THE P HPLES AND PRAOT E OF MEDICIHE DESIGNED FOE THE USE OP PEACTITIONEES AND STUDENTS OF MEDICINE BY WILLIAM OSLER, M. D. FELLOW OF THE ROYAL COLLEGE OF PHYSICIANS, LONDON PROFESSOR OF MEDICINE IN THE JOHNS HOPKINS UNIVERSITY AND PHYSICIAN-IN-CHIEF TO THE JOHNS HOPKINS HOSPITAL, BALTIMORE FORMERLY PROFESSOR OF THE INSTITUTES OF MEDICINE, MC GILL UNIVERSITY, MONTREAL AND PROFESSOR OF CLINICAL MEDICINE IN THE UNIVERSITY OF PENNSYLVANIA, PHILADELPHIA SECOND EDITION NEW YORK D. APPLETON AND COMPANY 1897 Copyright, 1892, 1895, By D. APPLETON AND COMPANY. TO THE MEMORY OF MY TEACHERS : WILLIAM ARTHUR JOHNSON, PRIEST OF THE PARISH OF WESTON, ONTARIO. JAMES BOVELL, OF THE TORONTO SCHOOL OF MEDICINE, AND OF THE UNIVERSITY OF TRINITY COLLEGE, TORONTO. ROBERT PALMER HOWARD, DEAN OF THE MEDICAL FACULTY AND PROFESSOR OF MEDICINE, M°GILL UNIVERSITY, MONTREAL. PREFACE TO THE SECOND EDITION. I have to thank many friends for corrections and suggestions, and the profession at large for their kind reception of the first edition. I am under special obligations to Dr. H. M. Thomas and to Dr. W. S. Thayer for much valuable assistance; to Professor Welch and to Dr. Flexner for counsel on questions of pathology and bacteriology; and to Miss B. O. Ilumpton for help in the preparation of the index. Several sections have been rewritten, all carefully corrected, and here and there many fresh details have been added. The important additions are as follows : In Section I the article on Typhoid Fever has been thoroughly re- vised to date, and that on Malarial Fever in large part rewritten. The subject of Diphtheria has been completely recast, and extended from eleven to twenty pages. The article on Septicaemia and Pyaemia has been rearranged and largely rewritten. Short descriptions of the Bubonic Plague and of the Foot and Mouth Disease have been added. New matter will also be found in connection with Cholera, Syphilis, Tuberculosis, and others of the infectious diseases. In this section, in describing the stage of incubation, the report of the Clinical Society of London has been adopted. In Section II the articles on Gout and Diabetes have been ex- tended. A description of Infantile Scurvy and of the Haemorrhagic Diseases of the New-born has been added. In Section III there has been added an account of Eczema of the Tongue and of Leukoplakia, and under Chronic Tonsillitis will be found additional details regarding the injurious effects of mouth- breathing. The Methods of Clinical Examination of the Stomach have been omitted, since they more correctly belong to, and are more fully given in, manuals of diagnosis. The subject of Appendicitis has VI PREFACE TO THE SECOND EDITION. been completely rewritten and much extended. A new section has been added on Affections of the Mesentery, and under Diseases of the Liver a description of the dislocations and deformities of the organ. Under Localized Peritonitis a new section will be found on the Sub- phrenic Variety. In Sections IV and V many minor additions and corrections have been made. In writing on Angina Pectoris, it was a pleasure to be able to give the credit of the “ intermittent claudication ” theory to that distinguished old Glasgow professor, Allan Burns. In Section VI the subjects of Anaemia and Leukaemia have been revised and rearranged. In the articles on Addison’s Disease and on Exophthalmic Goitre and Myxoedema will be found references to the new investigations. In Section VII a brief account of Anuria has been added, and a number of minor corrections and additions have been made. In Diseases of the Nervous System a new introductory section has been written, with new diagrams, which will prove helpful to the stu- dent. Most of the important points which have arisen during the past three years have been incorporated. In Section IX the article on Muscular Atrophies has been re- arranged. In Section X the important studies of Gosio and of Sanger upon Arsenical Poisoning have been referred to. In the section on Parasites the subject of Psorospermiasis has been recast, a short account of the Parasitic Infusoria has been added, and a number of minor corrections have been made. I am under special indebtedness to Dr. Stiles, the leading authority on parasites in this country, for a careful revision of the nomenclature in accordance with the rules of the International Committee, and for valuable advice relating to the subject. I could not, however, yield to the change of name from Triclmia to Trichinella. And, lastly, I have added, when possible, the description of certain special symptoms—as Cheyne-Stokes breathing, Trousseau’s phenome- non, and Oliver’s tracheal tugging—in the words of the authors. 1 Franklin St. W., July 1, 1895. CONTENTS. SECTION I. PAGE I. Typhoid Fever 1 II. Typhus Fever 43 III. Relapsing Fever 47 IV. Small-pox 50 Variola Vera 53 Haemorrhagic Small-pox 56 Varioloid 58 V. Vaccinia (Cow-pox)—Vaccination 64 VI. Varicella (Chicken-pox) 69 VII. Scarlet Fever 71 VIII. Measles 81 IX. Rubella (Rotheln) 85 X. Epidemic Parotitis (Mumps) 86 XI. Whooping-cough 88 XII. Influenza 92 XIII. Dengue 94 XIV. Cerebro-spinal Meningitis 96 XV. Diphtheria 103 XVI. Erysipelas 123 XVII. Septicaemia and Pyaemia 126 Septicaemia 127 Septico-Pyaernia 129 XVIII. Cholera Asiatica 132 XIX. Yellow Fever 139 XX. The Bubonic Plague 144 XXI. Dysentery 145 XXII. Malarial Fever 155 Intermittent Fever 163 Continued and Remittent Malarial Fever 167 Pernicious Malarial Fever 169 Malarial Cachexia 170 XXIII. Anthrax 174 XXIV. Hydrophobia 177 XXV. Tetanus 180 XXVI. Syphilis 184 Acquired 186 Congenital 188 Visceral 191 SPECIFIC INFECTIOUS DISEASES. VIII CONTENTS. PAGE XXVII. Tuberculosis 203 1. General Etiology and Morbid Anatomy 203 2. Acute Tuberculosis 217 3. Tuberculosis of the Lymph-glands (Scrofula) 224 4. “ of the Lungs (Phthisis, Consumption) . . . 228 5. “ of the Serous Membranes 255 6. “ of the Alimentary Canal 260 7. “ of the Liver 263 8. “ of the Brain and Spinal Cord 263 9. “ of the Genito-urinary System 264 10. “ of the Mammary Gland 267 11. “ of the Arteries 267 12. Prognosis in Tuberculosis 267 13. Prophylaxis in Tuberculosis 269 14. Treatment of Tuberculosis 270 XXVIII. Leprosy 277 XXIX. Glanders 280 XXX. Actinomycosis 282 XXXI. Infectious Diseases of Doubtful Nature 285 1. Febricula (Ephemeral Fever) 285 2. Weil’s Disease 286 3. Milk-sickness 287 4. Malta Fever 287 5. Mountain Fever 288 6. Miliary Fever (Sweating Sickness) 289 7. Foot and Mouth Disease 290 SECTION II. CONSTITUTIONAL DISEASES. I. Rheumatic Fever 292 II. Chronic Rheumatism 300 III. Pseudo-rheumatic Affections 301 IV. Muscular Rheumatism 303 V. Arthritis Deformans (Rheumatoid Arthritis) 305 VI. Gout 309 VII. Diabetes Mellitus 320 VIII. Diabetes Insipidus 330 IX. Rickets 332 X. Scurvy (Scorbutus) 337 XI. Purpura 343 XII. Haemophilia 348 SECTION III. DISEASES OF TIIE DIGESTIVE SYSTEM. I. Diseases of the Mouth 351 Stomatitis 351 Aphthous Stomatitis 351 Ulcerative Stomatitis 352 Parasitic Stomatitis (Thrush) 353 Gangrenous Stomatitis 354 Mercurial Stomatitis 355 CONTENTS. IX PAGE II. Diseases of the Salivary Glands 357 Hypersecretion 357 Xerostomia 357 Inflammation of the Salivary Glands 357 III. Diseases of the Pharynx 358 Circulatory Disturbances 358 Acute Pharyngitis 359 Chronic Pharyngitis 359 Ulceration of the Pharynx 360 Acute Infectious Phlegmon of the Pharynx 360 Retro-pharyngeal Abscess 361 Angina Ludovici 361 IV. Diseases of the Tonsils 361 Follicular or Lacunar Tonsillitis 361 Suppurative Tonsillitis 363 Chronic Tonsillitis 364 V. Diseases of the Oesophagus 369 Acute Oesophagitis 369 Spasm of the Oesophagus 370 Stricture of the Oesophagus 371 Cancer of the Oesophagus 372 Rupture of the Oesophagus 373 Dilatations and Diverticula 373 VI. Diseases of the Stomach 374 Acute Gastritis 374 Phlegmonous Gastritis 376 Toxic Gastritis 376 Diphtheritic Gastritis 377 Mycotic Gastritis 377 Chronic Gastritis (Chronic Dyspepsia) 377 Neuroses of Stomach 385 Gastralgia 385 Nervous Dyspepsia 386 Nervous Vomiting 387 Peristaltic Unrest 388 Rumination 388 Dilatation of Stomach 390 Peptic Ulcer (Gastric and Duodenal) 394 Cancer of Stomach 402 Haemorrhage from the Stomach . ■ 411 VII. Diseases of the Intestines . . . . 414 1. Diseases of the Intestines associated with Diarrhoea .... 414 Catarrhal Enteritis 414 Diarrhoea 414 Enteritis in Children 417 Diphtheritic or Croupous Enteritis 421 Phlegmonous Enteritis 422 Mucous Colitis 422 Ulcerative Enteritis 423 2. Appendicitis (Typhlitis and Perityphlitis) 429 3. Intestinal Obstruction 443 4. Constipation (Costiveness) ......... 451 X CONTENTS. PAGE 5. Miscellaneous Affections 454 Dilatation of the Colon 454 Affections of the Mesentery 454 VIII. Diseases of the Liver 457 1. Jaundice (Icterus) 457 2. Affections of the Blood-vessels of the Liver 461 3. Diseases of the Bile-passages 463 Catarrhal Jaundice 463 Cholelithiasis (Gall-stones) 465 Other Affections of the Bile-ducts 471 4. Cirrhosis . 474 5. Abscess of the Liver 480 6. New Growths in the Liver 485 7. Fatty Liver 489 8. Amyloid Liver 490 9. Anomalies in Form and Position of the Liver 491 IX. Diseases of the Pancreas 492 1. IlEemorrhage 492 2. Acute Pancreatitis 493 3. Chronic Pancreatitis 495 4. Pancreatic Cysts 495 5. Cancer 496 6. Pancreatic Calculi 497 X. Diseases of the Peritomeum 498 1. Acute General Peritonitis 498 2. Peritonitis in Infants 502 3. Localized Peritonitis 502 4. Chronic Peritonitis 505 5. New Growths in the Peritomeum 506 6. Ascites (Hydro-peritonaeum) 507 DISEASES OF THE RESPIRATORY SYSTEM. SECTION IV. I. Diseases of the Nose 512 Acute Coryza 512 Chronic Nasal Catarrh 513 Autumnal Catarrh (Hay Fever) 515 Epistaxis 516 II. Diseases of the Larynx 518 1. Acute Catarrhal Laryngitis 518 2. Chronic Laryngitis 519 3. (Edematous Laryngitis 519 4. Spasmodic Laryngitis (Laryngismus Stridulus) 520 5. Tuberculous Laryngitis 521 6. Syphilitic Laryngitis 523 111. Diseases of the Bronchi 524 1. Acute Bronchitis 524 2. Chronic Bronchitis 526 3. Bronchiectasis 529 4. Bronchial Asthma 531 5. Fibrinous Bronchitis 535 CONTENTS. XI PAGE IV. Diseases of the Lungs 537 1. Circulatory Disturbances in the Lungs 537 2. Pneumonia 545 3. Chronic Interstitial Pneumonia (Cirrhosis of Lung) .... 566 4. Broncho-pneumonia (Capillary Bronchitis) 570 5. Emphysema 578 Compensatory Emphysema 578 Hypertrophic Emphysema 579 Atrophic Emphysema 583 6. Gangrene of the Lung 584 7. Abscess of the Lung 586 8. Pneumonokoniosis 587 9. New Growths in the Lungs 590 V. Diseases of the Pleura 592 1. Acute Pleurisy 592 Fibrinous or Plastic Pleurisy 592 Sero-fibrinous Pleurisy 592 Purulent Pleurisy (Empyema) 597 Tuberculous Pleurisy 600 Other Varieties of Pleurisy 600 2. Chronic Pleurisy 605 3. Hydrothorax 608 4. Pneumothorax (Hydro-pneumothorax and Pyo-pneumothorax) . . 608 Affections of the Mediastinum 611 SECTION V. I. Diseases of the Pericardium 616 1. Pericarditis 616 2. Other Affections of the Pericardium 626 II. Diseases of the Heart 627 1. Endocarditis 627 Acute Endocarditis 627 Chronic Endocarditis 634 2. Chronic Valvular Disease 637 Aortic Incompetency 637 Aortic Stenosis 643 Mitral Incompetency 645 Mitral Stenosis 649 Tricuspid Valve Disease 653 Pulmonary Valve Disease 655 Combined Valvular Lesions 655 3. Hypertrophy and Dilatation ......... 663 Hypertrophy of the Heart 663 Dilatation of the Heart 670 4. Affections of the Myocardium 675 Aneurism of the Heart 681 Rupture of the Heart 682 New Growths and Parasites 682 Wounds and Foreign Bodies 683 DISEASES OF THE CIRCULATORY SYSTEM. CONTENTS. PAGE 5. Neuroses of the Heart 684 Palpitation 684 Arrhythmia , , . . . 685 Rapid Heart (Tachycardia) 687 Slow Heart (Bradycardia) 688 Angina Pectoris 690 6. Congenital Affections of the Heart 695 III. Diseases of the Arteries 699 1. Degenerations 699 2. Arterio-sclerosis (Arterio-capillary Fibrosis) 700 3. Aneurism 706 Aneurism of the Thoracic Aorta 707 Aneurism of the Abdominal Aorta 716 Aneurism of the Branches of the Abdominal Aorta .... 717 Arterio-venous Aneurism 718 Congenital Aneurism 718 SECTION VI. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. I. Anemia 720 Secondary Anemia 720 Primary or Essential Anemia 723 II. Leukemia 733 III. Hodgkin’s Disease 742 IV. Addison’s Disease 746 V. Diseases of the Thyroid Gland 750 Goitre 750 Tumors of the Thyroid 750 Exophthalmic Goitre 751 Myxcedema 754 SECTION VII. I. Anomalies in Form and Position 758 Movable Kidney 758 II. Circulatory Disturbances 762 III. Anomalies of the Urinary Secretion 763 1. Anuria 763 2. Hematuria 764 3. Hemoglobinuria 765 4. Albuminuria 767 5. Pyuria (Pus in the Urine) . 771 6. Chyluria (Non-parasitic) 772 7. Lithuria 772 8. Oxaluria 774 9. Cystinuria 774 10. Phosphaturia . 775 11. Indicanuria 776 12. Melanuria 776 13. Other Substances 777 DISEASES OF THE KIDNEYS. CONTENTS. XIII PAGE IV. Uraemia 778 V. Acute Bright’s Disease 782 VI. Chronic Bright’s Disease 787 Chronic Parenchymatous Nephritis 788 Chronic Interstitial Nephritis 790 VII. Amyloid Disease 798 VIII. Pyelitis 799 IX. Hydronephrosis 803 X. Nephrolithiasis (Renal Calculus) 806 XI. Tumors of the Kidney 811 XII. Cystic Disease of the Kidney 813 XIII. Perinephric Abscess 814 SECTION VIII. DISEASES OF THE NERVOUS SYSTEM. I. General Introduction 816 II. Diseases of the Nerves 833 1. Neuritis (Inflammation of the Nerve-fibres) 833 2. Neuromata 839 3. Diseases of the Cranial Nerves 840 Olfactory Nerve 840 Optic Nerve and Tract 841 Lesions of the Retina 841 Lesions of the Optic Nerve 844 Affections of the Chiasma and Tract 845 Affections of the Tract and Centres 845 Motor Nerves of the Eyeball 848 Fifth Nerve 853 Facial Nerve 855 Auditory Nerve 859 Glosso-pharyngeal Nerve 863 Pneumogastric Nerve 863 Spinal Accessory Nerve 867 Hypoglossal Nerve 870 4. Diseases of the Spinal Nerves 871 Cervical Plexus 871 Brachial Plexus 873 Lumbar and Sacral Plexuses 876 Sciatica 877 III. Diseases of the Spinal Cord 879 1. Topical Diagnosis 879 2. Affections of the Meninges 881 Diseases of the Dura Mater 881 Diseases of the Pia Mater 883 Haemorrhage into the Spinal Membranes 885 3. Affections of the Blood-vessels 886 4. Acute Affections of the Spinal Cord 889 Acute Myelitis 889 Myelitis of the Anterior Horns 892 Acute and Subacute Polio-myelitis in Adults 896 Acute Ascending (Landry’s) Paralysis 896 XIV CONTENTS. PAGE 5. Chronic Affections of the Spinal Cord 898 Spastic Paraplegia 898 Locomotor Ataxia 902 Hereditary Ataxia (Friedreich’s Ataxia) 911 Syringo-myelia 912 Compression of the Spinal Cord 914 Lesions of the Cauda Equina and Conus Medullaris .... 916 Tumors of Spinal Cord and its Membranes 917 Progressive (Spinal) Muscular Atrophy 919 Bulbar Paralysis 922 IY. Diseases of the Brain 924 1. Topical Diagnosis 924 2. Aphasia 927 3. Affections of the Meninges 932 Diseases of the Dura Mater (Pachymeningitis) 932 Diseases of the Pia Mater 933 4. Affections of the Blood-vessels 937 Hyperaemia 937 Anaemia 938 CEdema of the Brain 939 Cerebral Haemorrhage 940 Embolism and Thrombosis (Cerebral Softening) 949 Aneurism of the Cerebral Arteries 955 Endarteritis 956 Thrombosis of the Cerebral Sinuses and Veins 956 5. Hemiplegia and Diplegia in Children 958 Hemiplegia 958 Spastic Diplegia (Birth Palsies) 961 Spastic Paraplegia 962 6. Sclerosis of the Brain 963 Miliary Sclerosis 964 Diffuse Sclerosis 964 Tuberous Sclerosis 965 Insular Sclerosis (Sclerose en Plaques) 965 7. Chronic Diffuse Meningo-encephalitis 966 8. Tumors of the Brain 970 9. Inflammation of the Brain 974 10. Chronic Hydrocephalus 977 V. General and Functional Diseases 980 1. Acute Delirium (Bell’s Mania) 980 2. Paralysis Agitans . 982 Other Forms of Tremor 984 3. Acute Chorea (Sydenham’s Chorea; St. Vitus’s Dance) .... 985 4. Other Affections described as Chorea 996 Chorea Major; Pandemic Chorea 996 Habit Spasm; Convulsive Tic 996 Saltatoric Spasm 997 Chronic Chorea 998 Rhythmic Chorea 999 5. Infantile Convulsions (Eclampsia) 999 6. Epilepsy 1002 Grand Mai 1004 CONTENTS. XV PAGE Petit Mai 1006 Jacksonian Epilepsy 1007 7. Migraine 1011 8. Neuralgia 1013 9. Professional Spasms; Occupation Neuroses 1017 10. Tetany 1019 11. Hysteria 1021 <■ Convulsive Form 1022 Non-convulsive Form 1023 12. Neurasthenia 1032 13. The Traumatic Neuroses 1035 14. Other Forms of Functional Paralysis 1039 Periodical Paralysis 1039 Astasia—Abasia 1040 VI. Vaso-motor and Trophic Disorders 1041 1. Raynaud’s Disease 1041 2. Angio-neurotie (Edema 1043 3. Facial Hemi-atrophy 1044 4. Acromegalia 1045 5. Scleroderma 1048 Ainhum 1049 SECTION IX. I. Myositis 1050 II. The Muscular Dystrophies 1051 Progressive Neural Muscular Atrophy 1054 III. Thomsen’s Disease; Myotonia Congenita 1054 IV. Paramyoclonus Multiplex 1055 DISEASES OF THE MUSCLES. SECTION X. THE INTOXICATIONS; SUN-STROKE; OBESITY. I. Alcoholism 1057 1. Acute Alcoholism 1057 2. Chronic Alcoholism 1057 3. Delirium Tremens 1059 II. Morphia Habit 1061 III. Lead Poisoning 1063 IV. Arsenical Poisoning 1067 V. Ptomaine Poisoning 1069 1. Meat Poisoning 1069 2. Poisoning by Milk Products 1071 3. Poisoning by Shell-fish and Fish 1071 VI. Grain Poisoning 1072 1. Ergotism 1072 2. Lathyrism 1072 3. Pellagra 1073 VII. Sun-stroke 1073 Vlll. Obesity 1077 xvi CONTENTS. SECTION XI. DISEASES DUE TO ANIMAL PARASITES. PAGE I. Psorospermiasis 1080 1. Internal Psorospermiasis 1080 2. Cutaneous Psorospermiasis 1081 II. Parasitic Infusoria 1082 III. Distomiasis 1082 IV. Diseases caused by Nematodes 1083 1. Ascariasis 1083 2. Trichiniasis 1085 3. Anchylostomiasis 1090 4. Filiariasis 1091 5. Dracontiasis 1093 6. Other Nematodes 1094 Acanthocephala 1095 V. Diseases caused by Cestodes 1096 1. Intestinal Cestodes; Tape-worms 1096 2. Visceral Cestodes 1099 Cysticercus Cellulosae 1099 Echinococcus Disease 1100 Multilocular Echinococcus 1105 VI. Parasitic Arachnida 1106 VII. Parasitic Insects 1108 VIII. Myiasis 1109 CHARTS AND ILLUSTRATIONS. CHART PAGE I. Typhoid Fever with Relapse 14 II. Illustrating the Blood Changes in Typhoid Fever 19 III. Typhoid Fever—Haemorrhage from the Bowels * 22 IV. Illustrating Influence of Baths in Typhoid Fever 39 V. Relapsing Fever (after Murchison) 49 VI. Small-pox (after Striimpell) 54 VII. Haemorrhagic Small-pox 57 VIII. Scarlet Fever (after Striimpell) 74 IX. Measles (after Striimpell) 82 X. Malaria—Tertian Ague 164, 165 XI. Illustrating Heredity in Tuberculosis 207 XII. Chronic Tuberculosis, Two-hourly Chart for Three Days .... 244 XIII. Blood Chart, illustrating Rapid Production of Antenna in Purpura Haemorrhagica 346 XIV. Temperature, Pulse, and Respiration Chart in Pneumonia . . . 552 XV. Blood Chart, illustrating Anaemia in Purpura Haemorrhagica . . . 721 XVI. Blood Chart, illustrating Chlorosis 724 XVII. Blood Chart, illustrating Pernicious Anaemia 730 XVIII. Blood Chart, illustrating Leukaemia 739 XIX. Case of Sun-stroke treated with the Ice-bath. Recovery. (Rectal Tem- peratures) 1075 FIGURE 1. Diagram of Motor Path (Van Gehuchten) 817 2. Diagram of Motor Path from Right Brain (Van Gehuchten) . . . 818 3. Diagram of Cerebral Localization 822 4. Diagram of Motor and Sensory Representation in the Internal Capsule . 823 5. Diagram of Motor and Sensory Paths in Crura 824 6. Diagram of Cross-section of Spinal Cord 824 7, 8. Head’s Diagrams of Skin Areas corresponding to the Different Spinal Segments 826, 827 9. Diagram of Visual Paths (Vialet) 846 10. Lichtheim’s Schema 927 11. Diagram of Motor Path from Right Brain 945 * The red shows the two-hourly, the black the morning and evening temperature. “ Experience is fallacious and judgment difficult.” Hippocrates : Aphorisms, I. “ And I said of medicine, that this is an art which considers the constitution of the patient, and has principles of action and reasons in each case.” Plato: Gorgias. A TEXT-BOOK ON THE PRACTICE OF MEDICINE. SECTION I. SPECIFIC INFECTIOUS DISEASES.. I. TYPHOID FEVER. Definition.—An infectious disease, characterized anatomically by hyperplasia and ulceration of the lymph-follicles of the intestines, swell- ing of the mesenteric glands and spleen, and parenchymatous changes in the other organs. The bacillus of Eberth is constantly present in the lesions. Clinically the disease is marked by fever, a rose-colored eruption, diarrhoea, abdominal tenderness, tympanites, and enlargement of the spleen; but these symptoms are extremely inconstant, and even the fever varies in its characters. Historical Note.—The dates 1813 and 1850 include the modern discussion of the subject. Prior to the former year many observers had noted clinical differences in the continued fevers. Huxham in particular, in his remarkable Essay on Fevers, had “ taken notice of the very great difference there is between the putrid malignant and the sloiv nervous fever.” In 1813 Pierre Bretonneau, of Tours, distinguished “ dothienen- terite ” as a separate disease ; and Petit and Serres described entero-mes- enteric fever. Trousseau and Velpeau, students of Bretonneau, were, in 1820, instrumental in making his views known to Andral and others in Paris. In 1829 Louis’ great work appeared, in which the name “ typhoid ” was given to the fever. At this period typhoid fever alone prevailed in Paris, and it was universally believed to be identical with the continued fever of Great Britain, where in reality typhoid and typhus coexisted ; and the intestinal lesion was regarded as an accidental occurrence in the course of ordinary typhus. Louis’ students returning to their homes in different countries had opportunities of studying the prevalent fevers in the thor- ough and systematic manner of their master. Among these were certain young American physicians, to one of whom, Gerhard, of Philadelphia, is due the great honor of having first clearly laid down the differences between the two diseases. His papers in the American Journal of the 2 SPECIFIC INFECTIOUS DISEASES. Medical Sciences, 1837, are undoubtedly the first in any language which give a full and satisfactory account of the clinical and anatomical distinc- tions we now recognize. No student should fail to read these articles, among the most classical in American medical literature. Louis’ influence was early felt in Boston, to which, in 1833, James Jackson, Jr., had returned from Paris. In this year he demonstrated, in his father’s wards at the Massachusetts General Hospital, the identity of the typhus of this country with the typhoid of Louis. He had already, in 1830, noticed the intestinal lesions in the common fever of New Eng- land. Though cut off at the very outset of his career, we may reasonably attribute to his inspiration the two elaborate memoirs on typhoid fever which, in 1838 and 1839, were issued from the Massachusetts General Hospital, by James Jackson, Sr., and Enoch Hale. These, with Gerhard’s articles, contributed to make typhoid fever, as distinguished from typhus, widely recognized in the profession here long before the distinctions were recognized generally in Europe. Thus, they were described under differ- ent headings in the first edition of Bartlett’s admirable work on Fevers, published in 1842. The recognition in Paris of a fever distinct from typhoid, without intestinal lesions, was due largely to the influence of the able papers of George C. Shattuck, of Boston, and Alfred Stille, of Philadelphia, which were read before the Societe medicale d’Observation in 1838. At Louis’ request, Shattuck went to the London Fever Hospital to study the disease in England, where he saw the two distinct affections, and brought back a report which was very convincing to the members of the society (Medical Examiner, Philadelphia, 1840). Stille had the advantage of going to Paris knowing thoroughly the clinical features of typhus fever, for he had been Gerhard’s house-physician at the Philadelphia Hospital during the epidemic of 1836. At La Pitie, with Louis, he saw quite a different affection, while in London, Dublin, and Naples he recognized typhus as he had seen it in Philadelphia. The results of his observation were given in an exhaustive paper which pre- sented in tabular form the contrasts and distinctions, clinical and ana- tomical, which we now recognize. In Great Britain the non-identity of typhus and typhoid was clearly established at Glasgow, where from 1836 to 1838 A. P. Stewart studied the continued fevers, and in 1840 published the results of his observations. In the decade which followed many important works were issued and more correct views gradually prevailed ; but it was not until the publica- tion of Jenner’s observations between 1849 and 1851 that the question was finally settled in England. Etiology.—Typhoid fever prevails especially in temperate climates, in which it constitutes the most common continued fever. Widely dis- tributed throughout all parts of the world, it probably presents every- where the same essential characters. TYPHOID FEVER. 