
         anatomical characters, 600
         causation,  600, 608
         clinical history, 603
         diagnosis,  608
         pathological  character, 600
 Hemorrhage, cerebral, prognosis, 610
         treatment, 610
     meningeal, 622
     pulmonary, 181, 188
;         relations  of, to  phthisis,  182-1*4
         treatment of, 1S4, 188
     spinal, 629
     spontaneous,  600
 Hemorrhagic diathesis, 1105
     infarction in cardiac disease, 253
 Henoch, statistics of tracheotomy in laryn-
       gitis with  exudation and  in  diph-
       theria, 210
 Hepar mobile, 563
 Hepatic colic, 466
 Hepatitis, chronic interstitial, 538
         anatomical characters, 538
         causation, 542
         clinical history, 540
         diagnosis, 543
         prognosis, 543
         treatment, 543
     suppurative,  533
         anatomical characters, 533
         causation, 535
         clinical history, 534
         diagnosis, 536
         prognosis, 537
         treatment, 537
     syphilitic, 544
 Hernia, diaphragmatic, 439
     dubdeno-jejunal, 438
     strangulated, Avithin abdomen, 438
 Hodgkin's disease, 307  (vide Pseudo-leu-
       cocythaemia).
 Hum, venous, in anaemia, 293
 Hydatids  in the kidneys, 850, 861
     in the liver, 587
     in the lungs, 196
     in the spleen, 582
 Hydrencephaloid affection, 590, 600, 708
 Hydrocephalus, 654
     acute, 639, 655
 Hydrochloric acid in gastric juice, tests
           for, 374, 375
         its absence from the gastric secre-
           tions in  cases  of gastric car-
           cinoma, 362
 Hydromyelia, 655
 Hydromyelus, 703
 Hydronephrosis, 852
     anatomical characters, 852
     causation, 852
     clinical history, 853
     diagnosis, 854
     prognosis, 854
     treatment, 855
 Hydropericardium, 235
 Hydro-peritoneum, 526
     causation, 527, 555
     clinical history, 528
     diagnosis, 529
     fluid of, 527
     prognosis, 529
     treatment, 530
 Hydrophobia, 1115 (vide Rabies). 
1132

Hydrops adiposus, 528
    chylosus, 528
    cystidis felleae, 569
Hydrorrhaehis, 654
Hydrothorax, 62
    characters of effusion in, 62
Hygienic treatment of disease, 21
Hyperacidity, 389
Hyperaemia, active cerebral, 586
    cerebral, 585
         anatomical  characters, 586
         causation, 586
    of kidneys,  812
    of liver, 565
    of lungs, 96
    of spinal cord and its meninges, 628
    passive cerebral, 586, 588
Hypersecretion,  389
Hypertrophy of heart, 265
         in  chronic  Bright's disease, 826,
           829
Hypnotism, 789
Hypochondriasis, 799
Hypodermic  injections  of  morphia  in
      neuralgia and other affections, 742
    injections of quinia in malarial fevers,
           959,  963
         in neuralgia, 744
    syringe in diagnosis, 46
Hypoglossus nerve, paralysis of, 735
Hysteria, 780
    causation, 785
    clinical history, 780
    diagnosis, 782
    pathological character, 785
    prognosis, 786
    treatment, 786
Hysterical coma, 782
    condition, 780
    convulsions, 781
    cough,  781
    delirium, 781
Hystero-epilepsy, 787


                    I.

Icterus, 21, 567, 570 (vide Jaundice).
    acute febrile, 575
    gravis,  542, 544, 545
    haematogenous,  570, 873
    hemorrhagic, 545
    hepatogenous, 570
    infectious, 575
Ileo-colitis, 422
Ileus, idiopathic, 432, 444
Impotence, 891, 893
Inanition, 395
Incision for pleuritis Avith pneumothorax,
       59
    free, for empyema, 52
Incontinence of the pylorus, 382
Induration, brown or pigment, of lungs, 96
Infarction, anaemic or Avhite, 591
     cerebral, 591
     embolic, 591
     hemorrhagic, 93, 186
INDEX.

     Infarction, intestinal, 430
     Infiltration of heart, 269, 318
     Inflammation, acute, treatment of, 33
         use of opium in, 36
     Influenza, 138, 327,1050
         anatomical alterations, 1052
         bacteriologv, 1052
         definition, 1050
         diagnosis, 1056
         duration, 1055
         etiology, 1050
         incubation, 1052
         invasion, 1053
         prognosis, 1056
         symptoms, 1052
         treatment, 1057
     Inhalations of oxygen  and warm  vapor,
           147
     Inoculation to prevent variola, 994
     Insolation, 623
         anatomical characters, 624
         causation, 625
         cerebral congestion  in, 587
         clinical history, 624
         diagnosis, 626
         hemiplegia in,  717
         pathological characters, 624
         prognosis, 626
         treatment, 626
     Insufficiency, relative, of heart-valves, 249
     Insufflation 155
     Intestine, carcinoma of,  431
         compression and stricture of, 432, 440
         functional affections of,  445
         hemorrhage into, 450, 541
              in typhoid fever, 903,  909, 921,
                933
         inflammatory diseases of,  397
         intussusception  or invagination  of,
                403, 432
              anatomical characters, 433
              causation,  434
              clinical history, 434
              diagnosis,  435
              laparotomy in, 437
              prognosis,  433, 434, 436
              treatment, 436
         new growths in, 431
         obstruction of,  432
              from enteroliths, 432, 442
              from feces, 432, 442
              from foreign bodies,  432, 442, 469
         perforation  of, in typhoid  fever, 909,
            933, 982
         rotation or twisting of, 432, 438
         rupture of, in obstruction, 441
         Simon's method of  exploring, 441
         stricture and compression of, 432, 440
         structural affections of,  427
         tuberculosis of, in phthisis,  110
         twisting of, 432, 438
         ulcers of, 427
         waxy degeneration of, 431
     Intubation of larynx in diphtheria, 1047
     Intussusception, 432
     Irritation, spinal, 609, 722 
INDEX.
1133
                   J.
Jaundice, 21, 567, 570
     clinical history, 571
     diagnosis, 574
     fatal, 545
     haematogenous, 570
     hepatogenous, 570
     malignant, 545
     pathological  characters, 573
     prognosis, 573
     treatment, 574

                   K.
Kak-ke, 726
Kidney, abscess of, 846
     atrophy, granular, of, 828, 832
     carcinoma of, 864
         anatomical characters, 864
         clinical history, 866
         diagnosis, 867
         prognosis, 867
         treatment, 868
     cirrhosis of, 828,  832
     congestion of, active, 812
         passive, 813
     degeneration of, cvstic, 861
         fatty, 814
         parenchymatous, 814
     echinococci in, 861
     fibroid, 828, 832
     floating, 869
     gouty, 828, 829, 832, 837, 839
     granular, small, 828, 832
     hydatids in, 861
     induration, cyanotic, of,  813
     inflammation,  acute, of,  815   (vide
           Nephritis, acute diffuse).
         acute  interstitial or suppurative,
           of, 846  (vide  Nephritis, acute
           interstitial or suppurative).
         chronic  diffuse,  of,  823   (vide
           Nephritis, chronic diffuse).
     large,  Avithout   Avaxy   degeneration,
           480, 825
         with  waxy degeneration, 826, 838
     large red, 825
     large white, 825
     movable, 869
         indications for operation in, 870
     new growths in, 861
     small granular, 828, 832. 840
     spirit, 838
     surgical, 846
     tuberculosis of, 135, 862
     wandering, 869
     waxy degeneration of, 826, 840
Klebs-Loffler bacillus, 1039, 1040
Knee-jerk, 674, 1039

                   L.
Lactic acid in rheumatism, 242
Laparotomy  in intestinal obstruction, 437,
       440
Laryngismus stridulus, 218
Laryngitis, acute simple, 199
Laryngitis,  acute simple, anatomical cha-
           racters, 199
         causation, 200
         clinical history, 199
         diagnosis,  201
         pathological character, 200
         prognosis, "201
         treatment, 202
     chronic, 118, 121, 204
     subacute, 203
     syphilitic, 204
     with fibrinous exudation, 207
             causation, 211
             clinical history,  209
             diagnosis, 211
             pathological character, 210
             prognosis, 212
             treatment, 213
Laryngoscope, 207, 224
Laryngotomv in cases of  thoracic aneur-
       ism,  289
Larynx, diseases of, 197
     fistulous orifice within, 223
     morbid growths within, 223
     paralysis of, 200, 208,  220
     spasm of, 200, 209, 217, 1116.
     topical applications within, 206
Lavage in  chronic gastritis, 345
     in dilatation of the stomach, 369
Lead colic,  460 (vide Colic from lead).
     encephalopathy, 461, 709
     enteralgia, 461
     paralysis, 461,  463, 794
     poisoning by, 460
Lepra, 1028
     nervosa, 1029
     tuberosa, 1030
Leprosy, 1028
     anatomical characters, 1030
     diagnosis, 1030
     prognosis, 1031
     symptoms, 1029
     treatment, 1031
Leptomeningitis, 632, 634 (vide Meningitis,
       acute cerebral).
Leucocythaemia or leukaemia,  298
     causation, 305
     clinical history, 301
     diagnosis, 304
     hemorrhagic  tendency in, 301, 303,
       601
     myelocytes in the blood of, 305
     pathological character, 298, 580
     prognosis, 304
     treatment, 306
Leucocytosis, 298
Leucomyelitis, chronic posterior, 684
Lipsemia, 881
Lithaemia,  1072, 1076, 1080
     diagnosis, 1073
     treatment, 1073
Litliiasis, 857
Lithuria, 85S
Liver, abscess of, 533 (vide Hepatitis, sup-
           purative).
         amoebic, 536 
1134                                INDEX.
Liver, acute yellow atrophy of, 545
        anatomical characters, 545
        causation,  549
        clinical history, 547
        diagnosis, 549
        pathological  changes. 548
        prognosis,  549
        treatment,  549
    amyloid, 553
    atrophy of, 563
        broWn, 563
        red, 252, 525
    bronzed, 965
    cancer of,  555
        anatomical characters, 555
        clinical history, 556
        diagnosis,  557
        treatment,  557
    changes  in  position  and  shape  of,
      563
    cirrhosis of, 344, 538, 966
        hypertrophic, 544
        infantile, 542
    congestion of, 564, 578
    diseases of, 532
    fatty,.550, 969
    functional affections of, 577
    gin, 542
    hydatids in, 557 (vide Echinococcus of
      the liver).
    hypertrophy of, 563
    lardaceous or  waxy, 553 (ride Liver,
      waxy).
    new growths in, 557
    nutmeg, 252, 565
    parenchymatous degeneration of, 552
    pigmentary deposit in, 563, 965
    pulsating, 255
    syphilitic disease of, 544
    torpor of, 578
    tuberculosis of, 135, 557
    wandering, 564
    waxy or lardaceous, 553
        anatomical characters, 553
        causation, 554
        diagnosis, 554
        pathological  characters, 553
        prognosis,  554
        treatment,  554
    whiskey, 542
Localization of cerebral disease, 613
    in cerebellum, 614
    in centrum ovale, 619
    in corpora quadrigemina, 616
    in corpora striata, 617
    in cortex cerebri, 595, 619
    in crura cerebelli, 614
    in medulla oblongata, 616
    in pedunculi cerebri, 616
    in pons Varolii, 615
    in thalami optici, 617
Locomotor ataxia, 685
Lockjaw, 790
Lotura carnium, 402, 409
Lumbago, 748
Lumbodynia, 809
Lumbricoid worms, 498, 499
Lung, carnified, 25
    carcinoma of, 134
    cirrhosis of, 134
    senile atrophy of, 156
Lungs, diseases of,  23  (ride  Pulmonary
       diseases).
    brown or pigment induration of, 96
    hyperaemia of, 96
    splenization of, 97
Lymphoma, 381
Lympho-sarcoma,  malignant, 307
    of lung, 195
Lysis, 897

                  M.
Macrocytes, 312
Magnetic sleep, 789
Main  en griffe, 698
Mal, haut or grand, 766
    petit,  766
Malacia, 386
Malaria,  954
Malignant pustule, 1110
Malum coxae senile, 1088
Mania-a-potu, 794, 796
Marrow  of bone  in  leucocythaemia, 299,
       300
    in pseudo-leucocythaemia, 309
    in pernicious anaemia, 313
Masturbation, 894
McBurney's tender point, 420
Measles, 1018 (vide Rubeola).
    false, 1024 (vide Roseola).
    German, 1025 (vide Rotheln).
Meckel's diverticulum, 438
Megrim, 754
Meigs,  A. V.,  diet in cholera infantum,
       479
Melaena, 450, 494
Melanaemia, 965
    pigment, seat of, in,  965
Melanosis, 965
Melasma supra-renale, 317
Melituria, 879 (vide Diabetes mellitus).
Meniere's disease, 710
Meninges of brain and spinal cord,  dis-
       eases of, 631
Meningitis, basilar, 639 (vide Tuberculous
       meningitis).
    cerebral, acute, 632,  634
        anatomical characters, 634
        causation, 636
        clinical history, 635
        diagnosis, 636
        pathological  characters,  634
        prognosis, 637
        treatment, 637
    cerebral, chronic, 638
    cerebro-spinal, 648
         anatomical characters, 648
         causation, 652
         clinical history, 649
         diagnosis, 652
         pathological  character, 651
         prognosis, 653 
INDEX.
1135
Meningitis, cerebro-spinal, treatment, 653
    gummatous, 665
    spinal, acute, 644
         anatomical characters, 644
         clinical history, 644
         diagnosis, 645
         etiology, 644
         pathological characters, 644
         treatment, 645
    spinal, chronic, 645
    tuberculous, 110, 639
         anatomical characters, 639
         clinical history, 641
         diagnosis, 642
         pathological characters, 640
         treatment, 643
Meningo-myelitis, 644, 645
Mervcismus, 380
    definition, 380
    diagnosis, 382
    etiology,  381
    prognosis, 382
    symptoms, 381
    treatment, 382
Mesmeric or magnetic sleep, 789
Metamorphosis, diphtheroid, 982, 983
Miasm, marsh, 954
Micrococci in variola, 983, 984
Microcytes, 312
Migraine,  745
Milk sickness, 1047
         treatment, 1049
Mind, disorders of, 707
Monoplegia in cortical diseases, 621
Morbid growths (vide New growths).
Morbilli, 1018 (vide Rubeola).
Morbus anglicus, 1092
    coxae senilis, 1088
    haemorrhagicus maculosus, 1104
Motor oculi communis,  paralysis  of, 606,
           617, 730
         externus, paralysis of, 732
Movements, muscular, anomalous,  760
         compelled, 615, 666
Mucus, 150
Mumps, 332 (vide Parotiditis).
Murmurs,  anaemic, 259
    aortic, 241, 258
    bellows, 229
    cardiac—friction, 229
    cardiac—pleural friction,  230
    cardiac—pulmonary 258
    endocardial, 229, 240, 257
    exocardial, 229
    haemic, 259
    inorganic, 259
    mitral, 241,  259
    pericardial, 229
    pulmonic, 241, 259
    tricuspid, 134, 259
Muscles, atrophy of, in cerebral  hemor-
           rhage, 607
         in progressive hemorrhage, 696
Myalgia, 750
Myelitis, acute, 676
         anatomical characters, 677
Myelitis, acute, causation, 680
        clinical history, 678
        pathological character, 677
        prognosis, 679
        treatment, 6S]
    ascending, 676
    central, 676
    chronic, 678, 680
    cortical, 676
    descending, 676
    diffuse, 676
    transverse, 676
    varieties of, 676
Myocarditis, 225, 246
    chronic interstitial, 246
    fibrous, 246
    gummatous, 247
    indurative, 246
    interstitial, acute, 247
    parenchymatous, 247
    suppurative,  247
Myxoedema,  804
    morbid anatomy, 804
    relation  between atrophy  of thyroid
       gland  and, 805
    treatment, 806

                   N.
Necrosis in acute Bright's disease, 817
    in diphtheria, 1034
    in dysentery, 401
    in endocarditis, ulcerative, 243
    in variola, 982, 983
Needles, evils of their use in thoracentesis,
       49
Nematoda, 502, 507
Neoplasms (vide New growths).
Nephritis,  acute diffuse, 815
        anatomical characters,  816
         causation, 820
        clinical history, 817
        diagnosis, 821
        pathological character, 819
        prognosis, 821
        treatment, 822
    acute interstitial or suppurative, 846
        anatomical characters,  846
        causation, 846, 848
        clinical history, 847
        diagnosis, 848
        prognosis, 848
        treatment, 848
    after scarlatina, 1006, 1008, 1011
    chronic diffuse, 823
        anatomical characters,  825
        causation, 837
        classification of its varieties, 823
        clinical history, 830
        diagnosis, 839
        pathological characters, 837
        prognosis, 841
        treatment, 842
Nephro-lithiasis,  855
Nephro-phthisis,  863
Nervous dyspepsia, 390
    system, diseases of, 585, 723 
113(i
INDEX.
Nervous vomiting, 377
         diagnosis, 378
         prognosis, 378
         symptoms, 378
         treatment, 378, 379
Neuralgia, 739
    causation, 740
    cervico-brachial, 747
    cervico-occipital, 746
    clinical history, 739
    crural, 748
    cutaneous, 750
    diagnosis, 741
    dorso-intercostal, 97, 747
    epileptiform, 746
    lumbo-abdominal, 747
    muscular, 750
    sciatic, 748
    treatment, 741
    trifacial, 744
Neurasthenia, 721
Neuritis, 724
    ascending, 724
    circumscribed, 724
    descending,  724
    multiple, 725
Neuroses, 585, 721,  755
New growths in  the brain, 664
         in the chest, 194
         in the heart, 272
         in the kidney, 861 et seq.
         in the larynx, 223
         in the liver, 557
         in the lungs, 194
         in the spleen,  582
         in the thorax, 194
Noma in typhus fever,  924
Nosology, 21
Nymphomania in rabies, 1117


                   O.
Obstipation, 452
Obstruction of bowels, 432
(Edema, 21, 62
    cardiac, 254
    collateral, 80, 191, 216
    of the glottis, 215
    pulmonary,  acute,  191
         anatomical characters, 191
         causation,  191
         symptoms, 193
         treatment, 193
    pulmonary,  collateral, 191
Oesophagus, inflammatory and other affec-
      tions of, 330
Oligaemia, 312
Oligochromaemia, 296
Oligocythaemia,  312
Opisthotonos, 644, 650, 782, 790
Orchitis, variolous, 988
Orthopncea, 63,  145
Ovarian cyst, diagnosis of, from hydroperi-
      toneum, 530
Oxaluria, 857, 858
Oxyuris vermicularis, 500
Pachymeningitis, 632
    cervical, hypertrophic, 647, 704
    externa, 632
    haemorrhagica, 622
    interna, 632
Palsy, shaking, 703
    wasting or creeping, 696
Pancreas, affections of, 583
    calculi in, 584
    cancer of, 583
    diarrhoea, fatty, in diseases of, 440, 583
    enlargement of, 583
    fatty disease of, 584
    inflammation of, 583
Pancreatitis, 583
    hemorrhagic, 584
Paracentesis from necessity,  51
    in ascites, 531,  566
    in empyema, 52
    in pericarditis, 235, 236
    in pleuritis, 47
Paralysis, 712
    acute ascending, 720
    acute, bulbar, 636, 664, 703
    agitans, 763
    alcoholic, 793
    alternating, 605, 615
    Bell's, 732
    bulbar, acute, 616,  664,  703
    bulbar, chronic, 616, 661
         anatomical characters, 661
         causation, 663
         clinical history, 662
         pathological character, 661
         prognosis, 662
         treatment, 663
    cerebral, general, of insane, 715
    crossed, 615, 616
    from arsenic,  copper,  mercury,  and
       phosphorus, 739
    from Bright's disease, 834
    from cerebral  embolism  and throm-
       bosis, 594
    from cerebral hemorrhage, 603
    from chorea, 756
    from commotion, 714
    from compression of spinal cord, 704
    from cranial tumors, 666
    from diphtheria, 729, 1036
    from encephalitis, 658
    from hysteria,  781
    from insolation, 625
    from lead, 461 463, 737
    from locomotor ataxia,  688
    from meningitis, 635, 642, 645, 650
    from myelitis,  678
    from neuritis, multiple, 726
    from paralysis agitans,  763
    from poliomyelitis  anterior, 692, 694
    from primary lateral sclerosis, 700
    from spinal hemorrhage, 630
    from variola, 989
    glosso-labio-laryngeal,  661  (vide Bul-
       bar paralysis, chronic). 
INDEX.
1137
Paralysis, hemiplegic, 594, 602
    infantile spinal, 691
    Landry's, 720
    local,  of other than cranial nerves,
       735
    mimetic, 732
    myo-pathic, 713
    myo-sclerotic, 706
    neuropathic, 713
    of cervical  sympathetic nerve, 736
    of eighth cranial nerve, 734
    of fifth cranial nerve, 731
    of fourth cranial nerve, 731
    of laryngeal muscles, 200, 208, 220
    of motor portion  of seventh cranial
       nerve, 732
    of ninth cranial nerve, 735
    of sixth cranial nerve,  732
    of the insane, 715
    of third cranial nerve, 606,  616, 730
    paraplegic, 629, 705, 718, 739
     peripheral, 713, 726
     pseudo-hypertrophic or myo-sclerotic,
       706
     reflex, 714, 719
     spastic cerebral, of children, 660
     spinal, chronic atrophic, 695
         general, 716
         of children and adults, 676, 691,
           694   (vide  Poliomyelitis,  acute
           anterior).
         spasmodic, 700
         spastic, 672, 683, 700
 Paraphasia, 594
 Paraplegia, 629, 704, 718, 739, 1039
     alcoholic, 794
     reflex, 719
 Parenchymatous degeneration (vide Degen-
       eration).
 Paresis,  713, 715
 Parotiditis, 332
    in typhoid fever, 333
 Pathology, general and special, 19
    special, introduction to, 19
 Pathophobia, 799
 Pentastomum, 562
 Perforation of  intestine in  typhoid fever,
       515 _
 Periarteritis, 601
 Peribronchitis in phthisis, 102, 103
 Pericarditis, acute, 22o
         anatomical characters,  226
         causation, 228
         clinical history, 227
         diagnosis, 229
         pathological  character, 228
         prognosis, 231
         treatment, 232
    chronic, 234
    in Bright's disease, 227, 231
    in rheumatism,  227, 228,  229,  231,
       1058, 1060
    micro-organisms  in the causation ot,
       229
    pneumo-, 236
    purulent, 226, 228, 247
         72
Pericarditis,   rheumatic,  227-229,   231,
      1059, 1060
Perichondritis, laryngeal, 205
Perihepatitis, 521
Perinephritis, 858
Peristaltic unrest, 379
Peritoneum,  diseases of, 511
Peritonitis, acute diffuse, 512
         anatomical characters, 512
         cathartics  in  the treatment of,
           518, 519
         causation,  515
         clinical history, 513
         diagnosis,  515
         pathological character, 514
         prognosis,  517
         treatment, 518
     cancerous, 522, 555
     chronic, 522
         anatomical characters, 522
         clinical history, 525
         diagnosis,  525
         treatment, 526
         varieties of, 522
     hemorrhagic, 524
     proliferative, 523
     serous, 522
     tuberculous, 106, 110,  524
Perityphlitis, or  perityphlitic abscess, 418,
     " 420
Perspiration, elimination of urea by, 823
Pertussis, 174
     causation, 177
     clinical  history, 174
     diagnosis, 177
     pathological character, 177
     prognosis, 178
     treatment, 178
Pharyngeal,  retro-, abscess, 327
Pharyngitis, 326
     acute, 326
     chronic, 327
     epidemic, 326, 948
     erysipelatous, 327
     exanthematous, 327
     follicular, 327
     gangrenous, 327
     phlegmonous,  327
     pseudo-membranous or fibrous, 327
     subacute, 327
     syphilitic, 328
     tuberculous, 328
Phlebitis, portal, 353,  565
Phosphuria,  858
Phthisis, acute, 101, 110
     clinical  history of first stage,  105
           of second stage, 108
     coal-miner's, 95,134
     complications  of,  110
     curabilitv of, 118
     fibroid, 103,  133
     florida, 102, 110
     laryngeal, 204
     methods of cure of,  105
     pathology of, 110
     pneumothorax in, 109 
1.138
INDEX.
Phthisis, pulmonary, 99
        anaemia in, 107
        anatomical characters, 99
        causation,  99
        clinical history, 105
        diagnosis,  115, 117, 134
        formation  of cavities in, 101
        identity of bovine and human, 112
        pathological character, 110
        prognosis,  118, 134
        Rasmussen's aneurism in,  101
        treatment, 121, 135
        tuberculin in the treatment of, 133
    renal, 862
    sputa of, 105, 107,  116, 135
    stages of, 104
    stone-cutter's, 95, 134
Pica, 452
Pleuritis, acute, 23
        anatomical characters, 23
        causation,  28
        clinical history, 25, 40,
        diagnosis,  29
        pathological character, 28
        prognosis,  32
        treatment, 32
    chronic, 25, 40, 103, 105
        anatomical characters, 40
        causation,  43
        clinical history, 141
        diagnosis,  45
        pathological character, 42
        prognosis,  43
        relations to tuberculosis, 42-45
        Skoda's resonance in, 30
        treatment, 46
    circumscribed,  25, 61, 66
    diaphragmatic or phrenic, 61
    dry, 26
    in Bright's disease, 42
    paracentesis in, 47, 62
    pulsating, 54
    relation of tuberculosis to, 43
    sicca, 26
    suppurative, 50 (vide  Empyema).
    varieties of, 40
    with pneumothorax, 54
        anatomical characters, 55
        causation,  55, 154
        clinical history, 55
        diagnosis,  56
         prognosis, 58
        treatment, 59
Pleurodynia, 97, 751
Pleuro-pneumonitis, 66
Pleurosthotonos, 790
Pneumo-haemothorax, 54
Pneumo-hydrothorax,  20, 54, 121
Pneumokoniosis, 94
Pneumonic fever,  64
Pneumonitis or pneumonia, 63
    acute circumscribed, 117
    acute lobar, 64
             anatomical characters, 64
             causation, 72, 77
             clinical history, 67
Pneumonitis, acute lobar, diagnosis, 75
             herpes labialis in, 71
             pathological character, 77
             prognosis, 78-80
             treatment, 80-86
    an infectious disease, 74
    broncho-, 88
    caseous or tuberculous, 90, 102, 133
    catarrhal, 88
    croupous, 64
    deglutition, 92
    embolic, 92
    heart-thrombus in, 79
    hypostatic, 96, 97
    interstitial,  103, 134
    in young children, 87, 88
    lobular, 88, 143
         anatomical characters, 89
         causation, 91
         clinical history, 90
         diagnosis, 91
    suppurative, 92
         pneumonotomy in, 94
    treatment, 92
    typhoid, 72
Pneumo-pericarditis, 236
Pneumo-pericardium, 237
Pneumo-pyothorax, 54
    simulated  by  abscess between  liver
      and diaphragm, 57
Pneumorrhagia, 181, 185, 186,  262
Pneumothorax, 59
    anatomical characters, 59
    case of, 60
    causation, 60
    clinical history, 60
    coin-sound in, 57
    prognosis, 61
    treatment, 61
    varieties  of percussion  resonance in,
      56
Poisons,  antidotes  for  corrosive and acrid,
      339
Poliomyelitis, anterior, 676
    acute, 691
         anatomical characters, 691
         causation, 694
         clinical history, 692
         degeneration, reaction of,  in, 693
         diagnosis, 694
         in adults, 694
    chronic, 695
    subacute, 695
Polyarthritis, rheumatic,  1058, 1059
Polydipsia, 386, 388, 879
Polyphagia, 386, 882
Polypus, cardiac, 321, 249, 274
    nasal, in asthma, 167
Polyuria, 878
    in Bright's  disease, 832
    in diabetes, 881
Portal thrombosis, 565
Priapism in leucocythaemia, 303
Proctitis, 421
Prodromes of disease, definition of, 19
Prognosis, consideration of, 20 
INDEX.                                1139
 Prognosis, definition of, 20
 Prophylactic treatment, 20
 Prophylaxis, consideration of, 20
     definition  of, 20
 Prosopalgia, 744
 Psammoma, 666
 Pseudo-hypertrophic   (or   myo-sclerotic)
       paralysis, 706
 Pseudo-leucocythaemia,  or  Hodgkin's  dis-
       ease, 307
     anatomical characters, 307
     causation,  310
     clinical history, 309
     diagnosis,  310
     prognosis,  310
     treatment, 310
 Ptomaines in fevers, 897
 Pulmonary apoplexy, 186
     carcinoma, 194
     congestion, 96
     diseases, 23
     echinococci, 216
     gangrene,  188
     hemorrhage, 181
     hydatids, 196
     lympho-sarcoma, 195
     new growths, 194
     oedema, 191, 195
     phthisis, 99 (vide Phthisis, pulmonary).
     sarcoma, 195
     syphilis, 196
     tuberculosis,  97  (vide  Phthisis, pul-
            monary).
         acute  miliary, 110, 135
 Pulsating pleuritis,  54
 Pulse after bloodletting, 135
     collapsing, 255
     jerking, 255
     of  fatty heart, 270
 Pupil, pin-hole, in typhus fever, 923
 Purpura haemorrhagica, 1104
     rheumatica, 1104
     simplex, 1103
 Pus, characters of, 150
 Pyelitis, 848
     anatomical characters, 849
     causation,  849
     clinical history, 849
     diagnosis,  850
     prognosis,  851
     treatment, 851
 Pyelo-nephritis, 846
 Pyle-phlebitis,   adhesive and  suppurative,
       353,  565
 Pyle-thrombosis, 565
 Pvlorus, hypertrophic stenosis of, 347, 348
     incontinence of, 382
     stricture of, 352, 360, 366
 Pyonephrosis, 848, 851,  863
 Pyo-pericardium, 235
 Pyothorax, 50  (vide Empyema).