3 It prevails most in the autumn months. Of 1,889 cases admitted to the Montreal General Hospital in twenty years, more than fifty per cent were in the months of August, September, and October. Of 1,381 cases treated during twelve years at the Toronto General Hospital, 761 oc- curred in these months (Graham). It has been well called the autumnal fever. It has been observed to prevail most in hot and dry seasons. Accord- ing to Pettenkofer, epidemics are most common when the ground-water is low, under which circumstances the springs and water-sources drain more thoroughly contaminated foci and are more likely to be highly charged with poison. It may be also, as Baumgarten suggests, that in dry seasons the poison is more disseminated in the dust. Males and females are about equally liable to the disease, but males with typhoid are much more frequently admitted into hospitals. Typhoid fever is a disease of youth and early adult life. The greatest susceptibility is between the ages of fifteen and twenty-five. Of 660 of the Montreal cases there were under fifteen years of age, 51; between fifteen and twenty-five years, 308 ; between twenty-five and thirty-five years, 153; between thirty-five and forty-five years, 43; between forty-five and fifty-five years, 6; and over fifty-five years, 9. Cases are rare over sixty. It is not very infrequent in childhood, but infants are rarely attacked. Murchison has seen a case at the sixth month. The disease may be con- genital in cases in which the mother has had the disease late in pregnancy. As in other fevers, not all exposed to the infection take the disease, and there are grades of susceptibility. Some families seem more disposed to infection than others. Typhoid fever is becoming less prevalent in the large cities in conse- quence of improved sanitation. In suburban and country districts it is apparently on the increase. The Specific Germ.—The researches of Eberth, Koch, Gaffky, and others have shown that there is a special micro-organism constantly asso- ciated with typhoid fever. It is a rather short, thick, motile bacillus, with rounded ends, in one of which, sometimes in both (particularly in cul- tures), there can be seen a glistening round body, believed to be a spore; but these polar structures are probably only areas of dense protoplasm. It grows readily on various nutritive media, and can now be differentiated from the bacterium coli commune, with which, and with certain other bacilli, it is apt to be confounded. This organism fulfils two of the re- quirements of Koch’s law—it is constantly present, and it grows outside the body in a specific manner. The third requirement, the production of the disease experimentally by the cultures, has not yet been met. Probably the animals used for experimentation are not susceptible to typhoid fever. The bacilli or their toxins inoculated in large quantities into the blood of rabbits are pathogenic, and in some instances ulcerative and necrotic lesions in the intestine may be produced. But similar intes- 4 SPECIFIC INFECTIOUS DISEASES. tinal lesions may be caused by other bacteria, including the bacterium coll commune. Cultures are killed at a temperature of 60° C. It is not probable that the typhoid bacillus produces spores, but it resists drying for days. Bouil- lon cultures are destroyed by carbolic acid, 1 to 200, and by corrosive sub- limate, 1 to 2,500. In recent cases of typhoid fever the bacilli are found in the lymphoid tissues of the intestines, in the mesenteric glands, in the spleen, in the bone marrow, in the liver, and in the bile. The bacilli occur also in ir- regular clumps in the contents of the intestines and in the stools; but the studies of Sanarelli and of Wathelet, with more recent methods of differ- entiating the colon bacillus, have shown that they are scanty in the fasces, and may not be present in the stools until the tenth day or later. Cul- tures from the contents of the small intestine in fatal cases may be nega- tive. The bacilli have been found in the blood and in the rose-colored spots. In the urine they may be present in numbers, and they have been found in the sweat. From the endocardial vegetations, from meningeal and pleural exudates, and from foci of suppuration in various parts, the bacilli have also been isolated. Outside the body the bacilli retain their vitality for weeks in water. Whether an increase can occur is not yet finally settled. Bolton denies it, but the general opinion seems to be that such increase may take place to some extent. They disappear from ordinary water in competition with saprophytes in a few days. In milk they undergo rapid development with- out changing the appearance of the milk. They may increase in the soil and retain their vitality for months. They are not killed by freezing, but, as Prudden has shown, may live in ice for months. In many epidemics the bacilli have been detected in the infected water. The detection how- ever of the typhoid bacillus in drinking-water is by no means easy, and the question in individual cases must be settled by experts who have had special experience with this germ. Both Prudden and Ernst have found it in water-filters. The direct infection by dust of exposed food-stuffs, such as milk, is very probable. The bacilli retain their vitality for many weeks; in gar- den earth twenty-one days, in filter-sand eighty-two days, in dust of the street thirty days, on linen sixty to seventy days, on wood thirty-two days (Uffelmann). Modes of Conveyance.—(a) Contagion.—The possibility of the direct transmission through the air from one person to another must be acknowledged. There are house epidemics in which contamination of the water or food could be almost positively excluded. The nurses and attendants who have to do with the stools and body-linen of the pa- tients are alone liable to direct infection. During the past six years one nurse, one orderly, and one patient contracted the disease in my wards. TYPHOID FEVER. 5 (6) Infection of ivater is unquestionably the most common mode of conveyance. Many epidemics have been shown to originate in the con- tamination of a well or a spring. A very striking one occurred at Plym- outh, Pa., in 1885, which was investigated by Shakespeare. The town, with a population of eight thousand, was in part supplied with drink- ing-water from a reservoir fed by a mountain stream. During January, February, and March, in a cottage by the side of and at a distance of from sixty to eighty feet from this stream, a man was ill with typhoid fever. The attendants were in the habit at night of throwing out the evacua- tions on the ground toward the stream. During these months the ground was frozen and covered with snow. In the latter part of March and early in April there was considerable rainfall and a thaw, in which a large part of the three months’ accumulation of discharges was washed into the brook, not sixty feet distant. At the very time of this thaw the patient had numerous and copious discharges. About the 10th of April cases of typhoid fever broke out in the town, appearing for a time at the rate of fifty a day. In all about twelve hundred people were affected. An im- mense majority of all the cases were in the part of the town which received water from the infected reservoir. (c) Infection of Food.—Milk may be the source of infection. One of the most thoroughly studied epidemics due to this cause was that investi- gated by Ballard in Islington. The milk may be contaminated by infected water used in cleansing the cans. In fresh milk it has been shown that the germs grow rapidly. In addition to the milk, the germs may be conveyed in ice, salads of various sorts, celery; and the food may be readily contaminated by the soiled fingers of the attendants, or of the patient himself. A fly which has alighted on the soiled linen of a typhoid patient in a ward may sub- sequently contaminate the milk or other food. Oysters may become infected during the process of fattening or fresh- ening. In the Middletown epidemic, reported by H. W. Conn, the chain of circumstantial evidence seems complete; and most suggestive sporadic cases have been recorded by Sir William Broadbent and others. C. J. Foote has made an interesting bacteriological study of the sub- ject. Oysters taken from the feeding-grounds in rivers contain a very much larger number of micro-organisms of all sorts than those from the sea. He has shown, too, that Eberth’s bacillus will live in the brackish water in which oysters are fattened even when frozen ; and that it will also live in the oyster itself, and for a longer time than in the water in which the oyster grows. Whether multiplication takes place in the oyster is doubtful. (d) Contamination of the Soil.—Pettenkofer holds that the poison is not eliminated in a condition capable of communicating the disease di- rectly, but that it must first undergo changes in the soil, which changes are favored by the ground-water. 6 SPECIFIC INFECTIOUS DISEASES. Filth, bad sewers, or cesspools can not in themselves cause typhoid fever, but they furnish the conditions suitable for the preservation of the bacillus, and possibly for its propagation. Once in the intestinal canal the germs probably do not, as do the chol- era bacilli, increase in the contents, but penetrate the epithelial lining and reach the lymphoid tissue, upon which they exert their specific action, causing a cell proliferation greatly in excess of the physiological process. The necrosis may be regarded as the result of the maximum intensity of the action of the bacilli—an action not confined to the lymphatic appa- ratus of the intestinal wall, but also met with in a typical manner in the enlarged mesenteric glands and in the liver and spleen. Products of the Growth of the Bacilli.—Brieger and Fraenkel have separated from bouillon cultures a poison belonging to the group of tox- albumins, and to this typhotoxin, as it has been called, the more serious features of the disease are ascribed. Sanarelli has found that in addition to a general toxic action similar to other poisons of its class, the typho- toxin produces in animals changes in the small bowel, particularly in the lymph elements. Morbid Anatomy.—The statistical details under this heading are based upon eighty autopsies, a majority of which were performed at the Montreal General Hospital, and upon the records of two thousand post- mortems at the Munich Pathological Institute.* Intestines.—A catarrhal condition exists throughout the small and large bowel, and to this is due, in all probability, the diarrhoea with the thin pea-soup-like stools. Associated with this catarrh there is some epi- thelial desquamation. Specific changes occur in the lymphoid elements of the bowel, chiefly at the lower end of the ileum. The alterations which occur are most con- veniently described in four stages : 1. Hyperplasia, wdiich involves the glands of Peyer in the jejunum and ileum, and to a variable extent those in the large intestine. The follicles are swollen, grayish-white in color, and the patches may project to a dis- tance of from three to five mm. In exceptional cases they may be still more prominent. The solitary glands, which range in size from a pin’s head to a large pea, are usually deeply imbedded in the submucosa, but project to a variable extent. Occasionally they are very prominent, and may be almost pedunculated. Microscopical examination shows at the outset a condition of hyperaemia of the follicles. Later there is a great increase and accumulation of cells of the lymph-tissue which may even infiltrate the adjacent mucosa and the muscularis; and the blood-vessels are more or less compressed, which gives the whitish, anaemic appearance to the follicles. The cells have all the characters of ordinary lymph-cor- puscles. Some of them however are larger, epithelioid, and contain several * Miinchener medicinische Wochenschrift, Nos. 3 and 4, 1891. TYPHOID FEVER. 7 nuclei. Occasionally cells containing red blood-corpuscles are seen. This so-called medullary infiltration, which is always more intense toward the lower end of the ileum, reaches its height from the eighth to the tenth day and then undergoes one of two changes, resolution or necrosis. Death very rarely takes place at this stage. Resolution is accomplished by a fatty and granular change in the cells, which are destroyed and absorbed. A curious condition of the patches is produced at this stage, in which they have a reticulated appearance, the plaques a surface reticulee. The swoll- en follicles in the patch undergo resolution and shrink more rapidly than the surrounding framework, or what is more probable the follicles alone owing to the intense hyperplasia become necrotic and disintegrate, leaving the little pits. In this process superficial haemorrhages may result, and small ulcers may originate by the fusion of these superficial losses of sub- stance. There is nothing distinctive in the hyperplasia of the lymph-follicles in typhoid fever; but apart from this disease we rarely see in adults a marked affection of these glands with fever. In children however it is not uncommon when death has occurred from intestinal affections, and it is also met with in measles, diphtheria, and scarlet fever. 2. Necrosis and Sloughing.—When the hyperplasia of the lymph-fol- licles reaches a certain grade resolution is no longer possible. The blood- vessels become choked, there is a condition of anaemic necrosis, and sloughs form which must be separated and thrown off. The necrosis is probably due in great part to the direct action of the bacilli. The process may be superficial, affecting only the upper part of the mucous coat, or it may extend to and involve the submucosa. The “ slough ” may sometimes lie upon the Peyer’s patch, scarcely involving the epithelium (Marchand). It is always more intense toward the ileo-caecal valve, and in very severe cases the greater part of the mucosa of the last foot of the ileum may be converted into a brownish-black eschar. The necrotic area in the solitary glands forms a yellowish cap which often involves only the most promi- nent point of a follicle. The extent to which the necrosis reaches is very variable. It may pass deep into the muscular coat reaching to or even perforating the peritonseum. 3. Ulceration.—The separation of the necrotic tissue—the sloughing— is gradually effected from the edges inward, and results in the formation of an ulcer, the size and extent of which are directly proportionate to the amount of necrosis. If this be superficial, the entire thickness of the mucosa may not be involved and the loss of substance may be small and shallow. More commonly the slough in separating exposes the submucosa and muscularis, particularly the latter, which forms the floor of a majority of all typhoid ulcers. It is not common for an entire Peyer’s patch to slough away, and a perfectly ovoid ulcer opposite to the mesentery is rarely seen. Irregularly oval and rounded forms are most common. A large patch may present three or four ulcers divided by septa of mucous SPECIFIC INFECTIOUS DISEASES. 8 membrane. The terminal six or eight inches of the mucous membrane of the ileum may form a large ulcer, in which are here and there islands of mucosa. The edges of the ulcer are usually swollen, soft, sometimes congested, and often undermined. At a late period the ulcers near the valve may have very irregular sinuous borders. The base of a typhoid ulcer is smooth and clean, usually formed of the submucosa or of the muscularis. There may be large ulcers near the valve and swollen hypersemic patches of Peyer in the upper part of the ileum. 4. Healing.—This begins with the development of a thin granulation tissue which covers the base and gives to it a soft, shining appearance. The mucosa gradually extends from the edge, and a new growth of epi- thelium is formed. The glandular elements are reformed ; the healed ulcer is somewhat depressed and is usually pigmented. Occasionally an appearance is seen as if an ulcer had healed in one place and was extend- ing in another. In death during relapse healing ulcers may be seen in some patches with fresh ulcers in others. We may say, indeed, that healing begins with the separation of the sloughs, as, when resolution is impossible, the removal of the necrosed part is the first step in the process of repair. Practically, in fatal cases, we seldom meet with evidences of cicatrization, as the majority of deaths occur before this stage is reached. Large Intestine.—The caecum and colon are affected in about one third of the cases. Sometimes the solitary glands are greatly enlarged. The ulcers are usually larger in the caecum than in the colon. Perfora- tion of the caecum is rare. The appendix may be involved. Are the enteric lesions constant and specific ? In an immense major- ity of all cases the intestinal lymph-follicles are involved, but it is claimed that exceptionally the disease may exist without lesions of the bowel. Several instances are reported; but Du Cazel’s case is the most satisfac- tory. The symptoms were those of typhoid fever, and at the autopsy the spleen, mesenteric glands, and kidneys were swollen and congested. There was no lesion of the intestine. Typhoid bacilli were isolated by the most approved recent methods. Perforation of the Bowel.—In one hundred and fourteen cases of the two thousand Munich autopsies (5-7 per cent) and in twenty-two instances in my series, the intestine was perforated and death caused b}r peritonitis. The perforation may occur in ulcers from which the sloughs have already separated, or it may be directly due to the extension of a necrosis through all the coats. In only a few cases is the perforation at the bottom of a clean thin-walled ulcer. In one instance the perforation occurred two weeks after the temperature had become normal. The sloughs are, as a rule, adherent about the site of perforation, which in a majority of the cases occur in small deep ulcers. There may be two or even three perforations. The orifice is usually within the last foot of the ileum. In only one of TYPHOID FEVER. 9 my cases was it distant eighteen inches. In four cases of my series the appendix was perforated and in two the large bowel. Peritonitis was present in every instance. Hcemorrhage from the bowels occurred in ninety-nine of the Munich cases. The bleeding seems to result directly from the separation of the sloughs. I was not able in any instance to find the bleeding vessel. In one case only a single patch had sloughed, and a firm clot was adherent to it. The bleeding may also come from the soft swollen edges of the patch. The mesenteric glands at first show intense hyperaemia and subse- quently become greatly swollen. Spots of necrosis are common. In sev- eral of my cases suppuration had occurred, and in one a large abscess of the mesentery was present. The bunch of glands in the mesentery, at the lower end of the ileum, is especially involved. The retroperitoneal glands are also swollen. The spleen is invariably enlarged in the early stages of the disease. In only one of my cases did it exceed 20 ounces (600 grammes) in weight. The tissue is soft, even diffluent. Infarction is not infrequent. Rupture may occur spontaneously or as a result of injury. In the Munich autop- sies there were five instances of rupture of the spleen, one of which re- sulted from a gangrenous abscess. The liver shows signs of parenchymatous degeneration. Early in the disease it is hyperaemic, and in a majority of instances it is swollen, some- what pale, on section turbid, and microscopically the cells are very granu- lar and loaded with fat. Nodular areas (microscopic) occur in many cases, as described by Handford. Reed, in Welch’s laboratory, could not deter- mine any relation between the groups of bacilli and these areas. Some of the nodules are lymphoid, others are necrotic (Amyot). In twelve of the Munich autopsies liver abscess was found, and in three, acute yellow atrophy. Diphtheritic inflammation of the gall-bladder is occasionally met with. This may lead to perforation and fatal peritonitis. The typhoid bacilli have been demonstrated in the inflamed organ (Chiari). Pylephlebitis may follow abscess of the mesentery or perforation of the appendix. Kidneys.—Cloudy swelling, with granular degeneration of the cells of the convoluted tubules, less commonly an acute nephritis, may be present. Rayer, Wagner, and others described the occurrence of numerous small areas infiltrated with round cells, which may have the appearance of lymphomata, or may pass on to softening and suppuration, producing the so-called miliary abscesses. It is usually a late change. The typhoid bacilli alone have been found by some observers in these areas. They may also be found in the urine. In ten cases of pyuria in typhoid fever in my wards Blumer found the bacilli in two. Diphtheritic inflammation of the pelvis of the kidney may occur. It was present in three of my cases, in one of which the tips of the papillae were also affected. Catarrh of the 10 SPECIFIC INFECTIOUS DISEASES. bladder is not uncommon. Diphtheritic inflammation of it may also occur. Orchitis is occasionally met with. Respiratory Organs.—Ulceration of the larynx occurs in a certain number of cases; in the Munich series it was noted one hundred and seven times. It may come on at the same time as the ulceration in the ileum, but the bacilli have not yet, I believe, been found in the ulcers. They occur in the posterior wall, at the insertion of the cords, at the base of the epiglottis, and on the ary-epiglottidean folds. In the later periods catar- rhal and diphtheritic ulcers may be present. (Edema of the glottis was present in twenty of the Munich cases, in eight of which tracheotomy was performed. Diphtheritis of the pharynx and larynx is not very uncommon. It occurred in a most extensive form in two of my cases. Lobar pneumonia may be found early in the disease (see Pneumo-typhus), or it may be a late event. Hypostatic congestion and the condition of the lung spoken of as splenization are very common. Gangrene of the lung occurred in forty cases in the Munich series; ab- scess of the lung in fourteen; haemorrhagic infarction iu one hundred and twenty-nine. Pleurisy is not a very common event. Fibrinous pleurisy occurred in about six per cent of the Munich cases, and empyema in nearly two per cent. Changes in the Circulatory System.—Endocarditis is rare. I have met with it twice, and it existed in eleven only of the Munich autopsies, in which also there were fourteen cases of pericarditis. Myocarditis is not very infrequent. Dewevre, in a series of forty-eight cases, found in six- teen granular or fatty degeneration, and in three a proliferating endarter- itis in the small vessels. It is remarkable that even in cases of death from heart-failure, with intense fever, the cell-fibres may present little or no observable change. The arteries are not infrequently involved in typhoid fever. Barie distinguishes an acute obliterating arteritis and a partial arteritis, and states that they both occur most commonly in the arteries of the lower extremities. They are responsible, no doubt, for certain of the cases of blocking of the arterial trunks. This arteritis may affect the smaller vessels, particularly those of the heart. In the veins, thrombi are not infrequently found, particularly in the femoral veins, and more rarely in the cerebral veins or sinuses. Nervous System.—There are very few coarse changes met with. Men- ingitis is extremely rare. It was not present in any one of my autopsies, and occurred in only eleven of the two thousand Munich cases. The exu- dation may be either serous or purulent, and in both typhoid bacilli have been demonstrated (Pictine). Thrombosis of the cortical veins of the pia mater caused the death, on the eighth day, of one of my assistants. The anatomical lesion of the aphasia—seen not infrequently in children —is not known, possibly it is an encephalitis. Parenchymatous changes have been met with in the peripheral nerves, and appear to be not very uncommon, even when there have been no symptoms of neuritis. TYPHOID FEVER. 11 The voluntary muscles show, in certain instances, the changes described by Zenker, which occur however in all long-standing febrile affections, and are not peculiar to typhoid fever. The muscle substance within the sar- colemma undergoes either a granular degeneration or a hyaline transfor- mation. The abdominal muscles, the adductors of the thighs, and the pectorals are most commonly involved. Rupture of a rectus abdominis has been found post-mortem. Haemorrhage may occur. Abscesses may develop in the muscles during convalescence. Typhoid Septicaemia.—There are instances of the general infection of the body with the Eberth bacilli. The human blood-serum as a rule rapidly kills the typhoid germ; but under certain conditions, as yet un- known—either increased virulence of the germ or diminished bacteri- cidal power of the blood-serum—it multiplies in all the organs and in the blood, constituting a veritable septicaemia. Such a case has been described recently by Flexner from my wards.* The intestinal lesions were slight. Until the development of parotitis the symptoms pointed rather to cerebro- spinal meningitis. The temperature was low and irregular. Symptoms.—In a disease so complex as typhoid fever it will be well first to give a general description, and then to study more fully the symp- toms, complications, and sequelae according to the individual organs. General Description.