                   Q.
Quinia, hypodermic injection of, in  mala-
      rial  fever, 959, 969
Quinia in neuralgia, 743
Quinsy, 324, 325


                   K.
Rabies canina, 1115
         causation,  1115
         clinical history, 1115, 1118
         diagnosis,  1117
         prognosis,  1116
         treatment, 1118
Rasmussen's aneurism, 101
Raynand's disease, 810
         diagnosis,  811
         prognosis,  811
         symptoms, 810
         treatment, 811
Reaction of degeneration in cerebral par-
       alysis, 714
    in amyotrophic lateral sclerosis, 702
    in chronic bulbar paralysis, 672, 675
    in lead paralysis, 738
    in myelitis, 679
    in neuritis, 724, 729
    in peripheral paralysis, 729
    in poliomyelitis anterior, 693, 695
    in progressive muscular atrophy, 699
    in spinal paralysis, 672, 676
Reflexes in acute ascending paralysis, 720
    in cerebral hemorrhage, 605
    in cerebral and spinal paralysis, 724
    in chorea,  757
    in compression of spinal cord, 704
    in diphtheria, 1038
    in neuritis, multiple, 726
    in peripheral paralysis, 729
    in spastic paralysis, 673
    in spinal diseases, 674
         ankle, 674
         cutaneous, 673, 679, 688, 692, 695
         patellar, 674, 687, 688
         tendon, 673,  683, 693, 701, 702
Relapsing fever, 938
Respiration, Cheyne-Stokes, 270, 642
    in chronic Bright's disease, 834
    in meningitis, 635
    in tubercular meningitis, 642
Respiratory system, diseases of, 23
Retention cysts, 828, 829
Retinitis albuminurica,  829, 834
Rhachitis,  1092
    diagnosis, 1095
    etiology, 1092,  1093
    prognosis,  1095
    symptoms and  anatomical  characters,
       1094
    treatment,  1095
Rheumatism, acute  articular, 1058
        causation, 1064
        clinical history, 1059
        diagnosis, 1065
        pathological  character, 1064
        prognosis, 1065
        treatment,  1066
    articular, chronic, 1070
        subacute, 1070 
1140
INDEX.
Rheumatism, cerebral, 1061
    gonorrhoea!, 1065
    muscular, 750 (vide Mvalgia).
Rickets, 1092
Risus sardonicus, 761, 790
Rose-cold, 167
Roseola, 1024
Rose-rash, 1024
Rotheln, 1025
Rubeola, 1018
    causation, 1021
    clinical history, 1018
    diagnosis, 1022
    hemorrhagic, 1020
    nigra, 1020
    prognosis, 1023
    sine catarrho, 1020
    sine eruptione, 1020
    treatment,  1023
Rumination, 380


                   S.

Sago spleen, 581
Salaam convulsions, 760
Sarcinae ventriculi  in cancer  of  stomach,
           361
        in dilatation of stomach, 367
Sarcoma of brain, 665
    of liver, 557
    of lung, 195
Satyriasis in rabies, 1117
Scanning speech  in cerebro-spinal sclero-
      sis, 684
Scapulodynia, 752
Scarlatina, 1004
    anatomical characters, 1005
    anginosa, 1005, 1007, 1010, 1016
    causation, 1012
    clinical history 1006
    diagnosis, 1013
    diphtheria in, 1005, 1010
    "faucium, 1010
    hemorrhagic, 1010
    latens, 1011
    maligna, 1005, 1009, 1010
    prognosis, 1013
    rheumatica, 1025
    simplex, 1005
    sine eruptione, 1010
    treatment,  1014
Sclerema, 803
Scleroderma, 803
Sclerose en plaques disseminees, 682
Sclerosis, amyotrophic lateral, 697, 702
    cerebro-spinal, 682
        clinical history, 683
        diagnosis, 684
        pathological anatomy, 682
        prognosis,  684
        treatment, 684
    disseminated, of cord, 682
    multiple or insular, 682  (vide Sclero-
      sis, cerebro-spinal).
    muscular, 706
    of lung, 133
Sclerosis, posterior spinal, 685 (vide  Loco-
       motor ataxia).
     primary lateral, 700
Scorbutus, 1097
     anatomical characters, 1097
     blood in, 1098
     causation, 1100
     clinical history, 1098
     diagnosis, 1100
     pathological character, 1099
     prevention, 1101
     prognosis, 1101
     treatment, 1102
Scurvy, 1097 (vide Scorbutus).
Scybala, 402, 415
Secretory neuroses, 389
Seminal emissions, involuntary, 891
Sickness, milk, 1047
Siderosis of lung, 95
Sleep, mesmeric or magnetic, 789
Smallpox, 982 (vide Variola).
     natural,  990, 994
Softening of  brain, 592
Somnambulism, 789
Sopor, 708
Sordes in typhoid fever, 910, 923
Sore throat, clergyman's, 328
Spasm, essential or.idiopathic, of the mus-
      cles of the extremities, 762
     local, 760
     of glottis, 226
Speech, lesions of cortical centre  of, 621
     loss  of, after apoplexy, 594
Spermatorrhoea, 891
Sphygmograph, trace of, in aortic valvular
           lesions,  255
         in mitral valvular lesions, 254
         in thoracic aneurism, 288
Spina bifida,  655
Spinal apoplexy, 629
     cord, anaemia of, 628
         compression  of, 703
             clinical  history, 704
             morbid anatomy, 703
             prognosis, 705
             treatment, 705
         congestion of, 628
         degeneration, ascending and de-
           scending, of, 671, 677,  678
         functional diseases of, 707
         hemorrhage Avithin, 629
         hyperaemia of, 628
         inflammatory and structural dis-
           eases of, 670
         tumors of, 703
     irritation, 629, 722
     menigitis, 644
SpirillumObermeieri in relapsing fever, 939
Spirochaete, 939
     Obermeieri in relapsing fever, 939
Spleen, abscess of, 579
     affections of, 578
     cancer of, 582
     congestion of, 579
     enlargement of, 580, 953
     extravasations in, 581 
INDEX.
1141
Spleen, hydatids of, 582
    infarction of, 579
    inflammation of, 580
    removal of,  582
    sago, 581
    syphilitic disease of, 582
    tuberculous disease of, 135, 587
    tumor, acute, of, 580
    wandering,  582 _
    waxy degeneration of, 581
Splenic fever, 1110
Splenization of  lung, 97, 191
Sputa, nummular, 108
Status epilepticus, 768
Stomach, abscess of, 345
     absorbent power of, 376
             test of, 376
     atony of, 383
     atrophy of, 370, 371
     carcinoma of, 359
     cirrhosis of, 347
     degeneration of tubules of, 348, 370
     dilatation of, 349,  352, 365 (vide Gas-
       trectasia).
     fibroid degeneration of,  347
     functional disorders of, 373
     hemorrhage into, 353, 355, 392
     induration of, 347
     inflammation of, 334 (vide Gastritis).
     inflammatory diseases of, 334
     insufficiency of, 367
     motor neuroses of, 377
     motor power of, tests of, 376
     neuroses of, 373
     sclerosis of, 347
     softening of, 350
     structural affections of, 350
     suppurative inflammation of, 345
     tumors of, 359
     ulcer of, 351 (vide Ulcer, gastric).
     waxy degeneration of, 370
  Strongylus gigas, 850
  Strychnia,  effects of, contrasted  with  tet
        anus, 791
  St. Vitus's dance, 756 (vide Chorea).
  Subsultus tendinum  in typhoid fever, 909,
        921, 923
  Sugar, presence of, in urine, 879
     tests for, in urine, 881
  Summer complaint, 448, 475
  Sunstroke, 623 (vide Insolation).
  Suprarenal capsules,  disease of, 317 (vide
        Addison's disease).
  Symptoms, precursory, 19
      prodromal, 19
  Synovitis, 1065
  Syphilis of brain, 669
      of heart, 247, 272
      of larynx, 204
      of liver, 545
      of lungs, 196
      of spleen, 582
  Syringe,  Flint's modification of
        son's, for aspiration, 48, 49
  Syringomyelia, 655, 703
  Syringomyelus, 703
David-
                   T.
Tabes dorsalis, 685 (vide Locomotor ataxia).
Tdches bleuatres, 912
Tachycardia, 276, 280
Taenia lata, 503
    mediocanellata, 503
    saginata, 503
    solium, 502
Taeniae or tape-worms, 502
    clinical history, 504
    diagnosis,  504
    habitat, 504
    natural history, 502, 557
    treatment, 505
Tenesmus, 403
    gastric, 340
    laryngeal, 200
    of bladder,  856
Test-meals, 374
Tetanus,  789
     an infectious disease, 790
     clinical history, 789
     diagnosis, 791
     idiopathic, 789
     prognosis, 790
     traumatic, 789
     treatment, 792
 Tetany or tetanilla, 762
 Thompson, W.  Gilman,  observations  on
       Addison's disease, 320
 Thoracentesis  in empyema,  52
     in hydrothorax, 63
     in pleuritis, 47, 59
     in pneumothorax, 61
 Thrombosis, 591
     capillary, of brain, 600
     cerebral,  591  (vide Embolism,  cere-
        bral).
     of cerebral  sinus, 599
     of heart,  79,  238, 243,  246, 273
     portal, 566
 Thrombus, 591
     ante-mortem, 273
     marantic, 253, 274, 599
      white, red,  mixed, 274
  Tic douloureux, 744
  Tinnitus aurium, 781, 958
  Tongue, strawberry-like, in  scarlatina, 1008
  Tonsillitis, 324
      follicular, 324
  Tophi, 1075
  Tormina, 403
  Torticollis, rheumatic, 747, 751
  Torulae  cerevisiae  in  cancer of  stomach,
        361
      in diabetic urine, 882
      in dilatation  of stomach, 367
  Trachea, affections of, 197
  Tracheotomy in aphonia, nervous, III
      in diphtheria, 1046
      in laryngeal growths, morbid, 116
      in laryngitis, 200, 204, 207, 214
      in oedema of glottis, 217

  Transfusion of  blood, 317,  394, 980 
1142
INDEX.
Treatment, ectrotic, 993
     hygienic, 20
     preventive or prophylactic, 20
Trembling, mercurial, 739, 765
     senile, 763
Tremor, 760, 763
     mercurial, 739, 765
     senile, 763
     shaking, 693
Trichina spiralis, 507
Trichiniasis, 507
Trichinosis, 507
Trichocephalus dispar, 501
Trifacial nerve, neuralgia of, 744
         paralysis of, 731
Trismus, 790
Tubercle, 101, 102, 103, 133, 135
     in choroid, 642
     infiltrated, 135
     in kidneys, 135, 862
     morphology of, 100
     obsolete, 118
     pneumonic,  102
     structure of, 102, 135
     within cranium, 665
Tuberculosis, acute miliary, 110, 135
        general, 135
     genito-urinary, 862
     pulmonary, 99 (vide Phthisis, pulmon-
      ary).
     relation of pleuritis to, 43
     renal, 862
     sputa of,  103,  105, 108, 111, 118, 134
Tubules, gastric, degeneration of, 370
Tumors, intracranial, 664
        anatomical characters, 664
         clinical history, 666
         pathological characters, 665
         prognosis, 668
        treatment, 668
     intraspinal,  703
     intrathoracic, 194
Tussis hysterica, 220
Tympanites in typhoid fever, 909
Typhlitis, 417, 859
Typhlo-enteritis, 411
Typhoid fever, 900 (vide Fever, typhoid).
Typho-malarial   fever,  964  (vide  Fever,
      typho-malarial).
Typho-mania, 909, 923
Typhus fever, 922 (vide Fever, typhus),


                  U.

Ulcer, duodenal, 349
     gastric, 351
        anatomical characters, 351
        causation, 353
        clinical history, 355
         diagnosis, 356
        pathogenesis, 353
         prognosis, 357
        treatment, 358
Ulcers, duodenal, 350, 429, 515
     intestinal, 103, 427
        anatomical characters, 428
Ulcers, intestinal, clinical history, 429
     laryngeal, 204
     syphilitic, 428
     tuberculous, 427
     typhoid, of intestine, 427, 440, 902
Umbilication of variolous vesicle, 983, 'JS6
Uraemia in Bright's disease, 818, 820, 836,
       837, 840
     in cystic degeneration of kidnevs, 861
     in diphtheria, 1037
     in relapsing fever, 942, 945
     in rheumatism, 1061
     in scarlatina, 1009, 1011, 1014
     in typhoid fever, 909, 914, 934
     in typhus  fever, 923, 934
     in variola, 985, 992
     in yellow fever, 974, 979
Urica?mia, 1072,  1076, 1080
     deposits of urates in, 1076
Urine, condition  of, in acute nephritis, 818
     in chronic nephritis, 831, 839, 840, 841
     in chyluria,  876
     in congestion, renal, 813, 814
     in cystic degeneration of kidneys, 861
     in diabetes insipidus, 877
     in diabetes mellitus, 881, 882
     in diphtheria, 1038
     in haematuria, endemic, 872
     in haematuria, renal, 872
     in haemoglobinuria, 873, 875
     in hydronephrosis, 854
     in intermittent fever, 952, 961
     in milk sickness, 1049
     in nephritis, suppurative, 848
     in perinephritic abscess, 860
     in relapsing  fever, 942, 946
     in remittent fever, 967
     in renal cancer, 867
     in renal colic, 855
     in renal cystic degeneration, 861
     in renal parenchymatous degeneration,
       815
     in renal tuberculosis, 864
     in rheumatism, 1060
     in scarlatina, 1011, 1014
     in scorbutus, 1099
     in typhoid fever, 935
     in typhus fever, 925
     in yellow fever, 974, 978
     tests for sugar in, 886

                   V.
Vaccination, 996
    operation  for, 1001
Vaccinia, 996, 1000
Vaccinoid, 997
Vagabonds' disease,  322
Valvular cardiac lesions, 248
            aortic, 250, 251
            clinical history of, 253
            mitral, 250
            pulmonic, 251
            tricuspid, 251
Varicella, 1003
    differential diagnosis of, from variola,
      1003 
INDEX.
1143
Varicella, varieties of, 1003
Variola, 982
    anatomical characters, 982
    causation, 989
    clinical history, 984
    coagulation necrosis in,  982
    confluent, 984
    diagnosis, 990
    differential diagnosis of,  from scarla-
      tina, rubeola, and roseola, 990
    discrete, 984
    hemorrhagic, 988
    prognosis, 991
    sine Variolis, 990
    treatment, 992
    varieties of, 984, 988, 996
Variolation, 994
Varioloid, 994, 998
Vegetations in endocarditis, 238, 244
Venesection in acute inflammations, 33, 81
    in bronchorrhagia, 184
    in cerebral congestion, 588
    in cerebral hemorrhage, 610
    in insolation, 627
    in laryngitis, 201, 213
    in meningitis, 637, 645, 654
    in nephritis, 822
    in pericarditis, 322
    in pernicious malarial fever, 962, 970
    in poliomyelitis anterior, 694
    in pulmonary oedema, 193
    in thoracic aneurism, 288
Venous hum, 293
Vermes, 498
Vermiform appendix of caecum, inflamma-
       tion and perforation  of, 419
Vermis cucurbitirius, 503
Vertigo, 710
    epileptic, 766
    stomachal, 711
Vomica*, 105, 117, 118, 133, 188,  190, 194,
    196
                  W.
Water,  employment  of, in  pleuritis and
           pneumonitis, 37, 81, 82
         in scarlatina, 1015
         in typhus and typhoid fever, 930
Weil's disease, 575
Werlhof's disease, 1104
Whooping cough, 174 (vide Pertussis).
Wool-sorters' disease, 1110
Word-blindness,  595, 622
Word-deafness, 622
Worms, intestinal, 498
         anchylostoma duodenale, 498, 509
         ascaris lumbricoides, 499
         lumbricoid, 499
         oxyuris vermicularis, 498, 500
         pin-, 501
         seat-, 501
         tape- (vide Taeniae), 498, 502
         thread-, 501
         trichinae, 498, 507
         trichocephalus dispar, 498, 501
Wrist-drop, 737
Writer's cramp, 762
Xanthine calculi, 857

                   Y.

Yellow fever, 971 (vide Fever, yellow).


                   Z.

Zoogloea in diphtheria, 1036
    in endocarditis, acute ulcerative, 244
    in hepatitis, suppurative, 533
    in suppurative nephritis, 846
    in typhoid fever, 905
    in variola, 984 
 
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The Medical News  Visiting  List  for 1894

Is published in four styles, Weekly (dated for 30  patients) ; Monthly (undated, for 120
patients per month) ; Perpetual (undated, for 30 patients weekly per  year) ; and  Per-
petual  (undated, for 60  patients  weekly per year).  The 60-patient Perpetual consists
of 256  pages of  assorted blanks.  The first three styles  contain 32  pages of important
data and 176 pages of assorted blanks.  Each style is in one wallet-shaped book, leather-
bound,  with pocket, pencil, rubber, and catheter-scale.  Price, each, $1.25.
  This list is all that could be desired. It con-
tains a vast amount of useful information, especi-
ally for emergencies, and gives good tables of doses
and therapeutics.—Canadian Practitioner.
  Its compactness and  simplicity are such as to
indicate that the highest point of perfection has
been reached in works of this class.— University
Medical  Magazine.
 The new issue maintains its previous reputation.
It adapts itself to every style of book-keeping;
there is space for all kinds of professional records;
it is furnished with a ready reference thumb-letter
index, and  has a most valuable  text.—Medical
Record.
                                          For convenience and elegance it is not surpass-
                                        able.—Obstetric Gazette.

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      Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Medical Dictionary,  Quiz  Manuals.
                    THE   STUDENTS'


DICTIONARY   OF   MEDICINE

            AND  THE  ALLIED   SCIENCES,
comprising  the pronunciation, derivation and full  explanation of medical
        terms;  together with much collateral descriptive  matter,
                             numerous tables, etc.
                  By ALEXANDER  DUANE, M. D.,
   Assistant Surgeon to the New York Ophthalmic and Aural Institute; Reviser of Medical Terms for
                           Webster's International Dictionary.
    In one square octavo volume of 658 pages.  Cloth, $4.25; half leather, $4.50; full
sheep, $5.00.  Just ready.  Thumb-letter Index for quick use, 50 cents extra.
 Dr. Duane has spared no time, pains or expense
in his endeavor to bring before the profession,
and especially the students of medicine, a book em-
bodying completeness and explicitness.  The
vocabulary is abundant and its fulness is paral-
leled by the explanation accorded each word.  It
also  contains extensive tables.  Each word is fol-
lowed by its correct pronunciation, a new feature
in works of this kind, given by means of a simple
and  obvious phonetic  spelling.  Derivation, the
greatest aid to memory, is fully treated of, and for
the convenience of those who do not understand
Greek, the English  letters are substituted for
those of the Greek in giving the roots of the words
derived from that language. The author's expe-
rience as a lexicographer is fully attested by his
position as Reviser of Medical Terms for  Web
ster's International Dictionary. We predict that
thi9  will become a standard and favorite work of
its class.—Medical Fortnightly, March, 1894.
From A. L. Loomis, M. D., Professor Pathology and
 Practice of Medicine, Medical Department, Univer-
 sity City of New York, New York.
 It seems to me entirely satisfactory for the pur-
pose for which it is intended.
From J C. Wilson, M. D., Professor of  Medicine,
 Jefferson Medical College, Philadelphia.
 It appears to  be well suited to the purposes of
the medical student, being simple as regards deri-
vations and pronunciation, explicit yet sufficiently
comprehensive in definitions, and thoroughly up
to the times.
From James T. Whittaker, M. D., Professor Theory
 and Practice of Medicine, Medical College of Ohio,
 Cincinnati, O.
 I find it admirably adapted to the wants of stu-
dents, and thoroughly  modern in every particular
in  which I have taken occasion to consult it.  I
shall certainly recommend it to my class.
   THE   STUDENTS'   QUIZ   SERIES.

    ANEW Series of Manuals, comprising all departments of medical science and practice,
      and prepared to meet the needs of students and practitioners.  Written by promi-
nent medical teachers  and specialists in  New York, these volumes may  be  trusted as
authoritative and abreast of the day.  Cast in the form of suggestive questions, and concise
and clear answers, the text will impress vividly upon the reader's memory the salient
points of his subject.  To the student these volumes will be of the utmost service in pre-
paring for examinations, and they will also be of great me to the practitioner in recalling
forgotten details, and in paining the latest  knowledge, whether in theory or in the actual
treatment  of disease.   Illustrations have  been inserted wherever advisable.  Bound in
limp cloth, and  in size  suitable for the hand and  pocket, these volumes are  assured of
enormous popularity, and  are  accordingly placed  at an exceedingly low price  in com-
parison with their value.  For details of subjects and prices see below.
ANATOMY  (Double Number) —By Fred J.
   Brockway, M. D., Assistant Demonstrator of
   Anatomy, College of Physicians and Surgeons,
   New York, and A. O'Malley, M.D., Instructor
   in Surgery, New York Polyclinic.  $1.75.
PH YSIOLOC Y—By F. A. Manning, M.D.,
   Attending Surgeon, Manhattan Hosp., N. Y. $1.
CHEMISTRY  AND  PHYSICS —By  Joseph
   Struthers, Ph. B., Columbia College School of
   Mines, N.Y., and D. W. Ward, Ph. B., Columbia
   College School of Mines, N. Y., and Chas. H.
   Willmarth, M. S., N. Y.  $1.
HISTOLOGY, PATHOLOCY AND  BAC-
   TERIOLOCY—By Bennett S. Beach, M. D.,
   Lecturer on Histology, Pathology and Bacte-
   riology, New York Polyclinic.  $1.
MATERIA  MEDICA  AND THERAPEU-
   TICS—By  L. F. Warner, M. D., Attending
   Physician, St. Bartholomew's Disp., N.Y. $1.
PRACTICE OF MEDICINE,  INCLUDINC
   NERVOUS DISEASES—By EdwinT. Dou-
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   ety, and J. D.  Nagel, M. D,  Member N. Y.
   County Medical Association. $1.
SURCERY (Double Number)—By Bern B. Gal-
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   Presbyterian Hospital, N. Y. $1.75.
CENITO - URINARY   AND  VENEREAL
   DISEASES—By Charles H. Chetwood, M.D.,
   Visiting Surgeon, Demilt Dispensary, Dep. of
   Surg, and (ien.-Urin. Dis., New York.  $1.

DISEASES  OF THE  SKIN—By Charles C
   Ransom, M. D., Assistant Dermatologist, Van-
   derbilt Clinic, New York. $1.

DISEASES OF THE EYE, EAR, THROAT
   AND NOSE—By Frank E. Miller, M.D.,
   Throat Surgeon, Vanderbilt Clinic, New York,
   James P. McEvoy, M.D., Throat Surgeon, Belle-
   vue Hosp., Out-Patient Dep., New York,  and
   J.  E. Weeks, M. D.,  Lect. on  Ophthal.  and
   Otol., Bellevue Hosp., Med. Col., N. Y.  $1.

OBSTETRICS —By Charles W. Hayt, M.D.,
   House Physician, Nursery and Child's Hospi-
   tal, New York.  $1.

CYNECOLOCY—By G. W. Bratenahl, M.D.,
   Assistant  in Gynecology, Vanderbilt  Clinic,
   New York, and Sinclair Tousey, M. D., Assist-
   ant Surgeon, Out-Patient Department, Roose-
   velt Hospital, New York. $1.

DISEASES  OF CHILDREN-ByC.A.Rhodes,
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Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
4
Dictionaries.
  NEW  (21st)  EDITION.  THOROUGHLY  REVISED.  JUST  READY.