—The period of incubation lasts from “ eight to fourteen days, sometimes twenty-three” (Clinical Society), during which there are feelings of lassitude and inaptitude for work. The onset is rarely abrupt. There may be prodromal symptoms, either a rigor, which is rare, or chilly feelings, headache, nausea, loss of appetite, pains in the back and legs, and nose-bleeding. These symptoms increase in severity and the patient at last takes to his bed. From this event, in a majority of cases, the definite onset of the disease may be dated. During the first iveek there is, in some cases (but by no means in all, as has long been taught), a steady rise in the fever, the evening record rising a degree or a degree and a half higher each day, reaching 103° or 104°. The pulse is rapid, from 100 to 110, full in volume, but of low tension and often dicrotic; the tongue is coated and white ; the abdomen is slightly distended and tender. Unless the fever is high there is no delirium, but the patient complains of headache, and there may be mental confusion and wandering at night. The bowels may be constipated, or there may be two or three loose move- ments daily. Toward the end of the week the spleen becomes enlarged and the rash appears in the form of rose-colored spots, seen first on the skin of the abdomen. Cough and bronchitic symptoms are not uncommon at the outset. In the second weelc, in cases of moderate severity, the symptoms be- come aggravated; the fever remains high and the morning remission is slight. The pulse is rapid and loses its dicrotic character. There is no * Journal of Pathology and Bacteriology, April, 1895. 12 SPECIFIC INFECTIOUS DISEASES. longer headache, but there are mental torpor and dulness. The face looks heavy; the lips are dry; the tongue, in severe cases, becomes dry also. The abdominal symptoms are more marked—diarrhoea, tympanites, and tenderness. Death may occur during this week, with pronounced nerv- ous symptoms, or, toward the end of it, from haemorrhage or perfora- tion. In mild cases the fever declines, and by the fourteenth day may be normal. In the third week, in cases of moderate severity, the pulse ranges from 110 to 130; the temperature now shows marked morning remissions, and there is a gradual decline in the fever. The loss of flesh is now more noticeable, and the weakness is pronounced. The diarrhoea and meteor- ism may persist. Unfavorable symptoms at this stage are the pulmo- nary complications, increasing feebleness of the heart, and pronounced delirium with muscular tremor. Special dangers are perforation and haemorrhage. With the fourth week, in a majority of instances, convalescence begins. The temperature gradually reaches the normal point, the diarrhoea stops, the tongue cleans, and the desire for food returns. In severe cases the fourth and even the fifth week may present an aggravated picture of the third ; the patient grows weaker, the pulse is more rapid and feeble, the tongue dry, and the abdomen distended. He lies in a condition of pro- found stupor, with low muttering delirium and subsultus tendinum, and passes the fasces and urine involuntarily. Heart-failure and secondary complications are the chief dangers of this period. In thQ fifth and sixth iveeks protracted cases may still show irregular fever, and convalescence may not set in until after the fortieth day. In this period we meet with relapses in the milder forms or slight recru- descence of the fever. At this time, too, occur many of the complications and sequelae. Special Features and Symptoms.—Mode of Onset.— As a rule, the symptoms develop insidiously, and the patient is unable to fix definitely the time at which he began to feel ill. The following are the most im- portant deviations from this common course : (a) Onset with Pronounced Nervous Manifestations.—Headache, of a severe and intractable nature, is by no means an infrequent initial symp- tom. Again, a severe facial neuralgia may for a few days put the practi- tioner off his guard. In cases in which the patients have kept about and, as they say, fought the disease, the very first manifestations may be pro- nounced delirium. Such patients may even leave home and wander about for days. In rare cases the disease sets in with the most intense cerebro- spinal symptoms, simulating meningitis—severe headache, photophobia, retraction of the head, twitching of the muscles, and even convulsions. Occasionally drowsiness, stupor, and signs of basilar meningitis may exist for ten days or more before the characteristic symptoms develop ; occa- sionally the onset is with mania. TYPHOID FEVER. 13 (b) With Pronounced Pulmonary Symptoms.—The initial bronchial catarrh may be of great severity and disguise the other features of the disease. More striking still are those cases in which the disease sets in with a single chill, with pain in the side and all the characteristic features of lobar pneumonia, or of acute pleurisy. (c) With Intense Gastro-intestinal Symptoms.—The vomiting may be incessant and uncontrollable. Occasionally there are cases with such intense vomiting and diarrhoea that a suspicion of poisoning may be aroused. (d) With Symptoms of an Acute Nephritis.—Smoky or bloody urine, with much albumen and tube-casts. (e) Ambulatory Form.—Deserving of especial mention are those cases of typhoid fever in which the patient keeps about and attempts to do work, or perhaps takes a long journey to his home. He may come under observation for the first time with a temperature of 104° or 105°, and with the rash well out. Many of these cases run a severe course, and in general hospitals they contribute largely to the total mortality. Finally, there are rare instances in which the first symptom is perforation, or a profuse haemorrhage from the bowels. Facial Aspect.—Early in the disease the cheeks are flushed and the eyes bright. Toward the end of the first week the expression becomes more listless, and when the disease is well established the expression is dull and heavy. There is never the rapid anaemia of malarial fever, and the color of the lips and cheeks may be retained even to the third week. Fever.—(a) Regular Course. (Chart I.)—In the stage of invasion the temperature rises steadily during the first five or six days. The even- ing temperature is about a degree or a degree and a half higher than the morning remission, so that a temperature of 104° or 105° is not uncom- mon by the end of the first week. Having reached the fastigium or height, the fever then persists with slight morning remissions. The tem- perature curve follows the normal diurnal variations, the maximum oc- curring between four and eight o’clock in the evening and the minimum between four and eight in the morning. At the end of the second and throughout the third week the temperature becomes more distinctly re- mittent. The difference between the morning and evening may be three or four degrees, and the morning temperature may even be normal. It falls by lysis, and the temperature is not considered normal until the evening record is at 98-2°. (£) Variations in the normal temperature curve are common. We do not always see the gradual step-like ascent in the early stage; the cases do not often come under observation at this time. When the disease sets in with a chill, the temperature may rise at once to 103° or 104°. In many cases defervescence occurs at the end of the second week and the temperature may fall rapidly, reaching the normal within twelve or twenty 14 SPECIFIC INFECTIOUS DISEASES. __.Ward. Chart I.—Typhoid Fever with relapse. .Admitted... No. TYPHOID FEVER. 15 hours. An inverse type of temperature, high in the morning and low in the evening, is occasionally seen but has no especial significance. Sudden falls in the temperature may occur; thus, as shown in Chart III, a drop of 10° may follow an intestinal haemorrhage, and the fall may be very apparent even before the blood has appeared in the stools. Hy- perpyrexia, temperature above 106°, is not very common in typhoid fever except just before death, when I have known the thermometer to register 109-5°. (ic) Post-Typhoid Elevations—Fever of Convalescence.—During con- valescence, after the temperature has been normal, perhaps for five or six days, the fever may rise suddenly to 102° or 103°, and, after persisting for from one to three days or even longer, falls to normal. With this there is no constitutional disturbance, no furring of the tongue, no distention of the abdomen. These so-called recrudescences are by no means uncom- mon, and are of especial importance, as they cause great anxiety to the practitioner. They are attributed most frequently to errors in diet, con- stipation, emotions, and excitement of any sort, such as seeing friends. There are cases in which the temperature declines almost to the nor- mal at the end of the third wreek, the tongue cleans, and the patient enters apparently upon a satisfactory convalescence. The evening temperature, however, does not reach 98-5°, but constantly keeps about 99*5° or 100°, and occasionally rises to 100-5°. This, in the late stages of convalescence, I have seen due to the post-typhoid anaemia. Complications should be carefully looked for, particularly insidious pleurisy or bone lesions. In certain of these cases the persistence of the fever seems to be really a nervous phenomenon, and there is nothing in the condition of the patient to cause uneasiness except the evening elevation of temperature. If the tongue is clean, the appetite good, and there are no intestinal symptoms, it may be disregarded. I have frequently found this condition best met by allowing the patient to get up and by stopping the use of the thermometer. This prolonged slight elevation of the fever after the dis- appearance of all the symptoms is most common in children and in pa- tients of marked nervous temperament. (cl) The Fever of the Relapse.—This is a repetition in many instances of the original fever, a gradual ascent and maintenance for a few days at a certain height and then a gradual decline. It is shorter than the original pyrexia, and rarely continues more than two or three weeks. (Chart I.) (e) Afebrile Typhoid.—There are cases described in which the chief features of the disease have been present without the existence of fever. They are extremely rare in this country. No instance of the kind has come under my observation. Fisk, of Denver, has met with it. (/) Chills occur (a) sometimes with the fever of onset; (Z>) occasion- ally at intervals throughout the course of the disease, and followed by sweats (so-called sudoral form); (c) with the advent of complications, 16 SPECIFIC INFECTIOUS DISEASES. pleurisy, pneumonia, otitis media, periostitis, etc.; (d) with active anti- pyretic treatment by the coal-tar remedies; (e) occasionally during the period of defervescence without relation to any complication or sequel, probably due to a septic infection. There are cases in which throughout the latter half of the disease chills recur with great severity. Skin.—The rash of typhoid fever is very characteristic. It consists of a variable number of rose-colored spots, which appear from the seventh to the tenth day, usually first upon the abdomen. The spots are flattened papules, slightly raised, of a rose-red color, disappearing on pressure, and ranging in diameter from two to four millimetres. They can be felt as distinct elevations on the skin. Sometimes each spot is capped by a small vesicle. The spots may be dark in color and occasionally become pete- chial. After persisting for two or three days they gradually disappear, leaving a brownish stain. They come out in successive crops, but rarely appear after the middle of the third week. They are present in the typ- ical relapse. The rash is most abundant upon the abdomen and lower thoracic zone, often abounds upon the back, and may spread to the ex- tremities or even to the face. I can not say that in my experience these cases with the more abundant eruption have been of specially severe type. The rash is not always present. Murchison states that it is frequently absent in children. A branny desquamation is not rare in cases in which the sudaminal vesicles have been abundant; occasionally the skin may peel in large flakes. The following accidental rashes are met with in typhoid fever: 1. Erythema.—It is not very uncommon in the first wreek of typhoid fever to find the skin of the abdomen and chest of a vivid red color; the rash may also spread to the extremities. It may possibly in some in- stances, but certainly not always, be due to quinine. I have seen it much more frequently in the past five years (during which time I have rarely ordered a dose of quinine in this disease) than I did in Montreal, where we used quinine largely as an antipyretic. 2. The tache bleudtre—Peliomata.—These are pale-blue or steel-gray spots, subcuticular, from 4 to 10 mm. in diameter, of irregular outline and most abundant about the chest, abdomen, and thighs. They sometimes give a very striking appearance to the skin. It can be readily seen that the injection is in the deeper tissues and not superficial. This rash is quite without significance. Since my attention was called to its associa- tion with body lice, I have met with no instance in which these wTere not present. Several French observers maintain that they are due to the irritating effects of the fluid secreted by pediculi (vide Ilewetson, J. H. II. Bulletin, vol. v.). They are not peculiar to typhoid fever (Duck- worth). 3. Sudaminal and miliary eruptions are common in all cases in which there is profuse sweating. TYPHOID FEVER. 17 4. Urticaria is occasionally met with; and lastly herpes, but this is very uncommon in comparison with its frequency in malaria and pneu- monia. The tache cerebrale, a red line with white borders, can be produced by drawing the nail over the skin. It is a vaso-motor phenomenon which, as in other fevers, can be readily elicited, particularly in nervous subjects. Exposure of the abdomen may be sufficient to cause a pinkish injection, which may in places change to an ivory white, giving a curious mottled appearance to the skin. A similar appearance may be seen on the arms. The general tint may be white, with irregular patches or streaks of pink or dark red. The skin of the palms of the hands may become very dry and yellow. Sweats.—At the height of the fever the skin is usually dry. Profuse sweating is rare, but it is not very uncommon to see the abdomen or chest moist with perspiration, particularly in the reaction which follows the bath. Sweats in some instances constitute a striking feature of the dis- ease. They may occasionally be associated with chilly sensations or actual chills. Jaccoud and others in France have especially described this sudoral form of typhoid fever. There may be recurring paroxysms of chill, fever, and sweats (even several in twenty-four hours), and the case may be mistaken for one of intermittent fever. The fever toward the end of the second week and during the third week may be intermittent. The characteristic rash is usually present, and if absent the negative con- dition of the blood is sufficient to exclude malaria. I have seen cases of this form in Montreal, where there could have been no suspicion of mala- rial infection. (Edema of the skin occurs: 1. As the result of vascular obstruction, most commonly of a vein, as in thrombosis of the femoral vein. 2. In connection with nephritis. 3. In association with the anaemia and cachexia. The hair is very apt to fall out after an attack of typhoid fever. In- stances of permanent baldness are of extreme rarity. As in other diseases associated with fever the nutrition of the nails suffers, and during and after convalescence transverse ridges are seen. It is stated that a peculiar odor is exhaled from the skin in typhoid fever. Whether due to a cutaneous exhalation or not, there certainly is a very distinctive smell connected with many patients. I have repeatedly had my attention directed to it by nurses. Nathan Smith describes it as of a “ semi-cadaverous, musty character.” As a sequence, lines of atrophy of the skin may develop on the abdo- men and lateral aspects of the thighs, similar in all respects to those seen after pregnancy. These linece atrophica are possibly due to neuritis, and Duckworth has reported a case in which the. skin adjacent to them was hypergesthetic. 18 SPECIFIC INFECTIOUS DISEASES. Circulatory System.—The blood presents important changes. The following statements are based on studies which W. S. Thayer has made in my wards : * During the first two weeks there may be little or no change in the blood. Profuse sweats or copious diarrhoea may, as Hayem has shown, cause the corpuscles—as in the collapse stage of cholera—to rise above normal. In the third week a fall usually takes place in corpuscles and haemoglobin and the number may sink rapidly even to 1,300,000 per c. mm., gradually rising to normal during convalescence. When the pa- tient first gets up, there may be a slight fall in the number of the cor- puscles. They diminish slightly throughout the course, and reach the lowest point toward the end of convalescence. The amount of haemoglobin is always reduced, and usually in a greater relative proportion than the number of red corpuscles, and during recov- ery the normal color standard is reached at a later period. The number of colorless corpuscles varies little from the normal standard (6,000 ± per c. mm.). They diminish slightly throughout the course and reach the lowest point toward the end of convalescence. The absence of leucocyto- sis may be at times of real diagnostic value in distinguishing typhoid fever from various septic fevers and acute inflammatory processes. The accompanying blood-chart shows these changes well. (Chart II.) The post-typhoid anaemia may reach an extreme grade. In one of my cases the blood-corpuscles sank to 1,300,000 per cubic mm. and the haemo- globin to about twenty per cent. These severe grades of anaemia are not common in my experience. In the Munich statistics there were fifty- four cases with general and extreme anaemia. Of changes in the blood plasma very little is known. The pulse in typhoid fever presents no special characters. It is in- creased in rapidity in proportion to the height of the fever. As a rule, in the first week it is above 100, full in volume and often dicrotic. There is no acute disease with which, in the early stage, a dicrotic pulse is so fre- quently associated. Even with high fever the pulse may not be greatly accelerated. As the disease progresses the pulse becomes more rapid, feebler, and small. In the extreme prostration of severe cases it may reach 150 or more, and is a mere undulation—the so-called running pulse. The lowered arterial pressure is manifest in the dusky lividity of the skin and coldness of the hands and feet. During convalescence the pulse gradually returns to normal, and occa- sionally becomes very slow. After no other acute fever do we so fre- quently meet with bradycardia. I have counted the pulse as lowy as thirty, and instances are on record of still fewTer beats to the minute. The heart-sounds are at first clear and loud, and free from murmur, but in severe cases, as the prostration develops, the first sound becomes feeble and there is often to be heard, at the apex and along the left sternal * Report on Typhoid Fever, I, J. II. II. Reports, vol. iv. TYPHOID FEVER. 19 margin, a soft systolic murmur. The first sound may be gradually anni- hilated, as pointed out by Stokes. In the extreme feebleness of the graver forms, the first and second sound become very similar, and the long pause is much shortened. MEAN NORM. NUMBER OF WHITE CORPUSCLES BLACK. RED CORPUSCLES. RED, HAEMAGLOBIN. BLUE, COLORLESS CORPUSCLE8. Chart II. Of cardiac complications, pericarditis is rare and has been met with -chiefly in children and in association with pneumonia. It was not pres- ent in any of my cases and occurred in only fourteen of the two thousand Munich post-mortems. Endocarditis is also uncommon. I have seen only two cases ; and there were only eleven cases noted in the Munich records. Myocarditis is more common. The following statement may be made with reference to the condition of the heart-muscle in this disease : In 20 SPECIFIC INFECTIOUS DISEASES. protracted cases the muscle-fibre is usually soft, flabby, and of a pale yel- lowish-brown color. The softening may be extreme, though rarely of the grade described by Stokes, in which, when held apex up by the vessels, the organ collapsed over the hand, forming a mushroom-like cap. Micro- scopically, the fibres may show little or no change, even when the impulse of the heart has been extremely feeble. A granular parenchymatous de- generation is common. Fatty degeneration may be present, particularly in long-standing cases with anaemia. The hyaline change is not common. The segmenting myocarditis, in which the cement substance is softened so that the muscle-cells separate, has also been found, but probably as a post-mortem change. Complications in the Arteries.—Obliteration of large or small arterial trunks is one of the rare complications of typhoid fever. A considerable number of cases are scattered through the literature. The obliteration may be due either to embolism or to thrombosis. In a majority of cases the femoral artery is involved and gangrene of the foot and leg occurs. In several cases there has been obliteration of both femorals with extension of the clot into the aorta with gangrene of both legs. In a case which I saw with Roddick, of Montreal, the obliteration of the left femoral occurred on the sixteenth day. On the twentieth day the patient had pain in the right leg and there was no pulsation in the femoral artery. Gangrene gradually developed in both feet, and death took place in the sixth week. In these cases the condition is probably due to thrombosis, not embolism, and is associated with a blood state which favors clotting, or possibly with a local arteritis. The condition is not invariably fatal. Of twenty cases collected by Barchoud,* eight died. Keen collected forty-three cases of gangrene during or after typhoid fever (Toner Lec- ture, 1876). Thrombi in the Veins.—This is a much more frequent complication, and, according to Murchison, is met with in about one per cent of the cases. It occurs most frequently in a crural vein, and more commonly in the left than in the right; due possibly, as suggested by Liebermeister, to the fact that in the left common iliac vein, being crossed by the right iliac artery, the flow of blood is not so free as in the right vein. Throm- bosis is indicated by enlargement and oedema of the limb, but gangrene never results from obstruction of the vein alone. It is not a very un- favorable complication. In one case of my series the thrombus suppu- rated and there was pyaemia. Occasionally the thrombosis may extend into the pelvic veins and into the vena cava. In one instance the throm- bus was in the right circumflex iliac vein alone, and the superficial veins on the right side of the abdomen were in consequence greatly enlarged. Sudden death has been caused by dislodgment of a thrombus. Typhoid bacilli have been found in the wall of the vein and in the clot. A rare * Paris Thesis, 1881. TYPHOID FEVER. 21 lesion, which killed a valued assistant (Dr. Oppenheimer), is thrombosis of the cortical veins of the pia mater. Infarcts in the kidneys, spleen, and lungs are by no means uncommon in typhoid fever. They are associated usually with thrombosis in the arteries, rarely with embolism. Digestive System.—Loss of appetite is early, and, as a rule, the relish for food is not regained until convalescence. Thirst is constant, and should be fully and freely gratified. Even when the mind becomes benumbed and the patient no longer asks for water, it should be freely given. The tongue presents the changes inevitable in a prolonged fever, but there are no distinctive characters. Early in the disease it is moist, swollen, and coated with a thin white fur, which, as the fever progresses, becomes denser. It may remain moist throughout. In severe cases, par- ticularly those with delirium, the tongue becomes very dry, partly owing to the fact that such patients breathe with the mouth open. It may be covered with a brown or brownish-black fur, or with crusts between which are cracks and fissures. In these cases the teeth and lips may be covered with a dark brownish matter called sordes—a mixture of food, epithelial debris, and micro-organisms. By keeping the mouth and tongue clean from the outset the fissures, which are extremely painful, may be pre- vented. During convalescence the tongue gradually becomes clean, and the fur is thrown off, either insensibly or occasionally in flakes. The secretion of saliva is often diminished ; salivation is rare. Parotitis, not so frequent as in typhus fever, was present in forty-five of the two thousand Munich cases. It occurred in only two of my series of fatal cases. Usually unilateral, and in a majority of cases going on to suppuration, it is regarded as a very fatal complication, but recovery has followed in four or five of my cases. It undoubtedly may arise from ex- tension of inflammation along Steno’s duct. This is probably not so seri- ous a form as when it arises from metastatic inflammation. The submaxillary gland may be involved alone. Parotitis may occur after the fever has subsided. The pharynx may be the seat of slight catarrh. Sometimes the fauces are deeply congested. Membranous pharyngitis, a serious and fatal com- plication, may come on in the third week. The gastric symptoms are extremely variable. Nausea and vomiting are not common. There are instances, however, in which vomiting, re- sisting all measures, is a marked feature from the outset, and may directly cause death from exhaustion. Vomiting does not often occur in the sec- ond and third week, unless associated with some serious complication. In a few 01 these cases ulcers have been found in the stomach. Intestinal symptoms are very inconstant. Of the 229 cases analyzed in the Report on Typhoid Fever, I, from the medical department of the Johns Hopkins Hospital, there was looseness of the bowels in seventy-six cases; in. twenty-eight of these the discharges were frequent. In 153 22 SPECIFIC INFECTIOUS DISEASES. cases the bowels were regular or constipated. In seventeen of the twenty- two fatal cases diarrhoea was present. Its absence must not be taken as an indication that the intestinal disease is of slight extent. I have seen, on several occasions, the most extensive infiltration and ulceration of the Resp.l Pulse I 75 70 65 60 56 50 45 40 35 30 25 .20 15 10 6 190 180 170 160 150 140 130 120 110 100 90 80 70 60 50 10 30 ..Ward Chart III.—Haemorrhage from the bowels. Rapid fall of temperature. No. Peyer’s glands of the small intestine, with the colon filled with solid faeces. The diarrhoea is caused less by the ulcers than by the associated catarrh, and, as in tuberculosis, it is probable that when this is in the large intes- tine the discharges are more frequent. It is most common toward the end of the first and throughout the second week, but it may not occur TYPHOID FEVER. 23 until the third or even the fourth week. The number of discharges ranges from three to eight or ten in the twenty-four hours. They are usually abundant, thin, grayish-yellow, granular, of the consistency and appear- ance of pea-soup, and resemble very much, as Addison remarked, the nor- mal contents of the small bowel. The reaction is alkaline and the odor offensive. On standing, the discharges separate into a thin serous layer, containing albumin and salts, and a lower stratum, consisting of epithelial debris, remnants of food, and numerous crystals of triple phosphates. Blood may be in small amount, and only recognized by the microscope. Sloughs of the Peyer’s glands occur either as gravish-yellow fragments or occasionally as ovoid masses, an inch or more in length, in which portions of the bowel tissue may be found. The bacilli are not found in the stools until the end of the first or the middle of the second week. Hcemorrhage from the bowels is a serious complication, occurring in from three to five per cent of all cases. It occurred in ninety-nine of the two thousand Munich autopsies. There may be only a slight trace of blood in the stools, but too often it is a profuse, free hajmorrhage, which rapidly proves fatal. It occurs most commonly between the end of the second and the beginning of the fourth week, the time of the separation of the sloughs. Occasionally it results simply from the intense hyperaemia. It usually comes on without warning. A sensation of sinking or collapse is experienced by the patient, the temperature falls, and may, as in the an- nexed chart, drop eight or ten degrees in a few hours. Fatal collapse may supervene before the blood appears in the stool. Haemorrhage usually occurs in cases of considerable severity. Graves and Trousseau held that it was not a very dangerous symptom, but statistics show that death fol- lows in from thirty to fifty per cent of the cases. It must not be forgotten that melaena may also be part of a general haemorrhagic tendency, in which case it is associated with petechiae and haematuria. There may be a special family predisposition to intestinal haemorrhages in typhoid fever. Thus Pate * reports thirty-four cases in four genera- tions in one family occurring between the years 1884 and 1891. Intestinal haemorrhage occurred in eighteen, and was the cause of death in twelve cases. The bleeding developed on the first day of the fourth week in two cases, during the third week in fourteen cases, and during the second week in two cases. There was apparently no other special haemorrhagic tendency in the family. Meteorism, a frequent symptom, is not serious if of moderate grade, but when excessive is usually of ill-omen. Owing to defective tone in the walls, in severe cases to their infiltration with serum, gas accumulates in the small and large bowels, particularly in the latter. It is rightly held to be to some extent a measure of the intensity of the local lesions. When * North Carolina Medical Journal, September, 1894. SPECIFIC INFECTIOUS DISEASES. extreme, it pushes up the diaphragm and interferes very much with the action of the heart and lungs. It undoubtedly also favors perforation. Abdominal tenderness on pressure and gurgling in the right iliac fossa exist in a large proportion of all the cases. The tenderness may be more or less diffuse over the abdomen, but it is commonly limited to the right side. It is rarely excessive and may be elicited only on deep pressure. Gurgling indicates simply the presence of gas and fluid faeces in the colon and caecum. Occasionally severe pain may be associated with the degeneration of the abdominal muscles, or with rupture of the recti abdominales. It is stated that the thickened ileum may be felt in typhoid fever, and also that the mesenteric glands may be palpable. This is a point of some moment. The resistance and apparent tumor have led to the diagnosis of appendicitis and operation. Perforation of an ulcer into the peritonaeum, the most serious abdom- inal complication of the disease, occurred in one hundred and fourteen of the two thousand Munich cases, and in twenty of the eighty of my series. It is usually indicated by the onset of sudden acute pain in the abdomen, and symptoms of collapse. It is most common at the end of the second or in the third week, but in one of my cases it occurred as early as the eighth day and in another in the sixth week, two weeks after the evening temperature had become normal. It is not infrequently associated with haemorrhage. The presence of indigestible food, severe vomiting, exces- sive meteorism, and ascarides have been assigned as causes. This accident is much more common in men than in women. The perforation is usually in the ileum, but may occur in the colon. As a rule it promptly causes symptoms of peritonitis—distention of the abdomen, marked tenderness, rigidity of the abdominal walls, vomiting, a collapsed, pinched expression, and a rapid, small pulse. In very severe cases with marked mental dis- turbance the symptoms may not excite suspicion, but the temperature usually falls and the symptoms of collapse are well marked. The diag- nosis is easy, except in cases in which tympanites and tenderness have been prominent features, when it may be very difficult to say whether perforation has occurred. An indication of value in such instances is the obliteration of the liver dulness by gas in the peritoneal cavity. It is somewhat lessened by the fact that extreme tympany may almost, if not quite, obliterate the liver dulness. Perforation of the appendix is not very uncommon, and may cause pain in the right iliac fossa. General peritonitis or a localized abscess may result. Recovery from perforation is undoubtedly possible, though rare. Peritonitis without perforation may also occur by extension from the ulcer or occasionally by rupture of a softened mesenteric gland. It was present in 22 per cent of the Munich autopsies. The spleen is invariably enlarged in typhoid fever, and in a majority of cases the edge can be felt below the costal margin. By the end of the first TYPHOID FEVER. 25 week the enlargement is evident, unless there is great distention of the colon, when the spleen may be pushed far back and difficult to feel. Even the normal area of dulness may not be obtainable. I have seen a very large spleen post-mortem, when during life the increase in size was not observable. Toward the fourth week it diminishes in size. In four of my autopsies it weighed less than normal. Infarcts and abscesses are occasionally found. Rupture of the spleen in typhoid fever, due to a slight blow, has been seen by Bartholow. Spontaneous rupture may also occur. Liver.—Symptoms on the part of this organ are rare. Enlargement is occasionally detected. Jaundice is a very rare complication. It may be either of a catarrhal nature or due to parenchymatous changes. It was present in only IT per cent of the Munich autopsies. Abscess of the liver is a very rare sequela. Respiratory System.—Bpistaxis, an early symptom, precedes typhoid fever more commonly than any other febrile affection. It is occasionally profuse and serious. Laryngitis is not very common. The ulcers and the perichondritis have already been described. (Edema apart from ulceration is rare. In this country the laryngeal complications of typhoid fever seem much less frequent than on the Continent. I have seen ulcers in only four or five instances, and twice only perichondritis, both of which cases recovered, one after the expectoration of large portions of the thyroid cartilage. Bronchitis is one of the most frequent initial symptoms. It is indi- cated by the presence of sibilant breathing. It may come on with great severity, and in a case at the Philadelphia Hospital I regarded for several days the bronchial catarrh as the primary affection. The smaller tubes may be involved, producing urgent cough and even slight cyanosis. Col- lapse and lobular pneumonia may also occur. Lobar pneumonia is met with under two conditions : 1. It may be the initial symptom of the disease. After an indisposition of a day or so, the patient is seized with a chill, has high fever, pain in the side, and within forty-eight hours there are signs of consolidation, and the evidences of an ordinary lobar pneumonia. The intestinal symptoms may not develop until toward the end of the first week or later; the pul- monary symptoms persist, crisis does not occur; the aspect of the patient changes, and by the end of the second week the clinical picture is that of typhoid fever. Spots may then be present and doubts as to the nature of the case are solved. In other instances, in the absence of a characteristic eruption the case remains dubious, and it is impossible to say whether the disease has been pneumonia, in which the so-called typhoid symptoms have developed, or whether it was typhoid fever with early implication of the lungs. Whether this condition depends upon the pneumococcus or is the result of an early localization of the typhoid bacillus has not yet been settled. I have twice performed autopsies in cases of this pneumo-typhus, 26 SPECIFIC INFECTIOUS DISEASES. as it is called by the French and Germans, and can speak positively of its onset with all the symptoms of a frank pneumonia. 2. Lobar pneumonia forms a serious and by no means infrequent com- plication of the second or third week. It was present in over 8 per cent of the Munich cases. The symptoms are usually not marked. There may be no rusty sputa, and, unless sought for, the condition is frequently overlooked. Infarction, abscess, and gangrene are occasional pulmonary complications. Hypostatic congestion of the lungs and oedema, due to enfeebled circu- lation in the later periods of the disease, are very common. The physical signs are defective resonance at the bases, feeble breath-sounds, and, on deep inspiration, moist r&les. Pleurisy is by no means an uncommon com- plication. It was present in about 8 per cent of the Munich autopsies. It may develop at the outset—pleuro-typhoid—or slowly during convalescence, in which case it is almost always purulent. Another occasional pulmo- nary complication is haemoptysis, which I once saw at the height of the disease. After death, no lesions of the lungs or bronchi were discovered. Nervous System.—As already noted, the disease may set in with in- tense and persisting headache or an aggravated form of neuralgia. There are cases in which the effect of the poison is manifested on the nervous system early and with the greatest intensity. There are headache, photo- phobia, retraction of the neck, marked twitching of the muscles, rigidity, and even convulsions. In such cases the diagnosis of meningitis is invari- ably made. I have examined post mortem three such cases, in two of which the diagnosis of cerebro-spinal fever had been made. In not one of them was there any trace of meningeal inflammation, only the most in- tense congestion of the cerebral and spinal pia. Meningitis, however, may occur, but is extremely rare, as shown by the Munich record, in which there were only eleven among the two thousand cases. Stokes’s dictum that “ there is no single nervous symptom which may not and does not occur independently of any appreciable lesion of the brain, nerves, or spinal cord,” is too often forgotten. Delirium, usually present in very severe cases, is certainly less frequent under a rigid plan of hydrotherapy. It may exist from the outset, but usually does not develop until the second and sometimes not until the third week. It may be slight and only nocturnal. It is, as a rule, a quiet delirium, though there are cases in which the patient is very noisy and constantly tries to get out of bed, and, unless carefully watched, may es- cape. The patient does not often become maniacal. In heavy drinkers the delirium may have the character of delirium tremens. Even in cases which have no positive delirium, the mental processes are usually dulled and the aspect is listless and apathetic. In severe cases the patient passes into a condition of unconsciousness. The eyes may be open, but he is ob- livious to all surrounding circumstances and neither knows nor can indi- cate his wants. The urine and fasces are passed involuntarily. In this TYPHOID FEVER. pseudo-wakeful state, or coma vigil as it is called, the eyes are open and the patient is constantly muttering. The lips and tongue are tremulous; there are twitchings of the fingers and wrists—subsultus tendinum and carphologia. He picks at the bedclothes or grasps at invisible objects. These are among the most serious symptoms of the disease, and always indicate danger. Convulsions are rare, even in children. In the only case which I have seen they developed suddenly on the eighth day, and proved fatal in about twelve hours. Thrombosis of the veins of the pia mater on the left side was found. Among important complications and sequelae are several nervous affec- tions. Neuritis, which is not uncommon, may be local, or a widespread affec- tion of the nerves of the legs or both arms and legs. Local Neuritis.—This may occur during the height of the fever or after convalescence is established. It may set in with agonizing pain, and with sensitiveness of the affected nerve trunks. In two instances I have seen great tenderness of the muscles, and some of these cases may be myo- sitis. There may be extreme sensitiveness of the muscles without any signs of neuritis. The condition may subside without leaving any atrophy. The local neuritis following typhoid fever may affect the nerves of an arm or of a leg, and involve chiefly the extensors, so that there is wrist-drop or foot-drop of the affected limb. Some of these cases are very difficult to separate from the poliomyelitis. A curious condition, probably a local neuritis, is that which was first described by Handford as tender toes, and which appears to be much more common after the cold-bath treatment. The tips and pads of the toes, rarely the pads at their bases, become exquisitely sensitive, so that the pa- tient can not bear the weight of the bedclothes. There is no discolora- tion and no swelling, and it disappears usually within a week or ten days. Multiple neuritis in typhoid fever develops usually during convales- cence. The legs may be affected, or the four extremities. The cases are often difficult to differentiate from the subacute poliomyelitis. Eecovery is the rule. Of four cases with involvement of arms and legs, three re- covered completely and one is now improving.* Poliomyelitis may develop with the symptoms of acute ascending paral- ysis and prove fatal in a few days. More frequently it is less acute, and causes either a paraplegia or a limited atrophic paralysis of one arm or leg. Among other sequences may be mentioned aphasia, which is more apt to occur in young children, and great slowness of speech, which may or may not be associated with mental weakness. True tetany occurs sometimes, and a number of cases have developed in certain epidemics. It may set in during the full height of the disease. * Neuritis during and after Typhoid Fever, Johns Hopkins Hospital Reports, vol. v. SPECIFIC INFECTIOUS DISEASES. 28 This complication is extremely rare in this country, and Janeway, so far as I know, has alone reported instances. Post-febrile insanity is perhaps more frequent after typhoid than after any other disease. Wood regards it as confusional insanity, the result of impaired nutrition and exhaustion of the nervous centres. Five cases have come under my observation, in four of which recovery took place. Disturbances of the organs of the special senses are rare. Otitis media occasionally develops and may cause chills and septic symptoms. Eye affections are rare, but cataract has been known to follow in young persons. Renal System.—Retention of urine is an early symptom in many cases, and is more frequent in some epidemics than in others. The condition may recur for several weeks. The urine is usually diminished at first, has the ordinary febrile characters, and the pigments are increased. Later in the disease it is more abundant and lighter in color. Ehrlich has described a reaction, which he believes is rarely met with except in typhoid fever. This so-called diazo-readion is produced as fol- lows : Two solutions are employed, kept in separate bottles: one contain- ing a saturated solution of sulphanilic acid in a solution of hydrochloric acid (50 c. c. to 1,000 c. c.) ; the other a £ per cent solution of sodium nitrite. To make the test, a few cubic centimetres of urine are placed in a small test-tube wdth an equal quantity of a mixture of solution of the sulphanilic acid (40 c. c.) and the sodium nitrite (1 c. c.), the whole being thoroughly shaken. One cubic centimetre of ammonia is then allowed to flow carefully down the side of the tube, forming a colorless zone above the yellow urine, and at the junction of the two a deep brownish-red ring will be seen if the reaction is present. With normal urine a lighter brownish ring is produced, without a shade of red. The color of the foam of the mixed urine and reagent, and the tint they produce when largely diluted with water, are characteristic, being in both cases of a delicate rose-red if the diazo-reaction be present; but if not, brownish-yellow. It was present in one hundred and thirty-six of one hundred and ninety-six cases examined at my clinic.* It may be present previous to the occurrence of the rash, and as late as the twenty-second day. The value of the test is lessened by its occurrence in cases of miliary tubercu- losis, and occasionally in the acute diseases associated with high fever. The toxicity of the urine is much increased in typhoid fever, and the toxic products are eliminated in greater quantities in cases treated with the cold bath. The renal complications in typhoid fever may be thus grouped : {a) Febrile albuminuria, which is very common and of no special sig- nificance ; thus, in the first two hundred and twenty-nine cases admitted * Hewetson, The Urine, and the Occurrence of Renal Complications in Typhoid Fever. Johns Hopkins Hospital Reports, vol. iv. TYPHOID FEVER. 29 to the Johns Hopkins Hospital albuminuria was noted in one hundred and sixty-four, and tube casts is in one hundred and three. (b) Acute nephritis occurring at the onset or during the height of the disease—the nephro-typhus of the Germans, the fievre typhoide a forme renale of the French—may set in, with all the symptoms of the most in- tense Bright’s disease, masking in many instances the true nature of the malady. After an indisposition of a few days there may be fever, pain in the back, and the passage of a small amount of bloody urine. In twenty- one of the two hundred and twenty-nine cases evidence was present of a definite nephritis—much albumin and many tube casts. In ten there were also red blood-corpuscles. In two the cases were really haemorrhagic nephritis. Seven of these twenty-one cases died—five from perforation, not one from the renal complication. (c) The nephritis of convalescence. This is more common but less serious. It develops after the fall of the fever, and is usually associated with oedema. It does not present characters different from the ordinary post-febrile nephritis. (d) The remarkable lymphomatous nephritis, described by E. Wagner and others, and already referred to in the section on morbid anatomy, produces, as a rule, no symptoms. (ie) Pyuria is a not uncommon complication. Blumer * has studied ten cases in my wards. In seven the colon bacillus was present, in two the typhoid bacillus, and in one the staphylococcus albus. (/) Post-typhoid pyelitis.—In this the pelves of the kidney, and the calices are at first covered with a membranous exudation, but erosion and ulceration may subsequently occur. There may be blood and pus in the urine. This condition occurred in three of my cases, in one of which it was associated with extensive membranous inflammation of the bladder. Simple catarrh of the bladder is rare. Orchitis is occasionally met with during convalescence. Sadrain col- lected sixteen cases in the literature. It is usually associated with a catarrhal urethritis. Induration or atrophy may occur, and more rarely suppuration. Osseous System.—A multiple arthritis occasionally occurs ; more com- monly it is limited to a single joint, and may pass on to suppuration. Spontaneous luxation may develop. Necrosis of the bones may occur during the fever, but it is most often a lesion of convalescence. Keen collected thirty-seven cases (Toner Lecture, 1876). Paget dealt fully with the clinical features, particularly the chronic course and slight tend- ency to spontaneous recovery. Some of the cases developing during the fever are due to streptococcus infection ; but in a majority the typhoid bacilli are found, even months or years after convalescence. The ribs and tibiae are the favorite sites. The lesion is sometimes a slowly developing * Report on Typhoid Fever, No. II. Johns Hopkins Hospital Reports, vol. v. 30 SPECIFIC INFECTIOUS DISEASES. node, which does not suppurate for months. Of six cases at the Johns Hopkins Hospital during the year 1894, cultures were made from five: in four the Eberth bacillus occurred alone, and in one in conjunction with the staphylococcus aureus (Harold Parsons). There is a remarkable disorder of convalescence to which Gibney has given the name “ typhoid spine.” The patient has usually been up and about, and may have had a slight jar or shock, after which he complains of great pain in the back, and of pain on moving the legs. The condition may persist for weeks without fever or any signs of Pott’s disease, spon- dylitis, or neuritis; but there are usually marked nervous or hysterical symptoms. The outlook is good. It is not known upon what this con- dition depends. It seems to be a neurosis rather than a perispondylitis. The muscles may be the seat of the degeneration already referred to, but it rarely causes any symptoms. Ilsemorrhage occasionally occurs into the muscles, and late in protracted cases abscesses may develop, sometimes in or between the abdominal muscles. Association of other Diseases.—Erysipelas is a rare complica- tion, most commonly met with during convalescence. In 1,420 cases at Basle it occurred ten times. Griesinger states that it is met with in 2 per cent. Measles may develop during the fever or in convalescence. Chicken- pox and noma have been reported in children. Pseudo-membranous in- flammations may occur in the pharynx, larynx, or genitals. Malarial and typhoid fevers may be associated, but a majority of the cases of so-called typho-malarial fever are either remittent or true typhoid. Typhoid fever may attack an individual the subject of tuberculosis. In four of my eighty cases tuberculous lesions coexisted with those of typhoid fever. Miliary tuberculosis occasionally develops after it, but my personal experience does not warrant the belief held by some writers, that there is a greater susceptibility to tuberculosis after typhoid than after other fevers. Acute miliary tuberculosis and typhoid fever have been met with in the same subject. In epilepsy and in chronic chorea the fits and movements usually cease during an attack, and in typhoid fever in a diabetic subject the sugar may be absent during the height of the disease. Varieties of Typhoid. — Typhoid fever presents an extremely complex symptomatology. Many forms have been described, some of which present exaggeration of common symptoms, others modification in the course, others again greater intensity of action on certain organs. As we have seen, when the nervous system is specially involved, it has been called the cerebro-spinal form ; when the kidneys are early and severely affected, nephro-typhoid ; when the disease begins with pulmonary symp- toms, pneumo-typhoid ; with pleurisy, pleuro-typhoid ; when the disease is characterized throughout by profuse sweats, the sudoral form of the disease. It is a mistake, I think, to recognize or speak of these as varie- TYPHOID FEVER. 