  Dunglison's    Dictionary


              OF   MEDICAL   SCIENCE.
   With the Pronunciation, Accentuation and  Derivation of the Terms.
Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology,
Medical  Chemistry, Pharmacology, Pharmacy, Therapeutics, Medicine, Hygiene, Dietet-
ics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecology, Obstetrics,
Pediatrics," Medical Jurisprudence  and Dentistry, etc., etc.  By Robley Dunglison,
M. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Phila-
delphia.  New (21st) edition, thoroughly revised and greatly enlarged.  With the Pro-
nunciation,  Accentuation and Derivation  of  the  Terms, by  Richard  J. Dunglison,
A.M., M.D.  In one very large and  handsome  royal  octavo volume  of 1191  pages.
Cloth, $7.00; leather, raised bands, $8.00. Thumb-letter Index for quick use, 75 cents extra.
      THIS great medical dictionary, which has been for more than two  generations the
       . standard of the English speaking race, is now issued in a thoroughly revised and
        greatly enlarged and improved edition.   The new words and phrases aggregate
by actual count over 44,000.  Though  the new  edition contains far more matter than its
predecessor, the whole is accommodated within a volume convenient for the hand.
    The  revision has not  only covered  every word, but it has resulted in a number of
important new features designed to confer on the work the utmost usefulness, and to make
it answer the most advanced demands of the times.
    Pronunciation  has been  introduced  throughout by means  of a simple  and obvious
system of phonetic spelling.  At a glance the proper sound of a word is clearly indicated,
and thus a most important desideratum is supplied.
    Derivation affords the utmost aid in recollecting the meanings of words, and gives
the power of analyzing and understanding those which are unfamiliar.   It is indicated in
the simplest manner.   Greek words are spelled with English letters, and  thus placed at
the command of those unfamiliar with the Greek alphabet.
    Definitions, the essence of a  dictionary,  are clear and full,  a characteristic in
which this work has always  been preeminent.   In this edition much explanatory  and
encyclopedic matter has been added, especially upon subjects of practical importance. Thus
under the various diseases will be found their symptoms, treatment, etc.; under drugs their
doses and effects, etc., etc. A vast amount of information has been clearly and conveniently
condensed into tables in the alphabet.
    In a word, Dunglison''s Medical Dictionary, in its remodelled and enlarged shape, is
equal  to all that the student and practitioner can expect from such a work.
  The new " Dunglison" is new indeed.  The vast
amount of new matter and the thoroughness with
which the work has been brought down to date
cannot fail to strike even  the  least  observant
reader.   The immense advances made  in all
branches of medical science here find represen-
tation. A prominent and very useful feature of
the old book is retained and amplified in this—we
mean the tables, which recur  with great fre-
quency and represent a vast amount of condensed
information. In respect to accuracy the book quite
equals and usually surpasses any of its contempo-
raries that we are acquainted with.  The new
"Dunglison" has been brought  down to date, so
as to represent adequately the latest advances in
medical science.—The American Journal  of the
Medical Sciences, January, 1894.
  The subjects and terms contained in this edition,
over and above those In the last, amount by actual
count to  forty-four thousand. We notice  that a
system of pronunciation has for the first time
been introduced into the work—a  valuable ad-
dition,_we think.  So fully have  derivations and
definitions been considered, and so great is the
amount of practical matter, such as symptoms,
treatment and prognosis of many of the diseases
described, that the volume is entitled to be called
an encyclopedia rather than a  dictionary.  The
reviser has elaborated the  fundamental purpose
of the distinguished author, "to make the work
not a mere lexicon of terms, but to afford under
each a condensed view of its various medical re-
lations, and thus to render the work an epitome of
the existing conditions of medical science."—The
Brooklyn Medical Journal, June, 1894.
  It  has been  the  standard  of  reference
for medical scholars for over a half-century.  The
twenty-first edition comes  to us thoroughly re-
vised and greatly enlarged, with new features
treating of pronunciation, accentuation and deri-
vation of terms.  Covering the entire  field of
medicine, surgery and the  collateral sciences, its
range  of usefulness  can scarcely be  measured.
Perhaps the most valuable feature in the present
work is the addition of a vast amount of practif al
matter. The type is commendably clear. We
predict for the book another term of usefulness.
—Medical Record, February 24,1894.
The National Medical Dictionary,
        Including English, French, German, Italian and Latin Technical Terms used in
Medicine and the Collateral Sciences, and a Series of Tables of Useful Data.   By John
S. Billings, M. D., LL. D., Edin. and  Harv., D. C. L., Oxon., member  of the National
Academy of Sciences, Surgeon U. S. A., etc.  In two very handsome royal octavo volumes
containing 1574 pages, with two colored plates.  Per volume—cloth, $6.00: leather, $7.00;
half morocco, marbled edges,  $8.50.  Subscription only.  Address the publishers.
                                         which may be gained by the study of a good diction-
                                         ary, one is enabled by the work under notice to read
                                         intelligently any technical treatise in any of the four
 The work is remarkable for its fulness.  It pres-
ents to the English reader a thoroughly scientific
mode of acquiring a rich vocabulary and offers an
accurate and ready means of reference in consult-
ing works in any of the three modern continental
languages which are richestin medical literature.
Apart from the boundless stores of information
chief modern languages.  There cannot be two
opinions as to the great value of this dictionary as
a book of ready reference for all sorts and condi-
tions of medical men.—London Lancet, Apr., '90.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Anatomy,  Dictionary.
         NEW (THIRTEENTH) EDITION.   JUST  READY



GRAY'S    ANATOMY
                     IN  COLORS  OR  IN  BLACK.


Anatomy,  Descriptive  and   Surgical,

                   BY HENRY  GRAY,  P. R.  S.,
          LECTURER  ON ANATOMY AT  ST. GEORGE'S  HOSPITAL, LONDON.
                   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 thirteenth enlarged and improved London  edition.  In one
   imperial octavo volume of 1118 pages, with 636 large and elaborate engravings
        on wood.  Price, with illustrations in colors,  cloth,  $7 ; leather, $8.
            Price, with  illustrations  in black,  cloth,  $6;  leather,  $7.
     SINCE 1857 Gray's Anatomy  has been  the  standard work used by students of
       medicine and practitioners in all English-speaking races.  So preeminent has it
       been among the many works on the subject that thirteen editions have  been
       required to meet the demand. This opportunity for frequent  revisions has  been
fully utilized and the work has thus been subjected to the careful scrutiny of many of the
most distinguished anatomists of a generation, whereby a degree of completeness and ac-
curacy has been secured which is not attainable in any other way.  In no former revision
has so much  care been exercised as in the present to provide for the student all the
assistance that a text-book can furnish.   The engravings have always formed a distin-
guishing feature of this work, and in the present edition the series has been enriched and
rendered complete  by  the addition of  many new  ones.  The  large scale  on which the
illustrations are drawn and the clearness of the execution render them of unequalled
value  in affording a grasp of the complex details of the subject.  As heretofore the name
of  each part is printed upon  it,  thus conveying to the  eye at once the position, extent
and relations of each  organ, vessel,  muscle, bone  or  nerve with  a clearness impossible
when  figures or lines of reference are employed.  Distinctive  colors have  been  utilized
to  give additional  prominence  to the  attachments of muscles,  the veins,  arteries
and nerves.   For the sake of those who prefer not to  pay the  slight  increase in cost
necessitated by the use of colors, the volume is published also in black alone.
    The illustrations thus constitute 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 practice the necessity of recalling
the details of the dissecting room.  Combining as it does a complete Atlas of Anatomy
with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers
a more extended range of subjects than  is customary in the ordinary text-books. It not
only answers every need of the student in laying the groundwork of a thorough  medical
education, but owing to its application of anatomical details to the practice of medicine
and surgery, it also furnishes an admirable work of reference for the active practitioner.
  We always had a kindly regard for the illustra-
tions in Gray, where each organ, tissue, artery, and
nerve bear their respective names, and in this edi-
tion color has been worked to advantage in bring-
ingoutthe relationship of vessel and nerve.  Of late
years,  many works on anatomy have been intro-
duced to the profession, but as a reference book for
the practical everyday physician, and as a text-book
for the student, we think it will be difficult to sup-
plant Gray.—Buffalo Med. and Surg. Jour., Jan., 1894.
  No book deals with the complex subject so sys-
tematically, or presents the material in  a way
better  fitted for the student to memorize.—Inter-
national Medical Magazine, Dec. 1893.
  It embraces the whole of human anatomy, and
it particularly dwells on the practical or applied
part of the subject, so that it forms a most useful,
Intelligible and practical treatise for the student
and general practitioner.— Dublin Journal of Medi-
cal Science, December, 1893.
  In modern times no book on any medical sub-
ject has held the position of a standard so long as
Gray's Anatomy.   For logical arrangement, clear,
terse, pointed,  and yet full  description, it is the
peer of any work on  any  scientific subject.  A
pioneer in helpful drawings, it is still in the van
itself a complete atlas of anatomy.  Dear to so
many thousands for old and helpful associations,
it will be no hard task for < ;ray to remain in the
lead so long as it shall find revisers comparable in
aptitude to the present editor.  The physician or
student who requires but one work on anatomy
will not need to ask  which, nor will those who will
have more than one need to ask which one to add.
The work is admitted to be easily first on anatomy
in any language— The American Practitioner and
News, June, 1894.                    ...
  Gray's has  been  the unvarying standard for
anatomical study by the vast majority of English-
speaking medical students for so  long that it
would seem an anomaly to see a student acquire
such knowledge from some other source.—Medi-
cal Fortnightly, February, 1894.       ...
  Few treatises can claim such a record of endur-
ance of usefulness.  To say that it still maintains
its reputation is to give it the highest compliment
within the  range of the critic's privilege.  It has
grown and strengthened with the advancements
and requirements of the modern knowledge of
anatomy, enlarging its scope for newer adapta-
tions in surgery and physiology.—Medical  Record,
March 3,1894.
and leads in every improvement.  Indeed, it is of
HOBLYN'S DICTIONARY OF MEDICINE.  A Dictionary of the Terms Used inMedicine «<j^
 Collateral Sciences. By Richard D. Hoblyn, M. D.  In one large royal 12mo. volume of 520 double
 columned pages.  Cloth, $1.50; leather, $2.00.

      Lea Brothers & Co., Publishers, 706,  708 & 710 Sansom Street, Philadelphia. 
6
Anatomy,  Physiology.
      HUMAN    MONSTROSITIES

BY  BARTON C.  HIRST,  M. D.,  and   GEORGE A.  PIERSOL,  M. D.
   Professor of Obstetrics in the University              Professor of Anatomy and Embryology
            of Pennsylvania.                          »« the University of Pennsylvania.

    Magnificent folio, containing 220 pages of text,  illustrated with engravings,  and
39 full-page, photographic plates from nature.  In four parts, price, each, $5.  Complete
work just ready.  Limited edition, for sale by subscription only.   Address the Publishers.
  We have before us  the fourth and last part of
the latest and best work on human monstrosi-
ties.  This completes one of the masterpieces of
American medical literature.  Typographically
and from an artistic standpoint, the work is un-
exceptionable.  In  this  last and final  volume
is presented the most complete bibliography of
teratological literature  extant.  No library will be
complete without this magnificent work.—Jour-
nal of the American  Medical Asso , May 6,1893.
 Altogether, Human Monstrosities is a satisfactory
production.  It will  take its  place as a standard
work on teratology in medical libraries, and it
must always retain the honor of being the first of
its kind written in the English language.—The
British Medical Journal, May 27,1893.
  This work promises to be one for which a place
must be found in the library of every anatomist,
pathologist, obstetrician and teratologic.  It is the
joint production of an obstetrician, and an embry-
ologist, and histologist, and this fact makes it
certain that both the obstetric and anatomical
sides of the subject will be fully represented and
described.  The book promises to be one of the
greatest value to the English-speaking  medical
world.—Edinburgh Medical Journal, April,  1892.
Allen's  System  of Human  Anatomy.
        A System of Human Anatomy, Including Its Medical and Surgical
Relations.  For the use of Practitioners and  Students  of Medicine.  By  Harrison
Allen, M. D., Professor of Physiology in the  University of Pennsylvania.  With an
Introductory 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.   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.  Address the Publishers.

Holden's  Landmarks, Medical and  Surgical.
        Landmarks, Medical and Surgical.  By Luther Holden,  F. R. C. S.,
Surgeon to St. Bartholomew's Hospital, London.  Second  American from  the  third and
revised English ed., with additions by W. W. Keen, M. D.,  Professor of Artistic Anatomy
in the Penna. Academy of Fine Arts.   In one 12mo. volume of 148 pages.  Cloth, $1.00.

Clarke  & Lockwood's Dissector's  Manual.
        The  Dissector's Manual. By W. B. Clarke, F. E. C. S., and C.  B. Lock-
wood, F. R. C. S., Demonstrators of Anatomy at St. Bartholomew's'Hospital Medical
School, London.  In one pocket-size 12mo. volume of 396 pages,  with 49 illustrations.
Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 30.
  Messrs.Clarke and Lockwood have written abook
that can hardly be rivalled as a practical aid to the
dissector.  Their purpose,which is "how to de-
scribe the best way to display the  anatomical
structure," has been fully attained.  They excel in
a lucidity of demonstration and graphic terseness
of expression, which only a long training and
intimate association with  students could have
 fiven.  With such a guide as this, accompanied
 y so attractive a commentary as Treves' Surgical
Applied Anatomy (same series), no student could
fail to be deeply and absorbingly interested in the
study of anatomy.—New Orleans Medical and Sur-
gical Journal, April ,1884.
Treves'  Surgical  Applied  Anatomy.
        Surgical Applied Anatomy. By Frederick Treves, F. R. C. S., Senior
Demonstrator of Anatomy and Assistant Surgeon at the London Hospital.  In one pocket-
size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00.  See
Students' Series of Manuals, p. 30.

Bellamy's  Surgical  Anatomy.
        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. By Edward Bellamy, F. R. C. S., Senior Assistant-Surgeon to the
Charing-Cross Hospital.  In one 12mo. vol. of 300 pages, with 50 illus.  Cloth, $2.25.

Wilson's Human  Anatomy.
        A System  of  Human Anatomy, General and Special.   By Erasmus
Wilson, F. R. S.  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.
HARTSHORNE'S HANDBOOK  OF  ANATOMY
 AND PHYSIOLOGY.  Second edition, revised.
 12mo., 310 pages, 220 woodcuts.  Cloth, $1.75.

HORNER'S SPECIAL ANATOMY AND HISTOL-
  OGY.  Eighth edition.  In two octavo volumes
  of 1007 rages, with 320 woodcuts.  Cloth. $6.00.
CLELAND'S DIRECTORY FOR THE DISSEC-
  TION OF THE HUMAN BODY. 12mo., 178 pp.
  Cloth, $1.25.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
       Physics, Physiology, Anatomy,  Chemistry.      7


Draper's  Medical  Physics.

       Medical Physics.   A Text-book for Students and Practitioners of Medicine.
By John C.  Draper, M. D., LL. D., Prof,  of Chemistry in the Univ. of the City of
New York.  In one octavo vol. of 734 pages, with 376 woodcuts, mostly original.  Cloth, $4.
 No man in America was better fitted than Dr. culties to be encountered in bringing his subject
Draper for the task he undertook and he  has pro- within the  grasp of the average stulent, and that
vided the student and practitioner of medicine >"» >><»°  =.^^-«j«j —__•■__?_..  .
with a volume at once readable and thorough.
Even to the student who has some knowledge of
physics this book is  useful,  as it shows him its
applications to the profession that he has  chosen,
Dr. Draper, as an old teacher, knew well the diffi-
he has succeeded so well proves once more that
the man to write for and examine students is the
one who has taught and is teaching them.  The
book is  well printed and fully illustrated, and in
every way deserves grateful recognition.—The
Montreal Medical Journal, July, 1890.
Reichert's Physiology.—Preparing.
        A Text-Book on Physiology. By Edward T. Reichert, M. D., Professor
of Physiology in the University of Pennsylvania, Philadelphia.  In one very  handsome
octavo volume of 800 pages, fully illustrated.

Power's  Human Physiology.—Second  Edition.
        Human Physiology.  By Henry Power, M.B., F.R.C.S., Examiner in
Physiology, Royal College of Surgeons of England.  Second edition.  In one 12mo. vol.
of 509 pp., with 68 illustrations.  Cloth, $1.50.  See Students' Series of Manuals, p. 30.

Robertson's  Physiological Physics.
        Physiological  Physics.  By J.  McGregor  Robertson,  M.A.,  M. B.,
Muirhead Demonstrator of Physiology, University of Glasgow.  In one 12mo.  volume of
537 pages, with 219 illus.  Limp cloth, $2.  See Students' Series of Manuals, page 30.
 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 would be particu-
larly useful  as a guide to his laboratory experi-
ments.  It will be found of great value to the
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  on the  Circulation  of  the Blood.
        Doctrines of the  Circulation  of the  Blood.  A History of Physio-
logical Opinion and Discovery in regard to the Circulation of the Blood.  By John C.
Dalton, M. D., Professor Emeritus of Physiology in the College of Physicians and Sur-
geons, New York.  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 gratitude 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.
Bell's  Comparative  Anatomy  and  Physiology.
        Comparative Anatomy and Physiology. By F. Jeffrey Bell, M. A.,
Professor of Comparative Anatomy at King's College, London.  In one 12mo. vol. of 561
pages, with 229 illustrations. Limp cloth, $2.  See Students' Series of Manuals, page 30.
 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
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'  Demonstrations  of Anatomy.—Eighth  Edition.
        Demonstrations  of  Anatomy.   Being a Guide to the Knowledge of the
Human Body by Dissection.   By George Viner Ellis, Emeritus Professor of Anatomy
in University College, London.  From the  eighth and revised London edition.  In one
very handsome octavo volume of 716 pages, with 249 illus.  Cloth, $4.25; leather, $5.25.

Roberts' Compend of  Anatomy.
        The Compend of Anatomy.  For use in the dissecting-room and in pre-
paring for examinations. By John B. Roberts, A. M., M. D., Lecturer in Anatomy in
the University of Pennsylvania.  In one 16mo. vol. of 196 pages.  Limp cloth, 75  cents.
WOHLER'S OUTLINES  OF ORGANIC CHEM-
 ISTRY. Edited by Fittio. Translated by Ira
 Remsen, M. D,  Ph. D.  In one 12mo. volume  of
 650 pages. Cloth, $3.
LEHMANN'S MANUAL OF CHEMICAL PHYS-
 IOLOGY.  In one octavo volume of 327 pages,
 with 41 illustrations.  Cloth, $2.25.
CARPENTER'S HUMAN PHYSIOLOGY.  Edited
  bv Henry Power. In one octavo volume.
CARPENTER'S PRIZE ESSAY ON THE USE AND
  Abuse of Alcoholic Liquors in Health and Dis-
  ease. With explanations of scientific words. Small
  12mo. 178 pages. Cloth, 60 cents.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street. Philadelphia. 
8
Physiology—(Continued),  Chemistry.
Foster's Physiology.—New (5th) American Ed.   Just Ready.
        Text-Book of Physiology.   By Michael Foster, M. D, F. R. S., Prelec-
tor in  Physiology and Fellow of Trinity College, Cambridge, England.  New (fifth) and
enlarged American from the fifth and revised English edition, with notes and additions.
In one handsome octavo vol. of 1083 pages, with 316 illus.  Cloth, $4.50; leather, $5.50
  This is the standard work on physiology, bein,
most thorough and complete in all branches and
details; moreover it contains considerable mate-
rial which has never before been presented to the
medical public.  Evidence of its success is shown
in the fact that it is now in its fifth English and
fifth American edition.  In its high character, in
the care which  is shown in the statements and
their verification, and in its thorough dealing with
physiological and histological problems, it is far
ahead of any book of the class yet issued.— The
Medical Age, December 26,1893.
  One cannot read a single chapter without being
impressed with the care that the author has be-
stowed upon it.  Apparently nothing that is known
up to the present year concerning vital processes
has escaped his painstaking attention. The details
receive the fullest consideration. The additions
which have  been made to this  last edition  are
caused by an effort to explain more fully and at
greater length what seemed to be the most funda-
mental and  important topics.  The  publishers
have subjected it to the searching revision of one
of the foremost American professors of physio-
logy.  We have nothing but words of the highest
praise for the classical and thorough manner in
which the work is written, as well as for the liber-
ality of  the publishers for selling  such a large
work, and one which must necessarily be very
costly to produce, for  an extremely moderate
price.— The Canada Medical Record, March, 1894.
Dalton's Physiology.—Seventh  Edition.
        A Treatise on Human Physiology.  Designed for the use of Students
and Practitioners of Medicine.  By John C. Dalton, M. D., Professor of Physiology in
the College of Physicians and Surgeons, New York, etc.  Seventh  edition,  thoroughly
revised and rewritten.  In one very handsome octavo volume of 722 pages, with 252 beau-
tiful engravings on wood.  Cloth, $5.00; leather, $6.00,
  From the first appearance of the book it has
been a favorite, owing as  well to the author's
renown as an oral teacher as to  the charm of
simplicity with which, as  a writer, he always
succeeds in  investing  even intricate subjects.
It must be gratifying to him to observe the fre-
quency with which his work, written for students
and practitioners, is quoted by other writers on
physiology.  This fact  attests its  value, and, in
great measure, its originality. It now needs no
such seal of approbation, however, for the thou-
sands who have studied it in its various editions
have never been in any doubt as to its sterling
worth.—N. Y. Medical Journal, Oct. 1882.
  Professor Dalton's well-known and deservedly-
appreciated work has long passed the stage at
which it could  be reviewed in the ordinary sense.
The work is eminently one for the medical prac-
titioner, since it treats most fully of those branches
of physiology which have a direct bearing on the
diagnosis and treatment of disease.  The work is
one which we can highly recommend to all our
readers.—Dublin Journal of Medical Science, Feb.'83.
Chapman's Human  Physiology.
        A Treatise on  Human Physiology.  By Henry C. Chapman, M. D.,
Professor of  Institutes of Medicine  in the  Jefferson Medical College of Philadelphia.
In one octavo volume of 925 pages, with 605 engravings.  Cloth, $5.50;  leather, $6.50.
  It represents very fully the existing state of
physiology.  The present work has a special value
to the student  and practitioner as devoted more
to the practical application of well-known  truths
which the advance of science has given  to the
profession in this department, which may be con-
sidered the foundation of rational  medicine.—Buf-
falo Medical and Surgical  Journal, Dec. 1887.
  Matters which have a  practical bearing on the
practice of medicine are  lucidly expressed; tech-
nical matters are given in minute detail; elabo-
rate directions are stated for the guidance of stu-
dents  in the laboratory.  In every respect the
work fulfils  its promise,  whether as a complete
treatise for the student or for the physician ; for
the former it is so complete that he need look no
farther, and the latter will find entertainment and
instruction in an admirable book of reference.—
North Carolina Medical Journal, Nov. 1887.
Schofield's Elementary  Physiology.
        Elementary Physiology for Students.  By Alfred T.  Schofield,
M. D., Late House Physician London Hospital.  In  one 12mo. volume  of 380  pages, with
227 engravings and 2 colored plates containing 30 figures.  Cloth, $2.00.

Frankland  & Japp's Inorganic  Chemistry.
        Inorganic Chemistry.   By E. Frankland, D. C. L., F. R. S.,  Professor  of
Chemistry in the Normal School of Science,  London., and F. R. Japp, F. I. C,  Assistant
Professor of Chemistry in the Normal School  of Science,  London.   In one handsome
octavo volume of 677 pages with 51 woodcuts and 2 plates.  Cloth, $3.75 ; leather, $4.75.

Clowes'  Qualitative  Analysis.—Third  Edition.
        An Elementary Treatise on Practical Chemistry and Qualitative
Inorganic  Analysis.  Specially  adapted for use in the Laboratories of Schools and
Colleges and by Beginners.  By Frank Clowes, D. Sc,  London, Senior Science-Master
at the High School, Newcastle-under-Lyme,  etc.  Third American from  the fourth and
revised English edition.  In one 12mo. vol. of 387 pages, with 55 illus.  Cloth, $2 50
CLASSEN'S  ELEMENTARY  QUANTITATIVE
  ANALYSIS.  Translated, with notes and addi-
  tions, by Edgae F. Smith, Ph. D., Assistant Pro-
fessor of Chem istry in the Towne Scientific School,
University of Penna.  In one 12mo. volume of 324
pages, with 36 illus. Cloth, $2.00.
Lea Brothers A Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Chemistry—(Continued).
                                                                                 9

Simon's  Chemistry.—New  (4th)  Edition.

        Manual of Chemistry. A Guide to Lectures and Laboratory work for Begin-
ners m«ph^7-  A Text-book specially adapted for Students of Pharmacy and S-
cine.   By AV. Simon, Ph. DM. D., Professor of Chemistry and Toxicology in the College
of Physicians and Surgeons Baltimore, and Professor of Chemistry in  th!  Maryland Coh
lege of Pharmacy   New (4th) edition. In one 8vo. vol. of 490 pp., with 44 woodcuts and
7 colored plates illustrating 56 of the most important chemical tests   f^lnth  «s 91
  A work which rapidly parses to its fourth edition  &*-* -' «—--■    -  .  .  V10tn> v6-^
need* no further proof of having achieved a suc-
cess.  In the present case the claims to favor are
obvious. Emanating from an experienced teacher
of medical and pharmaceutical students the vol-
ume is closely adapted to their needs.  This is
shown not only by the careful  selection and clear
presentation  of its  subject matter, but by  the
colored plates of reactions, which form a unique
feature. Every teacher will appreciate the saving
of his own time, and the advantages accruing to
the student from a permanent and accurate stan-
dard of comparison for tests depending on colors,
and frequently upon their changes.  To the prac-
titioner, who is likely to be confronted at any time
with important pathological or toxicological ques-
tions to be answered by the test tube, the volume
will be of the utmost value.  Such it has proved
in the. past, and the author has accordingly been
enabled, through frequent and thorough revisions
to keep his work constantly in touch with tr.e
progress of its science and the best methods of its
Presentation.—Kansas City Medical  Index, May,
Fownes' Chemistry.—Twelfth  Edition.
        A Manual of Elementary Chemistry;  Theoretical and Practical.  By
George Fownes, Ph. D.  Embodying Watts'  Physical and Inorganic Chemistry. New
American, from the twelfth English edition.  In one large royal 12mo. volume of 1061
pages, with 168 engravings 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 Med. News, Oct. '85.
Attfield's  Chemistry.—Twelfth  Edition.
        Chemistry,  General, Medical  and Pharmaceutical; Including  the
Chemistry of the  U. S. Pharmacopoeia.  A Manual of the General  Principles  of  the
Science, and their Application to Medicine and Pharmacy.  By John Attfield, M. A.,
Ph.D., F.I.C., F. B. S., etc., Professor of  Practical Chemistry  to the Pharmaceutical
Society of Great Britain,  etc.  A new American, from the  twelfth English  edition,
specially revised by the Author for America.  In one handsome royal 12mo. volume of
782 pages, with 88 illustrations.  Cloth, $2.75; leather, $3.25.
 Attfield's Chemistry is the most popular book
among students of medicine and pharmacy.  This
popularity rests upon real merits. Attfield's work
combines in the happiest manner a clear exposi-
tion of the theory of chemistry with the practical
application of this knowledge to the everyday
dealings of the physician  and pharmacist.  His
book is precisely what the title claims for it. The
admirable arrangement of the  text enables a
reader to get a good idea of chemistry without
the  aid of experiments, and again it is a good
laboratory guide,  and finally it contains  such a
mass of well-arranged information that it will al-
ways serve  as a handy book of reference.  He
does not allow any unutilizable knowledge to slip
into his book; his long years of experience have
produced  a  work which is  both scientific and
practical, and which shuts out everything in the
nature of a superfluity, and therein lies the secret
of its success.  This last edition shows the marks
of the latest progress made in chemistry and chem-
ical teaching.—New Orleans Medical and  Surgical
Journal, Nov. 1889.
Bloxam's  Chemistry.—Fifth  Edition.
        Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professor
of Chemistry in  King's College, London.  New  American  from  the fifth  London
edition,  thoroughly revised  and much  improved.  In  one  very handsome  octavo
volume of 727 pages, with 292 illustrations.  Cloth, $2.00; leather, $3.00.
  Comment from us on this standard work is al-  complain that chemistry is a  hard study. Much
most superfluous.  It differs widely in scope and  attention is paid to experimental illustrations of
aim from that of Attfield, and in its way is equally  chemical  principles  and phenomena, and the
beyond criticism.  It adopts the most direct meth-  mode of conducting these experiments. The book
ods in stating the principles, hypotheses and facts  maintains the position it has always held as one of
of the science.  Its language is so terse and lucid,  the best manuals of general chemistry m the Eng-
and its arrangement of matter so logical in se-  lish language.—Detroit Lancet, Feb. 1884.
quence that  the student never has occasion to
Luff's  Manual  of  Chemistry—Just Ready.
        A Manual of Chemistry.  For the use of students of medicine. By Arthur
P. Luff, M. D., B. Sc, Lecturer on Medical Jurisprudence and Toxicological Chemistry
St. Mary's Hospital Medical School, London.   In one 12mo.  vol. of 522 pages,  with 36
engravings.  Cloth, $2.00.  See Students' Series of Manuals, page 30.