31 ties. It is enough to remember that typhoid may set in occasionally with symptoms localized in certain organs, and that many of its symptoms are extremely inconstant—in one epidemic uniform and text-book-like, in another slight or not met with. This diversified symptomatology has led to many clinical errors, and in the absence of the salutary lessons of morbid anatomy it is not surprising that practitioners have so often been led astray. We may recognize, with Murchison, the following varieties : 1. The mild and abortive forms. It is very important for the practi- tioner to recognize the mild type of typhoid fever, often spoken of as gastric fever or even regarded as simple febricula. In this form, the typhus levissinms of Griesinger, the symptoms are similar iu kind but altogether less intense than in the graver attacks, although the onset may be sudden and severe. The temperature rarely reaches 103°, and the fever of onset may not show the gradual ascending evening record. The spleen is enlarged, the rose-spots may be marked; often they are very few in number. The diarrhoea is variable, sometimes it is not present. In such cases the symptoms may persist for from sixteen to twenty days. In the abortive form the symptoms of onset may be marked with shiv- ering and fever of 103° or even higher. The date of onset is often defi- nite, a point upon which Jiirgenseii lays great stress. Kose-spots may occur from the second to the fifth day. Early in the second week or at the end of the first week the fever falls, often with profuse sweating, and convalescence is established. In this abortive form relapse may occur and may occasionally prove severe. When typhoid fever prevails extensively these cases are not uncommon. I agree with J. 0. Wilson, who states that they are not nearly so common in this country as in Europe. 2. The grave form is usually characterized by high fever and pro- nounced nervous symptoms. In this category, too, come the very severe cases setting in with pneumonia and Bright’s disease, and with the very intense gastro-intestinal or cerebro-spinal symptoms. 3. The latent or ambulatory form of typhoid fever, which is particu- larly common in hospital practice. The symptoms are often very slight, and the patient scarcely feels ill enough to go to bed. He has languor, perhaps slight diarrhoea, but keeps about and may even attend to his work throughout the entire attack. In other instances delirium sets in. The worst cases of this form are seen in sailors, who keep up and about, though feeling ill and feverish. When brought to the hospital they often develop symptoms of a most severe type of the disease. Haemorrhage or perfora- tion may be the first symptom of this ambulatory type. Sir W. Jenner has called attention to the dangers of this form, and particularly to the grave prognosis in the case of persons who have travelled far with the dis- ease in progress. Haemorrhagic typhoid is a rare and very fatal form, characterized by cutaneous and mucous haemorrhages. The term should be restricted to 32 SPECIFIC INFECTIOUS DISEASES. the cases with multiple bleedings, and not used to designate cases with hseinorrhage from the bowels. An afebrile typhoid fever is recognized by authors. Liebermeister says that the cases were not uncommon at Basle. The patients presented las- situde, depression, headache, furred tongue, loss of appetite, slow pulse, and even the spots and enlarged spleen. I have no personal knowledge of such cases. Typhoid Fever in Children.—Cases are not uncommon under the age of ten, but the disease is rare in infants under two years of age. Cases have been reported, however, in sucklings (nine months, Fuller; four and a half months, Ogle), and perforation has been met with in an infant five days old. Epistaxis rarely occurs; the rise in temperature is less gradual; the initial bronchial catarrh is often observed. The nervous symptoms are often prominent; there are wakefulness and delirium ; diarrhoea is often absent. The rash may be very slight, but the most copious eruption I have ever seen was in a child of eight. The abdominal symptoms are often slight. Fatal haemorrhage and perforation are rare. Among the sequelae, aphasia, noma and bone lesions may be mentioned as more com- mon in children than in adults. The mortality of typhoid fever in chil- dren is low. In fatal cases only a careful bacteriological examination can decide whether the swollen Peyer’s patches and mesenteric glands— not uncommon in children with fever—depend upon an infection with typhoid bacilli. Cultures have been made from the foetus delivered at the eighth month, which lived five days. Lungs, spleen, liver, intestines showed Eberth’s bacillus. Typhoid Fever in the Aged.—After the fortieth year the disease runs a less favorable course, and the mortality is very high. Of sixty-four fatal cases, seven were over forty years of age ; one was aged sixty-three, another seventy. The fever is not so high, but complications are more common, particularly pneumonia and heart failure. Typhoid Fever in Pregnancy.—The disease is rare in pregnant women. Only one case occurred among nearly four hundred cases under my care during the past six years. The majority of the patients are affected during the first half of pregnancy. In more than half the cases abortion or premature delivery follows, usually in the second week of the disease. The foetus may itself be infected, and the typhoid bacilli have been culti- vated from it. The mortality in pregnant women with typhoid fever is high—nineteen in ninety-one cases (Brieger). The experience of Brand and of the physicians of the Lyons school would show that the cold-bath treatment is not only not contraindicated, but most efficacious. Relapse.—Relapses vary in frequency in different epidemics, and, it would appear, in different places. The percentages of different authors range from 3 per cent (Murchison), 11 per cent (Baumler), to 15 or 18 per cent (Immermann). In Wagner’s clinic, from 1882 to 1886, there TYPHOID FEVER. 33 were 49 relapses in 561 cases. F. C. Shattuck reports 21 relapses in 129 cases. R. L. MacDonnell 1 relapse in 100 cases. A relapse is a repeti- tion, sometimes only a summary, of the original attack. Yon Ziemssen insists correctly that two of the three important symptoms—step-like tem- perature at onset, roseola, and enlarged spleen—should be present to de- termine the diagnosis of a relapse. The intestinal lesions are repeated, though with less intensity and regularity. It is to be carefully distin- guished from the fever of convalescence—or recrudescence—already de- scribed, which is usually transitory, not lasting longer than a day or two. There are occasional instances in which the fever persists for four or five days without rose-spots, or without enlargement of the spleen, and it may be impossible to determine whether there has been a relapse or not. The true relapse usually sets in after complete defervescence. Irvine noted the average duration of the interval in his cases at a little over five days. In eleven of Shattuck’s cases the relapse began before complete deferves- cence. The onset is usually abrupt, though the step-like ascent is some- times well seen, as in Chart I. The eruption may be seen as early as the third or fourth day. The attack is usually less severe and of shorter dura- tion. Of Murchison’s fifty-three cases the mean duration of the first attack was about twenty-six, of the interval eleven, of the relapse fifteen days. The mortality of the relapse is not high. There may be a third or fourth relapse. Da Costa has twice seen five relapses. The relapse is a reinfection from within, but we are still quite ignorant of the conditions favoring its occurrence. It is not at all likely that any special methods of treatment favor the relapse, though hydrotherapy has labored under this reproach. Diagnosis.—If the patient is seen from the outset there is rarely any difficulty in diagnosing typhoid fever of typical course. In the prefebrile period the headache, weakness, loss of appetite and epistaxis are extremely suggestive, and, with an ascending pyrexia, scarcely need the distinctive rash to clinch the diagnosis. The early and intense localization of the symptoms in certain organs is a frequent source of error in diagnosis. Cases coming on with severe headache, photophobia, delirium, twitch- ing of the muscles and retraction of the head are almost invariably regarded as cerebro-spinal meningitis. Under such circumstances it may for a few days be impossible to make a satisfactory diagnosis. I have thrice performed autopsies on cases of this kind in which no suspicion of typhoid fever had been present; the intense cerebro-spinal manifestations having dominated the scene. Until the appearance of abdominal symp- toms, or the rash, it may be quite impossible to determine the nature of the case. Cerebro-spinal meningitis is, however, a rare disease; typhoid fever a very common one, and the onset with severe nervous symptoms is by no means infrequent. Fully one half of the cases of the so-called brain-fever belong to this category. SPECIFIC INFECTIOUS DISEASES. I have already spoken of the misleading pulmonary symptoms, which occasionally develop at the very outset of the disease. The bronchitis rarely causes error, though it may be intense and attract the chief at- tention. More difficult are the cases setting in with chill and followed rapidly by pneumonia. I have brought such a case before the class one week as typical pneumonia, and a fortnight later shown the same case as undoubtedly one of typhoid fever. In another case, in which the onset was with definite pneumonia, no spots developed, and, though there were diarrhoea, meteorism, and the most pronounced nervous symptoms, the doubt still remains whether it was a case of typhoid fever or one of pneumonia in which severe secondary symptoms developed. There is less danger of mistaking the pneumonia which develops at the height of the disease, and yet this is possible, as in a case admitted a few years ago to my wards—a man aged seventy, insensible, with a dry tongue, tremor, ecchymoses upon the wrists and ankles, no rose-spots, enlarge- ment of the spleen, and consolidation of his right lower lobe. It was very natural, particularly since there was no history, to regard such a case as senile pneumonia with profound constitutional disturbance, but the au- topsy showed the characteristic lesions of typhoid fever. From malarial fever, typhoid is, as a rule, readily recognized. There is no such disease as typho-malarial fever—that is, a separate and distinct malady. Typhoid fever and malarial fever in rare instances may coexist in the same patient. Of nearly four hundred cases of typhoid fever, all with blood examinations, and a majority of them coming from malarial regions, in not a single instance were the malarial parasites found in the blood. There is now no excuse whatever for the continued use by prac- titioners of the term typho-malarial fever, and still less for the falsifica- tion of vital statistics by sending death certificates signed with this diag- nosis. The principle is bad and the practice is worse, since it gives a false sense of security, and may prevent proper measures of prophy- laxis. In regions where malarial fever prevails, the autumnal type may pre- sent a striking similarity in its early days to typhoid fever. Differentia- tion may be made only by the blood examination. There may be no chills, the remissions may be extremely slight, there is a history perhaps of malaise, weakness, diarrhoea, perhaps vomiting. The tongue is furred and white, the cheeks flushed, the spleen slightly enlarged, and the tem- perature continuous, or with very slight remissions. A low, long-continued fever in obscure, deep-seated suppuration, with- out chills or sweats, may simulate typhoid. The presence or absence of leucocytosis would be an important aid. Acute miliary tuberculosis is not infrequently mistaken for typhoid fever. The points in differential diagnosis will be discussed under that disease. Tuberculous peritonitis in certain of its forms may closely simu- late typhoid fever. TYPHOID FEVER. 35 Puncture of the spleen for the purpose of obtaining cultures is justifi- able only in exceptional circumstances. Prognosis.—The mortality ranges from 10 to 30 per cent. Of the enormous number of deaths analyzed by Murchison, the mortality was nearly 19 per cent. The death-rate at the Montreal General Hospital, for twenty years, was 11 2 per cent. In recent years the mortality in typhoid fever has certainly diminished, and, under the influence of Brand, the reintroduction of hydrotherapy has reduced the mortality in institu- tions in a remarkable manner, even as low as 5 or 6 per cent. Especially unfavorable symptoms are high fever, delirium with toxic symptoms, haemorrhage—though by some this is not thought very unfavorable—and peritonitis. Sudden Death.—It is difficult in many cases to explain this most lam- entable of accidents in the disease. There are cases in which neither cerebral, renal, nor cardiac changes have been found ; there are instances too in which it does not seem likely that there could have been a special localization of the toxic poisons in the pneumogastric centres. McPhe- dran, in reporting a case of the kind, in which the post-mortem showed no adequate cause of death, suggests that the experiments of McWilliam on sudden cardiac failure probably explain the occurrence of death in cer- tain of the cases in which neither embolism nor uraemia is present. Under conditions of abnormal nutrition there is sometimes induced a state of delirium cordis, which may develop spontaneously, or, in the case of ani- mals, on slight irritation of the'heart, with the result of extreme irregu- larity and finally failure of action. Sudden death occurs more frequently in men than in women, according to Dewevre’s statistics, in a proportion of 114 to 26. It may occur at the height of the fever, and, as pointed out by Graves, may also happen during convalescence. Fat subjects stand typhoid fever badly. The mortality in women is greater than in men. The complications and dangers are more serious in the ambulatory form in which the patient has kept about for a week or ten days. Early involvement of the nervous system is a bad indication ; and the low, muttering delirium with tremor means a close fight for life. Prognostic signs from the fever alone are deceptive. A temperature above 104° may be well borne for many days if the nervous system is not involved. Prophylaxis.—In cities the prevalence of typhoid fever is directly proportionate to the inefficiency of the drainage and the Tvater-supply. There is no truer indication of the sanitary condition of a town than the returns of the number of cases of this disease. With the improvement in drainage the mortality in many cities has been reduced one half or even more. One of the most striking instances is afforded by the city of Munich. Yon Ziemssen has published charts illustrating the extraordinary reduc- tion in the prevalence of typhoid fever since the completion of the drain- age system of that city. The average yearly number of admissions to 36 SPECIFIC INFECTIOUS DISEASES. hospital of cases of typhoid fever was, between the years 1866 and 1880, 594, while from 1881 to 1888 inclusive the average was only about 100. During this same period the typhoid mortality of the whole city presented a yearly average of 208, but from 1881 to 1888 the yearly average was only 40. By most rigid methods of disinfection much may be done to prevent the spread of the infection. The following procedures, suggested by Fitz, should be carried out in hospital practice, and, with modifications, in private houses: 1. “ Mattresses and pillows (when liable to become soiled) are to be protected by close-fitting rubber covers. 2. “ Bed and body linen are to be changed daily. Bed-spreads, blank- ets, rubber sheets and rubber covers are to be changed at once when soiled. Avoid shaking any of the articles. 3. “ All changed linens, bath-towels, rubber sheets and covers are to be immediately wrapped in a sheet soaked in carbolic acid (one to forty). Remove them to the rinse-house as soon as possible, and soak six hours in carbolic acid (one to forty). Then boil the linen for a half-hour, and wash with soft soap. The rubber sheets and covers are to be rinsed in cold water, dried, and aired for eight hours. The bed-spreads and blankets are to be aired eight hours daily. 4. “ Feeding-utensils, immediately after using, are to be thoroughly cleansed in boiling water. 5. “ Dejections are to be received into a bed-pan containing half a pint of carbolic acid (one to twenty). The nates are to be cleansed with paper, and afterward with a compress cloth wet with carbolic acid (one to forty). 6. “ Add two quarts of carbolic acid (one to twenty), in divided por- tions, to the contents of the bed-pan; mix thoroughly by shaking and throw the liquid into the hopper. The bed-pan and hopper are to be cleansed with carbolic acid (one to twenty) and wiped dry. The cloth used for the above purpose is to be at once burned. 7. “ The corpse is to be covered with a sheet wet with carbolic acid (one to forty). 8. “ After the discharge of the patient from the hospital, the mat- tresses are to be aired every day for a week. The bedstead is to be washed with corrosive sublimate (one to one thousand). 9. “ These directions are to be followed until the patient is free from fever.” When epidemics are prevalent the drinking-water and the milk used in families should be boiled. These precautions should be taken also by recent residents in any locality, and it is much safer for travellers to drink light wines or mineral water rather than ordinary water or milk. Care should be taken to thoroughly cook oysters which have been fattened or freshened in streams contaminated with sewage. TYPHOID FEVER. 37 Treatment.—(a) General Management.—The profession was long in learning that typhoid fever is not a disease to be treated by medicines. Careful nursing and a regulated diet are the essentials in a majority of the cases. The patient should be in a well-ventilated room (or in summer out of doors during the day), strictly confined to bed from the outset, and there remain until convalescence is well established. The bed should be single, not too high, and the mattress should not be too hard. The woven wire bed, with soft hair mattress, upon which are two folds of blanket, combines the two great qualities of a sick-bed, smoothness and elasticity. A rubber cloth should be placed under the sheet. An intelligent nurse should be in charge. When this is impossible, the attending physician should write out specific instructions regarding diet, treatment of the dis- charges, and the bed-linen. (b) Diet.—Those forms of food should be given which are digested with the greatest ease, and which leave behind the smallest amount of resi- due to form faeces. Milk is the most suitable food. If used alone, three pints at least may be given to an adult in twenty-four hours, always diluted with water, lime-water, or aerated waters. Partially peptonized milk, when not distasteful to the patient, is occasionally serviceable. The stools of a patient on a strict milk diet should be examined with great care, to see if the milk is entirely digested. Fever patients often receive more than they can utilize, in which case masses of curds are seen in the stools, or microscopically fat-corpuscles in extraordinary abundance. Under these circumstances it is best to substitute, for part of the milk, mutton or chicken broths, or beef-juice, or a clear consomme, all of which may be made very palatable by the addition of fresh vegetable juices. Some patients will take whey or buttermilk when the ordinary milk is distasteful. Thin barley-gruel, well strained, is an excellent food for typhoid-fever patients. Eggs may be given, either beaten up in milk or, better still, in the form of albumen-water. This is prepared by straining the whites of eggs through a cloth and mixing them with an equal quantity of water. It may be flavored with lemon, and, if the patient is taking spirits, whisky or brandy is very conveniently given with this. Patients who are unable to take milk can subsist for a time on this alone. The patient should be encouraged to drink water freely, which may be pleasantly cold. Iced tea, barley-water, or lemonade may also be given, and there is no objection to coffee or cocoa in moderate quantities. Fruits are not, as a rule, allowable, though the juice of lemon or orange may be given. Typhoid patients should be fed at stated intervals through the day. At night it depends upon the general condition of the patient whether he should be aroused from sleep, or not. In mild cases it is not well to disturb the patient. When there is stupor, however, the patient should be roused for food at the regular intervals night and day. Alcohol is not necessary in all cases, but may be given when the weak- ness is marked, the fever high, and the pulse failing. In young healthy 38 SPECIFIC INFECTIOUS DISEASES. adults, without nervous symptoms and without very high fever, alcohol is not required ; but in any case, when the heart-beat is feeble and the first sound becomes obscure, if there are a muttering delirium, subsultus tendi- num and a dry tongue, brandy or whisky should be freely given. In such a case from eight to twelve ounces of brandy in the twenty-four hours is a moderate amount. It would be too much like hoisting the teetotaler with his own petard to attribute the high rate of mortality at the London Temperance Hospi- tal—fifteen to sixteen per cent during the past twenty years—to failure to employ alcohol. (c) Hydrotherapy.—The persistent pyrexia is in itself a danger, but perhaps not the chief danger. Cases with high fever alone, without delir- ium or signs of involvement of the nervous system, are not nearly so serious as those cases in which, with a temperature of 104°, there are pronounced nervous symptoms. For the fever and its concomitants there is no treat- ment so efficacious as that by cold water, introduced at the end of the last century by Currie, of Liverpool, and of late years forced upon the profes- sion by Brand, of Stettin. In institutions a rigid system of hydrotherapy should be carried out. At my clinic the following plan is followed : Every third hour, if the temperature is above 102-5°, the patient is placed in a bath (at 70° Fahr.), which is wheeled to the bedside. In this he re- mains from fifteen to twenty minutes, and is then taken out, wrapped in a dry sheet and covered with a light blanket. Enough water is used to cover the patient’s body to the neck. The head is sponged during the bath, and, if there is much torpor, cold water is poured over it from a height of a foot or two. The limbs and trunk are rubbed thoroughly either with the hand or with a suitable “ rubber.” The rectal temperature is taken immediately after the bath, and again three quarters of an hour later. The patient often complains bitterly when in the bath, and shiver- ing and blueness are almost a constant sequence. Food is usually given with a stimulant after the bath. The only contra-indications are perito- nitis and haemorrhage. Neither bronchitis nor pneumonia are so regarded. The accompanying chart shows the number of baths and the influence on the fever during two days of treatment. The good effects of the baths are: (1) the reduction of the fever; (2) the intellect becomes clearer, the stupor lessens, and the muscular twitchings disappear; (3) a general tonic action on the nervous system and particularly on the heart; (4) insomnia is lessened, the patient usually falling asleep for two or three hours after each bath; and (5), most important of all, the mortality is, under this plan of treatment, reduced to a minimum. This Brand method, as it is called, has steadily advanced in favor both in hospital and private prac- tice, and in spite of the difficulties and the unpleasant features necessarily connected with it, there is no plan of treatment which gives such results. In the hospitals which carry out a strict hydrotherapy the death-rate is about seven per cent, while in other institutions the death-rate is from ten TYPHOID FEVER. 39 to fifteen per cent. Last year, in the Metropolitan Fever Hospitals (Lon- don), the death-rate was seventeen per cent. Of the 356 cases under my care since the introduction of the method in the Johns Hopkins Hos- pital the mortality has been in five years 7*02 per cent. Among the most striking figures are those recently published by Hare, from the Brisbane Hospital, Australia. Under the expectant plan, 1,838 cases—mortality, 14-8 per cent; incomplete bath treatment, 171 cases—mortality, 12-3 per cent; strict bath treatment, 797 cases—mortality, 7 per cent. Chart IY. The lukewarm bath, gradually cooled, may be used in private practice when the Brand method is not practicable. A bath at from 90° to 80°, and cooled down 10° or 12° by pouring cold water on the patient, will be found very satisfactory. When an insuperable objection to the bath exists, other hydrotherapeutic measures may be taken. The body may be sponged with tepid or cold water every time the temperature rises above 102-5°. If done thoroughly, taking limb by limb first, and then the trunk, occupying from twenty minutes to half an hour in the process, the rectal temperature may be reduced two or even three degrees. In private practice, when the bath is not available, the cold-pack is a good substitute. The patient is wrapped in a sheet wrung out of water at 60° or 65°, and cold water is sprinkled over him with an ordinary watering-pot. This is very efficacious in cases with pronounced nervous symptoms. 40 SPECIFIC INFECTIOUS DISEASES. Medicinal antipyretics are rarely indicated. Quinine, which was em- ployed so much in former years, has a slight though positive action, but its use has very wisely been restricted. The same may be said of the more recent antipyretics. Personally, I abandoned their employment some years ago. If given, antifebrin is the most suitable in doses of from four to eight grains. The action is prompt, and it is less depressing than antipyrin. (d) Antiseptic Medication.—Very laudable endeavors have been made in many quarters to introduce methods of treatment directed toward the destruction of the typhoid bacilli, or the toxic agent which they produce, but so far without success. Good results have been claimed from the carbolic and iodine treatment. Others advocate corrosive sublimate or calomel, /3-naphthol, and the salicin preparations. I can testify to the inefficiency of the carbolic acid and iodine and of the /3-naphthol. With the mercurial preparations I have no experience. Fortunately for the patients, a majority of these medicines meet one of the two objects which Hippocrates says the physician should always have in view—they do no harm. Burney Yeo advocates the use of chlorine water and quinine. The solution is made in the following manner: Into a twelve-ounce bottle put thirty grains of potassic chlorate, and pour in sixty minims of strong hydrochloric acid. Fit a cork into the mouth of the bottle and keep it closed until it has become filled with a greenish-yellow gas. Shake the mixture well, and then pour water into the bottle little by little, closing the bottle and shaking well at each addition, until the bottle is full. It is well not to fill the bottle too quickly with water, or the chlo- rine will be driven out by the water, instead of being dissolved in it. To twelve ounces of this solution add twenty-four to thirty-six grains of qui- nine and an ounce of syrup of orange-peel. The dose is an ounce every two, three, or four hours, according to the severity of the case. Irriga- tion of the colon has been recommended, with a view of washing out the toxic matters (Mosler, Seibert). (e) Eliminative and Antiseptic Treatment.—Based on an entirely er- roneous view, that the bacterial growth is chiefly in the intestine itself, Thistle and others have advocated what is known as the eliminative and antiseptic treatment. The elimination is accomplished by thorough evacuation of the bowels daily, and the other factor in the treatment is the use of intestinal antiseptics, of which salol is recommended. If, as in cholera, the bacilli developed and produced the poison in the intestinal contents, there might be some reasonableness in this method, but the bacilli multiply in the intestinal walls, and in the mesenteric glands, and in the spleen. They are sometimes not found in the stools until the end of the second week. An important objection to the use of purgatives is the fact that in any large series of cases those with diarrhoea do badly. To check bacterial activity, as aimed at by advocates of this plan, would be a disastrous interference with the normal processes in the bowel. TYPHOID FEVER. 41 No one has been foolish enough yet to claim that so-called intestinal anti- septics can kill the pathogenic and spare the useful organisms. (f) Specific Method.—E. Fraenkel has used the dead cultures of typhoid bacilli grown in thymus bouillon ; 05 c. c., and on the following day 1 c. c. of the culture is injected deep into the muscular tissue in the lateral gluteal region. Then the injections are repeated every second day, each time in- creasing the dose 1 c. c. Chills may follow the first or second injection. With the continuance the fever becomes more remittent in type, and defer- vescence may occur in a comparatively short time, sometimes by crisis. In fifty-seven cases treated in this way the general results were good. Rumpf has used the cultures of the bacillus pyocyaneus prepared and used in this way, with good results, losing only two out of thirty patients. Lambert reports twenty-eight cases, of which fifteen showed benefit; there was one death. Attempts, too, have been made to use the blood serum of convalescent typhoid patients, but no satisfactory results have been yet obtained. (g) Treatment of the Special Symptoms.—The abdominal pain and tympanites are best treated by fomentations or turpentine stupes. The latter, if well applied, give great relief. Sir William Jenner, at his clinic, used to lay great stress on the advantages of a well-applied turpentine stupe. He directed it to be applied as follows : A flannel roller was placed beneath the patient, and then a double layer of thin flannel, wrung out of very hot water, with a drachm of turpentine mixed with the water, was applied to the abdomen and covered with the ends of the roller. The meteorism is a difficult and distressing symptom to treat. When the gas is in the large bowel, a tube may be passed or a turpentine enema given. For tympanites, with a dry tongue, turpentine was extensively used- by the older Dublin physicians, and it was introduced into this coun- try by the late George B. Wood. Unfortunately, it is of very little service in the severer cases, which too often resist all treatment. Sometimes, if beef-juice and albumen-water are substituted for milk, the distention lessens. Charcoal, bismuth, and /3-naphthol may be tried. For the diarrhoea, if severe—that is, if there are more than three or four stools daily—a starch and opium enema may be given; or, by the mouth, a combination of bismuth, in large doses, with Dover’s powder; or the acid diarrhoea mixture, acetate of lead (grs. 2), dilute acetic acid (TTt 15-20), and acetate of morphia (gr. |). The stools should be exam- ined to see that the diarrhoea is not aggravated by the presence of curds. Constipation is present in many cases, and though I have never seen it do harm, yet it is well every third or fourth day to give an ordinary enema. I have never used the initial dose of calomel, which is so highly recom- mended by some practitioners. If a laxative is needed during the course of the disease, the Hunyadi-janos or Friedrichsliall water may be given. Hcemorrhage from the bowels is best treated with full doses of acetate of lead and opium. As absolute rest is essential, the greatest care should SPECIFIC INFECTIOUS DISEASES. be taken in the use of the bed-pan. It is perhaps better to allow the patient to pass the motions into the draw sheet. Ice may be freely given, and the amount of food should be restricted for eight or ten hours. If there is a tendency to collapse, stimulants should be given and, if necessary, hypodermic injections of ether. The patient may be spared the usual styptic mixtures with which he is so often drenched. Turpentine is warmly recommended by certain authors. Peritonitis.—In a majority of the cases this is an inevitably fatal complication. The only hope lies in restriction of the inflammation. Cases have unquestionably recovered. Morphia should be given sub- cutaneously. If the peritonitis be due to perforation, the question of laparotomy may be discussed. Van Hook’s statistics give 19 laparotomies in typhoid fever with 4 recoveries. During 1894 there were 5 additional cases with 2 recoveries, making in all 24 cases with 6 recoveries. If of these cases we reject those which appear somewhat doubtful, “ then the cor- rect statistics revised up to date stand 17 cases with 3 recoveries” (Abbe). For the progressive heart-weakness alcohol, strychnine hypodermically in full doses, digitalis, and hypodermic injections of ether may be tried. The nervous symptoms of typhoid fever are best treated by hydrother- apy. One special advantage of this plan is that the restlessness is allayed, the delirium quieted, and sedatives are rarely needed. In the cases which set in early with severe headache, meningeal symptoms and high fever, the cold bath, or in private practice the cold-pack, should be employed. An ice-cap may be placed on the head, and if necessary morphia administered hypodermically. The practice, in such cases, of applying blisters to the nape of the neck and to the extremities is, to paraphrase Huxham’s words, an unwholesome severity, which should long ago have been discarded by the profession. For the nocturnal restlessness, so distressing in some cases, Dover’s powder should be given. As a rule, if a hypnotic is indi- cated, it is best to give opium in some form. Pulmonary complication should, if severe, receive appropriate treatment. In protracted cases very special care should be taken to guard against bed- sores. Absolute cleanliness and careful drying of the parts after an evacu- ation should be enjoined. The patient should be turned from side to side and propped with pillows, and the back can then be sponged with spirits. On the first appearance of a sore, the water or air bed should be used. (h) The Management of Convalescence.—Convalescents from typhoid fever frequently cause greater anxiety than patients in the attack. The question of food has to be met at once, as the patient develops a ravenous appetite and clamors for a fuller diet. My custom has been not to allow solid food until the temperature has been normal for ten days. This is, I think, a safe rule, leaning perhaps to the side of extreme caution ; but, after all, with eggs, milk toast, milk puddings, and jellies, the patient can take a fairly varied diet. Many leading practitioners allow solid food to a pa- tient so soon as he desires it. Peabody gives it on the disappearance of TYPHOID FEVER. 43 the fever; the late Austin Flint was also in favor of giving solid food early; and Naunyn, at the Strasburg Aledical Clinic, told me that this was his practice. I had an early lesson in this matter which I have never forgotten. A young lad in the Montreal General Hospital, in whose case I was much interested, passed through a tolerably sharp attack of typhoid fever. Two weeks after the evening temperature had been normal, and only a day or two before his intended discharge, he ate several mutton chops, and within twenty-four hours was in a state of collapse from per- foration. A small transverse rent was found at the bottom of an ulcer which was in process of healing. It is not easy to say why solid food, particularly meats, should disagree, but in so many instances an indiscre- tion in diet is followed by slight fever, the so-called febris carnis, that it is in the best interests of the patient to restrict the diet for some time after the fever has fallen. An indiscretion in diet may indeed precipitate a relapse. The patient may be allowed to sit up for a short time about the end of the first week of convalescence, and the period may be prolonged with a gradual return of strength. He should move about slowly, and when the weather is favorable should be in the open air as much as possible. The patient should be guarded at this period against all un- necessary excitement. Emotional disturbance not infrequently is the cause of a recrudescence of the fever. Constipation is not uncommon in convalescence and is best treated by enemata. A protracted diarrhoea, which is usually due to ulceration in the colon, may retard recovery. In such cases the diet should be restricted to milk, and the patient should be confined to bed ; large doses of bismuth and astringent injections will prove useful. The recrudescence of the fever does not require special treatment. The treatment of the relapse is essentially that of the original attack. Among the dangers of convalescence may be mentioned tuberculosis, which is said by Murchison to be more common after this than after any other fever. There are facts in the literature favoring this view, but it is a rare sequence in this country. II. TYPHUS FEVER. Definition.—An acute infectious disease characterised by sudden onset, a maculated rash, marked nervous symptoms, and a termination, usually by crisis, about the end of the second week. Etiology.—The disease has long been known under the names of hospital fever, spotted fever, jail fever, camp fever, and ship fever. In Germany it is known as exanthematic typhus, in contradistinction to abdominal typhus. Typhus is now a rare disease. Sporadic cases occur from time to time in the large centres of population, but epidemics are infrequent. In this 44 SPECIFIC INFECTIOUS DISEASES. country during the past ten years there have been very few outbreaks. In New York in 1881-’82 seven hundred and thirty-five cases were admitted into the Riverside Hospital; in Philadelphia a small epidemic occurred in 1883 at the Philadelphia Hospital. The special elements in the etiology of typhus are overcrowding and poverty. As Hirsch tersely puts it, “ Die Geschichte des Typhus ist die des menschlichen Elends.” Overcrowding, lack of cleanliness, intem- perance and bad food are predisposing causes. The disease still lurks in the worst quarters of London and Glasgow, and is seen occasionally in New York and Philadelphia. It is more common in Great Britain and Ireland than in other parts of Europe. Murchison held that the disease might originate spontaneously under favorable conditions. This opinion is suggested by the occurrence of local outbreaks under circumstances which render it difficult to explain its importation, but the analogy of other infectious diseases is directly against it. In 1877 there occurred a local outbreak of typhus at the House of Refuge, in Montreal, in which city the disease had not existed for many years. The overcrowding was so great in the basement-rooms of the refuge that at night there were not more than eighty-eight cubic feet of space to each person. Eleven per- sons were affected. It was not possible to trace the source of infection. Typhus is one of the most highly contagious of febrile affections. In epidemics nurses and doctors in attendance upon the sick are almost inva- riably attacked. There is no disease which has so many victims in the profession. In the extensive epidemic in the early and middle part of this century many hundred physicians $ied in the discharge of their duty. Casual attendance upon cases in limited epidemics does not appear to be very risky, but when cases are aggregated together in wards the poison appears concentrated and the danger of infection is much enhanced. Bedding and clothes retain the poison for a long time. The microbe of typhus fever has not yet been determined. Strepto- bacilli, diplococci, and an ascotnycete have been described in the blood and tissues, but the question still remains open for investigation. Morbid Anatomy.—The anatomical changes are those which result from intense fever. The blood is dark and fluid, the muscles are of a deep red color and often show a granular degeneration, particularly in the heart; the liver is enlarged and soft and may have a dull cl ay dike lustre; the kidneys are swollen; there is moderate enlargement of the spleen, and a general hyperplasia of the lymph-follicles. Peyer’s glands are not ulcer- ated. Bronchial catarrh is usually, and hypostatic congestion of the lungs often, present. The skin shows the petechial rash. Symptoms.—Incubation.—This is placed at about twelve days, but it may be less. There may be ill-defined feelings of discomfort. As a rule, however, the invasion is abrupt and marked by chills or a single rigor, followed by fever. The chills may recur during the first few days, and there is headache with pains in the back and legs. There is early pros- TYPHUS FEVER. 45 tration, and the patient is glad to take to his bed at once. The tempera- ture is high at first, and may attain'' its maximum on the second or third day. The pulse is full, rapid, and not so frequently dicrotic as in typhoid. The tongue is furred and white, and there is an early tendency to dry- ness. The face is flushed, the eyes are congested, the expression is dull and stupid. Vomiting may be a distressing symptom. In severe cases mental symptoms are present from the outset, either a mild febrile delir- ium or an excited, active, almost maniacal condition. Bronchial catarrh is common. Stage of Eruption.—From the third to the fifth day the eruption ap- pears—first upon the abdomen and upper part of the chest, and then upon the extremities and face; developing so rapidly that in two or three days it is all out. There are two elements in the eruption : a sub- cuticular mottling, “a fine, irregular, dusky red mottling, as if below the surface of the skin some little distance, and seen through a semi- opaque medium ” (Buchanan); and distinct papular rose-spots which change to petechiae. In some instances the petechial rash comes out with the rose-spots. Collie describes the rash as consisting of three parts —rose-colored spots which disappear on pressure, dark-red spots which are modified by pressure, and petechiae upon which pressure produces no effect. In children the rash at first may present a striking resem- blance to measles, and give as a whole a curiously mottled appearance to the skin. The term mulberry rash is sometimes applied to it. In mild cases the eruption is slight, but even then is largely petechial in character. As the rash is largely haemorrhagic, it is permanent and does not disappear after death. Usually the skin is dry, so that sudaminal vesicles are not common. It is stated by some authors that a distinctive odor is present. During the second week the general symptoms are usually much aggra- vated. The prostration becomes more marked, the delirium more intense, and the fever rises. The patient lies on his back with a dull expressionless face, flushed cheeks, injected conjunctivse, and contracted pupils. The pulse increases in frequency and is feebler, the face is dusky, and the condition becomes more serious. Retention of urine is common. Coma- vigil is frequent, a condition in which the patient lies with open eyes, but quite unconscious. Subsultus tendinum and picking at the bedclothes are frequently seen. The tongue is dry, brown, and cracked, and there are sordes on the teeth. Respiration is accelerated, the heart’s action becomes more and more enfeebled, and death takes place from exhaustion. In favorable cases, about the end of the second week occurs the crisis, in which, often after a deep sleep, the patient awakes feeling much better and with a clear mind. The temperature falls, and although the prostra- tion may be extreme, convalescence is rapid and relapse very rare. This abrupt termination by crisis is in striking contrast to the mode of termi- nation in typhoid fever. Fever.—The temperature rises steadily during the first four or five 46 SPECIFIC INFECTIOUS DISEASES. days, and the morning remissions are not marked. The maximum tem- perature is usually reached by the fifth day, when the temperature may reach 105°, 100°, or 107°. In mild cases it seldom rises above 103°. After reaching its maximum the temperature generally continues with slight morning remissions until the twelfth or fourteenth day, when the crisis occurs, during which the temperature may fall below normal with- in twelve or twenty-four hours. Preceding a fatal termination, there is usually a rapid rise in the fever to 108° or even 109°. The heart may early show signs of weakness. The first sound becomes feeble and almost inaudible, and a systolic murmur at the apex is not in- frequent. Hypostatic congestion of the lungs occurs in all severe cases. The brain symptoms are usually more pronounced than in typhoid, and the delirium is more constant. The urine in typhus shows the usual febrile increase of urea and uric acid. The chlorides diminish or disappear. Albumen is present in a large proportion of the cases, but nephritis seldom occurs. Variations in the course of the disease are naturally common. There are malignant cases which rapidly prove fatal within two or three days; the so-called typhus siderans. On the other hand, during epidemics there are extremely mild cases in which the fever is slight, the delirium absent, and convalescence is established by the tenth day. Complications and Sequelae.—Broncho-pneumonia is perhaps the most common complication. It may pass on to gangrene. In certain epidemics gangrene of the toes, the hands, or the nose, and in children noma or cancrum oris, have occurred. Meningitis is rare. Paralyses, which are probably due to the post-febrile neuritis, are not very uncommon. Septic processes, such as parotitis and abscesses in the subcutaneous tissues and in the joints, are occasionally met. Nephritis is rare. Hsemateinesis may occur. Prognosis.—The mortality ranges in different epidemics from 12 to 20 per cent. It is very slight in the young. Children, who are quite as frequently attacked as adults, rarely die. After middle age the mortality is high, in some epidemics 50 per cent. Heath usually occurs toward the close of the second week and is due to the toxaemia. In the third week it is more commonly due to pneumonia. Diagnosis.—During an epidemic there is rarely any doubt, for the disease presents distinctive general characters. Isolated cases may be very difficult to distinguish from typhoid fever. While in typical instances the eruption in the two affections is very different, yet taken alone it may be deceptive, since in typhoid fever a roseolous rash may be abundant and there is occasionally a subcuticular mottling and even petecliise. The difference in the onset, particularly in the temperature, is marked; but cases in which it is important to make an accurate diagnosis are not usu- ally seen until the fourth or fifth day. The suddenness of the onset, the greater frequency of the chill, and the early prostration are the distinctive TYPHUS FEVER. features in typhus. The brain symptoms too are earlier. It is easy to put down on paper elaborate differential distinctions, which are prac- tically useless at the bedside, particularly when the disease is not pre- vailing as an epidemic. In sporadic cases the diagnosis is sometimes extremely difficult. I have seen Murchison himself in doubt, and more than once I have known a diagnosis to be deferred until the sectio cada- ver is. Severe cerebro-spinal fever may closely simulate typhus at the out- set, but the diagnosis is usually clear within a few days. Malignant vari- ola also has certain features in common with severe typhus, but the greater extent of the haemorrhages and the bleeding from the mucous membranes make the diagnosis clear within a short time. The rash at first resembles that of measles, but in this disease the eruption is brighter red in color, often crescentic or irregular in arrangement, and appears first in the face. The frequency with which other diseases are mistaken for typhus is shown by the fact that during and following the epidemic of 1881 in New York one hundred and eight cases were wrongly diagnosed—one eighth of the entire number—and sent to the Riverside Hospital (F. IV. Chapin). Treatment.—Practically the general management of the disease is like that of typhoid fever. Hydrotherapy should be thoroughly and sys- tematically employed. Judging from the good results which we have obtained by this method in typhoid cases with nervous symptoms much may be expected from it. Certain authorities have spoken against it, but it should be given a more extended trial. Medicinal antipyretics are less suitable than in typhoid, as the tendency to heart-weakness is often more pronounced. As a rule the patients require from the outset a supporting treatment; water should be freely given, and alcohol in suitable doses according to the condition of the pulse. The bowels may be kept open by mild aperients. The so-called spe- cific medication, by sulphocarbolates, the sulphides, carbolic acid, etc., is not commended by those who have had the largest experience. The spe- cial nervous symptoms and the pulmonary symptoms should be dealt with as in typhoid fever. In epidemics, when the conditions of the climate are suitable, the cases are best treated in tents in the open air. III. RELAPSING FEVER (Febris recurrens). Definition.—A specific infectious disease caused by the spirochsete (spirillum) of Obermeier, characterised by a definite febrile paroxysm which usually lasts six days and is followed by a remission of about the same length of time, then by a second paroxysm, which may be repeated three.or even four times, whence the name relapsing fever. Etiology.—This disease, which has also the names “ famine fever ” and “ seven-day fever,” has been known since the early part of the 48 SPECIFIC INFECTIOUS DISEASES. eighteenth century, and has from time to time extensively prevailed in Europe and in Ireland. It is common in India, where the conditions for its development seem always to be present, and where it has been spe- cially studied by Vandyke Carter, of Bombay. It was first seen in this country in 1844, when cases were admitted to the Philadelphia Hospital, which are described by Meredith Clyiner in his work on fevers. Flint saw cases in 1850-’51. In 1809 it prevailed extensively in epidemic form m New York and Philadelphia; since then it has not appeared. The special conditions under which it develops are very similar to those of typhus fever. Overcrowding and deficient food are the condi- tions which seem to promote the rapid spread of the virus. Neither age, sex, nor season seems to have any special influence. It is a contagious disease and may be communicated from person to person, but is not so contagious as typhus. Murchison thinks it may be transported by fomites. One attack does not confer immunity from subsequent attacks. In 1873 Obermeier described an organism in the blood which is now recognised as the specific agent. This spirillum, or more correctly spirochete, is from three to six times the length of the diameter of a red blood-cor- puscle, and forms a narrow spiral filament which is readily seen moving among the red corpuscles during a paroxysm. They are present in the blood only during the fever. Shortly before the crisis and in the inter- vals they are not found, though small glistening bodies, which are stated to be their spores, appear in the blood. The disease has been produced in human beings by inoculation of the blood during the paroxysm. It has also been produced in monkeys. Nothing is yet known with refer- ence to the life history of the spirochsete. Morbid Anatomy.