Greene's Medical Chemistry.
        A Manual of Medical Chemistry. For the use of Students.  By William
H. Greene, M. D., Demonstrator of Chemistry in the  Medical Department of the Un
versity of Pennsylvania.  In one 12mo. volume of 310 pages,  with 74 illus.  Cloth, $1.7&

      Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
10           Chemistry—(Continued),  Pharmacy.
Vaughan & Novy on Ptomaines and Leucomaines — 2d Edition.
        Ptomaines, Leucomaines and Bacterial Proteids; or the Chemi-
cal Factors in the  Causation of Disease.  By  Victor C. Vaughan, fh. v.,
M. D., Professor of Physiological and Pathological Chemistry, and Associate .Professor ot
Therapeutics and Materia Medica  in the University of Michigan, and Frederick  (j.
Novy, M. D, Instructor in Hygiene and Physiological Chemistry in Ihe University ol
Michigan. New (second) edition. In one handsome 12mo. vol. of 389 pages.  Cloth, $2.25.
  This book is one that is of the greatest import-  and sanitarian.  It contains information which
ance, and the modern physician who accepts
bacterial pathology cannot  have  a complete
knowledge of this subject unless he has carefully
perused it.  To the toxicologist the subject is
alike of great import, as well as to the hygienist
is not easily obtained elsewhere, and which is
of a  kind that no medical thinker should be
without.—The American Journal of the Medical
Sciences, April, 1892.
Remsen's Theoretical  Chemistry.—New  (4th)  Edition.
        Principles of Theoretical Chemistry, with special reference to the Con-
stitution of Chemical Compounds.  By Ira Kemsen, M. D, Ph. D., Professor of Chem-
istry in the Johns Hopkins University, Baltimore.  Fourth and thoroughly revised edi-
tion.  In one handsome royal 12mo. volume of 325 pages.  Cloth, $2.00.
 The fourth edition of Professor Remsen's well-
known book comes again, enlarged and revised.
Each edition has enhanced its value. We may say
without hesitation that it is a standard work on
the theory of chemistry, not excelled and scarcely
equalled by any other in any language.  Its trans-
lation into German and Italian speaks for its ex-
alted position and the esteem in which it is held
by the  most prominent chemists. We claim for
this little work a leading place in the chemical
literature of this country.—The American Journal
of the Medical Sciences, July, 1893.
Charles' Physiological  and  Pathological  Chemistry.
        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. By T.  Cranstotjn
Charles, M. D., F. R. S.^ M. S., formerly Assistant Professor and Demonstrator of Chem-
istry and Chemical Physics, Queen's College, Belfast.  In one handsome octavo volume
of 463 pages, with 38 woodcuts and 1 colored plate.  Cloth, $3.50.
 Dr. Charles is fully impressed with the impor-
tance and practical reach of his subject, and he
has treated it in a competent and instructive man-
ner.  We cannot recommend a better book than
the present.  In fact, it fills a gap in medical text-
books, and that is a thing which can rarely be said
nowadays. Dr. Charles has devoted much space
to the elucidation ot urinary mysteries. He does
this with much detail, and yet in a practical and
intelligible manner.  In fact, the author has filled
his book with many practical hints.—Medical Rec-
ord, December 20,1884.
Hoffmann and  Powers' Medicinal Analysis.
        A Manual of Chemical Analysis, as applied to the Examination of Medi-
cinal 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 Pharmaceu-
tical and Medical Students.  By Frederick Hoffmann, A. M., Ph. D., Public Analyst to
the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem-
istry in the Philadelphia College of Pharmacy.  Third  edition, entirely rewritten  and
much  enlarged.   In  one octavo volume of 621 pages, with 179 illustrations.  Cloth, $4.25.

Parrish's  Pharmacy.—Fifth Edition.
        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.
By Edward Parrish, late Professor of the Theory  and Practice of Pharmacy in  the
Philadelphia College of  Pharmacy.  Fifth edition* thoroughly  revised, by  Thomas S.
Wiegand, Ph. G.  In one handsome octavo volume of  1093 pages, with 256  illustrations
Cloth, $5.00; leather, $6.00.

Caspari's  Pharmacy.—Preparing.
        A Text-Book on Pharmacy, for Students  and Pharmacists.  By
Charles Caspari, Jr, Ph. G., Professor of the Theory and Practice of Pharmacy in  the
Maryland College of Pharmacy,  Joint Editor of The National Dispensatory of 1894.    In
one very handsome octavo volume, richly illustrated.

Ralfe's  Clinical  Chemistry.

t>u •  • Clilliicval Chemistry.  By Charles H. Ralfe, M. D., F. E. C. P., Assistant
Physician  at the London  Hospital.  In one pocket-size 12mo. volume of 314 pages
with 16 illus.  Limp cloth, red edges, $1.50.  See Students' Series of Manuals, page 30.  '

      Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
___Pharmacy,  natena^edic^Therapeutics.     11

           JUST READY-NEW AND THOROUGHLY REVISED EDITION.


  The  National  Dispensatory.

        Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi-
cines, including those  recognized in  the Pharmacopoeias  of the United States, Great
Britain and Germany,  with numerous references to the French Codex.   By Alfred
Stille, M. D., LL. D., Professor Emeritus of the Theory and Practice of Medicine and of
Clinical Medicine in the University of Pennsylvania, John M. Maisch Phar D late
Professor of Materia Medica and Botany in Philadelphia College of Pharmacy  Secretary
to the American Pharmaceutical Association, Charles Caspari, Jr., Ph. G., Professor
of Pharmacy in the Maryland College of Pharmacy, Baltimore, and Henry C. C. Maisch
Ph. G., Ph. D.  New (fifth) edition, thoroughly revised in accordance with the new  U. s!
Pharmacopoeia (Seventh Decennial Revision, 1894).  In one magnificent imperial octavo
volume of 1910 pages, with 320  engravings.  Cloth, $7.25,  leather,  $8.00.  With ReacW
Reference Thumb-letter Index, cloth, $7.75; leather, $8.50.
      ON the first appearance of The National Dispensatory fifteen years ago it was at once
        recognized by the pharmaceutical and medical professions as satisfying the  need
        for a work affording all necessary information upon  its subject, with authoritative
accuracy, and with a completeness and  convenience  attainable  only by the exclusion of
obsolete matter.  Its success in filling  this want is fully attested by the rapid demand for
five editions, and the opportunity thus afforded has been well used in successive revisions,
each placing it abreast  of the day and maintaining the characteristics which had won for
it a leading position.
    Of all its issues the  present embodies the results of the most exhaustive revision.
The sweeping changes in the new United States Pharmacopoeia are  thoroughly incorpor-
ated, with official authorization of the Committee of Revision, and full use has been made
of all valuable  material in the latest  issues of foreign Pharmacopoeias.   The volume is
accordingly rich in pharmaceutical and chemical information, with data, formulas, tables,
etc., gathered from all official sources, but this constitutes only a single department of its
usefulness.  As an encyclopaedia of the latest and  best  therapeutical knowledge it deals
not  only  with  all official drugs, but also with all the new synthetic remedies of value
and with the unofficial preparations now so largely in use.  Pharmacists  will  appreciate
its systematic descriptions of the materia medica, its clear explanations of chemical and
pharmaceutical  processes and  tests, and its illustrations of important drugs and of the
most improved apparatus.  Physicians will readily perceive the indispensable  assistance
offered by its authoritative statements as to the efficacy of drugs in the light of the  most
recent medical advances.  Arranged alphabetically in the text,  this information is
placed most suggestively at command by the recommendations grouped under the various
Diseases in the Therapeutical Index.  Together with the General Index this covers  more
than one hundred treble-columned pages containing  25,000 references.  The  immensity
of detail  comprised in this single volume of 1900 pages is thus most forcibly indicated.
Though the present edition contains far more matter than its predecessor it is maintained
at the same price in view of the ever-increasing  demand.   Weights and Measures are
given in both Ordinary and Metric Systems.
     In brief the new  edition of The National Dispensatory is presented to the medic*.
and pharmaceutical professions as the equivalent of a whole library of pharmaceutical and
therapeutic information; it is the standard of accuracy, the  embodiment  of  completeness
without inconvenient bulk, and a marvel of cheapness owing to  the  widespread demand
for it as the authority.
  The careful examination of this large volume
will strike the reader with surprise at the great
number of new articles added, and the amount of
useful and accurate information regarding their
properties, methods of preparation and therapeu-
tical effects.  The large number of  new articles
containing all the latest synthetic remedies  and
unofficial remedies, compass  the entire range of
available information in the line of the work. A
number of very complete tables together with all
the official re-agents and solutions for qualitative
and quantitative tests, appear in the  appendix.
Altogether this work maintains its previous high
reputation for accuracy, practical uselulness and
encyclopaedic scope, and is indispensable alike to
the pharmacist and physician.  Every druggist
knows of it and uses  it, and  almost every pbysl-
cian properly consults it when desirous of settling
all doubtful  questions regarding the properties,
preparation and uses  of drugs.—Medical Kecora,
April 7,1894.                    ,.       . „„
  The descriptions of materia medica are clear,
thorough and systematic, as are also the explana-
tions of  chemical and pharmaceutical processes
and tests.  The therapeutical portion has been re-
vised with equal care and the statements of the
action and uses have been arranged  not only
alphabetically under the various drugs, but for
practical medical usefulness have also been placed
at the instant command of those seeking infor-
mation in the  treatment of special diseases by
being arranged under the various diseases in a
therapeutical index. The readiness with which
anv of the vast amount of information contained
in this work is made available is indicated by the
twenty-five thousand references in the two in-
dexes at the end of the yo\uvae.-Boston Medical
and Surqical Journal, April, 1894.
  It is the official guide for the medical and phar-
maceutical profesaions.-Bvffalo Medical and Sur-
aical Journal, March, 1894.
9 The book is recommended  most highly as a
book of reference for the physician and is invalu-
ableTto the druggist in his every-day work.-2^
Therapeutic Gazette, March, 1894.
  This edition of the Dispensatory should be recog-
nized as a national standard.-The North American
Practitioner, March, 1894.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
12      Therapeutics,  Hateria  Hedica—(Continued)._____


A   System  of   Practical   Therapeutics

                  BY AHERICAN AND FOREIGN AUTHORS.

               Edited  by  HOBART  AHORY  HARE,  H.  D.
     Profettorof Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia.
         In a series of contributions by seventy-eight eminent authorities.  In three large
octavo volumes of 3544 pages, with 434 illustrations.   Price, per volume:  Cloth,  $5.00;
leather, $6.00; half Russia, $7.00.   For sale by subscription only.   Address the Publishers.
Full prospectus free to any address on application.
                                           is the treatment of disease, and a work which con-
                                           tributes to its successful  management is to be
                                           looked upon as of vast use to humanity.  It can-
                                           not be denied that therapeutic resources, whether
                                           the treatment be confined to the mere administra-
  The various divisions have been elaborated by
men selected in view of their special fitness.  In
every case there is to be found a clear and concise
description of the disease under consideration,
corresponding with  the most recent and well-
established views of the subject, embracing appo-
site pictorial illustrations where these are neces-
sary.  In treating of  the employment of remedies
and therapeutical measures, the  writers have
been singularly happy in giving in a definite way
the exact methods employed and the results ob-
tained, both by themselves and others, so that one
might venture with  confidence to use remedies
with which he was previously entirely unfamiliar.
The practitioner could hardly desire a book on
practical therapeutics which he could consult with
more interest and  profit.—The North American
Practitioner, September, 1892.
  The scope of this  work is beyond that  of any
previous one on the subject.  The goal, after all,
tion of drugs, or allowed its more extended appli-
cation to  the management of disease, have so
greatly multiplied within the  last few years as to
render previous treatises of little value.  Herein
will be found the great value of flare's encyclo-
pedic work, which groups together within a single
series of volumes the most modern  methods
known in the management of disease, and espe-
cially deals with important subjects comprehen-
sively, which could not be done in a more limited
treatise.   We cannot commend Hare's System
of Practical  Therapeutics too highly; it stands
out first and  foremost as a work to be consulted
by authors, teachers, and physicians, throughout
the world.—Buffalo Med. and Surg. Jour., Aug. 1892.
Hare's  Text-Book  of  Practical Therapeutics.—Third Edition.
        A Text-Book of Practical Therapeutics;  With Especial Reference to
the Application of Remedial Measures to Disease and their Employment upon a Rational
Basis.  By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica
in the Jefferson Medical College of Philadelphia; Sec. of Convention for Revision of U. S.
Pharmacopoeia of  1890.  With special chapters by Drs. G. E. de Schweinitz, Edward
Martin,  J. Howard Reeves and Barton C. Hirst.   New (3d)  and revised edition.
In one octavo volume of 689 pages.  Cloth, $3.75; leather, $4.75.
                                          presented with notes as to its usefulness in numer-
  The student of other works, has often, indeed,
very often, longed for less of the abstract materia
medica and more of the practical application of
drugs to disease. In this work that want is filled.
The  drugs  are  arranged alphabetically, which
enables one to find any name quickly, and. with
the excellent index at the end of the volume,
naught is left to be desired in the way of quick
reference.  Each drug, including all the newer
remedies which have been proved to possess true
merit, is considered in a rational and scientific
manner. This work also presents us with nearly
250 pages of practical  therapeutics, as  applied
to the individual  diseases.   The subjects are
arranged alphabetically.  It is in the chapter on
Diseases that the student finds the rationale of
therapeutics. This  section is  properly the com-
plement of the former, in which each drug was
ous diseases, while in the latter each disease is
considered very fully from a therapeutical stand-
point, the applications and special indications of
the different remedies in the different phases of
that particular affection being given.  It is not a
wonder that this work was quickly adopted  by
many colleges as a text-book and so liberally pur
chased as to necessitate the publication of a third
edition within two years.  The  student will find
its pages filled with the choicest of therapeutical
lore, systematically arranged and clearly and forci-
bly presented ; the practitioner will appreciate  its
rationality and its general utility as an elbow con-
sultant.  It  contains,  without question, the best
exposition  of modern therapeutics of any text-
book with which we are acquainted.—The Chicago
Clinical Review, March, 1893.
Maisch's  Materia Medica.—Fifth Edition.
        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.  By John M. Maisch, Phar. D, Prof, of Materia Medica and Botany in
the Philadelphia College of Pharmacy.  New (fifth) edition, thoroughly revised.  In one
very handsome 12mo. volume of 544 pages, with 270 engravings. Cloth  $3.00,
  Thia ia an avnallanttvinnnni <tf awahSa  «A_i.*._L__■„ a     *  . <•
  This is an excellentmanual of organic materia
medica, as are all the works that emanate from the
skilful pen of such a successful teacher as John
M. Maisch. The book speaks for itself in the most
forcible language. In the edition before us which
is the fifth one published within the comparatively
short space of eight years (and  this is the best
proof of  the great value of the work and the
just favor with  which it  has been received and
accepted), the original contents have been thor-
oughly revised and much good  and new matter
has been incorporated. We have nothing but praise
for Professor Maisch's work. It presents no weak
point, even for the most severe critic. The  book
fully sustains the wide and well-earned reputa-
tion of its popular author. In the special line of
work of which it treats it is fully up to the  most
recent observations and  investigations.  After a
careful perusal of the book, we do not hesitate to
recommend Maisch's  Manual  of Organic Materia
Medica as one of the best, if not the best work on
the subject thus far  published. Its usefulness
cannot well be dispensed with, and students, drug-
gists, pharmacists and physicians should all pos-
sess a  copy of such a valuable book.—Medical
News, December 31,1892.
Edes'  Therapeutics and  Materia Medica.

tt    *  of J6?*"-8?? of. TheraPeutics and Materia Medica.  Intended for the
Use  of  Students and Practitioners.  By Robert T. Edes, M.D, Jackson Professor  of
Clinical Medicine m Harvard University.  Octavo^ pp.   Cloth, $3.50 J leathertllso.

      Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Strett, Philadelphia. 
Practice  of  fledicine.
                                                           ___________13

Flint's  Practice of Medicine.—SixthMtion

,  ♦!.   A Tl^A1*? OXa the ^^ciples and Practice of Medicine   Designed
for the use of Students and Practitioners of Medicine.  Bv AitstitTft t^tt M r> t t^tT
Professor of the Principles and Practice of Medicine and of Ai^Ll lE  •    •'   &,?''
vue Hospital Medical College, N. Y.   Sixth ediSon' £^^£?^  reVrit £
by the Author,  assisted by William  H. Welch  M  D   Profile *T t> ?W i
Johns Hopkins University,  Baltimore, and Austin  Flini?Jb  M D  LLD  Prnl°£'
of Physiology Bellevue Hospital Medical College, K Y^n^very' W^ocTa^o
volume of 1160 pages, with illustrations.  Cloth, $5.50; leather $6.50.
  No text-book on the principles and practice of
medicine has ever met in this country with such
general approval by medical students and practi-
tioners as the work of Professor Flint.  In all the
medical colleges of the United States it is the fa-
vorite work upon Practice; and, as we have stated
        -"uai-~
            ing to it, there is no other medical
work that can be so generally found in the libra-
ries of physicians.  In every state and territory
of this vast country the book that will be most likely
to be found in the office of a medical man, whether
™-  i y,T^)Wn' Vlllage> or at some cross-roads, is
Flint s Practice.  We  make this statement to  a
considerable extent from personal observation, and
it is the testimony also of others.  An examina-
tion shows that very considerable changes have
been made in the sixth edition. The work may un-
doubtedly be regarded as fairly representing the
present state of the science of medicine, and as
reflecting the views of  those who exemplify in
their practice the present stage of progress of med-
ical art.—Cincinnati Medical New; Oct. 1886.
Hartshorne's Essentials  of  Practice.—Fifth  Edition.
        Essentials of the Principles and Practice of Medicine. A Handbook
for Students and Practitioners.  By Henry Hartshorne, M. D., LL. D, lately Professor
of Hygiene in the University of Pennsylvania.   Fifth  edition, thoroughly revised and
rewritten.  In one 12mo. vol. of 669 pages, with 144 illus.   Cloth, $2.75; half leather, $3.

Farquharson's  Therapeutics  and Materia  Medica—4th Ed.
        A Guide  to Therapeutics  and Materia Medica.  By Robert  Far-
quharson, M. D., F. R. C. P.,  LL. D., Lecturer on Materia Medica at St. Mary's Hospi-
tal  Medical  School,  London. Fourth American, from  the fourth English   edition.
Enlarged and adapted to the U. S.  Pharmacopoeia.  By Frank Woodbury, M. D., Pro-
fessor of Materia Medica and Therapeutics and Clinical Medicine  in the Medico-Chi-
rurgical College of Philadelphia.  In one handsome 12mo. vol. of 581 pp.  Cloth, $2.50.
                                           copceias, as well as considering all non-official but
  It may correctly be regarded as the most modern
work of its kind.  It is concise, yet complete.
Containing an account of all remedies that have
a place in the British and United States Pharma-
important new drugs, it becomes in fact a miniature
dispensatory.—Pacific Medical Journal, June, 1889.
Brace's  Materia Medica and  Therapeutics.—Fourth  Edition.
         Materia Medica and Therapeutics.  An Introduction to Rational Treat-
ment.  By J. Mitchell Bruce, M. D., F. R. C. P., Physician and Lecturer on  Materia
Medica and Therapeutics  at  Charing-Cross Hospital, London.   Fifth edition.  In  one
12mo. volume of 591 pages. Cloth, $1.50.   See Students' Series of Manuals, page 30.
  The pharmacology and therapeutics of each drug
are given with great fulness, and the indications for
its rational employment in the practical treatment
of disease are pointed out. The Materia Medica
proper contains all that is necessary for a medical
student to know at the present day.  The third
part of the book contains an outline of general
therapeutics, each of the symptoms of  the body
being taken in turn, and the methods of treat-
ment illustrated. A lengthy notice of abook so well
known is unnecessary.—Med. Chronicle, May, 1891.
COHEN'S HANDBOOK OF APPLIED THERA-
  PEUTICS.  Being a Study of Principles Applic-
  able and an Exposition of Methods Employed
  in the Management of  the Sick.  By Solomon
  Solis Cohen, M D., Professor of Clinical Medi-
  cine and Applied Therapeutics in the Philadel-
  phia  Polyclinic.  In one large  12mo. volume,
  with illustrations.  Preparing.
REYNOLDS' SYSTEM OF MEDTCINE.  Edited
  by J. Russell Reynolds, M. D., Professor of the
  Principles and Practice of Med. in University
  College, London.   With notes and additions by
  Henry Hartshorne, A. M., M. D., late Professor
  of Hygiene in the University of Pennsylvania.
  Three octavo volumes, containing 3056 double-
  columned pages, with  317 illustrations.  Price
  per  volume, cloth,  85.00;  sheep, $6.00; half
  Russia, $6.50.  Subucription only.       __
WATSON'S LECTURES ON THE PRINCIPLES
  AND PRACTICE OF PHYSIC.   From the fifth
  English edition. Edited with additions, and 190
  illustrations, by Henry 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.
FLINT'S  PRACTICAL  TREATISE ON THE
  DIAGNOSIS, PATHOLOGY AND TREATMENT
  OF DISEASES OF THE HEART.  Second re-
  vised and enlarged edition.  In  one octavo vol-
  ume of 550 pages, with a plate.  Cloth, $4.
FLINT ON PHTHISIS:  ITS MORBID ANAT-
  OMY, ETIOLOGY, SYMPTOMATIC EVENTS
  AND COMPLICATIONS,  FATALITY  AND
  PROGNOSIS, TREATMENT AND PHYSICAL
  DIAGNOSIS; in a series of Clinical Studies.  In
  one  octavo volume of 442 pages. Cloth, $3.50.
FLINT'S ESSAYS ON CONSERVATIVE MEDI-
  CINE AND KINDRED TOPICS.  In one very
  handsome royal 12mo. volume of 210  pages.
  Cloth ffil 38
LYONS' TREATISE ON FEVER.  In one 8vo.
  volume of 354 pages.  Cloth, $2.25.
HODSON'S LECTURES ON THE  STUDY OF
  FEVER.  In one octavo volume of  308 pages.
  Cloth, $2.50.
LA ROCHE ON YELLOW FEVER, in its Histori-
  cal, Pathological, Etiological and Therapeutical
  Relations. Two octavo vols., 1468 pp. Cloth, $7.00.
BRUNTON'S  PHARMACOLOGY, THERAPEU-
  TICS AND MATERIA MEDICA.  Octavo, 1305
  pages, 230 illustrations.          ___,.„^x
HERMANN'S EXPERIMENTAL PHARMACOL-
  OGY. A Handbook of Methods for Determining
  the Physiological Action of Drugs.  Translated,
  with the  Author's permission,  and with  exten-
  sive additions, by R.  M. Smith, M.  D.  12mo.,
  199 Dag«s. with 32 illustrations.  Cloth, $1.50.
STILLE'S THERAPEUTICS AND MATERIA
  MEDICA. A Systematic Treatise on  the Action
  and  Uses of Medicinal Agents, including their
  Description and History.  Fourth edition,  re-
  vised and enlarged. In two octavo volumes, con-
  taining 1936 pages.  Cloth, $10.00; leather, $12.00.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
14  Prac. of  fledicine, Treatment,  Digestive Syst.
Lyman's Practice  of Medicine.
        The Principles and Practice of Medicine.  For the  Use of Medical
Students and Practitioners.  By Henry M. Lyman, M.D.,  Professor of the Principles
and Practice of Medicine, Rush Medical College, Chicago.  In one very handsome octavo
volume of 925 pages, with 170 illustrations.  Cloth, $4.75; leather, $5.75.
  This is an excellent treatise on the practice of
medicine, written by one who is not only familiar
with his subject, but who has also learned through
practical experience in  teaching, what are the
needs of the student,and how to present the facts
to his mind in the most readily assimilable form.
Although the book contains over nine hundred
pages, there has been no space wasted by useless
historical essays, prolonged discussions on de-
batable topics, or "padding" of any kind.  Each
subject is taken up in order, treated clearly but
briefly, and dismissed  when all has been said that
need be said in order to give the reader a clean-
cut picture of the disease under discussion.  The
reader is not confused  by having presented to him
a variety of different methods of treatment, among
which he is left to choose the one most easy of exe-
cution, but the author  describes the one which is,
in his judgment, the best. This is as it should be.
What the student should be taught is the one
most approved method of treatment.  We have
spoken of the work as one for the student, and
this because the author occupies so prominent a
position as a teacher, but we would not be under-
stood that it is adapted only for students.  There
is many a practitioner of ten years' or more stand-
ing, who has been unable to follow the constant
advances made in medical science, to whom this
work will be of great use.  He will find here each
subject presented in its latest aspect, and only
such theories mentioned as have been generally
accepted by the highest authorities.  The practi-
cal and busy man who wants to ascertain in a
short time all the necessary facts concerning the
pathology or treatment of any disease, will find
here a safe and convenient guide.—Medical Rec-
ord, October 22,1892.
The Year-Book of Treatment for 1894.—Just Ready.
        A Comprehensive and Critical Review for Practitioners of Medi-
cine and Surgery.  In one 12mo. vol. of 501 pages.  Cloth, $1.50.
        **# For special commutations with periodicals see pages 1 and 2.
                                          enough to secure them. It is the very book the
  This is the tenth year of this valuable work,
which comes to hand with unerring  regularity.
It would be difficult indeed to imagine a book
more nearly suited to the every-day needs of the
medical practitioner or writer  than  this.  The
contributors to this volume are among the most
prominent and well-known writers and teachers
of the day, and their articles and opinions will be
appreciated by all who are fortunate and wise
busy practitioner needs.  He can find anything
 Eertaining to any subject in a moment's time, and
 e may rest assured that it is the most modern
and reliable view now accepted.  It, year by year,
keeps him  apprised of important advances in all
branches of medicine, and presents them in a
well-condensed  and classified form.—The  Char-
lotte Medical Journal, April, 1894.
The Year-Books  of  Treatment for  1891, 1892 and  1893.
        12mos., 485 pages.  Cloth, $1.50 each.

The Year-Books  of  Treatment for  1886 and 1887.
        Similar to above.   12mos., 320-341 pages.  Cloth, $1.25 each.


     A   System   of   Practical   Medicine.
                          BY AMERICAN AUTHORS.

            Edited by WILLIAM   PEPPER,  M. D., LL. D.,
   PROVOST AND PROFESSOR OP THE THEORY AND PRACTICE  OF MEDICINE AND OF
             CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA.
The complete work, in five volumes, containing 5573 pages, with 198 illustrations, is now ready.
    Price per volume, cloth, $5; leather, $6 ; half Russia, $7.  Subscription only.

                                         lowers of our home  school of medicine, and the
                                         combination of the scientific study of disease and
                                         the practical application of exact and experimen-
                                         tal  knowledge to  the treatment of human  mal-
                                         adies, makes every one of us share in the pride
                                         that has welcomed Dr. Pepper's labors.  Sheared
                                         of the prolixity that wearies the readers of the
                                         German school, the articles glean these same
                                         fields for all that is valuable.  It is the outcome of
                                         American brains, and is  marked throughout by
                                         much of the sturdy independence of thought and
                                         originality that is a national characteristic. Yet no-
                                         where is there lack of study of the most advanced
                                         views of the day.—N. C. Med. Jour., Sept. 1886.
  * * The greatest distinctively American work On
the practice of medicine, and, indeed, the super-
lative adjective would not be inappropriate were
even all other productions placed in comparison.
An examination of the five volumes is sufficient
to convince one of the magnitude of the enter-
prise, and of the success which  has attended its
fulfilment.— The Medical Age, July 26,1886.
  The feeling of proud satisfaction with which the
American profession sees this, its representative
system of practical medicine issued to the medi-
cal world, is fully justified by the character of the
work. The entire caste of the system is in keep-
ing with the best thoughts of the leaders and  fol-
Habershon on  the Abdomen.
        0n,t|ie Diseases of the Abdomen;  Comprising those of the Stomach and
other parts of the Alimentary Canal, (Esophagus, Csecum, Intestines and Peritoneum.' By
S. O. Habershon, M. D  Senior Physician to and late Lecturer on Principles and  Prac-
tice of  Medicine at Guy's Hospital London.  Second  American from third enlargedI and
revised Enghsh edition. In one handsome octavo vol. of 554 pages, with illus.  Cloth $3 50
  This valuable treatise on dis«ftSfiaAftH»0f^^„„v.  ___i..„   .  ,.f 6  '   ..    _0'  v,ioui, ipo.ou.
  This valuable treatise on diseases of the stomach
and abdomen will be found a cyclopaedia of infor-
mation, systematically arranged, on all diseases of
the alimentary tract, from the mouth  to the
rectum.   A fair proportion  of each chapter is
devoted to symptoms, pathology, and therapeutics.
—New York Medical Journal, April, 1879
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
          Practice  of  riedicine^Diagnosis,  Heart.       15


Musser's  Medical  Diagnosis.—Just Ready

  a t>   f, Practi°al TTreaSS?T°n Me^i?al Diagnosis   For the Use of Students
and Practitioners.  By John H Musser, M  D, Assistant Professor of Clinical Medicine
University of Pennsylvania, Philadelphia.  Jn one very handsome octavo volume of 873
pages, with 162 illustrations.  Cloth, $5; leather, $6.
                                           mended alike for its logical arrangement, accurate
 The  aim of the author has been  to make
the  work  eminently  practical.   Dr.  Musser
has  succeeded in bringing together a large and
valuable collection of clinical data drawn from his
own extended experience and from exhaustive
literary research, and has presented them in an
unusually clear and concise manner.  In brief,
the  book is thoroughly modern, readable and in-
structive, and, we believe, superior to any work of
the kind before the profession.— University Medical
Magazine, March, 189*.
 Modern methods of medical teaching and study
have rendered treatises like the present an abso-
lute necessity.  The present work is to be com-
observation and  clearness of expression.  The
cnapter on bacteriology is especially commenda-
ble, because  it contains everything practically
necessary for  clinical work.-Med. iJec, Apr. 21, '94.
  ihe book should receive a hearty reception from
students and  medical men; it contains much in-
formation essential to good,  scientific  medical
work. It is with pleasure that we can state that
the work has been adopted as a text-book  at the
Johns Hopkins Medical School and Harvard Uni-
versity, and that it has met with marked approval
in other teaching centres.—International Medical
Magazine, April, 1894.
Flint on  Auscultation and Percussion.—Fifth Edition.
        A. Manual of Auscultation and Percussion; Of the Physical Diagnosis
of Diseases of the Lungs and Heart, and of Thoracic Aneurism.  By Austin Flint M. D.
LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi-
cal College,  New York.  Fifth edition.  Edited by James C. Wilson, M. D.,  Lecturer
on Physical  Diagnosis in the Jefferson Medical College, Philadelphia.  In one hand-
some royal 12mo. volume of 274 pages, with 12 illustrations. Cloth, $1.75.

Whitla's  Dictionary  of  Treatment.
        A Dictionary of Treatment;  or Therapeutic  Index,  including
Medical and  Surgical  Therapeutics.  By William Whitla, M. D., Professor
of Materia Medica and Therapeutics in the Queen's College, BeKast. Kevised and adapted
to the United States Pharmacopoeia.  In one square, octavo vol. of 917 pp.  Cloth, $4.00.
  We have already dictionaries of medicine and
dictionaries of surgery; Dr. Whitla now provides
us with a dictionaryof treatment.  And reference
to the volume shows  that it really is  what  it
professes to be.   The  several diseased condi-
tions are arranged in  alphabetical  order, and
the  methods—medical, surgical,  dietetic, and
climatic—by which they may be met, considered.
On every page we find clear and detailed direc-
tions for treatment supported by the  author's
personal  authority and experience whilst the
recommendations of other competent observers
are also  critically examined.  The book  abounds
with useful, practical hints and suggestions, and
the younger practitioner will find in it exactly the
help he so often needs in the treatment both of
those who are ill, and those who are ailing. At the
same time the most experienced members of the
profession may usefully consult its pages for the
purpose of learning what is really trustworthy  in
the later therapeutic developments.  The Diction-
ary is, in short, the recorded experience of a prac-
tical  scientific therapeutist,  who has carefully
studied diseases and disorders at the bed-side and
in the  consulting-room, and has earnestly ad-
dressed himself to the cure and relief of hia
patients.—The Glasgow Medical Journal, April, 1892.
Fothergill's Handbook  of  Treatment.—Third  Edition.
        The Practitioner's  Handbook of Treatment; Or, The Principles of
Therapeutics.   By J. Milner Fothergill, M.D., Edin., M.E.C.P., Lond^, Physician
to the City of London Hospital for Diseases of the Chest,
volume of 661 pages.  Cloth, $3.75; leather, $4.75
  This is a wonderful book.  If there be such a
thing as " medicine made easy," this is the work to
accomplish this result.— Va. Med. Month.. June,'87.
  To have a description of the normal physiologi-
cal processes of an organ and of the methods of
treatment  of  its  morbid conditions brought
together in a single  chapter, and the relations
between the two clearly stated, cannot fail to prove
Third edition.  In one  8vo.
a great convenience to many thoughtful but busy
physicians. The practical value of the volume is
greatly  increased  by the introduction of many
prescriptions.  That the  profession appreciates
that the author has undertaken an important work
and has accomplished it is shown by the demand
for this third edition.— N. Y. Med. Jour., June 11,'87.
Broadbent  on the Pulse.
        The Pulse. By W. H. Broadbent, M. D., F. E. C. P., Physician to and Lecturer
on Medicine at St. Mary's  Hospital,  London.  In one 12mo.  volume  of  312 pages.
Cloth, $1.75.   See Series of Clinical Manuals, page 30.
TANNER'S MANUAL OF CLINICAL MEDICINE
 AND PHYSICAL DIAGNOSIS.  Third American
 from the second London edition.  Revised and
 enlarged  by Tilbury Fox, M. D.  In one 12mo.
 volume of 362 pp. with illus. Cloth, $1.50.
DAVIS' CLINICAL  LECTURES ON  VARIOUS
 IMPORTANT DISEASES.  By N. S. Davis,
 M. D. Edited by Fkank H. Davis, M. D. Second
 edition.  l2mo. 287 pages.  Cloth, 81.76.
TODD'S CLINICAL  LECTURES ON  CERTAIN
 ACUTE  DISEASES. In one octavo volume of
 320 pages.  Cloth. $2.60.               ,  mTT_
FLINT'S  PRACTICAL  TREATISE  ON  THE
 PHYSICAL EXPLORATION OF THE CHEST
  AND  THE DIAGNOSIS OF DISEASES AF-
  FECTING  THE  RESPIRATORY  ORGANS.
  Second and revised edition.  In one handsome
  octavo volume of 591 pages.  Cloth, $4.50.
STURGES' INTRODUCTION  TO THE STUDY
  OF CLINICAL MEDICINE.  Being a Guide to
  the Investigation of Disease.  In one handsome
  l2mo. volume of 127 pages. Cloth, $1.25.
WALSHE ON THE DISEASES OF THE HEAM
  AND GREAT VESSELS. Third American edi-
  tion.  In 1 vol. 8vo., 416 pp. Cloth, $3.00.
HOLLAND'S MEDICAL NOTES AND REFLEC-
  TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50.
Lea Brothers & Co., Publishel^06joT&7lTSansom Street, Philadelphia. 
16  Practice,  Electricity,  Cholera,  Food,  Hygiene.
Yeo's  Medical   Treatment.
         A Manual of Medical Treatment  or Clinical Therapeutics.  By
1. Burney Yeo, M. D., F. R. C. P., Prof, of Clinical Therapeutics in King's Coll., London.
In two 12mo. volumes containing 1275 pages, with illustrations.  Cloth, $5.50.
                                            cussion of the best methods of carrying out these
                                            indications.  Each section contains a number of
                                            prescriptions which the author  has found most
                                            useful, and at the end of every chapter is added a
  This work is devoted entirely to the treatment
of disease, being the first we have ever seen of the
kind.  Only so much of the pathology and etiol-
ogy of disease is introduced as is necessary to ar-
rive at the rational indications, without which the
administration  of a drug can hardly be  called
scientific.  Half a dozen choice formulae by lead-
ing physicians are appended to each  chapter.
The index is so arranged that one can find disease
and the  various remedies at  a glance.  Without
exaggeration, we can say that one could hardly
read anything affording at the  same time  so much
pleasure and profit as this  elegantly written  and
beautifully printed  book.—The  Canada Medical
Record, November, 1893.
  In Dr. Yeo's book the study of the treatment of
disease is approached, not from the side of the
drug or remedy as in works on therapeutics,  but
"from the side of the disease." The various  dis-
eases are grouped together, a short account is given
of the clinical  history, course and pathology of
each, and from a consideration  thereof, indications
for treatment are arrived at;  then follows a full  dis-
selection of formulae from the writings of various
well-known physicians. The work is exceedingly
practical, and the details of the various methods
of treatment are always given.  Full directions are
given with regard to diet, mode of life, and gen-
eral treatment, which are often as important as the
treatment by drugs.—Med. Chronicle, January, 1894.
  The discussion of the different ailments has a
distinctly practical turn toward the main purpose
of the book.  Standard formulae are  introduced
from eminent practitioners, and all the drugs of
recognized value are grouped in the order of their
importance.  The dosage receives  careful  atten-
tion, which is a feature that cannot be too highly
commended.  It cannot fail to be an exceedingly
useful,  suggestive  and instructive work to the
physician who wishes to be well up in the present
advanced and scientific therapeutics of the day.—
Medical Record, November 25,1893.
Teo  on Food  in  Healtli  and Disease.
         Food in Health and Disease.  By  I. Burney  Yeo,  M. D., F. B. C. P.,
Professor of Clinical Therapeutics in King's College, London.   In one 12mo. volume  of
590 pages. Cloth, $2.00.  See Series of Clinical Manuals,  page 30.
  Dr. Yeo supplies in a compact form nearly all that
the practitioner requires to know on the subject of
diet.  The work is divided into  two parts—food in
health and food in disease.  Dr. Yeo has gathered
together from all quarters an immense amount of
useful information within a comparatively small
compass, and he has arranged and digested his
materials with skill for the use of the practitioner.
We have seldom seen a book which more thor-
oughly realizes the object for which it was written
than this little work of Dr. Yeo.—British Medical
Journal, Feb. 8,1890.
Bartholow on Electricity in  Medicine  and Surgery.—3d Ed.
         Medical Electricity. A Practical Treatise on the Applications of Electricity
to Medicine and Surgery. By Roberts Bartholow, A. M., M. D., LL. D., Emeritus Pro-
fessor of Materia Medica and General Therapeutics in  the Jefferson Med. Coll. of Phila-
delphia, etc.  Third edition.  In one octavo volume of 308 pp., with 110 illus.  Cloth, $2.50.

Bartholow on  Cholera.—Just  Ready.
         Cholera: Its Causes, Symptoms, Pathology and Treatment.   By
Roberts Bartholow, M. D., LL. D.,  Emeritus  Professor of Materia Medica, General
Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia.  In one 12mo.
volume of 127 pages, with 9 illustrations.  Cloth,  $1.25.
  The most scientific work on  cholera  extant.
Broad yet comprehensive, concise but explicit, it
treats the subject in a way to invite but little criti-
cism. The most valuable chapter is the  one on
treatment, which, considering the author's thera
peutical experience, and the great improvements
made  in practice,  is indeed, a contribution to
medical literature  worthy of more than passing
notice — The Mtdical Fortnightly, July 15.1893.
  The author has sought to make a practical book
in the smallest compass.  The symptoms and
pathology of the disease  are  described separ-
ately in a brief and comprehensive manner.  The
final chapter, on the treatment of cholera, gives
the prophylactic measures, including quarantine
and the latest therapeutical methods in vogue in
India, Europe and America.  The volume is writ-
ten in the author's usual pleasant style, and will
satisfy the desire of any one that wishes to obtain
the most recent information on the subject.—The
New York Medical Journal, July 29,1893.
Richardson's  Preventive  Medicine.
i     * ,  Preventiv© Medicine.   By B. W. Richardson, M. D., LL. D., F. R. S., Fel-
low of the Royal Coll. of Phys., London. In one 8vo. vol. ot 729 pp.  Cloth, $4; leather, $5.
._ lhere is perhaps no similar work written for scholarlv: th«Hiqr.noahm «f f h«,;,^0h---/j,-„„I„»
  There is perhaps no similar work written for
the general public that contains such a complete,
reliable and instructive 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 knowledge on the subject, and
the preventive measures advised are accurate,
explicit and reliable.—The American Journal of the
Medical Sciences, April, 1884.
SCHREIBER'S MANUAL OF TREATMENT BY
  MASSAGE AND METHODICAL MUSCLE EX-
  ERCISE  Translated  by  Walter Mendelson.
  M.D., of New York.  In one 8vo. volume of 274
  pp., with 117 engraviDgs
CHAMBERS'MANUAL OF DIET AND REGIMEN
  IN HEALTH AND SICKNESS. In one hand
  some octavo volume of 302 pp.  Cloth, $2.76.
STILLE ON  CHOLERA:  Its Origin, History,
 Causation, Symptoms, Lesions, Prevention and
 Treatment.  In one handsome 12mo. volume of
 163 pages, with a chart.  Cloth, $1.25/
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.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
            Throat,  Nose^Joings^Tind^Nerves.          17

Seiler onJhTThroaTan^
m.     ♦AwHandboi>k__of  Diagnosis  and  Treatment of  Disease*  of tr,«
Throat,  Nose  and  Naso-Pharynx.   By Carl  SeiZ  ¥h    t  (      ne
Laryngoscopy in the University of Pennsylvania   New f4thfS*,'n   i'   Lec*uref   on
12mo volume of 414 najres  with 107 In   +  7-      i J  ih' edition.  In one handsome
 ^?",.» T ,  •     • Pa£es> Wltn iU7 illustrations and 2 colored nlate*   nnth jw ot;
 This little book is eminently Dracti™.!  .nj ™n  t„*___^,.".7., .V1~u.Plaie8'  Wotn, fyl.lb.
 This little book is eminently practical, and will
prove of interest not only to the specialist, but to
the general practitioner as well. It deals with the
subject in a  clear and distinct manner, and the
text is copiously illustrated with  diagrams and
colored plates.  So little  attention is paid ordi-
narily to the  examination of the larynx  that the
need of such a book has long been felt.  By con-
sulting its pages anyone can learn the necessary
manipulations, and, by a  little practice,  soon be-
come expeit in the use of the laryngeal mirror a
method of examination too often neglected.  The
anatomy of the larynx is explained with especial
care, and  the  operative  procedures for various
diseases of the throat, tonsils, etc., are carefully
explained.  Approved methods of treatment are
dealt with in a very satisfactory way, and all the
most  useful remedial agents  are described.__
    _ _.— _ „v,^v,va [;ittw:s.  v^ium, $z.zo.
International Medical Magazine, November 1893
fA'*™8 to the practitioner and a text-book
for the student, it is unexcelled, being plain  a£
C^at!* c,°TmPrehensive  and pleasantly written -
Atlanta Medical and Surgical Journal, August 1893

in th« ftfw M t0 -la,y that Jt is brough' UP ^ date
in the fullest possible sense of the term.  Rarely
has any treatise on any  specialty met with a more
cordial reception than the one under consider-
ation.  A. most generous recognition is given to
w,T™ k°f American laryngologists. The main
feature of the present  edition has been  the ex-
pansion  of that portion  which  deals with the
diseases of the nose. The  author is to be com-
mended on the excellence of his work, and con-
gratulated that a new edition has been so speedily
called for.—Medical Record, November 25 1893
Browne on the Throat  and Nose.—New  (4th) Edition.

r> t> n cT^e PJ?oatT£QC*  ?*ose aird Their Diseases.  By Lennox  Browne,
F.R.C.S., L., Senior  Physician  to  the Central London  Throat and Ear  Hospital
Fourth and enlarged edition.  In one imperial octavo volume of 751  pages  with 120
illustrations in color, and 235 engravings on wood.   Cloth, $6.50.
 Although quite complete enough for the use of   T± '- -   '---" ''
specialists, it is at the same time so clear as to be
of daily value to the general practitioner, who will
find at the end of the volume a number of well-
tried formulas most In vogue at the London hos-
pitals for  diseases of the throat.— The Canada
Medical Record, November, 1893.
  It is an admirable presentation of its subject in
the light of the large clinical experience of a care-
ful observer.  It is a book that no specialist can
afford not to have, and that the general nhysician
can rely upon as a safe guide and practical adviser.
—The Medical News, Oct. 14,1893.
Tuke  on  the Influence of the  Mind  on the  Body.
        Illustrations  of the Influence  of  the  Mind upon the Body in
Health and Disease.   Designed to elucidate the Action of the Imagination.  By
Daniel Hack Tuke,  M. D., Joint Author of the Manual of Psychological Medicine,
etc.  New edition.  Thoroughly revised and rewritten.  In one 8vo. volume of 467 pages,
with 2 colored plates.  Cloth, $3 00.
  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
has he adhered to a physiological and rational
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-
ing.—New York Medical Journal, September 6,1884.
Clouston on  Mental  Diseases.
        Clinical  Lectures  on  Mental Diseases.  By Thomas  S. Clouston,
M. D., Lecturer on Mental Diseases in the University of Edinburgh.  With an Appen-
dix, containing an Abstract  of  the Statutes  of  the United States and of the Several
States and Territories relating to the Custody  of  the Insane.   By Charles F. Folsom,
M. D., Ass't Professor of  Mental  Diseases,  Med. Dep. of Harvard Univ.  In one octavo
volume of 541 pages, with eight lithographic plates, four of which are colored.   Cloth, $4.
          r. Folsom's Abstract  also separate, in  one 8vo. vol. of 108 pages  Cloth, $1.50.
                                          and  descriptions given as to the practical man-
                                          agement and care of the cases. We can heartily
                                          recommend it to the student and  busy general
                                          practitioner. Dr. Folsom's work greatly increases
                                          the value of Dr. Clouston's book for the American
                                          practitioner.—Archives of Medicine, June, 1884.
  The descriptions of the diseases and cases are
simple and practical, but true; and one sees as he
reads that they are given by one perfectly familiar
from daily observation with the cases and diseases
he is speaking of.  One feature of the book which
commends it highly, and which is not to be found
in any other work on mental diseases, is the hints
Playfair  on  Nerve Prostration  and  Hysteria.
        The Systematic Treatment of Nerve Prostration and Hysteria.
By W. S. Playfair,  M. D.,  F. R. C. P.  In one 12mo. volume of 97 pages.  Cloth, $1.00.
BROWNE ON KOCH'S REMEDY IN RELATION
  TO THROAT CONSUMPTION.  In one octavo
  volume of 121 pages, with 45 illustrations, 4 of
  which are colored, and 17 charts, Cloth, $1.50.
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.
BLADE 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., 158 pp.  Cloth, $1.25.
SMITH ON CONSUMPTION; its Early and Reme-
  diable Stages. 1 vol. 8vo., 253 pp.  Cloth, $2.25.
LA ROCHE ON PNEUMONIA. 1 vol. 8vo. of 490
  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, $2.50.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
18
Nervous  and flental  Diseases,  Histology.
Gray on Nervons and Mental Diseases.
        A Practical  Treatise  on  Nervous  and  Mental  Diseases.  By
Landon Carter Gray, M. D., Professor of Diseases of the Mind and  JSTervous System
in the New York Polyclinic.  In one very handsome octavo volume of 681 pages, with
168 illustrations.  Cloth, $4.50;  leather, $5.50.
  A book that will  be welcomed by the many who | inal matter that renders it a desirable addition to
desire a modern text-book on  nervous diseases
that is comprehensive and practical, and especial-
ly full in the details of the treatment of these
affections that are so often matters of perplexity
to the general practitioner.  It will be  found, on
this account, to meet the wants of a large number
perhaps better than would another equally meri
torious text-book less full in this regard.  Dr. Gray
states in his preface, and it is evident to anyone
perusing the  work, that "especial care has been
taken to make the therapeutical suggestions suf-
ficiently detailed and pncise to cover the varying
stages, symptoms and complications of disease, as
well as to follow the important indications afford-
ed by differential diagnosis," and that "only  that
knowledge has been admitted  to these pages
which has stood the test of experience."  Its style
is clear and very readable, and the illustrations are
numerous and excellent.  A  glossary of special
terms is appended which will be found useful by
the student.  While it is intended as a text-book,
not assuming any special knowledge on the part
of its readers, the volume is full of valuable orig-
the library of the specialist in nervous and mental
diseases.—American Jour, of Mental Sci. Feb., 1893.
  None but one of the foremost neurologists in this
country could have succeeded in condensing
within less than seven hundred pages a text-book
on nervous and mental diseases. But the author's
long experience as  a teacher and his wide range
of information regarding the literature of his
subject have enabled him to discriminate nicely
as to what knowledge is most needed by the stu-
dent and practitioner. We wish that every medi-
cal college could have inscribed on its walls the
following: "Medical nihilism is an error of youth
and a  confession of impotence, for Nature  rarely
afflicts man beyond the hope  of  relief.   The
therapeutist has enormous re sources." Too often
the instructor informs his pupils with exceeding
care of the setiology, pathology, and diagnosis of
disease, and then says that it is incurable; he
makes no effort to teach tbem what to do to allevi-
ate, and Dr. Gray's optimism is in refreshing con-
trast to such instruction.—New York  Medical Jour-
nal, March, 1894.
Ross  on Diseases of the  Nervous  System.
        A  Handbook on Diseases  of  the  Nervous  System.  By James
Boss, M.D., F.B. C.P., LL.D.,  Senior Assistant Physician  to the Manchester  Boyal
Infirmary.   In one octavo vol. of 725 pages, with 184 illus.  Cloth, $4.50;  leather, $5.50.
  This admirable work is intended for students of
medicine and for suchmedical men as have no time
for lengthy treatises.  In the present instance the
duty of arranging the vast store of material at the
disposal of the author, and of abridging the de-
scription of the different aspects of nervous dis-
eases, has been performed with singular skill, and
the result is a concise and philosophical guide to
the department of medicine of which it treats.
Dr. Ross holds such a high scientific position that
any writings which bear his name are naturally
expected to have the impress of a powerful intel-
lect.  In every part this handbook merits the
highest praise, and will no doubt be found of the
greatest value to the student as well as to the prac-
titioner.— Edinburgh Medical Journal, Jan. 1887.
Hamilton  on  Nervous  Diseases.—Second  Edition.
        Nervous Diseases; Their Description and Treatment.  By Allen McLane
Hamilton, M. D., Attending Physician at the Hospital for Epileptics  and Paralytics
Blackwell's Island, JST. Y.   Second edition, thoroughly  revised  and  rewritten. In one
octavo volume of 598 pages, with 72 illustrations.  Cloth, $4.00.
 Savage on  Insanity  and  Allied  Neuroses.
         Insanity and Allied  Neuroses,  Practical  and Clinical.  By  George
 H. Savage, M. D., Lecturer on Mental Diseases at Guy's Hospital, London   In one
 12mo. vol. of 551 pp., with 18 illus.   Cloth, $2.00.  See Series of Clinical Manuals, p. 30.

Klein's Histology.—Fourth Edition.
         Elements of  Histology  By E.  Klein, M. D., F. K. S., Joint Lecturer on
General  Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital
London,   fourth edition.  In  one  12mo. volume ot 376 pages  with 194 illus   T;™
cloth, $1.75.   See Students' Series of Manuals, page 30.       P g '             US>  Limp
  The large number of editions through  which
Dr. Klein's little handbook of histology has  run
since its first appearance in 1883 is ample evidence
that it is appreciated by the medical student and
that it supplies a definite want.  The clear  and
X^.  m^nK6^ u?  which Jt is  written,  the
»*£/? °Xdebatable matter, of conflicting views,
added to the convenient size of the  book  and its
moderate  price, will  account  for its undoubted
success.—Medical Chronicle, Feb 1890   naOUOtea
Schafer's  Histology.—Third Edition.

i>  r    The Essentials of Histology.  By Edward A. Schafer, F E S  Jodrell
Professor of Physiology in University College, London.   New (thirdf JltT™  ' t
octavo volume of 311 pages, with 325 illustrations.  Cloth, $3.00.      }        '  In °De

                                            American Edition.  In one handsome octavo
                                            volume of 340 pages.   Cloth S3 25
                                          PEPPER'S SURPGfCAL PATHOLOGY.  In one
                                            FltttHZe 12m?-volume of 511 pages, wrth 8?
                                            illustrat ons.  Limp cloth, red edges, $2.00 See
                                            Students' Series of Manuals, page 30.
BLANDFORD ON INSANITY AND ITS TREAT-
  MENT.  Lectures on the Treatment, Medical
  and Legal, of  Insane Patients.  In one verv
  handsome octavo volume.
JONES' CLINICAL OBSERVATIONS ON FUNC-
  TIONAL NERVOUS  DISORDERS   Second
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
 ______Pathology,  Hjstoloog^jacteriology.            19


Gibbes'  Practical  Pathology  and  Morbid  Histology



one very handsome 8vo. vol.of 314 PP, with60^1^^^^^^^
 This is, in part, an expansion of the little work  *- m-*-.—-. .   •  .lu8r£lPnic-   Wotb, $2./5
published by the author some years ago, and his
acknowledged skill as a practical microscopist will
give weight to his  instructions.  Indeed, in ful-
ness of directions as to the modes of investigating
morbid tissues the book leaves little to be desired.
The work is throughout profusely illustrated with
reproductions of micro-photographs.   We  may
say that the practical histologist will gain much
useful information  from the book.—The London
Lancet, January 23,1892.
 The student of morbid histology and bacteri-
ology has at his hand, in this neat volume of some
three hundred pages, a most excellent guide and
one which, unless ne be a very advanced student,
he cannot afford to be  without.  The work is
divided into four parts, the first, that of practical
pathology, containing clear and precise directions
in histological technique, showing how toDrenare

 ect onS8Ueeto°rTharninati,011' cut' ^inYnSun*
off ? with ih*^»Jcond Part deals with bacteri-
ology, witn the  different forms of cultivation

Ther»1nar?avhi-nati°nS °? the b^terilfete!
th« wi  *par5'wlilch comprises more than half
the book, treats of morbid histology.  This part
is illustrated with a great number of beautiful

Pshr«°nrmHCr°gJiap^lin *hich the  mfcroscopfc fielJ
is reproduced with a distinctness that is really
2f^  The fourth part contains some very
practical  instruction on photography with the
microscope.  Works like this of Dr. Gibbes will

?a?£^Phi™« ^l°Sy &mon« the P^fessfon ai
large, whereas it is now to a  large  number of

oSfclTl891      * S6aled hoo*--Medical Record,
Abbott's  Bacteriology.

vu   • •  Th^ PrAinnciPles  of Bacteriology:  a Practical  Manual for Students and
Physicians.   By AC Abbott, M D., First Assistant, Laboratory of Hygiene, University
of Pennsylvania, Philadelphia. In one 12mo. vol. of 259 pp., with 32 illus. Cloth  $2 00
  To a person  desiring to learn the technique of  -
bacteriological work, we cannot recommend any
work which will be more suitable than  the one
before us.   Dr. Abbott has shown great judg>
ment  in the  selection   and  arrangement of
his material.  The student who follows it closely
will be in a condition to carry forward the work
for himself.  Medical practitioners generally could
read the work with profit, especially the chapters
on sterilization and disinfection,  and those on
tuberculosis and diphtheria in the second part —
The Canadian Practitioner, Nov. 1,1892.
Senn's  Surgical  Bacteriology.—Second  Edition.
        Surgical Bacteriology.  By Nicholas Senn,  M. D., Ph. D.,  Professor of
Surgery in Bush Medical College, Chicago.  New  (second) edition.  In one handsome
octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00
  The book is really a systematic collection in the
most concise form of such results as are published
in current medical literature by the ablest worker
in this field of surgical progress; and to these are
added the author's own views and the results of
his clinical experience and original investigations.
The book is valuable to the student, but its chief
value  lies in the fact that such a compilation
makes it possible for the busy practitioner, whose
time for reading is  limited and whose sources of
information are often  few, to become conversant
with the most modern  and advanced ideas in sur-
gical pathology, which have "laid the foundation
for the wonderful achievements of modern sur-
gery."—Annals of Surgery, March, 1892.
Green's Pathology  and  Morbid  Anatomy.—Seventh  Edition.
        Pathology and Morbid Anatomy.  By T. Henry Green, M. D., Lecturer
on Pathology and Morbid Anatomy at  Charing-Cross Hospital Medical School, London.
Sixth American from the seventh and  revised English edition.   Octavo, 539 pages, with
167 engravings. Cloth, $2.75.
  The Pathology  and Morbid Anatomy  of  Dr.
Green is too well known by members of the medi-
cal profession to need any commendation.  There
is scarcely an intelligent physician anywhere who
has not the work in his library, for it is almost an
essential.  In fact it is better adapted to the wants
of general practitioners than any work of the kind
with  which we are acquainted.   The works of
German authors upon pathology, which have been
translated into English, are too abstruse for the
physician.  Dr. Green's work precisely meets his
wishes.  The  cuts exhibit the appearances  of
pathological  structures just  as they are  seen
through the microscope.   The fact that it is  so
generally employed as a text-book by medical stu-
dents  is evidence that we have not spoken too
much  in its favor.—Cincinnati Medical News, Oct.
1889.
Payne's  General  Pathology.
        A Manual  of General Pathology.  Designed as  an Introduction  to the
Practice of Medicine.   By Joseph F. Payne, M. D., F. B. C. P., Senior Assistant Physi-
cian and Lecturer on Pathological Anatomy,  St. Thomas' Hospital,  London.  Octavo  of
524 pages, with 152 illustrations and a colored plate.  Cloth, $3.50.