—There are no characteristic anatomical appear- ances in relapsing fever. If death takes place during the paroxysm the spleen is large and soft, and the liver, kidneys and heart show cloudy swelling. There may be infarcts in the kidneys and spleen. The bone marrow has been found in a condition of hyperplasia. Ecchymoses are not uncommon. Symptoms.—The incubation appears to be short, and in some in- stances the attack develops promptly after exposure; more frequently, however, from five to seven days elapse. The invasion is abrupt, with chill, fever, and intense pain in the back and limbs. In young persons there may be nausea, vomiting, and convul- sions. The temperature rises rapidly and may reach 104° on the evening of the first day. Sweats are common. The pulse is rapid, ranging from 110 to 130. There may be delirium if the fever is high. Swelling of the spleen can be detected early. Jaundice is common in some epidemics. The gastric symptoms may be severe. There are seldom intestinal symp- toms. Cough may be present. Occasionally herpes is noted, and there may be miliary vesicles and petechias. During the paroxysm the blood invariably shows the spirochaste, and there is usually a leucocytosis (Ou- RELAPSING FEVER. 49 skow). After persisting with severity or even with an increasing intensity for five or six days the crisis occurs. In the course of a few hours, accom- panied by profuse sweating, sometimes by diarrhoea, the temperature falls to normal or even subnormal, and the period of apyrexia begins. Chart V.—Relapsing fever (Murchison). The crisis may occur as early as the third day, or it may be delayed to the tenth; it usually comes, however, about the end of the first week. In delicate and elderly persons there may be collapse. The convalescence is rapid, and in a few days the patient is up and about. Then in a week, usually on the fourteenth day, he again has a rigor, or a series of chills; the fever returns and the attack is repeated. A second crisis occurs from the twentieth to the twenty-third day, and again the patient recovers rapidly. As a rule the relapse is shorter than the original attack. A second and a third may occur, and there are instances on record of even a fourth and a fifth. In epidemics there are cases which terminate by crisis on the seventh or eighth day without the occurrence of relapse. In pro- tracted cases the convalescence is very tedious, as the patient is much exhausted. Relapsing fever is not a very fatal disease. Murchison states that the mortality is about 4 per cent. In the enfeebled and old, death may occur at the height of the first paroxysm. Complications are not frequent. In some epidemics nephritis and haematuria have occurred. Pneumonia appears to be frequent and may interrupt the typical course of the disease. The acute enlargement of the spleen may end in rupture, and the haemorrhage from the stomach, which has been met with occasionally, is probably associated with this enlarge- ment. Post-febrile paralyses may occur. Ophthalmia has followed cer- tain epidemics, and may prove a very tedious and serious complication. Jaundice has already been mentioned. In pregnant women abortion usu- ally takes place. 50 SPECIFIC INFECTIOUS DISEASES. Diagnosis.—The onset and general symptoms may not at first be distinctive. At the beginning of an epidemic the cases are usually regarded as anomalous typhoid ; but once the typical course is followed in a case the diagnosis is clear. The blood examination, which should be made in all doubtful cases of fever, affords a definite criterion by which the diagnosis can readily be made. Treatment.—The paroxysm can neither be cut short nor can its recurrence be prevented. It might be thought that quinine, with its pow- erful action, would certainly meet the indications, but it does not seem to have the slightest influence. The disease must be treated like any other continued fever by careful nursing, a regular diet, and ordinary hygienic measures. Of special symptoms, pains in the back and in the limbs and joints demand opium. In enfeebled persons the collapse at the crisis may be serious, and stimulants with ammonia and digitalis should be given freely. IV. SMALL-POX {Variola). Definition.—An acute infectious disease characterised by an erup- tion which passes through the stages of papule, vesicle, pustule and crust. The mucous membranes in contact with the air may also be affected. Severe cases may be complicated with cutaneous and visceral haemorrhages. Etiology.—It has not yet been determined in what country small- pox originated. The disease is said to have existed in China many centu- ries before Christ. The pesta magna described by Galen (and of which Marcus Aurelius died) is believed to be small-pox. In the sixth century it prevailed, and subsequently, at the time of the Crusades, became wide- spread. It was brought to America by the Spaniards early in the sixteenth century. The first accurate account was given by Rhazes, an Arabian phy- sician who lived in the ninth century, and whose admirable description is available in Greenhill’s translation for the Sydenham Society. In the seventeenth century a thorough study of the disease was made by the illus- trious Sydenham, who still remains one of the most trustworthy authori- ties on the subject. Special events in the history of the disease are the introduction of inoculation into Europe, by Lady. Mary Wortley Montagu, in 1718, and the discovery of vaccination by Jenner, in 1798. Small-pox is one of the most virulent of contagious diseases, and per- sons exposed, if unprotected by vaccination, are almost invariably attacked. There are instances on record of persons insusceptible to the disease. It is said that Diemerbroeck, a celebrated Utrecht professor in the seventeenth century, was not only himself exempt, but likewise many members of his family. One of the nurses in the small-pox department of the Montreal General Hospital stated that she had never been successfully vaccinated, SMALL-POX. 51 and she certainly had no mark. Such instances, however, of natural im- munity are very rare. An attack may not protect for life. There are undoubted cases of a second, reputed instances, indeed, of a third attack. Age.—Small-pox is common at all ages, but is particularly fatal to young children. The foetus in utero may be attacked, but only if the mother herself is the subject of the disease. The child may be born with the rash out or with the scars. More commonly the foetus is not affected, and children born in a small-pox hospital, if vaccinated immediately, may escape the disease; usually, however, they die early. Sex.—Males and females are equally affected. Race.—Among aboriginal races small-pox is terribly fatal. When the disease was first introduced into America the Mexicans died by thousands, and the North American Indians have also been frequently decimated by this plague. It is stated that the negro is especially susceptible, and the mortality is greater—about 42 per cent in the black, against 29 per cent in the white (W. M. Welch). The Contagium develops in the system of the small-pox patient and is reproduced in the pustules. It exists in the secretions and excretions, and in the exhalations from the lungs and the skin. The dried scales con- stitute by far the most important element, and as a dust-like powder are distributed everywhere in the room during convalescence, becoming at- tached to clothing and various articles of furniture. The disease is proba- bly contagious from a very early stage, though I think it has not yet been determined whether the contagion is active before the eruption develops. The poison is of unusual tenacity and clings to infected localities. It is conveyed by persons who have been in contact with the sick and by fomites. During epidemics it is no doubt widely spread in street-cars and public con- veyances. It must not be forgotten that an unprotected person may con- tract a very virulent form of the disease from the mild varioloid. The disease smoulders here and there in different localities, and when conditions are favorable becomes epidemic. Perhaps the most remarkable instance in modern times of the rapid extension of the disease occurred in Montreal in 1885. Small-pox had been prevalent in that city between 1870 and 1875, when it died out, in part owing to the exhaustion of suit- able material and in part owing to the introduction of animal vaccination. The health reports show that the city was free from the disease until 1885. During these years vaccination, to which many of the French Canadians are opposed, was much neglected, so that a large unprotected population grew up in the city. On February 28th a Pullman-car conductor, who had travelled from Chicago, where the disease had been slightly prevalent, was admitted into the Hotel-Dieu, the civic small-pox hospital being at the time closed. Isolation was not carried out, and on the 1st of April a serv- ant in the hospital died of small-pox. Following her decease, with a neg- ligence absolutely criminal, the authorities of the hospital dismissed all patients presenting no symptoms of contagion, who could go home. The 52 SPECIFIC INFECTIOUS DISEASES. disease spread like fire in dry grass, and within nine months there died in the citv, of small-pox, 3,164 persons. The nature of the contagion of small-pox is still unknown. Weigert and others have described micro-organisms in the pock, but they are the ordinary pus cocci, and the part which they play in the affection is by no means certain. Still less definite are the observations on the occur- rence of sporozoa in the pocks. It is not a little remarkable that in a disease which is rightly regarded as the type of all infectious maladies, the specific virus still remains unknown. Morbid Anatomy.—A section of a papule as it is passing into the vesicular stage shows in the rete mucosum, close to the true skin, an area in which the cells are smooth, granular, and do not take the staining fluid. This represents a focus of coagulation-necrosis due, according to AVeigert, to the presence of micrococci. Around this area there is active inflamma- tory reaction, and in the vesicular stage the rete mucosum presents re- ticuli, or spaces, which contain serum, leucocytes and fibrin filaments. The central depression or umbilication corresponds to the area of primary necrosis. In the stage of maturation the reticular spaces become filled with leucocytes and many of the cells of the rete mucosum become vesicu- lar. The papillae of the true skin below the pustule are swollen and infil- trated with embryonic cells to a variable degree. If the suppuration ex- tends into this layer, scarring inevitably results; but if it is confined to the upper layer, it does not necessarily follow. In the haemorrhagic cases, red corpuscles pass out in large numbers from the vessels and occupy the vesicular spaces. They infiltrate also the deeper layers of the epidermis in the skin adjacent to the papules. Frequently a hair-follicle passes through the centre of a papule. In the mouth the pustules may be seen upon the tongue and the buccal mucosa, and on the palate. The eruption may be abundant also in the pharynx and the upper part of the oesophagus. In exceptionally rare cases the eruption extends down the oesophagus and even into the stom- ach. Swelling of the Peyer’s follicles is not uncommon; the pustules have been seen in the rectum. In the larynx the eruption may be associated with a fibrinous exudate and sometimes with oedema. Occasionally the inflammation passes deeply and involves the cartilages. In the trachea and bronchi there may be ulcerative erosions, but true pocks, such as are seen on the skin, do not occur. There are no special lesions of the lungs, but congestion and bron- cho-pneumonia are very common. The liver is sometimes fatty. A diffuse hepatitis, associated with intense congestion of the vessels and migration of the leucocytes, has been described; AVeigert has noted small areas of necrosis. There is nothing special in the condition of the blood, and even in the most malignant cases there are no microscopic alterations. In the blood- drop, however, it will be seen that the corpuscles, instead of forming SMALL-POX. 53 rouleaux, aggregate together in irregular clumps. The heart occasionally shows myocardial changes, parenchymatous and fatty; endocarditis and pericarditis are uncommon. French writers have described an endarteritis of the coronary vessels in connection with small-pox. The spleen is mark- edly enlarged. Apart from the cloudy swelling and areas of coagulation- necrosis, lesions of the kidneys are not common. Nephritis may occur during convalescence. Chiari has called attention to the frequency of orchitis in this disease. There ate scattered areas of necrosis with cell in- filtration. In the haemorrhagic form extravasations are found on the serous and mucous surfaces, in the parenchyma of organs, in the connective tissues, and about the nerve-sheaths. In one instance I found the entire retro- peritoneal tissue infiltrated with a large coagulum, and there were also ex- tensive extravasations in the course of the thoracic aorta. Haemorrhages in the bone-marrow have also been described by Golgi. There may be haemorrhages into the muscles. Ponfick has described the spleen as very firm and hard in haemorrhagic small-pox, and such was the case in seven instances which I examined. The liver has been described as fatty in these rapid cases, but in five of my seven cases it was of normal size, dense, and firm. In two it was large and fatty ; but one man had necro- sis of the tibia, and the other was a drunkard. The ecchymoses are scat- tered over the meninges of the brain and cord, and in one case there was a clot in the right ventricle. In five of the cases there were areas of haem- orrhagic infarction of the lung. In four instances the pelves of the kidney were blocked with dark clots, which extended into the calices and down the ureters. In one instance the coats of the bladder were uni- formly haemorrhagic and not a trace of normal tissue could be seen. The extravasations in the mucous membrane of the stomach and intestines were numerous and large. Peyer’s glands were swollen and prominent in four instances. Symptoms.—Three forms of small-pox are described^ 1. Variola vera ; (a) Discrete, (b) Confluent. 2. Variola hcemorrhagica ; (a) Purpura variolosa or black small-pox -y (b) Haemorrhagic pustular form, variola haemorrhagica pustulosa. 3. Varioloid, or small-pox modified by vaccination. 1. Variola Vera.—The affection may be conveniently described under various stages: (a) Incubation.—“ From nine to fifteen days; oftenest twelve.” I have seen it develop on the eighth day after exposure to in- fection, and there are well-authenticated instances in which the stage of incubation has been prolonged to twenty days. It is unusual for patients to complain of any symptoms in this stage. (b) Invasion.—In adults a chill and in children a convulsion are com- mon initial symptoms. There may be repeated chills within the first twenty-four hours. Intense frontal headache, severe lumbar pains, and vomiting are very constant features. The pains in the back and in the 54 SPECIFIC INFECTIOUS DISEASES. limbs are more severe in the initial stage of this than of any other erup- tive fever, and their combination with headache and vomiting is so sug- Initial Fever Eruption. Suppurative Fever. Chart VI.—-True small-pox. gestive that in epidemics precautionary measures may often be taken several days before the eruption decides positively the nature of the dis- ease. The temperature rises quickly, and may on the first day be 103° or 104°. The pulse is rapid and full, not often dicrotic. In severe cases there may be marked delirium, particularly if the fever is high. The patient is restless and distressed, the face is flushed, and the eyes are bright and clear. The skin is usually dry, though occasionally there are profuse sweats. One cannot judge from these initial symptoms whether a case is likely to be discrete or confluent, as the most intense backache and fever may precede a very mild attack. Convulsions are not uncommon in children. In this stage of invasion the so-called initial rashes may occur, of which two forms can be distinguished—the diffuse, scarlatinal, and the macular or measly form; either of which may be associated with petechia? and occupy a variable extent of surface. In some instances they are gen- eral, but as a rule they are limited, as pointed out by Simon, either to the lower abdominal areas, to the inner surfaces of the thighs, and to the lat- eral thoracic region or to the axillae. Occasionally they are found over the extensor surfaces, particularly in the neighborhood of the knees and elbows. These rashes, usually purpuric, are often associated with an erythematous or erysipelatous blush. The scarlatinal rash may come out as early as the second day and be as diffuse and vivid as in a true scarla- tina. The measly rash may also be diffuse and identical in character with that of measles. Urticaria is only occasionally seen. It was present once in my Montreal cases. Apparently these initial rashes are more abundant in some epidemics than in others; thus they were certainly more numerous in the Montreal epidemics between 1870 and 1875 than they were in the more extensive epidemic in 1885. They occur in from 10 to 16 per cent SMALL-POX. 55 of cases. In the cases under my care in the small-pox department at the Montreal General Hospital the percentage was 13.* As will be subse- quently mentioned these initial rashes have considerable diagnostic value. (c) Eruption.—(1) In the discrete form, usually on the fourth day, small red spots appear on the forehead, particularly at the junction with the hair, and on the wrists. Within the first twenty-four hours from their appearance they occur on other parts of the face and on the extremities, and a few are seen on the trunk. As the rash comes out the temperature falls, the general symptoms subside, and the patient feels comfortable. On the fifth or sixth day the papules change into vesicles with clear summits. Each one is elevated, circular, and presents a little depression in the cen- tre, the so-called umbilication. About the eighth day the vesicles change into pustules, the umbilication disappears, the flat top assumes a globular form and becomes grayish yellow in color, owing to the contained pus. There is an areola of injection about the pustules and the skin between them is swollen. This maturation first takes place on the face, and follows the order of the appearance of the eruption. The temperature now rises— secondary fever—and the general symptoms return. The swelling about the pustules is attended with a good deal of tension and pain in the face; the eyelids become swollen and closed. There is a well-marked leuco- cytosis in the stage of suppuration. In the discrete form the temper- ature of maturation does not usually remain high for more than twenty- four or twenty-six hours, so that on the tenth or eleventh day the fever disappears and the stage of convalescence begins. The pustules rapidly dry, first on the face and then on the other parts, and by the fourteenth or fifteenth day desquamation may be far advanced on the face. There may be in addition vesicles in the mouth, pharynx, and larynx, causing sore- ness and swelling in these parts, with loss of voice. Whether pitting takes place depends a good deal upon the severity of the disease. In a majority of cases Sydenham’s statement holds good, that “ it is very rarely the case that the distinct small-pox leaves its mark.” (2) The Confluent Form,.—With the same initial symptoms, though usually of greater severity, the rash appears on the fourth, or, according to Sydenham, on the third day. The more the eruption shows itself before the fourth day, the more sure it is to become confluent (Sydenham). The papules at first may be isolated and it is only later in the stage of matu- ration that the eruption is confluent. But in severer cases the skin is swollen and hypersemic and the papules are very close together. On the feet and hands, too, the papules are thickly set; more scattered on the limbs; and quite discrete on the trunk. With the appearance of the eruption the symptoms subside and the fever remits, but not to the same extent as in the discrete form. Occasionally the temperature falls to normal and the patient may be very comfortable. Then, usually on the eighth day, the temperature again rises, the vesicles begin to change to *The Initial Rashes of Small-pox. Canada Medical and Surgical Journal, 1875. 56 SPECIFIC INFECTIOUS DISEASES. pustules, the hyperaemia about them becomes intense, the swelling of the face and hands increases, and by the tenth day the pustules have fully maturated, many of them have coalesced and the entire skin of the head and extremities is a superficial abscess. The fever rises to 103° or 104°, the pulse is from 110 to 120, and there is often delirium. As pointed out by Sydenham, salivation in adults and diarrhoea in children are common symptoms of this stage. There is usually much thirst. The eruption may also be present in the mouth, and usually the pharynx and larynx are involved and the voice is husky. Great swelling of the cervical lymphatic glands occurs. At this stage the patient presents a terrible picture, un- equalled in any other disease; one which fully justifies the horror and fright with which small-pox is associated in the public mind. Even when the rash is confluent on the face, hands, and feet, the pustules remain discrete on the trunk. The danger, as pointed out by Sydenham, is in proportion to the number upon the face. “ If upon the face they are as thick as sand it is no advantage to have them few and far between on the rest of the body.” In fatal cases, by the tenth or eleventh day the pulse gets feebler and more rapid, the delirium is marked, there is subsultus, sometimes diarrhoea, and with these symptoms the patient dies. In other instances between the eighth and eleventh day haemorrhagic symptoms develop. When recovery takes place, the patient enters on the eleventh or twelfth day the period of— (d) Desiccation.—The pustules break and the pus exudes and forms crusts. Throughout the third week the desiccation proceeds and in cases of moderate severity the secondary fever subsides; but in others it may persist until the fourth week. The crusts in confluent small-pox adhere for a long time and the process of scarring may take three or four weeks. The crusts on the face fall off, but the tough epidermis of the hands and feet may be shed entire. We had in the small-pox department of the Mon- treal General Hospital several moulds in epithelium of the hands and feet. 2. Haemorrhagic small-pox occurs in two forms. In one the special symptoms appear early and death follows in from two to six days. This is the so-called petechial or black small-pox—purpura variolosa. In the other form the case progresses as one of ordinary variola, and it is not until the vesicular or pustular stage that haemorrhage takes place into the pocks or from the mucous membranes. This is sometimes called variola Immorrhagica pustulosa. Hemorrhagic small-pox is more common in some epidemics than in others. It is less frequent in children than in adults. Of twenty-seven cases admitted to the small-pox department of the Montreal General Hos- pital there were three under ten years, four between fifteen and twenty, nine between twenty and twenty-five, seven between twenty-five and thirty- five, three between thirty-five and forty-five, and one above fifty. Young and vigorous persons seem more liable to this form. Several of my cases were above the average in muscular development. Men are more fre- SMALL-POX. 57 quently affected than women; thus in my list there were twenty-one males and only six females. The influence of vaccination is shown in the fact that of the cases fourteen were unvaccinated, while not one of the thirteen who had scars had been revaccinated. The clinical features of the forms of haemorrhagic small-pox are some- what different. In 'purpura variolosa the illness starts with the usual symptoms, but with more intense constitutional disturbance. On the evening of the second or on the third day there is a diffuse hyperaemic rash, particularly in the groins, with small punctiform haemorrhages. The rash extends, becomes more distinctly haemorrhagic, and the spots increase in size. Ecchymoses appear on the conjunctivae, and as early as the third day there may be haemorrhages from the mucous membranes. Death may take place before the rash appears. This is truly a terrible affection and well developed cases present a frightful appearance. The skin may have a uniformly purplish hue and the unfortunate victim may even look plum- colored. The face is swollen and large conjunctival haemorrhages with the deeply sunken corneae give a ghastly appearance to the features. The mind may remain clear to the end. Death occurs from the third to the sixth day; thus in thirteen of my cases death took place on or be- fore this date. The earliest death was on the third day and there were no traces of papules. There may be no mucous haemorrhages; thus in one case of a most virulent character death occurred without bleeding early on the fourth day. Haematuria is perhaps most common, next hae- matemesis, and melaena was noticed in a third of the cases. Metrorrhagia was noticed in one only of the six females on my list. Haemoptysis oc- curred in five cases. The pulse in this form of small-pox is rapid and often hard and small. The respira- tions are greatly increased in fre- quency and out of all proportion to the intensity of the fever. In the case of a negro, whose respirations the morning after admission were 32 and temperature 101°, after ex- amining the lungs and finding noth- ing to account for the increased breathing, my suspicions were aroused, and even on the dark skin I was able on careful inspection to detect haemorrhages in and about the papules. The annexed chart is from a case of malignant small-pox which came on abruptly on Thursday, October 24, 1874, and which terminated early on the fourth day. It shows the moderate temperature range. Chart VII.