Coats' Treatise  on  Pathology.
        A  Treatise on  Pathology.  By Joseph  Coats, M.D., F.F.P.S., Patholo-
gist to the Glasgow Western Infirmary.  In one very handsome  octavo volume of 829
pages, with 339 beautiful illustrations.  Cloth, $5.50; leather, $6.50.
  Medical students  as well as physicians,  who
desire a work for study or reference, that treats
the subjects in the various departments in a very
thorough manner, but without prolixity, will cer-
tainly give this one the  preference 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.—Cincinnati Medical News, Oct. 1883.
Lea Brothers & Co., Publishers, 706^08 & 710 Sansom Street, Philadelphia. 
20
Surgery.
Ashhurst's  Surgery—New  (6th)  Edition.    Just  Ready.
        The Principles and Practice  of Surgery.  By John Ashhurst, Jr.
M. D., Professor of Surgery and Clinical Surgery in the Univ. of Penna., Surgeon to the
Penna.  Hospital, Philadelphia.   New (6th) edition, enlarged and thoroughly  revised.
Octavo,  1161 pages, 656 engravings and a colored plate.  Cloth, $6.00;  leather, $7.00.
                                          meritacontinuanceofthe confidence of the profes-
                                          sion.  In this  edition  he has incorporated an ac-
                                          count of the more important recent observations in
  Ashhurst's Surgery maintains in its sixth edition
the high standard of excellence which has always
been its characteristic.  The author has so thor-
oughly revised his work that the most recent
appliances and methods in surgery are mentioned.
Dr. Ashhurst's well-known, comprehensive, and
yet concise treatment of the various subjects is
even more marked in this  than in the previous
editions.  A  great deal of new matter has been
added without making the volume unwieldy. Con-
densation and elimination have been most skil-
fully done where necessary.— The Chicago Medical
Recorder, January, 1894.   *
  The author has been before the surgical world
so long and is so versatile  and resourceful that
his several editions are rapidly  taken  up and
others follow in equally prompt measures of time.
Ashhurst has taken great pains to render this
sixth edition fully equal to  the demands of the
present,  and has constructed it on lines.which
 surgical science, as well as such novelties in sur-
 gical practice as meritthe classification of improve-
 ments.  Dr. Charles B. Nancrede, of Ann Arbor,
 has contributed a new chapter on surgical bacteri-
 ology ; Dr. Barton C. Hirst has revised the sections
 on gynecological  subjects; and Drs. George E.
 de Schweinitz and B. Alexander Randall have re-
 vised the chapters on diseases of the eye and ear.
 Those surgeons who possess earlier editions of
 Ashhurst's treatise will make haste to obtain this
 new one. and those who are not familiar with the
 work will  necessarily add it to their libraries.
 Surgical science is so varied and extensive in its
 application, that one must needs have at hand all
the contemporary authors extant in order to  keep
 pace intelligently with its progress.—Buffalo Medi-
cal and Surgical Journal, March, 1894.
 Roberts' Modern Surgery.
         The Principles and Practice of Modern Surgery. For the use of Stu-
 dents and  Practitioners of Medicine and Surgery.  By John  B. Boberts, M. D.,  Prof, of
 Anatomy and  Surgery in the Philadelphia Polyclinic.  Prof,  of Surgery in the Woman's
 Medical College of Pennsylvania.   Lecturer in- Anatomy in the Univ. of Penna.   Octavo,
 780 pages, 501 illustrations.  Cloth, $4.50; leather, $5.50.
  This work is a very comprehensive manual upon I vanced doctrines and methods of practice of the
 general  surgery, and will doubtless meet with  a  present day.   Its  general arrangement follows
 favorable reception  by the profession.   It has a  this rule, and the author in his desire to be con-
 thoroughly  practical character,  the subjects  are  cise and practical is at times almost dogmatic, but
 treated with rare judgment, its conclusions are in  this is entirely excusable considering the admira-
 accord with those of the  leading practitioners of  ble manner in  which he has  thus increased the
 the art, and its literature is fully up to all the ad- ) usefulness of his work.—Med. Rec, Jan.  17, 1891.

 Druitt's Modern Surgery.—Twelfth  Edition.
         Manual of Modern Surgery.  By Eobert Druitt, M. B. C. S.  Twelfth
 edition,  thoroughly revised  by Stanley  Boyd, M.B., B.S., F.B. C.S.   In  one 8vo
 volume of 965  pages,  with 373 illustrations.  Cloth, $4.00; leather, $5.00.

 young's OrthopaBdicltargery.—Readylnafew days.
         A Manual  of Orthopaedic  Surgery,  for Students  and  Practi-
 tioners.  By James  Iv Young, M. D.,  Instructor in Orthopedic Surgery, University of
 Pennsylvania, Philadelphia. In one octavo volume of about 475 pp., with about 285 illus
     The correction of deformities  constitutes so large and important  a  department  of
 surgery that it cannot be  adequately dealt with except in a special treatise.   The  able
 author of this forthcoming work has provided a guide which in clearness of  text and
 richness and beauty of illustration  will leave nothing to be desired.   The  afflictions
 therein  treated are unfortunately frequent in every community, and the work is therefore

 w'ethf or'hoptdLt.         St ^^ t0 thG geneml Practitioner> *he surgeon and Ske-


 Sutton on  Tumors, Innocent and Malignant.—Just Ready.

     • , Trumtors'iIn^oeTe^t and Malignant.  Their Clinical  Features and  An-
propnag Treatment   By J  Bland Sutton, F. E. C. S., Assistant Surgeon to the Mid-
dlesex Hospital London.  In one very handsome octavo'volume of 526 pTges with 250
engravings and 9 full page plates.  Cloth, $4.50.                       P g  '
  Sutton has without doubt "written the best
general work on tumors which has yet appeared
in the English language.  His classification is a
most excellent one, and his clinical descriptions
are clear-cut and sharp.  Throughout the  work
comparative anatomy is brought into play as well
as embryology, and the usefulness of these  com-
BUTLIN ON DISEASES OF THE TONGUE  Bv
  Henry T.Butlin, F.R.C.S., Assistant Surgeon
  to St. Bartholomew's Hospital, London. In one
  12mo. volume of 456 pages, with 8 colored plates
  and 3 woodcuts. Cloth, $3.50. See Series of Clin,
  ical Manuals, page 30.
G0N^f'S ELEMENTS  OF  SURGICAL DIAG-
  £°*>IS-  By A. Pearce Gould, M. S., M B
  *.K.C.S., Assistant Surgeon to Middlesex Hos-
parisons is at once apparent to the reader. His

Inen^i^oCaU^er fre -su,ch a9  wil1 immediately
appeal to a rational mmd. The large number of
Ulustrations is of the greatest help, being wen
made and judiciously chosen in  every instance
book"^fl0 °Ur Leaders,to, ^t this splendfd
Dook.—The St. Louis Med. and Surg. Jl., April, 1894.


 K'QL™£°an' n^DLpocket-size 12mo- volume
 nf mLP ^e9' Cloth'$2-00-  See  Students'Series
 of Manuals, page 30.
Lea Broths t Co.. PuUMeHJieTJiFU^S^ Sfreet PlliMelphia 
Surgery—(Continued).
                                                                                 21

Wharton's Minor Surgery  and Bandaging.-2dEd.^ustReadv
        Minor  Surgery  and Bandaging.  By Henry  E.  Wharton  M D
Demonstrator of Surgery in the University of Pennsylvania.  In one 12mo. volume  of
529 pages, with 416 engravings, many being photographic.  Cloth $3 00
  It is but little more than two years ago  that we
published a  review notice of  Wharton's first
edition.  At that time, we remarked that the book
was one of the very best treatises on minor sur-
gery that had been published, that it ought to be
adopted as a text-book on the subjects of which it
treats, and that it contained more practical sur-
gery within its limits and  boundaries than any
book of  its kind we had ever seen.  What was
true of the first edition may be, with propriety,
repeated and accentuated in regard to this second
and revised edition.  Its illustrations are to  be
?£* <  I? c°mniended, particularly those that re-
late to bandaging, most of which have been taken
from photographs of applied  bandages in the
several localities of the body. The author has
thoroughly  revised  that  portion of  the  work
relating to the aseptic and antiseptic methods of
wound treatment, than which there is no more
important subject in the whole domain of sur-
gery.  Much new matter has  been added, which
brings it abreast of the very latest knowledge on
the subjects of which it treats.-.Bujfafo Medical
ana Surgical Journal, January, 1894.
Treves' Operative  Surgery.—Two Volumes.
        A Manual of Operative  Surgery.  By  Frederick Treves F E C S
Surgeon andLecturer on Anatomy at  the London Hospital.  In  two octavo volumes
containing 1550 pages, with 422 engravings
  Mr. Treves in this admirable manual of opera-
tive surgery  has in each instance  practically
assumed that operation has been decided upon
and has then proceeded to give the various opera-
tive methods which may be employed, with a
criticism of their comparativevalueandadetailed
and careful description  of each particular stage
of their performance.  Especial attention has been
paid to the preparatory treatment of the patient
and to the details of the after treatment of  the
case, and this is one of the most distinctive among
the many excellent features of the book.  We have
no hesitation in declaring it the  best work on the
subject in the  English language, and  indeed, in
many  respects, the best in any language. It can-
                                          Complete work, cloth, $9.00; leather, $11.00.
                                           not fail to be of the greatest use both to practical
                                           surgeons and to those general practitioners who,
                                           owing to their isolation or to other circumstances
                                           are forced to do much of their own operative work!
                                           We feel called upon to recommend the book so
                                           strongly for the excellent judgment displayed in
                                           the arduous task  of selecting  from among the
                                           thousands  of varying  procedures  those  most
                                           worthy  of description; for the way in which the
                                           still more difficult task of choosing among the
                                           best of those has been accomplished; and for the
                                           simple,  clear, straightforward manner in which
                                           the information thus gathered from all surgical
                                           literature has been conveyed  to the reader.—
                                           Annals of Surgery, March, 1892.

        Treves'  Student's Handbook of  Surgical  Operations.   In one
square 12mo. volume of 508 pages, with 94 illustrations.  Cloth, $2.50.

        A Manual of Surgery.  In Treatises by Various Authors, edited by Fred-
erick Treves, F. E. C. S.  In three  12mo.  volumes, containing 1866 pages, with 213
engravings.  Price  per set, cloth, $6.00.   See Students' Series of Manuals, page 30.
  We  have  here the opinions of thirty-three
authors, in an encyclopaedic  form for easy and
ready  reference.  The  three volumes embrace
every  variety of surgical affections likely to be
met with, the paragraphs are short and pithy, and
the salient points and the beginnings of new sub-
jects are always printed in extra-heavy type, so
that a person may find whatever information he
may  be in need of at a  moment's glance.—Cin-
cinnati Lancet-Clinic, August 21,1886.
        Treves on Intestinal Obstruction.  In one 12mo. volume of 522 pages,
with 60 illus.  Limp cloth, blue edges, $2.00.  See Series of Clinical Manuals, page 30.

Erichsen's Science and  Art  of  Surgery.—Eighth Edition.
        The Science and Art of Surgery; Being a Treatise on Surgical Injuries,
Diseases and Operations.  By John E. Erichsen, F. E. S., F. E. C.S., Professor of Sur-
gery in University College,  London, etc.  From the eighth and enlarged English edition.
In two large 8vo. vols, of 2316 pp., with 984 engravings on wood.  Cloth, $9;  leather, $11.
                                           of the former edition has  been dropped and no
                                           discovery,  device or improvement which has
                                           marked the progress of surgery during the last
                                           decade has been omitted.  The illustrations are
  For many years this classic work  has been
made by preference of teachers  the  principal
text-book on surgery for medical students, while
through translations into the leading continental
languages it may be said to guide the surgical
teachings of the civilized world. No excellence
many and executed in the highest style of art.
—Louisville Medical News, Feb. 14,1885.
Bryant's Practice of Surgery.—Fourth  Edition.
        The Practice of  Surgery.  By Thomas Bryant, F. E. C. S., Surgeon and
Lecturer on Surgery at Guy's Hospital, London.   Fourth American from the fourth  and
revised English edition.   In one large and very handsome imperial octavo volume of 1040
pages, with 727 illustrations.  Cloth, $6.50; leather, $7.50.
                                         " practitioner to  review any subject in every-day
                                           practice in a short time. In short, the work is
                                           eminently clear, logical  and  practical.—Chicago
  The present  edition is a thorough revision of
those which preceded it, with much new matter
added.  Almost every topic  in surgery is pre-
sented in such a form as to enable  the busy

MILLER'S PRACTICE  OF SURGERY.  Fourth
  and revised American edition.  In one large 8vo.
  vol. of 682 pp.. with 364 illustrations. Cloth, $3.75.
MILLER'S PRINCIPLES OF SURGERY. Fourth
  American from the third Edinburgh ed. In one
  8vo. vol. of 638 naeres. with 340 illus.  Cloth, $3.75.
HOLMES' SYSTEM OF SURGERY. THEORET-
Med. Jour, and Examiner, Apr. 1886.
ICAL AND PRACTICAL.  By Various Authors.
Edited by Timothy Holmes, M. A.  American edi-
tion revised and re-edited by John H. Packard,
M D.  Three large octavo volumes, 3137 pages,
979 illustrations on wood and  13 lithograpnic
plates.  Per set. cloth, $18.00;  leather, $21.00.
Subscription only.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia 
22    Surgery—(Continued),  Fractures,  Dislocations.
Smith's Operative Surgery.—Revised  Edition.
        The Principles  and Practice  of Operative  Surgery.  By Stephen
Smith, M. D., Professor of Clinical Surgery in the University of the City of New  York.
Second and thoroughly revised edition.  In  one very handsome octavo volume of 892
pages, with 1005 illustrations.   Cloth, $4.00;  leather, $5.00.
  This excellent and very valuable book is one of I surgeon, and even as a book of reference for the
the most satisfactory works on modern operative  physician  not especially engaged in the practice
surgery yet published. The book is a compendium  of  surgery, this  volume will  long hold a most
for the modern surgeon.  The present edition is | conspicuous place, and seldom will its readers, no
much enlarged, and the text has been thoroughly
revised, so as to give the most improved methods
in aseptic surgery, and  the  latest instruments
known for operative work. It can be truly said that
as a handbook for the student, acompanion for the
matter how unusual the subject, consult its pages
in vain.  Its compact form, excellent print, num-
erous illustrations, and especially its decidedly
practical character, all combine to commend it.—
Boston Medical and Surgical Journal, May 10,1888.
Holmes'  Treatise  on Surgery.—Fifth  Edition.
        A  Treatise on Surgery;  Its Principles and Practice.  By Timothy
Holmes, M. A.,  Surgeon and Lecturer on Surgery at St. George's Hospital, London.
From the  fifth  English edition,  edited by  T. Pickering  Pick,  F. B. C. S.  In one
octavo volume of 997 pages, with 428 illustrations.  Cloth, $6.00; leather, $7.00.
                                          for the general practitioner, teaching those things
                                          that are necessary to be known for the successful
                                          prosecution of the surgeon's career, imparting
  To the younger members of the profession and
to others not acquainted with  the book and its
merits, we take pleasure in recommending it as a
surgery complete, thorough, well-written, fully
illustrated, modern, a work sufficiently volumi-
nous for the surgeon specialist, adequately concise
nothing that in onr present knowledge is consid-
ered unsafe, unscientific or inexpedient.—Pacific
Medical Journal, July, 1889.
Hamilton  on Fractures  and  Dislocations.—Eighth Edition.
        A Practical Treatise on  Fractures and Dislocations.   By Frank
H. Hamilton, M. D., LL. D., Surgeon to Bellevue Hospital, New York.  New (8th) edi-
tion, revised and edited by Stephen Smith, M. D., Prof, of Clinical Surgery in Univ. of
City of N. Y.  In one octavo volume of 832 pp., with 507 illus.  Cloth, $5.50; leather, $6.50.
  Its numerous editions are convincing proof if any
is ueeded, of its value and popularity. It is pre-
eminently the authority on fractures and disloca-
tions, and universally quoted as such.  In the new
edition it has lost none of its former worth.  The
additions it has received by its recent revision make
it a work thoroughly in accordance with modern
practice, theoretically, mechanically, aseptically.
The task of writing a complete treatise on a sub-
ject of such magnitude is no easy one.  Dr. Smith
has aimed to make the present volume a correct
exponent of our knowledge of this department
of surgery.  The  more one  reads  the  more
one is impressed with its completeness. The work
has been accomplished, and has been done clearly,
concisely, excellently well.—Boston Medical ana
Surgical Journal, May 26,1892.
Stimson's  Operative  Surgery.—Second  Edition.
        A Manual of Operative Surgery.  By Lewis A. Stimson, B. A., M. D.,
Professor of Clinical  Surgery in the University of  the City of New York.  Second edi-
      In one royal 12mo. volume of 503 pages, with 342 illustrations.   Cloth, $2.50.
                                         the antiseptic system, and has added an account
                                         of many new operations and variations in  the
                                         steps of older operations.  We do not desire to
                                         extol this manual above many excellent standard
                                         British publications of the same class, still we be-
                                         lieve that it contains much that is worthy of imi-
                                         tation.— British Medical Journal, Jan. 22,1887.
tion.
  The author knows the difficult art of condensa-
tion.  Thus the manual serves as a work  of
reference, and  at  the same  time  as a handy
guide.  It teaches  what it professes, the steps
of operations.  In this edition Dr. Stimson has
sought to indicate the changes that have been
effected in operative methods and procedures by
Stimson  on Fractures and  Dislocations.
        A Treatise  on Fractures and Dislocations.  By Lewis  A. Stimson,
M.D.  In two handsome octavo volumes.  Vol. I., Fractures, 582 pages, 360 illustra-
H°n^ .V?a  ?"' ,r>ISL0CATI0NS> 54<>  Pages,  with  163 illustrations.   Complete work,
cloth, $5.50; leather, $7.50.  Either volume separately, cloth, $3.00; leather, $4.00.
                                         exhibits the surgery of Dislocations as it is taught
  The appearance of the second volume marks the
completion of the author's original plan of prepar-
ing a work which should present in  the fullest
manner all that is known on the cognate  subjects
of Fractures and Dislocations.  The volume on
Fractures assumed at once the position of authority
on the subject, and its companion on Dislocations
will no doubt be similarly received.  This volume
and practised by the most eminent surgeons of the
present time. Containing the results of such ex-
tended researches it must for a long time be re-
garded as an authority on all subjects pertaining
to dislocations. Every practitioner of surgery will
feel it incumbent on him to have it for constant
reference.—Cincinnati Medical News, May 1888
Pick on  Fractures  and Dislocations!
        Fractures  and Dislocations.  By T. Pickering Pick, F. E. C. S.,  Sur-
geon to and Lecturer on Surgery at St. George's Hospital, London.   In  one 12mo  vS
of 530 pp., with 93 illus.  Limp cloth, $2.00.  See Series 'of Clvnital Manuals, pagTsO

Marsh on  the  Joints.
        Diseases of the Joints.  By Howard Marsh, F. E. C. S  Senior Assistant
Surgeon to St. Bartholomew s Hospital, London.  In one 12mo. volume>  of46?pages with
64 woodcuts and a colored plate.  Cloth, $2.00. See Series of Clinical MarZlsfl^e 30
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Ophthalmology.
23
Norris  & Oliver's  Ophthalmology.

ProfessortfOpS^^^^^
M.D,  Surgeon  to Wills'  Eye  Hospital  PhiladS
vol. of 641 Wes, with 357 engraving S^ftte.  cToth"^. *^m« «*™>
  Thfc ,-<> +>.« first taTLKnnb ^f AioE.*,^ ~Au____        . p^ies.  oiotn, $o leather, $6.
                                           LeKCi°lniie„da:u*h!ori.ty-.  TheillustrationsTmany of
  This is the first text-book of diseases of the eye
written by American authors for American col-
leges and students.  Every method of ocular pre-
cision that can be of any clinical advantage to the
every-day student and  the scientific observer is
offered to the reader,  Rules and procedures for
the ordinary methods of examination of the ex-
ternal appearances of the eye, for ophthalmoscopy,
and for the application of the fundus-reflex tests j
are made so plain and so evident, even to  the
most careless reader, that any student can easily
understand and employ them. It is succinct in
recital, practical in its teachings, judicious  in the
selection of material and conservative, yet radical
when necessary.  In treatment it can be accepted
as from the voice and the pen of a respected and
which are ori^^ \&r Z^S^osTof ul
contemporaries, whilst the  high  grade and un-
biased opinions of the teachings serve to give It a
aenrni?lvPe,h2r to-any ^ould "be conjetltof"Von'
derfully cheap in price, beautifully printed and

of ?he9hnenE illlU»tXte/i' the  mechanical maL u2
of the book is all that can be desired. After most
conscientious  and painstaking  perusal of the
St InHT686"?^ endorse « *9 *he beVt, Ihl
?Spestf1nd ^e most comprehensive volume  upon
a™ Ji« J    hat .has ever been offered to the
fhTJ  C*n Td^ pub.lic-  We  sincerely  hope
that it may find its way into the list of text-books
LZT/Jn g'^P^ing college of medicine.-
Annals of Ophthalmology and Otology, Oct. 1893.
Berry  on  the  Eye.—New~(2dTEdition.

        Diseases of the Eye.  A Practical Treatise for Students of ODhthalmnWv
By George A. Berry,  MB  F. E  C. S., Ed., Ophthalmic Surgeon, eSSJS^B^S
Infirmary.   New (second) edition.  In one octavo volume of 750 pages with 197 illustra
tions, mostly lithographic.   Cloth, $8.00.                        P S '          *
  This is by far the best work upon its theme in
the English language that we have seen, for the
diction is pure and clear, and besides, the beauti-
ful illustrations of normal and diseased conditions
make it a valuable addition to the library of  all
practitioners, general as well as special.  We have
never seen more real delineation of disease, the
coloring is perfect, and  each illustration is  an
 object-lesson."  We cannot but reiterate what we
said at the beginning, that we have had great pleas-
ure in the perusal of this work, and great profit, and
that we consider it the best on the subject in the
English language to-day, not only for its diction
but for its instructive illustrations.— The American
Journal of the Medical Sciences, August, 1893
Juler's Ophthalmic  Science  and Practice.—New (2d) Edition.
        A Handbook of Ophthalmic  Science and Practice.   By Henry E.
Juler, F. E. C. S., Senior Assistant Surgeon, Eoyal Westminster  Ophthalmic Hospital-
Late Clinical Assistant, Moorfields, London.   New (2d) edition.  Handsome 870. volume
of 561 pages, with 201 woodcuts, 17 colored plates, selections from Test-types of Jaeger
and Snellen, and Holmgren's Color-blindness Test.  Cloth, $5.50; leather, $6.50.
  The continuous approval manifested towards
this work testifies to the success with which the
author  has produced concise  descriptions and
typical illustrations of all the important affections
of the eye.  The  volume is particularly  rich in
matter of practical value. The sections devoted to
treatment are singularly full, and at the same time
concise, and couched in language that cannot fail
to be understood.—The Medical Age, Nov. 10, 1893.
Nettleship  on  the Eye.—Fifth Edition.

        Diseases  of  the  Eye.  By  Edward Nettleship, F. E. C. S., Ophthalmic
Surgeon at St. Thomas' Hospital,  London.  Surgeon to the Eoyal London (Moorfields)
Ophthalmic  Hospital.   Fourth  American   from  the  fifth  English  edition, thor-
oughly revised.  With a Supplement on  the Detection of  Color Blindness, by Wil-
liam Thomson, M. D., Professor of Ophthalmology in the  Jefferson  Medical College
Philadelphia.  In one  12mo. volume of 500 pages, with 164 illustrations, selections from
Snellen's test-types and formulae, and a colored plate.  Cloth, $2.00.
  This is a well-known and a valuable work.  It
was primarily intended for the use of students,
and supplies" their needs admirably, but it is as
useful for the practitioner, or indeed more so.  It
does not presuppose the large amount of recondite
knowledge to be present which seems to be as-
sumed in some of our larger works, is not tedious
from over-conciseness, and yet covers the more
important parts of clinical ophthalmology.—New
York Medical Journal, December 13,1890.
Carter  &  Frost's Ophthalmic Surgery.
        Ophthalmic Surgery.   By E. Brudenell Carter, F. E. C. S., Lecturer on
Ophthalmic Surgery  at St. George's Hospital, London, and W. Adams Frost, F. E. C. S.,
Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London.   In one 12mo.
volume of 559 pages, with 91 woodcuts, color-blindness test, test-types and dots and appen-
dix of formulas.  Cloth, $2.25.  See  Series of  Clinical Manuals, page 30.
THOMPSON  ON  THE  URINARY  ORGANS.
  Lectures on Diseases of the Urinary Organs.
  By Sir Henry Thompson, Professor of Clinical
  Surgery in University College Hospital, London.
  Second American from the third English edition.
  Octavo, 203 pages, 25 illustrations  Cloth, $2 25.
THOMPSON  ON   THE   PATHOLOGY   AND
  TREATMENT   OF  STRICTURE  OF   THE
  URETHRA   AND   URINARY  FISTULA.
  From the third English  edition.  In one octavo
  volume of 359 pages, with 47 engravings and 3
  plates.  Cloth, $3.50.
BASHAM ON RENAL DISEASES: A Clinical
 Guide to their Diagnosis and Treatment.  12mo.
 304 pages, with 21 Illustrations.  Cloth, $2.00.
WELLS ON THE EYE. In one octavo volume.
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 illus. Cloth, $2.75.
LAWSON ON INJURIES TO THE EYE, ORBIT
 AND EYELIDS: Their Immediate and Remote
 Effects. In one octavo volume of 404 pages, with
 92 illustrations. Cloth, $3.50.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
24     Otology,  Urinary  &  Renal  Pis.,  Dentistry.  ___

Politzer on  Diseases of the  Ear.—New Edition.   Just Ready.
        A  Text-Book  of  Diseases of the Ear  and  Adjacent  Organs.
By Dr. Adam Politzer, Imperial-Eoyal Professor of Aural Therapeutics in the Univer-
sity of Vienna, Chief of the Imperial-Eoyal University Clinic for Diseases of the Ear in
the General Hospital,  Vienna.   Translated into English  from the third  aEd revised
German edition, by Oscar Dodd, M.  D., Clinical Instructor in Diseases of the Eye and
Ear, College of  Physicians and  Surgeons, Chicago.  Edited by Sir William Dalby,
F. E. C. S., M. B., Consulting Aural Surgeon to St. George's Hospital, London.  In one
large octavo volume of 748 pages, with 330 illustrations. Cloth, $5.50.
  This standard treatise, by a recognized German
authority, will be eagerly welcomed by those
English readers unacquainted with the work in
the original.  Politzer's views on otological sub-
jects are those of an advanced yet conservative
surgeon. His advice is that of a careful observer
of vast and varied experience. The illustrations
accompanying the text are good.—Medical Record,
April 21, 1894.
Field's  Manual of  Diseases  of the  Ear.—Just Ready.
        A Manual of Diseases of the Ear.  By George P. Field, M. E. C. S,
Aural Surgeon and  Lecturer on Aural Surgery in St Mary's Hospital Medical School,
London.  In one octavo of 391 pp., with 73 engravings and 21 colored plates.  Cloth, $3.75
  The author's views are so plainly and forcibly
expressed that the student and general practi-
tioner of medicine cannot afford to be without
their teaching and careful guidance if they would
do the justice to their patients that the present
advanced state of otology demands.  Within the
covers of this book will be found information suf-
ficient to supply the needs of the student and
practitioner of general medicine in practical mat-
ters pertaining to diieases of the ear.—The Thera-
peutic Gazette, January 15,1894.
 Burnett on  the Ear.—Second Edition.
         The Ear, Its Anatomy,  Physiology  and  Diseases.  A Practical
 Treatise for the  use of Medical Students and Practitioners.  By Charles H. Burnett,
 A.M., M. D.,  Professor of Otology in  the Philadelphia  Polyclinic;  President of the
 American Otological Society.   Second edition.  In one handsome octavo volume of 580
 pages, with 107 illustrations. Cloth, $4.00; leather, $5.00.

 Roberts on  Urinary  and Renal  Diseases.—Fourth  Edition.
         A Practical Treatise on Urinary and Renal Diseases, including
 Urinary  Deposits.  By Sir William Boberts, M. D., Lecturer on Medicine in the
 Manchester School  of Medicine,  etc.   Fourth American  from the fourth  London edi-
 tion.  In one handsome octavo volume of 609 pages, with  81  illustrations.  Cloth, $3.50.
  It may be said to be the best book in print on the I sis, prognosis and treatment of urinary  diseases,
 subject of which it treats.—The American Journal  and possesses  a  completeness not found else-
 of the Medical Sciences, Jan. 1886.                where in our language in its account of the differ-
  It is an unrivalled exposition of  everything  ent affections.—Manchester Med. Chron.,  July, '85.
 which relates directly or indirectly to  the diagno- |


 Purdy on  Bright's  Disease and  Allied  Affections.
         Bright's   Disease  and  Allied  Affections  of  the  Kidneys.  By
 Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases  in the Chi-
 cago Polyclinic.  In one octavo vol. of 288 pages, with illustrations.  Cloth, $2.00.
  On treatment the writer is particularly strong, I items which are all important to the general orac-
 steenng  clear of generalities and seldom omit- titioner.—The Manchester  Medical Chronicle Oct.
 ting, what text-books usually do, the unimportant ! 1886.

 The American System  of  Dentistry.

         In Treatises by Various Authors.  Edited by Wilbur F. Litch  M D
 D. D. S., Professor of Prosthetic  Dentistry, Materia Medica and  Therapeutics in 'the
 Pennsylvania College of Dental Surgery.  In three  very handsome  octavo volumes con-
 taining 3160 pages, with  1863 illustrations and 9 full-page plates.  Per volume, cloth $6 •
 leather,  $7 ; half Morocco, gilt top, $8.  For sale by subscription only.
  As an encyclopaedia of Dentistry it  has no su-  J
 perior. It should form a part of every dentist's
 library, as the information  it  contains is of the
 freatest value to all engaged  in the practice of
 entistry.—American Jour. Dent. Sci., Sept. 1886.
  A grand system, big enough and good enough
and  handsome  enough for  a monument (which
doubtless it is), to mark an epoch in the history of
dentistry.  Dentists will be satisfied with it and
proud of it—they must.  It is sure to be precisely
what the student needs to put him and keep him
m the right track,  while the profession at large
will receive incalculable benefit from it.—Odonto-
graphic Journal, Jan. 1887.
Coleman's  Dental Surgery.—American Edition.

L  E C PA FE1 Cas ° F^Tfl??^ and Pathol°gy.  By Alfred Coleman
Hofpi^n^^^^^
by Thomas C. Stellwagen, M. A., M. D., D.L\S., Prof"of Physiolo^^h?pK&!f
phia Dental College.  Octavo volume of 412 pages! ^&1U^&£  Cloth^$3^5
MORRIS ON  SURGICAL  DISEASES OF THE
 KIDNEY. By Henry Morris, F. R. C. S., Surgeon
 to Middlesex Hospital, London.  12mo., 554 pp.
                                  Hoth 1&£00d£uts'c,and 6 colored plates.  Limp
                                  cloth, $2.25.   See Series of Clinical Manuals, p. 30.


Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Impotence, Sterility,  Venereal, Skin.
25
Gross on Impotence, Sterility,  etc.—Fourth EditionT

        Ao?£act1ir3ai1  treatise  on  Impotence, Sterility, and Allied Dis-
orders of the Male  Sexual  Organs.  By Samuel W. Gross,  £ M®MLD,
ihP^^rfVhn^^v  Surgery and of Clinical Su     'in the ^efrers0I^
Medical College of Philadelphia   Fourth edition, thoroughly  revised by  F. R. Sturgis,
L^^JMiTL0   ^  Genit0"U^ry Organs and of Venereal Diseases
N. Y. Post Grrad. Med. School.  In one 8vo. vol. of 165 Daees with 18 illus   Plnth  *i *n
  Three editions of Professor Gross'valuable book , rhcea ^d ^Kl  ffLv HS
have been  exhausted,, and still the demand is  one "andMdttontfthe^cfentiflc^nYv'ery ?n
unsupphed.  Dr. Sturgis has revised and added  terestlng discussions on etiologv eymptoms etc
to the previous editions, and the new one appears  there are lines of treatment llidE that any
morecomp ete and more valuable than before,  practitioner can follow and which have met witE
Four important and generally misunderstood sub-  success in the hands of author and Vdho?.-Medl
jects are treated—impotence, sterility, spermator- | cal Record, Feb. 25,1891.


Taylor  on Venereal Diseases.—Sixth Edition.   Preparing.
        The Pathology and Treatment of Venereal Diseases.  Including the
results of recent investigations  upon the subject.  By Robert W. Taylor, A. M.  M. D.
Clinical Professor of Genito- Urinary Diseases in the College of  Physicians'and Surgeons'
New York.  Being the sixth edition of Bumstead and Taylor, rewritten by Dr. Taylor.
Large  8vo. volume, about 900 pages, with about 150 engravings, as well as numerous
chromo-lithographs.  In active preparation.   A notice of the previous edition is appended.
  It is a splendid record of honest labor, wide  upon the subjects of which it treats, but also one
research, just comparison, careful scrutiny and  which has no equal in other tongues for its clear,
original experience, which will always be held as  comprehensive and  practical  handling of  its
a high credit to American medical literature. This  themes.—Am. Jour, of the Med. Sciences, Jan. 1884.
is not only the best work in the English language
Culver & Hayden's Manual of Venereal Diseases.
        A Manual of Venereal Diseases.  By Everett  M. Culver,  M. D.,
Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James
R. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur-
geons, New York.  In one 12mo. volume of 289 pages, with 33 illus.  Cloth, $1.75.
 This book is a practical treatise, presenting in a
condensed form the essential features of our pres-
ent knowledge of the  three venereal diseases,
syphilis, chancroid and  gonorrhea.  We have ex-
amined this work carefully and have come to the
conclusion that it is the most concise, direct and
able treatise that has appeared on the subject of
venereal diseases for the general practitioner to
adopt as a guide.  The general practitioner needs
a few simple, concise and clearly presented laws,
in the execution of which he cannot fail either to
cure or prevent the ravages of the maladies in
question and their direful results.—Buffalo Medical
and Surgical Journal, May, 1892.
Cornil on  Syphilis.
        Syphilis, its  Morbid Anatomy, Diagnosis and Treatment.  ByV.
Cornil, Professor to the  Faculty of Medicine of Paris, and Physician to theLourcine Hos-
pital.  Specially revised by the Author, and translated with notes and additions by J.
Henry C. Simes, M. D., Demonstrator of Pathological Histology in the Univ. of Pa.,
and J. William  White, M. D., Lecturer on Venereal Diseases, Univ. of Pa.  In one
handsome octavo volume of 461 pages, with 84 very beautiful illustrations.  Cloth, $3.75.

Hutchinson on Syphilis.
        Syphilis.  By Jonathan Hutchinson, F. R. S., F. R. C. S., Consulting Sur-
geon to the  London  Hospital.  In  one 12mo. volume of  542 pages, with 8  chromo-
lithographs.   Cloth, $2.25.  See Series of Clinical Manuals, page 30.


Hardaway's Manual  of  Skin  Diseases.
        Manual of  Skin Diseases. With Special Reference to Tiagnosis and Treat-
ment.  For the use of Students and General Practitioners.  By W. A. Hardaway, M. D.,
Professor of Skin Diseases in the Missouri Medical College.  12mo., 440 pp. Uotn  *o\ W
 Dr. Hardaway's large experience as a teacher embraces all essential points connected withthc
and writer has admirably fitted him for the diffi-
cult task of preparing a book which, while suffi-
ciently elementary for the student is yet suffi-
ciently thorough and comprehensive to serve as a
book of reference for the general practitioner. It
embraces all essential points connected with the
diagnosis and treatment of diseases of the skin,
and we have no hesitation in commending it as
the best manual that has yet appeared in this
department  of medicine.-JoMrnai of Cutaneous
and Genito- Urinary Diseases.
GROSS' PRACTICAL TREATISE ON THE DIS-
 EASES,  INJURIES  AND MALFORMATIuNS
 OF THE URINARY BLADDER, THE PROS-
 TATE GLAND AND THE  URETHRA.  By
 Samuel D. Gross, M.D., LL.D., D.C.L., etc.  Third
 edition, thoroughly revised by Samuel W. Gross,
 M.D.  In one octavo volume of 574 pages, with
 170 illustrations.  Cloth, $4.50.
FOX'S EPITOME OF SKIN DISEASES.  WITH
 FORMULAE.  Third edition, revised and en-
 larged.  In one 12mo. vol. of 238 pp.  Cloth, $ 1.25.
HILLIER'S HANDBOOK OF SKIN DISEASES;
 for Students and Practitioners.  Second Ameri-
 can edition. In one 12mo. volume of 353 pages,
 with plates. Cloth, $2.25.       /vwrAnnnq
HILL ON SYPHILIS AND LOCAL CONTAGIOUS
 DISORDERS. In one 8vo vol..of'»t»P-.^^JftfS
r vv» T.F.nTTIRES ON 8YPHILIS AND HOMli
L FORMS OP  LOCAL  DISEASE  AFFECTING
 THE  ORGANS OF GENERATION   In  one


WMLEmCINETNDNr)ISEASES OF THE SKIN
 In  one handsome small octavo volume of 535
 pages.  Cloth, $3.50.
Lea Brothers & Co., Publishel^olrioT&TlTsansom Street, Philadelphia. 
Venereal  and  Skin  Diseases.
26

Hyde  on  thelkin^New  (3dTEdition    Just  Ready.
        A Practical Treatise on Diseases of the^^in-  * °rr^aetol    and Ven
and Practitioners.   By J. Nevins Hyde  A.M., M.D  Professor ot iJerr    jy^ ^^
ereal Diseases in Rush Medical College, Chicago. Third edition
of 802 pages, with 9 colored plates  and 108 -
In one octavo volume
  The third edition, just issued, fulfils all the ex-
pectations warranted by the great accumulation
of dermatological  material since  the earlier
editions were brought out, and puts  this work at
the head of the modern American  treatises  on
skin diseases.  The author has introduced thirty-
five new diseases in this edition.  He is especially
to be congratulated on his chapter on tuberculosis.
Five plates and twenty-two woodcuts, all of great
excellence, have been added to the  illustrations.
The excellence of the chapters on treatment, to-
gether with the care that  has been  bestowed on
subjects that have acquired new interest, make
of therapeutical information.  The^writer Knows
no hook in which one can seek more satisiacioniy
f^r informaTion as to how to manage his patients
Sithskir"diseases.  The piesent .aditioj,i rnay^be
commended as being an ex position^of the subject
fully up to the present state of our knowledge.
— The Chicago Clinical Review, April, 1894.
Tavlor's Clinical  Atlas~or^nereaTanT Skin  Diseases.
layiOr S "^ £Jtf Venereal  and Skin Diseases:  M^^-j-
nosis, Prognosis and  Treatment.  By Robert W. Taylor,  A. W0™1'^.
fessor of Genito-Urinary Diseases in the College of Physidans and bujgeons, Nwlo*.
In  eight large folio parts, and comprising 58 beautifully colored plates wi h 213 fcgures
and 431 pages of text with 85 engravings.  Price per part, $2.50.  Bound in one ™ume,
half Russia, $27; half Turkey Morocco, $28.  For sale by subscnption ^-  »]£»£«*
plates sent on receipt  of 10 cents.  A full prospectus sent to any ^dr^ ^ ^pliation
r Ti___u u„ v,._j *„ f,^ ,„«^a OThi^h woniH ner- student can examine these true- to-me cnroiuu w
  It would be hard to use words which would per
spicuously enough convey to the reader the great
value of this Clinical Atlas.  This Atlas is more
complete even than an ordinary course of clinical
lectures, for in no one college or hospital course
is it at all probable that all of the diseases herein
represented would be seen.  It is also more ser-
viceable to the majority of students than attend-
ance  upon clinical  lectures,  for most  of  the
students who sit on remote seals in the lecture
hall cannot see  the subject  as well as the office
student can examine these teae-^hfe ohromo-lith-
ographs.  Comparing the text to aJecturer, it is
n?oreP satisfactory in exactness and fulnesthan
he would be likely to be in lecturing oyer a single
case. Indeed, this Atlas is invaluable to the gen-
eral practitioner, for  it enables the. eye of the
physician to make  diagnosis of a  given  case of
skin manifestation  by  comparing;; the case, wth
the picture in the Atlas, where will be found also
the text of diagnosis, pathology,^and ^11 sections
on treatment.— Virginia Medical Monthly, Dec. 1889.
Jackson's Ready-Reference  Handbook  of  Skin Diseases.
        The  Ready-Reference  Handbook  of Diseases of the Skin.  By
George Thomas Jackson, M. D., Professor of Dermatology, Woman's Medical  College
of the New York Infirmary.  In one 12mo. volume  of  544 pages, with 50 illustrations
and  a colored plate.   Cloth, $2.75.                                            . ..   ,.
                            .. ,__-,. *-_ «... , ment."  It treats in alphabetical order of the dis-
                                          eases of the skin and their management.   This
                                          book seems to us the best of its class  that has
                                          yet appeared.—Boston Medical and Surgical Jour-
                                          nal, May 18,1893.
 Intended to serve as a reference book for the
general practitioner, "no attempt has been made
to discuss debatable questions," and "hence pa-
thology and etiology do not receive as full consid-
eration as symptomatology, diagnosis and treat-
Morris on  the Skin.—Just Ready.
         Diseases of the Skin.  An Outline of the Principles and Practice of Der-
matology.  By Malcolm Morris, F. R. C. S., Surgeon to the Skin Department, St. Mary s
Hospital, London.  In one square octavo volume of 572 pages, with 19 chromo-lithographic
figures and 17 engravings.  Cloth, $3.50.
  This admirable manual, written as it evidently
is by a keen, clever specialist  of  exceptionally
wide experience, most satisfactorily meets the
requirements of the American practitioner of
medicine, in that it gives him a clear, comprehen-
sive picture of every skin-affection, and formu-
lates for him a system of therapeutics in the follow-
ing of which he can feel well assured of obtaining
the best results.—The Therapeutic Gazette, March,
1894.
Pye-Smith  on Diseases of the  Skin.
        A  Handbook of Diseases of the  Skin.  By P. H. Pye-Smith, M. D.,
F.R.S., Physician  to Guy's  Hospital, London.  In one  octavo volume  of  407 pages,
with 26 illustrations, 18 of which are colored.   Cloth, $2.00.
  It is a plain, practical treatise on dermatology,
written for the student and general practitioner
by a general practitioner of broad experience in
the special subject of which he writes.  He simpli-
fies the nomenclature, and succeeds in removing
much of the difficulty. After reviewing the recent
advances made in this department of medicine,
he pays a merited compliment to the "important
contributions  made  by the  newest school  of
dermatology, that of America."—Pittsburg Medical
Review, June, 1893.
Jamieson  on Diseases  of  the Skin.—Third Edition.
        Diseases of the Skin.  A Manual  for  Students  and  Practitioners.  By
W. Allan Jamieson, M. D., Lecturer on Diseases of the  Skin, School of Medicine, Edin-
burgh.  Third edition, revised and enlarged.   In one octavo volume of 656 pages, with
woodcut and 9 double-page chromo-lithographic illustrations. Cloth, $6.00.
  The scope of the work is essentially clinical, lit-
tle reference being made to pathology or disputed
theories.  Almost every subject is followed  by
illustrative cases. The pages are filled with inter-
est to all those occupied with skin diseases. The
general practitioner will find the book of great
value in matters of diagnosis and treatment.  The
latter is quite up to date, and the formulae have
been selected with care.—Medical Record, April 9,
1892.
Lea Brothers &  Co., Publishers,  706,  708 & 710 Sansom Street,  Philadelphia. 
Diseases  of  Women.
27
The American  Systems of  Gynecology  and Obstetrics.

    Systems of Gynecology and  Obstetrics,  in Treatises by American
Authors. Gynecology edited by Matthew D. Mann, A. M, M. D., Professor of ObstS
and Gynecology in the Medical Department of the University of Buffalo; and Obstet-
rics edited by Barton  Cooke Hirst  M. D, Associate Professor of Obstetrics in the
University of Pennsylvania, Philadelphia   In four very handsome octavo volumes, con-
taining 3612 pages, 1092 engravings and 8 plates.  Complete work now ready.  Per vol-
ume:  Cloth,  $5 00;  leather  $6.00; half Russia,  $7.00.  For  sale by subscription  only.
Address the Publishers,  h ull descriptive circular free on application.
 These volumes are the contributions of the most
eminent gentlemen of this country in these de-
partments of the profession.  Each contributor pre-
sents a monograph upon his special topic, so that
everything in the way of history, theory,methods,
and results is presented to our fullest need.  Asa
work of general reference, it will be found remarka-
bly full  and instructive  in  every direction of
inquiry.—The Obstetric Gazette, September, 1889.
 One is at a loss to know what to say of this vol-
ume, for fear that just and merited praise may be
mistaken for flattery.  The papers of Drs. Engel-
mann, Martin, Hirst, Jaggard and Reeve are incom-
parably beyond  anything that can be found in
obstetrical works.—Journalofthe American Medical
Association, Sept. 8,1888.
 In our notice of the "System of Practical Medi-
cine by American Authors," we made the follow-
ing statement:—"It is a work of which the pro-
fession in this country can feel proud. Written
exclusively by American physicians who are ac-
quainted with all the varieties of climate in the
United States, the character of the soil, the man-
ners  and customs of the people, etc., it is pecul-
iarly adapted to the wants of American practition-
6Is 2  medicine. and it seems to us that every one
of them would  desire to have it."  Every word
thus  expressed in regard to the "American Sys-
tem of Practical Medicine" is applicable to the
 System of Gynecology by American Authors."
It, like the  other, has been written exclusively
by American physicians who are acquainted with
all the characteristics of American people, who are
well  informed in regard to  the  peculiarities  of
American women, their manners, customs, modes
of living,  etc.   As every practising physician is
called upon to treat diseases of females, and  as
they constitute a class to which the family phy-
sician must give attention, and cannot pass over
to a specialist, we do not know of a work in any
department of medicine that we should so strongly
recommend medical men generally purchasing.—
Cincinnati Med. News, July, 1887.
Emmet's  Gynaecology.—Third Edition.
        The Principles and Practice of Gynaecology; For the use of Students
and Practitioners of Medicine.   By Thomas Addis  Emmet, M. D., LL. D.,  Surgeon to
the  Woman's Hospital, New York,  etc.   Third edition, thoroughly revised.   In one
large and very handsome 8vo. vol. of  880 pp., with  150 illus.  Cloth, $5; leather, $6.
  We are in doubt whether to  congratulate the
author more than the profession upon the appear-
ance of the third edition of this well-known work.
Embodying, as it does, the life-long experience of
one who has conspicuously distinguished himself
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, May 16,1885.
Tait's  Diseases of Women  and Abdominal  Surgery.
        Diseases  of  Women and Abdominal  Surgery.  By Lawson Tait,
F.R.C.S., Professor of Gynaecology in Queen's College,  Birmingham,  late President of
the British Gynecological Society, Fellow American Gynaecological  Society.  In  two
octavo vols.  Vol. I., 554 pp., 62 engravings and 3 plates. Cloth, $3.  Vol. II., preparing.
 The plan of the work does not indicate the regu-
lar system of a text book, and yet nearly every-
thing of disease pertaining to the various organs
receives a fair consideration.  The description of
diseased  conditions is exceedingly clear, and the
treatment, medical or surgical, is very satisfactory.
Much of the text is abundantly illustrated with
cases, which add  value in showing the results of
the suggested plans of treatment.  We feel con-
fident that few gynecologists of the  country will
fail to place  the  work in their libraries.— The
Obstetric Gazette, March, 1890.
Edis  on  Diseases  of Women.
        The Diseases of Women.  Including their Pathology, Causation, Symptoms,
Diagnosis and Treatment.  A Manual for Students and  Practitioners.  By Arthur W.
EDis,M.D.,Lond., F.R.C.P., M. R.C.S., Assistant Obstetric Physician  to Middlesex
Hospital, late Physician to British Lying-in-Hospital.  In one handsome octavo volume
of 576 pages, with 148 illustrations.   Cloth, $3.00; leather, $4.00.
                                            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 resume of the whole subject  Specialists too
                                            will find many useful hints in its pages.-£oston
  The special qualities which  are  conspicuous
are thoroughness in covering the whole ground,
clearness of description and conciseness of state-
ment.  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
Med. and Surg. Journ., March 2,1882.
HODGE ON DISEASES PECULIAR TO WOMEN.
 Including Displacements of the Uterus.  Second
 edition, revised and enlarged.  In one beauti-
 fully printed octavo volume of 519 pages, with
 original illustrations.  Cloth, $4.60.
WEST'S LECTURES  ON  THE DISEASES OF
  WOMEN  Third American from the third Lon-
  don edition.  In one octavo volume of 643 pages.
  Cloth, $3.75; leather, $4.75.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
28              Diseases  of  Women—(Continued).
Thomas  & Munde on  Diseases of Women.—Sixth  Edition.
        A Practical Treatise  on the Diseases of Women.  By T.Gaillard
Thomas, M. D., LL. D, Emeritus  Professor of  Diseases of Women  in the College of
Physicians and Surgeons, New York, and Paul F. Munde, M. D., Professor of Gynecol-
ogy in the New York Polyclinic.   New (sixth) edition, thoroughly revised and  rewritten
by Dr.  Munde.   In one large and handsome  octavo volume of 824 pages,  with  347
illustrations, of which 201 are new.   Cloth, $5.00; leather, $6.00.
 The profession has sadly felt the want of a text- l acquaintance with the world's literature of this
book on diseases of women, which should be com
prehensive and at the  same time not diffuse,
systematically arranged so as to be easily grasped
by the student of limited experience, and which
should embrace the wonderful advances which
have been  made within the last two decades.
1 homas'work fulfilled these conditions, and the
announcement that a new edition was about to be
issued, revised by so competent a writer as Dr.
Munde, was hailed  with  delight. Dr. Munde
brings to his work a most practical knowledge of
the subjects of which he treats and an exceptional
important  branch  of  medicine. The  result
what is, perhaps, on the whole, the best practical
treatise on the subject in the English  language.
It is, as we have said, the best text-book we Know,
and will be of especial value to the general practi-
tioner as well as to the specialist. The illustra-
tions are  very  satisfactory.  Many of  them are
new  and  are  particularly clear and attractive.
The book will undoubtedly meet with a favorable
reception  from the profession.—Boston Medical
and Surgical Journal, January 14,1892.
Sntton  on the  Ovaries  and Fallopian  Tubes.
        Surgical Diseases of the Ovaries and Fallopian Tubes, including
Tubal Pregnancy.  By J. Bland  Sutton,  F. R. C. S., Assistant  Surgeon  to  the
Middlesex Hospital, London.  In one  square  octavo volume  of 544  pages, with  119
engravings and 5 colored plates.  Cloth, $3.00.
  This is not a book to be read and then shelved ;
it is  one to be studied.  It is not based upon
hypotheses but upon facts. It makes pathology
Practical, and inculcates a practice based upon
pathology.  It is succinct, yet  thorough;  practi-
cal, yet scientific;  conservative, yet bold. It is
probably on the table of all gynecologists; but it
is not for them alone; the general practitioner
needs just such a book.  It will be of immense
service to him in the study of pelvic diseases, and
will assuredly open his eyes to the progress made
by conscientious,  painstaking workers like Dr.
Sutton in--the field of pathology and differential
diagnosis.—International  Medical Magazine, Sep-
tember, 1892.
Davenport's  Non-Surgical  Gynaecology.—Second  Edition.

        Diseases of Women, a  Manual  of  Non-Surgical  Gynsecologv.
Resigned especially for the Use  of Students and  General Practitioners.  By Francis
±1. Davenport, M. D, Assistant in Gynaecology in the Medical Department of Harvard
University,  Boston.  New  (second) edition,  in one handsome 12mo.  volume  of 314
pages, with  107 illustrations.   Cloth, $1.75.

surS a^eSJof «n£e? *,rtad7 exIt8* on *he I the actual test of experience, and being concisely
^a^^^rI^Coioe7\buXBeaat atten<ion  and clear'y written, conveys a great amount of in-
treatmentP of 12 ^ *° the r?on"surSical  formation in a convenientIp&et-Annals of Gynce-
volumef deaW ££h \l^-S™StS-  v The Present  eotogy and Podiatry, June, 1893.          J  V
voiume, dealing with nothing which has not stood |
May's  Manual  of  Diseases  of Women.—Second  Edition.
exnflRitin^ ??a^Uai°f tneDiseases of Women.  Being a  concise and systematic
late fiS <?      .  T7 and Pra-Ctice of gynecology.  By Charles H.  May, M. D.,
L  S Ratt M r,e0nA^°  M.oun* Sinai Hospital, New York/ Second edition, edited by
volume tf\fiO ^>Mten.^fij^ogist at the Harlem Hospital, N. Y.  In one 12mo.
 ™?™f_   _    P.g!s' Wlth 31 ^lustrations.  Cloth, $1.75.
  This is a manual of gynecology in a verv con-
fer f°rm,' Td the fa«4 that a second eSitfon
a fLr„K,Called f0F indicates that it has met with
toltJn? /o°*MC?£t10?-., l\ is inten«ed, the author
fn ™ '    \d,the student who after having care-
subfe^t aUnd111«^r7K0rJi^desires t0 "view the
™3?*-' andhe adds that it may be useful to the
practitioner who wishes to refreshes memory
rapidly but has not the time to consult larger
works.   We are much struck with the readiness
and convenience with which one can refer to any
subject contained in this volume.  Carefully com-
piled indexes and ample illustrations also enrich
the work.  This manual will be found to fulfil its
purposes very satisfactorily.—The Physician and
Surgeon, June, 1890.
Duncan  on Diseases of Women


In one octavo volume of 175 pages.  Cloth $1.50            '        '            '  etC'

                                          rule adequately handled in the text-books; others
                                          ?r JXT^h? e tearinS uPou topics that are usually
                                          stamn  f * £*& V 8U°h WOrks> J6* bear 8Uch a
InllJ I V every way wortny of their author
vadno&.We, L°,ok upon them as among the most
valuable of his contributions. Thev are all Z
matters of great interest to the geneml prfcUtioner
Some of them deal with subjects that Le not™f a
AihsSes pftEt?^ JREatisb ON THE
 IMSEASES PECULIAR TO WOMEN. Third
of "" v "" v;"?"" *" ou«" worns, yei Dear sucn a
wtt~ ?dZld£*I1}?, that they deserve  to be
widely read.-i\r. Y. Medical Journal, March, 1880.
•H?Hn^anTfrom  che third and revised London
ealtlon-  In one 8vo. vol., pp. 520.  Cloth, $3.50.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
Obstetrics.
                                                                                29

Playfair's  Midwifery.-New  (8th)  EdltionriusrReadyr
        A Treatise  on the Science and Practice of MirJ^rif^xr   t>  ir c
pLAYEAiR, M. D.,OC. P,, Professor of pbSSfS^^^^nS,^
don, Examiner in  Midwifery in the Universities of Cambridge and  T nnL  ,!fl L ?u
Eoyal Collegeof Physicians.  Sixth American, from ^e^S^i^^^
with additions by  Egbert P Harris, M. D.  In one  handsome octavo volume of 697
pages, with 217 engravings and 5 plates.  Cloth, $4.00; leather, $5.00
  The demand for eight English and six American --*--■
editions of this standard work in seventeen years
testifies to the success with which the author has
executed his original purpose. His object " has
been to place in the hands cf his readers an epit-
ome  of the science and practice of midwifery
which embodies all  recent advances."  He has
endeavored to dwell especially on the practical
part of the subject, so as to make the work a use-
ful guide in this most anxious and responsible
branch of the profession." The present issue is
the result of a thorough revision of its predecessor
at the hands of the  author.  It has likewise re-
ceived the benefit of careful revision by Dr. Robert
P. Harris, of Philadelphia, whose  annotations in
this and in previous editions have covered the
&? Tu  American practice differs  from
that of English obstetricians. The work will con-
tinue to be a favorite text-book for the student
*£  a trustworthy guide for the practitioner.—
Memphis Medical Monthly, December 1893
  In the method of treating its  theme, that is in
clearness  perspicuity, in a smooth-flowing and
yet terse literary style, notwithstanding the great
number of new claimants in the field, this work
still stands without a superior. The teachings on
the various forms of anomalous and difficult labors
are clear, full and  explicit, and these  practical
matters bear the full stamp of the author's high
authority. A book that already has the praise of
the civilized world.—The  American Practitioner
and News, December 16,1893.
Parvin's  Science  and  Art  of  Obstetrics.—Second  Edition.
        The  Science  and Art of Obstetrics.  By Theophilus Parvin M. D.
LL. D., Professor of Obstetrics and the Diseases of Women and Children  in  Jefferson
Medical College, Philadelphia.   Second edition-.  In one handsome 8vo. volume of 701
pages, with239 engravings and a colored plate.  Cloth, $4.25; leather, $5.25.
                                          scholar and a master.  Rarely in the range of
                                          obstetric literature can be found a work which is
                                          so comprehensive and yet compact and practical.
                                          In such respect it is essentially a text book of the
                                          first merit. The treatment of the subjects gives a
                                          real value to the work—the individualities of a
                                          practical  teacher, a skilful obstetrician, a close
                                          thinker and a ripe scholar.—If ed. Rec., Jan. 17, '91
  The second edition of this work is fully up to the
present state of advancement of the obstetric art.
The author has succeeded exceedingly  well in
incorporating new matter without apparently in-
creasing the size of  his work or interfering with
the smoothness and  grace of its literary construc-
tion.  He is very felicitous in his descriptions of
conditions, and proves himself in this respect a
King'
     I's Manual of Obstetrics.—Fifth Edition.
        A Manual of Obstetrics.  By A. F. A. King, M. D., Professor of Obstetrics
and Diseases of Women in the Medical Department of the Columbian University, Wash-
ington, D. G, and in the University of Vermont, etc.  New (fifth) edition.  In one 12mo.
volume of 446  pages, with 150 illustrations.  Cloth, $2.50.
  So comprehensive a treatise could not be brought
within the limits of a book of this size were not
two things especially true.  First, Dr. King is a
teacher of many years' experience, and  knows
just how to present his subjects in a manner for
them to be best received; and, secondly, he can
put his ideas in a clear  and concise form. In
other words, he knows how to use the English
language.  He gives us the plain truth, free from
unnecessary ornamentation. Therefore we say
there are nine hundred pages of matter between
the covers of this manual of four hundred and
fifty pages. We cannot imagine a better manual
for the hard-worked student; while its clear and
practical teachings make it invaluable to the busy
practitioner. The illustrations add much to the
subject matter.— The National Medical Review,
October, 1892.
Barnes' System  of  Obstetric  Medicine and  Surgery.
        A System  of Obstetric Medicine and Surgery,  Theoretical and
Clinical.  For the  Student and the Practitioner.  By Eobert Barnes, M. D., Phys-
ician to the General Lying-in Hospital, London, and Fancourt Barne?, M. D., Obstetric
Physician to St. Thomas' Hospital, London.  The Section on Embryology by Prof. Milnes
Marshall.   In one 8vo. volume of 872 pp., with 231 illustrations.  Cloth, $5; leather, $6.

Landis  on Labor  and  the  Lying-in  Period.
        The  Management  of  Labor,  and  of  the  Lying-in   Period.
By Henry G. Landis, A. M., M. D., Professor of Obstetrics and the Diseases of Women
in Starling Medical College, Columbus, Ohio.   In one handsome 12mo. volume of 334
pages, with 28 illustrations.  Cloth, $1.75.
LEISHMAN'S SYSTEM OF MIDWIFERY, IN-
  CLUDING THE DISEASES OF PREGNANCY
  AND THE PUERPERAL STATE. Fourth edi-
  tion. Octavo.
PARRY ON EXTRA-UTERINE PREGNANCY:
  Its Clinical History, Diagnosis, Prognosis and
  Treatment. Octavo, 272 pages. Cloth, $2.50.
RAMSBOTHAM'S  PRINCIPLES   AND PRAC-
  TICE  OF  OBSTETRIC  MEDICINE  AND
  SURGERY.  In reference to the Process oi
  Parturition. A new and enlarged edition, thor-
  oughly revised by the Author.  With additions
  by W. V. Keating, M. D., Professor of Obstetrics,
  etc., in the Jefferson Medical College  of Phila-
  delphia.   In one large and handsome imperial
  octavo volume of 640 pages, with 64 full page
  plates and 43 woodcuts in the text, containing in
  all nearly 200 beautiful figures.  Strongly bound
*  in leather, with raised bands, $7.
CHURCHILL  ON  THE  PUERPERAL  FEVER
  AND OTHER DISEASES PECULIAR TO WO-
  M EN. In one 8vo. vol. of 464 pages.  Cloth, $2.60.
TANNER ON  PREGNANCY.  Octavo, 490 pages,
  colored plates, 16 cuts.  Cloth, $4.25       ___
WINCKEL'S COMPLETE TREATISE ON THE
  PATHOLOGY AND  TREATMENT OF  CHILD-
  BED.  For Students and Practitioners. Trans-
  lated from the second German edition, by J. R.
  Chadwick, M. D.  Octavo 484 pages.  Cloth, $4.00.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 
30
Dis. of  Children, Obstetrics—(Cont'd), Manuals.
Smith on  Children.—Seventh  Edition.
        A  Treatise  on  the  Diseases  of  Infancy  and  Childhood.  By
J Lewis Smith, M. D., Clinical Professor of Diseases of Children in the Bellevue Hospital
Medical College New York.   New (seventh)  edition,  thoroughly  revised and rewritten.
In one handsome octavo volume of 881 pages, with 51 illus.   Cloth, $4 50; leather, $5.50.
                                           is  always conservative and thorough, and the
                                           evidence  of research has long since placed its
                                           author in the front rank of medical teachers.—
  We have always considered Dr. Smith's book as
one of the very best on the subject. It has always
been practical—a field  book, theoretical where
theory has been deduced from practical experi-
ence.  He takes his  theory from the bedside and
the pathological laboratory.  The very practical
character of this book has always appealed to us.
It is characteristic of Dr. Smith in all his writings
to collect whatever recommendations are found in
medical literature, and his search has been wide.
One seldom fails to find here a practical suggestion
after search in other  works has been in vain.  In
the seventh edition we note a variety of changes
in accordance with the progress of the times.  It
still stands foremost as the American  text-book.
The literary style could not be excelled, its advice
The American Journal of the Medical Sciences, Dec.
1891.
  In the present edition we notice that many of
the chapters have been entirely rewritten.  Full
notice is taken of all the recent advances that
have been made.  Many diseases not previously
treated of have received special chapters.  The
work is a very  practical one.  Especial care has
been taken that the directions for treatment shall
be particular and full. In no other work are such
careful instructions given in the details of infant
hygiene and the  artificial feeding  of infants.—
Montreal Medical Journal, Feb. 1891.
Herman's  First  Lines  in  Midwifery.
        First Lines in  Midwifery:  a Guide to  Attendance on Natural
Labor for Medical Students and Midwives.   By G. Ernest Herman, M. B.,
F.E.C.P., Obstetric Physician to the  London Hospital.   In one 12mo.  volume of 198
pages, with 80 illustrations.  Cloth, $1.25.  See Student's Series of Manuals, below.
                                         '  will prove valuable to the beginner in midwifery
                                           and could be read with advantage by the majority
                                           of  practitioners, old  and young.—The Medical
                                           Fortnightly, April 15,1892.
  This is a little  book, intended for the medical
student and the educated midwife.   The work
is written  in a  plain, simple style,  and is  as
much as possible devoid of technical terms.  It
Owen  on Surgical  Diseases  of Children.
         Surgical Diseases  of Children.  By Edmund Owen, M. B., F. E. 0. S.,
Surgeon to the Children's Hospital, Great Ormond Street, London.  In  one  12mo.  vol-
ume of 525 pages, with 4 chromo-lithographic  plates  and 85 woodcuts.  Cloth, $2.00.
See Series of Clinical Manuals, below.
 One is immediately struck on reading this book
with its agreeable style and the evidence it every-
where presents of the practical familiarity of its
author  with  his subject.  The  book may be
honestly  recommended to  both  students and
practitioners.   It is full of sound information,
pleasantly given.—Annals of Surgery, May, 1886.
Student's  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 volumes are now ready: Luff's Manual of Chem-
istry, $2; Herman's  First Lines in Midwifery, $1.25; Treves' Manual of Surgery, by various writers, in
three  volumes, per set, $6;  Bell's Comparative Anatomy and Physiology,  $2;  Gould's  Surgical
Diagnosis, $2; Robertson's Physiological Physics, $2; Bruce's Materia Medica and Therapeutics (5th edi-
tion), $1.50;  Power's Human Physiology (2d edition), $1.50;   Clarke and Lockwood's Dissectors' Man-
ual, $1.50; Ralfe's Clinical  Chem'stry,'$1.50; Treves' Surgical Applied Anatomy, $2; Pepper's Surgical
Pathology, $2; and Klein's Elements of Histology (4th edition), $1.75.   The following is in press:
Pepper's Forensic Medicine. For separate notices see index on last 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 clinical subjects in a cheap and portable form.
Ihe volumes contain about 550 pages and are  freely illustrated by chromo-lithographs and wood-
*Ck  "n. i   «,« 'lowing volumes are now ready:  Yeo on Food in Health and Disease, $2; Broadbent on
me Pulse, $1.75; Carter & Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25;  Marsh
°t?}   oS1^' S2;  0wEN^ on Sur9lml  Diseases of Children, $2;  Morris on Surqical Diseases of the
Kidney,p.25; Pick on Fractures and Dislocations, $2;  Butlin on the Tongue, $3.50;  Treves on Intesti-
nal Obstruction, $2;  and Savage on Insanity and Allied Neuroses, $2. The'following is in preparation:
Lucas on Diseases of the Urethra.  For separate notices see index on last page.

Hartshorne's  Conspectus  of  the^edicaT Sciences.

        A Conspectus of the Medical Sciences;  Containing Handbooks on Anat-
omy Physiology,  Chemistry, Materia Medica, Practice of Medicine, Surgery and Obstetrics.
By Henry Hartshorne, A. M., M. D., LL. D., lately Professor of Hygiene in  the Uni-
versity ot Pennsylvania.  Second  edition,  thoroughly revised and greatly improved.  In
one large royal 12mo. vol. of 1028  pages, with 477  illus.   Cloth, $4.25; leather, $5.00.
C°™£LS™P5ACTICAL TREATISE ON THE
  DISEASES OF CHILDREN.  Sixth edition, re-
  vised and augmented.  In one octavo volume of
Trr7™£a£t?-  Clotn> *5-25 ; leather, $6.25.
W£Stq £5LS0MB DISORDERS OF THE NERV-
  OUS SYSTEM  IN CHILDHOOD.  In one small
t TT2TmoA^?,,,ume of m Pa*es-  Cloth, $1.00.
LUDLOW'S MANUAL  OF EXAMINATIONS. A
  Manual of Examinations upon Anatomy, Physi-
ology, Surgery, Practice of Medicine, Obstetrics.
Materia Medica,  Chemistry,  Pharmacy  and
Therapeutics.  To which  is added a Medical
Formulary.  By J. L. Ludlow, M. D., Consulting
Physician  to the Philadelphia Hospital, etc.
Third edition, thoroughly revised, and greatly
enlarged.  In one 12mo. volume  of 816 pages,
with 370 illustrations. Cloth, $3.25; leather, 13.75.
Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street. Philadelphia. 
fledical Jurisprudence, Historical.             31
Taylor's  Medical  Jurisprudence.—Twelfth  Edition.
        A Manual of Medical Jurisprudence.  By Alfred S. Taylor, M. D.
Lecturer on Med. Jurisprudence and Chemistry in Guy's Hosp., London.  New American
from the 12th English edition.  Thoroughly revised by Clark Bell, Esq., of the New
York Bar.  In one octavo volume of 787 pages, with 56 illus.  Cloth, $4.50; leather, $5.50.
 This is a complete revision of all former Ameri
can and English editions  of this standard book.
This edition contains a large amount of entirely
new matter, many portions of the book having
been  rewritten by the editor. Many  cases and
authorities  have been cited,  and the citations
brought down to the latest date.  The book has
long been a standard treatise on  the subject of
medical jurisprudence, and  has  gone through
many editions—twelve English and eleven Ameri-
can. Mr. Clark Bell has enlarged and improved
what already seemed complete, by bringing his
many citations of cases down to date  to meet the
E resent law; and by adding much  new matter he
 as furnished the medical profession and the bar
with a valuable book of reference, one to be relied
upon in daily practice, and quite up to the present
needs, owing to its  exhaustive character. It
would seem that the book is indispensable to the
library of both physician and lawyer, and particu-
larly the legal practitioner whose duties take him
into the criminal courts.  The editor has given to
two professions a reference-book to be relied upon.
—The American Journal of the Medical  Sciences,
April, 1893.
  No library is complete without Taylor's Medical
Jurisprudence, as its authority is accepted and  un-
questioned by the courts.—Buffalo Medical  and
Surgical Journal, June, 1893.
  There is no other work upon the subject which
has been so uniformly recognized or so widely
quoted and followed by courts in England and this
country.  This eleventh American edition is fully
abreast with the most recent thought and knowl-
edge. On the basis of his own researches, of the
investigations of scientists throughout the world,
and of the decisions  of our  own courts, Mr. Bell
has incorporated in it a wealth of practical sug-
gestion and .instructive illustration which cannot
fail to  strengthen the hold it has so long  had
upon the  profession.—The Criminal Law Magazine
and Reporter, January, 1893.
                             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.

Lea's Superstition  and Force.—New  Edition.   Just Ready.
        Superstition  and Force:  Essays  on The Wager of  Law, The
Wager  of  Battle, The  Ordeal  and  Torture.   By Henry  Charles Lea,
LL. D., New  (4th) edition, revised and enlarged.  Royal 12mo., 629 pages.  Cloth, $2.75.
  Both abroad and at home the work has been
accepted as a standard authority, and the author
has endeavored by a complete revision and con-
siderable additions to render  it more worthy of
the universal favor  which has  carried  it to a
fourth edition. The style is severe and  simple,
and yet delights with its elegance and reserved
strength. The known erudition and fidelity of
the author are guarantees that all possible origi-
nal sources of information  have been not only
consulted but exhausted. The subject matter is
handled in  such an able and  philosophic man-
ner that to  read and study it is a step toward
liberal education.   It is a comfort to read a book
that is so thorough, well conceived and well done.
We should like to see it made a text-book in our
law schools and prescribed course for admission
to the bar.—Legal Intelligencer, March 3,1893.
 A work as remarkable for the wealth of histori-
cal material  treated as for the masterly style of
the exposition.—London Saturday Review, Feb. 25,
1893.
                             By the same Author.
    Chapters from the Religious History of Spain.—In one 12mo. volume
of 522 pages.  Cloth $2.50.
  The width, depth and thoroughness of research
which have earned Dr. Lea a high European place
as the ablest historian the Inquisition has yet
found are here applied to some side-issues of that
great subject. We have only to say of this volume
that it worthily complements the author's earlier
studies in ecclesiastical history. His extensive
and minute learning, much of  it from inedited
manuscripts in Mexico, appears  on every page.—
London Antiquary, Jan. 1891.
In one  8vo. volume of 221
                             By the same Author.
    The  Formulary of the Papal Penitentiary.
pages, with a frontispiece.  Cloth, $2.50.  Just Ready.

                             By the Same Author.
    Studies in Church History.  The Rise of the Temporal Power—Ben-
efit of Clergy—Excommunication—The Early Church and Slavery.  Sec-
ond and revised edition.   In one royal octavo volume of 605 pages.  Cloth, $2.50.
  The author is preeminently 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, and
the profuse citation of authorities and references
makes the work particularly valuable to the student
who desires an exhaustive review from original
sources. In no other single volume is the develop-
ment of the primitive church traced with so much
clearness and with so  definite a perception of
complex or conflicting  forces.—Boston Traveller.
                            By the Same Author.
    An  Historical  Sketch of  Sacerdotal  Celibacy  in  the
Church.  Second edition, enlarged.  In one octavo volume of 685 pages.
 Christian
Cloth, $4.50.
  This subject has recently been treated with very
great learning and with admirable impartiality by
an American author, Mr. Henry C Lea. in his His-
tory of Saceraotal Celibacy, which is certainly one
of the most valuable works that America has pro-
duced.  Since the great history of Dean Milman,
I know no work in English which has thrown
more light on the moral condition of the Middle
Ages, and none which is more fitted to dispel the
gross illusions concerning that period which posi-
tive writers and writers of a certain ecclesiastical
school have conspired to sustain.—Lecky's History
of European Morals, Chap. V.
Lea Brothers &  Co., Publishers, 706, 708 &  710 Sansom Street, Philadelphia. 
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Abbott's Bacteriology .
Allen's Anatomy      .     .     .     .
American Journal of the Medical Sciences
American Systems of Gynecology and Obstetrics
American System of Practical Medicine.
American System of Dentistry
Ashhurst's Surgery    ....
Ashwell on Diseases of Women
Attfield's Chemistry   ....
Barnes' System of Obstetric Medicine
Bartholow on Cholera
Bartholow on Electricity
Basham on Renal Diseases .
Bell's Comparative Anatomy and Physiology
Bellamy's Surgical Anatomy
Berry on the Eye     ....
Billings' National Medical Dictionary   .
Blandford on Insanity
Bloxam's Chemistry  ....
Broadbent on the Pulse
Browne on Koch's Remedy .
Browne on the Throat, Nose and Ear
Brace's Materia Medica and Therapeutics
Brunton's Materia Medica and Therapeutics
Bryant's Practice of Surgery .
Bumstead and Taylor on Venereal.  See Taylor.
Burnett on the Ear   ....
Butlin on the Tongue ....
Carpenter on the Use and Abuse of Alcohol
Carpenter's Human Physiology
Carter & Frost's Ophthalmic Surgery
Caspari's Pharmacy
Chambers on Diet and Regimen
Chapman's Human Physiology
 Charles' Physiological and Pathological Chem,
 Churchill on Puerperal Fever
 Clarke and Lockwood's Dissectors' Manual
 Classen's Quantitative Analysis
 Cleland's Dissector   ....
 Clouston on Insanity ....
 Clowes' Practical Chemistry
 Coats' Pathology     ....
 Cohen's Applied Therapeutics
 Coleman's Dental Surgery
 Condie on Diseases of Children
 Cornil on Syphilis     ....
 Cullerier <fc Bumstead on Venereal
 Culver & Hayden on Venereal Diseases .
 Dalton on the Circulation   .     .
 Dalton's Human Physiology
 Davenport on Diseases of Women .
 Davis' Clinical Lectures
 Draper's Medical Physics
 Druitt's Modern Surgery
 Duncan on Diseases of Women
 Dungllson'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
 Farquharson's Therapeutics and Mat. Med.
 Field's Manual of Diseases of the Ear
 Flint on Auscultation and Percussion
 Flint on Phthisis      ....
 Flint on Respiratory Organs
 Flint on the Heart
 Flint's Essays   .....
 Flint's Practice of Medicine
 Folsom's Laws of U. S. on Custody of Insane
 Foster's Physiology   .
 Fotnergill's 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   .
 Gant's Student's Surgery
 Gibbes' Practical Pathology
 Gould's Surgical Diagnosis
 Gray on Nervous and Mental Diseases
 Gray's Anatomy   .   .     ...
 Greene's Medical Chemistry .
 Green's Pathology and Morbid Anatomy
 Gross on Impotence and Sterility  .
 Gross on Urinary Organs
 Habershon on the Abdomen
 Hamilton on Fractures and Dislocations
 Hamilton on Nervous Diseases
 Hardaway on the Skin
 Hare's Practical Therapeutics
 Hare's System of Practical Therapeutics
 Hartshorne's Anatomy  and Physiology .
 Hartshorne's Conspectus of the Med. Sciences
  Hartshorne's Essentials of Medicine
  Herman's First Lines in Midwifery
  Hermann's Experimental Pharmacology
  Hill on Syphilis.....
  Rimer's Handbook of Skin Diseases
  Hirst & Piersol on Human Monstrosities
  Hoblyn's Medical Dictionary
  Hodge on  Women
  Hoffmann and Power's Chemical Analysis
  Holden's Landmarks ....
  Holland's Medical Notes and Reflections
  Holmes' Principles and Practice of Surgery
  Holmes' System of Surgery
  Horner's Anatomy and Histology
  Hndson on Fever
  Hutchinson on Syphilis
  Hyde on the Diseases of the Skin  .
  Jackson on the Skin  .
  Jamieson  on the Skin
  Jones (C. Handfleld) on Nervous Disorders
  Juler's Ophthalmic Science and Practice
  King's Manual of Obstetrics .
  Klein's Histology
  Landis on Labor
  La Roche on Pneumonia, Malaria, etc.  .
15,30
  17
  17
13,30
  13
  21
  25
  24
20,30
   7
   7
23,30
  10
  16
19 i La Roche on Yellow Fever  •..„;.„__•
 6 I Laurence and Moon's Ophthalmic Surgery
 2 Lawson on the Eye, Orb t and Eye"d   .
27 Lea's Chapters from KelWOuaHistorjjrt spall
14 I Lea's Formulary of the Papal Penitentiary
24 Lea's Sacerdotal Celibacy   .
20 i Lea's Studies in Church History   .
28 i Lea's superstition and Force
 9 ! Lee on Syphilis  .   ,   •   , ,„._  '
29 I Lehmannrs Chemical Physiology  .
16 j Leishmans Midwifery       •    •
16 Lucas on Diseases of the Urethra  .
23 Ludlow's Manual of Examinations
30 i Luff's Manual of Chemistry
 6 Lyman's  Practice of Medicine
23 Lyons on Fever .     .     ■
 4 Maisch's Organic Materia Medica .
18 Marsh on the Joints
   May on Diseases of Women  .
   Medical News   .     •  ,-.•-■
   Medical News Physicians' Ledger .
   Medical News Visiting List  .
   Miller's Practice of Surgery  .
   Miller's Principles of Surgery
   Morris on Diseases of the Kidney .
   Morris on the Skin       .  .
   Musser's  Medical Diagnosis .
   National Dispensatory
   National Medical Dictionary
   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
   Payne's General Pathology  .
    Pepper's Forensic Medicine  .
    Pepper's Surgical Pathology
    Pepper's System of Medicine
    Pick on Fractures and Dislocations
    Pirrie's System of Surgery .     .       .
    Playfair on Nerve Prostration and Hysteria
    Playfair's Midwifery   .
    Politzer on the Ear
    Power's Human Physiology  . A „ •  .„„„.,„„«.
    Purdy on Bright's Disease and Allied A Bectiona
    Pye-Smith on the Skin      .    . '
    Quiz Series     .     .      .    •
    Ralfe's Clinical Chemistry
    Ramsbotham on Parturition
    Reichert's Physiology  .
    Remsen's Theoretical  Chemistry .
6,30
  8
  6
  17
  8
  19
  13
  24
  30
  25
  25
  25
  7
  8
  28
  15
  7
  20
  28
  4
  12
  27
  7
  27
  21
  13
  24
  15
  13
  15
  13
  13
  13
  19
      Reynolds' System of Medicine
      Richardson's Preventive Medicine
      Roberts on Urinary Diseases
      Roberts' Compend of Anatomy   .
      Roberts' Surgery
      Robertson's Physiological Physics
      Ross on Nervous Diseases
      Savage on Insanity, including Hysteria
      Schafer's Essentials of Histology,
      Schofield's Physiology
      Schreiber on Massage  .     .     .
      Seiler on the Throat, Nose and Naso-Pnarynx
      Senn's Surgical Bacteriology
      Series of Clinical Manuals
      Simon's Manual of Chemistry
      Blade on Diphtheria
      Smith (Edward) on Consumption .
      Smith (J. Lewis) on Children
      Smith's Operative Surgery
      Stille on Cholera
  25  Stille & Maisch's National Dispensatory
      Stillfi's Therapeutics and Materia Medica
  17  Stimson on Fractures and Dislocations
  20  Stimson's Operative Surgery
  19  Students' Quiz Series   ....
20, 30  Students' Series of Manuals .
  18  Sturges' Clinical Medicine
      Sutton on the Ovaries and Fallopian Tubes
    9  Sutton on Tumors     ....
  19  Tait's Diseases of Women and Abdom. Surgery
  25  Tanner on Signs and Diseases of Pregnancy
  25  Tanner's Manual of Clinical Medicine  .
  14  Taylor's Atlas of Venereal and Skin Diseases
  22  Taylor on Poisons     ....
  18  Taylor on Venereal Diseases
  25  Taylor's Medical Jurisprudence
  12  Thomas & Munde on Diseases of Women
  12  Thompson on Stricture
    6  Thompson on Urinary Organs
  30  Todd on Acute Diseases
   13  Treves' Manual of Surgery   .
   30  Treves on Intestinal Obstruction  .
   13  Treves' Operative Surgery   .
   25  Treves' Student's Handbook of Surg. Operations,  21
   25  Treves'Surgical Applied Anatomy     .      .6,30
    6  Tuke on the Influence of Mind on the Body   .    17
    5  Vaughan & Novy's Ptomaines and Leucomaines  10
   27  Visiting List, The Medical News
   10  Walshe on the Heart .
    6  Watson's Practice of Physic .
   15  Wells on the Eye
   22  West on Diseases of Women
   21  West on Nervous Disorders in Childhood
    6  Wharton's Minor Surgery and Bandaging
   13  Whitla's Dictionary of Treatment
 25,30  Williams on Consumption   ....
   26  Wilson's Handbook of Cutaneous Medicine
   26  Wilson's Human Anatomy ....
   26  Winckel on Pathol, and Treatment of Childbed
   18  WOhler's Organic Chemistry
   23   Year-Books of Treatment  for 86, '87. '91, '92, '93.
   29 Yeo's Medical Treatment, or Clinical Therapeutics, 16
 18,30 Yeo on Food in Health and Disease     .     .  16,30
   29 Young's Orthopedic  Surgery     .          .    20
    17
  13
  23
  23
  31
  31
  31
  31
  31
  ■a
   7
  29
  30
  30
 9,30
  14
  13
  12
22,30
  28
   1
   2
   2
  21
  21
24,30
  26
  15
  11
   4
  23
  23
  30
  10
  29
  29
  16
  19
  30
 18,30
  14
 22,30
  20
  17
  29
  24
 7.30
  24
   26
    2
 10,30
   29
    7
   10
   13
   16
   24
    7
   20
 7,30
   18
 18.30
   18
  16
  17
  19
  30
   9
  17
  17
  30
  22
  16
  11
  13
  22
  22
   3
  30
  15
  28
  20
  27
  29
  15
  26
  31
  25
  31
  28
  24
  24
  15
21,30
21,30
  21 
 
 
 
 
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