—Haemorrhagic small-pox. 58 SPECIFIC INFECTIOUS DISEASES. In variola pustulosa hcemorrhagica the disease progresses as an ordi- nary case of severe variola, and the haemorrhages do not develop until the vesicular or pustular stage. The earlier the haemorrhage the greater is the danger. There are undoubtedly instances of recovery when the bleed- ing has taken place at the stage of maturation. Bleeding from the mu- cous membranes is also common in this form, and the great majority of the cases prove fatal, usually on the seventh, eighth, or ninth day. There is a form of haemorrhagic small-pox in which bleeding takes place into the pocks in the vesicular stage and is followed by a rapid abortion of the rash and a speedy recovery. Six instances of this kind came under my observation.* In four the haemorrhage took place on the fourth day; in two on the fifth day, just at the time of transition of the papule into the vesicle. Extravasation takes place chiefly into the pocks on the lower extremities and trunk, in only two instances occurring in those of the arms. The eruption in all proved abortive, and no patients under my care wdtli an equal extent of eruption made such rapid recover- ies. With these cases are to be grouped those in which the lieemorrhages occur in the pustules of the legs in patients who have in their delirium got out of bed and wandered about. This modified form of haemorrhagic small-pox is also described by Scheby-Buch. 3. Varioloid.—This term is applied to the modified form of small-pox which affects persons who have been vaccinated. It may set in with abruptness and severity, the temperature reaching 103°. More common- ly it is in every respect milder in its initial symptoms, though the head- ache and backache may be very distressing. The papules appear on the evening of the third or on the fourth day. They are few in number and may be confined to the face and hands. The fever drops at once and the patient feels perfectly comfortable. The vesiculation and maturation of the pocks take place rapidly and there is no secondary fever. There is rarely any scarring. As a rule, when small-pox attacks a person who has been vaccinated within five or six years the disease is mild, but there are instances in which it is very severe, and it may even prove fatal. There are several forms of rash; thus in what has been known as horn- pox, crystalline pox, and wart-pox the papules come out in numbers on the third or fourth day, and by the fifth or sixth day have dried to a hard, horny consistence. Writers describe a variola sine eruptione, which is met with during epidemics in young persons who have been well vaccinated, and who pre- sent simply the initial symptoms of fever, headache and backache. In a somewhat extensive experience in Montreal I do not remember to have met with an instance of this kind or to have heard of one. We do not now see the modified form of small-pox, resulting from inoculation, in which by the seventh or eighth day a pustule forms at the * Clinical Notes on Small-pox. Montreal, 1876. SMALL-POX. 59 seat of inoculation; then general fever sets in, and with it, about the eleventh day, a general eruption, usually limited in degree. Complications.—Considering the severity of many of the cases and the general character of the disease, associated with multiple foci of suppuration, the complications in small-pox are remarkably few. Laryngitis is serious in three ways : it may produce a fatal oedema of the glottis; it is liable to extend and involve the cartilages, producing necrosis ; and by diminishing the sensibility of the larynx, it allows irri- tating particles to reach the lower air-passages, where they excite bron- chitis or broncho-pneumonia. Broncho-pneumonia is indeed one of the most common complications, and is almost invariably present in fatal cases. Lobar pneumonia is rare. Pleurisy is common in some epidemics. The cardiac complications are also rare. In the height of the fever a systolic murmur at the apex is not uncommon; but endocarditis, either simple or malignant, is rarely met with. Pericarditis too is very uncom- mon. Myocarditis seems to be more frequent, and may be associated with endarteritis of the coronary vessels. Of complications in the digestive system, parotitis is rare. In severe cases there is extensive pseudo-diphtheritic angina. Vomiting, which is so marked a symptom in the early stage, is rarely persistent. Diarrhoea is not uncommon, as noted by Sydenham, and is very constantly present in children. Albuminuria is frequent, but true nephritis is rare. Inflammation of the testes and of the ovaries may occur. Among the most interesting and serious complications are those per- taining to the nervous system. In children convulsions are common. In adults the delirium of the early stage may persist and become violent, and finally subside into a fatal coma. Post-febrile insanity is occasionally met with during convalescence, and very rarely epilepsy. Many of the old writers spoke of paraplegia in connection with the intense backache of the early stage, but it is probably associated with the severe agonising lumbar and crural pains and is not a true paraplegia. It must be sepa- rated from the form occurring in convalescence, which may be due to peripheral neuritis or to a diffuse myelitis (Westphal). The neuritis may as in diphtheria involve the pharynx alone, or it may be multiple. Of this nature, in all probability, is the so-called pseudo-tabes, or ataxie- variolique. Hemiplegia and aphasia have been met with in a few in- stances, the result of encephalitis. Among the most constant and troublesome complications of small-pox are those involving the skin. During convalescence boils are very fre- quent and may be severe. Acne and ecthyma are also met with. Local gangrene in various parts may occur. Arthritis may develop, usually in the period of desquamation, and may 60 SPECIFIC INFECTIOUS DISEASES. pass on to suppuration. Acute necrosis of the bone is sometimes met with. Special Senses.—The eye affections which were formerly so common and serious are not now so frequent, owing to the care which is given to keeping the conjunctivas clean. A catarrhal and purulent conjunctivitis is common in severe cases. The secretions cause adhesions of the eyelids, and unless great care is taken a diffuse keratitis is excited, which may go on to ulceration and perforation. Iritis is not very uncommon. Otitis media is an occasional complication, and usually results from an extension of disease through the Eustachian tubes. Prognosis.—In unprotected persons small-pox is a very fatal disease. In different epidemics the death-rate is from 25 to 35 per cent. In Wil- liam M. Welch’s, report from the Municipal Hospital, Philadelphia, of 2,831 cases of variola, 1,534—i. e., 54T8 per cent—died, while of 2,169 cases of varioloid only 28—i. e., T29 per cent—died. The haemorrhagic form is invariably fatal, and a majority of those attacked with the severer confluent forms die. In young children it is particularly fatal. In the Montreal epidemic of 1885 and 1886, of 3,164 deaths there were 2,717 under ten years. The intemperate and debilitated succumb more readily to the disease. As Sydenham observed, the danger is directly pro- portionate to the intensity of the disease on the face and hands. “ When the fever increases after the appearance of the pustules, it is a bad sign; but, if it is lessened on their appearance, that is a good sign ” (Rhazes). Very high fever, with delirium and subsultus, are symptoms of ill omen. The disease is particularly fatal in pregnant women and abortion usually takes place. It is not, however, uniformly fatal, and I have twice known severe cases to recover after miscarriage. Moreover, abortion is not inevitable. Very severe pharyngitis and laryngitis are fatal complications. Death results in the early stage from the action of the poison upon the nervous system. In the later stages it usually occurs about the eleventh or twelfth day, at the height of the eruption. In children, and occasion- ally in adults, the laryngeal and pulmonary complications prove fatal. Diagnosis.—During an epidemic, the initial chill, followed by fever, headache, vomiting, and the severe pain in the back, are symptoms which should put the attending physician on his guard. Mistakes arise in the initial stage owing to the presence of the scarlatinal or measly rashes which may be extremely deceptive. The scarlatinal rash has not always the intensity of the true rash of this disease. In my Montreal experience I did not meet with an instance in which this rash led to an error, though I heard of several cases in which the mistake was made. These are doubt- less the instances to which the older writers refer of scarlet fever and small-pox occurring together. The measly rash cannot always be dis- tinguished from true measles, instances of which may be mistaken for the initial rash. I found in the ward one morning a young man who had been sent in on the previous evening with a diagnosis of small-pox. lie SMALL-POX. 61 had a fading macular rash with distinct small papules, which had not however the shotty hardness of variola. In the evening this rash was less marked, and as I felt sure that a mistake had been made, he was disin- fected and sent home. In another instance a child believed to have small- pox was admitted, but it proved to have simply measles. Neither of these cases took small-pox. In a third case, which I saw at the City Hospital, the mottled papular rash was mistaken for small-pox and the young man sent to the hospital. I saw him the day after admission, when there was no question that the disease was measles and not variola. Less fortunate than the other cases, he took small-pox in a very severe form. The gen- eral condition of the patient and the nature of the prodromal symptoms are often better guides than the character of the rash. In any case it is not well, as a rule, to send a patient to a small-pox hospital until the char- acteristic papules appear about the forehead and on the wrists. In the most malignant type of haemorrhagic small-pox the patient may die before the characteristic rash develops, though as a rule small, shotty papules may be felt about the wrists or at the roots of the hair. In only one of twenty-seven cases of haemorrhagic small-pox, in which death occurred on the third day, did inspection fail to reveal the papules. In three cases in which death took place on the fourth day the characteristic rash was beginning to appear. The disease may be mistaken for cerebro-spinal fever, in which purpuric symptoms are not uncommon. A four-year-old child was taken suddenly ill with fever, pains in the back and head, and on the second or third day petechias appeared on the skin. There was retraction of the head, and marked rigidity of the limbs. The haemorrhages became more abundant; and finally haematemesis occurred and the child died on the sixth day. At the post-mortem there were no lesions of cerebro-spinal fever and in the deeply haemorrhagic skin the papules could be readily seen. The post- mortem diagnosis of small-pox was unhappily confirmed by the mother taking the disease and dying of it. It might be thought scarcely possible to mistake any other disease for small-pox in the pustular stage. Yet I had an instance of a young man sent to me with a copious pustular eruption, chiefly on the trunk and cov- ered portions of the body, which, so far as the pustules themselves were concerned, was almost identical with that of variola; but the history and the distribution left no question that it was a pustular syphilide. It is not to be forgotten, however, that fever, which was absent in this case, may be present in certain instances of diffuse pustular syphilis. Lastly, chicken- pox and small-pox may be confounded. Indeed, sometimes it is not easy to distinguish between them, though in well-defined cases of varicella the more vesicular character of the pustules, their irregularity, the short stage of invasion, the slight constitutional disturbance, and the greater intensity of the rash on the trunk, should make the diagnosis clear. It is stated that the Chicago case, which was the starting-point in Montreal of the 62 SPECIFIC INFECTIOUS DISEASES. epidemic of 1885, was regarded as varicella and not isolated. If so, the mistake was one which led to one of the most fatal of modern outbreaks of the disease. Glanders in the pustular form has been mistaken for small-pox, and I know of an instance (during an epidemic) which was isolated on the sup- position that it was variola. Treatment.—In the interests of public health cases of small-pox should invariably be removed to special hospitals, since it is impossible to take the proper precautions in private houses. The general hygienic arrangements of the room should be suitable for an infectious disease. All unnecessary furniture and the curtains and carpets should be removed. The greatest care should be taken to keep the patient thoroughly clean, and the linen should be frequently changed. The bedclothing should be light. It is curious that the old-fashioned notion, which Sydenham tried so hard to combat, that small-pox patients should be kept hot and warm, still prevails; and I have frequently had to protest against the patient being, as Sydenham expresses it, stifled in his bed. Special care should be taken to sterilize thoroughly everything that has been in contact with the patient. In the early stage the pain in the back and limbs requires opium, which, as advised by Sydenham, may be freely given. The diet should consist of milk and broths, and of “ all articles which give no trouble to digestion.” Cold drinks may be freely given. Barley-water and the Scotch borse (oatmeal and water) are both nutritious and palatable. After the preliminary vomiting, which is often very hard to check by ordinary measures, the appetite is usually good, and, if the throat is not very sore, patients with the confluent form take nourishment well. In the haemorrhagic cases the vomiting is usually aggravating and per- sistent. The fever when high must be kept within limits, and it is best to use either cold sponging or the cold bath. When the pyrexia is combined with delirium and subsultus, the patient should be placed in a bath at 70°, and this repeated as often as every three hours if the temperature rises above 103°. When it is not practicable to give the cold bath, the cold pack can be employed. These measures are much preferable in small-pox to the administration of medicinal antipyretics. The treatment of the eruption has naturally engaged the special atten- tion of the profession. The question of the preventing of pitting, so much discussed, is really not in the hands of the physician. It depends entirely upon the depth to which the individual pustules reach. After trying all sorts of remedies, such as puncturing the pustules with nitrate of silver, or treating them with iodine and various ointments, I came to Sydenham’s conclusion that in guarding the face against being disfigured by the scars “ the only effect of oils, liniments, and the like, was to make the white scurfs slower in coming off.” There is, I believe, something in protecting SMALL-POX. 63 the ripening papules from the light, and the constant application on the face and hands of lint soaked in cold water, to which antiseptics such as carbolic acid or bichloride may be added, is perhaps the most suitable treatment. It is very pleasant to the patient, and for the face it is well to make a mask in lint, which can then be covered with oiled silk. When the crusts begin to form, the chief point is to keep them thoroughly moist, which may be done by oil or glycerin. This prevents the desicca- tion and diffusion of the flakes of epidermis. Vaseline is particularly use- ful, and at this stage may be freely used upon the face. It frequently relieves the itching also. For the odor, which is sometimes so character- istic and disagreeable, the dilute carbolic solutions are probably best. If the eruption is abundant on the scalp, the hair should be cut short to prevent matting and decomposition of the crusts. During convalescence frequent bathing is advisable, because it helps to soften the crusts. The care of the eyes is particularly important. The lids should be thoroughly cleansed three or four times a day, and the conjunctivee washed with some antiseptic solution. In the confluent cases, when the eyelids are much swollen and the lids glued together, it is only by watchfulness that kerati- tis can be prevented. The mouth and throat should be kept clean, and if crusts form in the nose they should be softened by frequent injections. Ice can be given, and is very grateful when there is much angina. In moderate cases, so soon as the fever subsides the patient should be allowed to get up, a practice which Sydenham warmly urged. The diarrhoea, when severe, should be checked with paregoric. When the pulse becomes feeble and rapid, stimulants may be freely given. The delirium is occasionally maniacal and may require chloroform, but for the nervous symptoms the bath or cold pack is the best. For the severe hasmorrhages of the malig- nant cases nothing can be done, and it is only cruel to drench the unfortu- nate patient with iron, ergot, and other drugs. Symptoms of obstruction in the larynx, usually from cedema, may call for tracheotomy. In the late stages of the disease, should the patient be extremely debilitated and the subject of abscesses and bed-sores, he may be placed on a water-bed or treated by the continuous warm bath. During convalescence the patient should bathe daily and use carbolic soap freely in order to get rid of the crusts and scabs. The patient should not be considered free from danger to others until the skin is perfectly smooth and clean, and free from any trace of scabs. I have not mentioned any of the so-called specifics or the internal antiseptics, which have been advised in such numbers; because, so far as I know, the experience of those who have seen the most of the disease does not favor their use. 64 SPECIFIC INFECTIOUS DISEASES. V. VACCINIA {Cow-pox)—VACCINATION. Definition.—All eruptive disease of the cow, the virus of which, inocu- lated into man (vaccination), produces a local pock Avith constitutional dis- turbance, which affords protection, more or less permanent, from small-pox. The vaccine is got either directly from the calf—animal lymph—in which the disease is propagated at regular stations, or is obtained from persons vaccinated (humanised lymph). It was in 1798 that Edward Jenner, a friend and pupil of Hunter, practising in Gloucestershire, announced that persons accidentally inocu- lated Avith the cow-pox Avere subsequently insusceptible to small-pox. From that time the process has extended over the civilized world and proved an incalculable boon to humanity. The precise nature of vaccinia is still in dispute. Many regard it as a specific disease in the coav analogous to sheep-pox and horse-pox. Others think that it is only small-pox modified by passing through the cow. Material from a small-pox pustule inoculated in a calf produces a vesicle like coAv-pox, which may be inoculated from animal to animal, and which successfully protects the calf from subsequent inoculations Avith vaccine matter. Children inoculated Avith this so-called variola-vaccine lymph are protected, and the pock produced is similar to that of ordinary vac- cinia. There is no generalized eruption, and the disease produced in the child is not contagious, and protects against small-pox. Quist, H. C. Ernst, and Martin have cultivated micrococci from the vaccine lymph. Lately, Copeman and Klein haA'e described independ- ently a bacillus, while Pfeiffer, Ruffer, and others have found protozoa in the vaccine vesicle. Phenomena of Vaccination.—In a primary vaccination, at the end of tAventy-four or thirty-six hours there is seen at the point of inser- tion of the virus a slight papular elevation surrounded by a reddish zone. The papule gradually increases and on the fifth or sixth day sIioavs a defi- nite vesicle, the margins of which are raised Avhile the centre is depressed. By the eighth day the vesicle has attained its maximum size. It is round and distended Avith a limpid fluid, the margin hard and prominent, and the nmbilication is more distinct. By the tenth day the vesicle is still large and is surrounded by an extensive areola. The skin is also SAvollen, indurated, and often painful. On the eleventh or twelfth day the hyperae- mia diminishes, the lymph becomes more opaque and begins to dry. By the end of the second Aveek the vesicle is converted into a broAvnisli scab Avliich gradually becomes dry and hard, and in about a Aveek (that is, about the tAventy-first or tAventy-fifth day from the vaccination) separates and leaves a circular pitted scar. If the points of inoculation have been close together, the vesicles fuse and may form a large combined vesicle. Con- stitutional symptoms of a more or less marked degree folloAv the vaccina- tion. Usually on the third or fourth day the temperature rises, and may persist, increasing until the eighth or ninth day. In children it is common VACCINIA-VACCINATION. 65 to have with the fever restlessness, particularly at night, and irritability; but as a rule these symptoms are trivial. If the inoculation is made on the arm, the axillary glands become large and sore; if on the leg, the in- guinal glands. The duration of the immunity is extremely variable, dif- fering in different individuals. In some instances it is permanent, but a majority of persons within ten or twelve years again become susceptible. Eevaccination should be performed between the tenth and fifteenth year, and whenever small-pox is epidemic. The susceptibility to revacci- nation is curiously variable, and when small-pox is prevalent it is not well, if unsuccessful, to be content with a single attempt. The vesicle in re- vaccination is usually smaller, has less induration and hyperaemia, and the resulting scar is less perfect. Particular care should be taken to watch the vesicle of revaccination, as it not infrequently happens that a spurious pock is formed, which reaches its height early and dries to a scab by the eighth or ninth day. The constitutional symptoms in revaccination are sometimes quite severe. An irregular course is uncommon in primary vaccination, but we occa- sionally meet with instances in which the vesicle develops rapidly writh much itching, has not the characteristic flattened appearance, the lymph early becomes opaque, and the crust forms by the seventh or eighth day. In such cases the operation should again be performed with fresh lymph. Generalized Vaccinia.—It is not uncommon to see vesicles in the vicinity of the primary sore. Less common is a true generalized pustular rash, developing in different parts of the body, often beginning about the wrists and on the back. The secondary pocks may continue to make their appearance for five or six weeks after vaccination. In children the disease may prove fatal. They may be most abundant on the vaccinated limb, and develop usually about the eighth to the tenth day. Complications.—In unhealthy subjects, or as a result of uncleanli- ness, or sometimes injury, the vesicles inflame and deep excavated ulcers result. Sloughing and deep cellulitis may follow. In debilitated children there may be wdth this a purpuric rash. Erysipelas may occur, or there may be deep gangrenous ulceration. Such instances are rare, but I have seen two which proved fatal. In one there was deep sloughing and in the other erysipelas. Cases of local dermatitis must not be mistaken for erysipelas. Among the most common complications are certain skin eruptions, some of which are due to the vaccine virus; others result from a mixed infection. More frequent, perhaps, is the erythematous or roseolous rash. Contagious impetigo can also be inoculated with the virus, and may appear as a gen- eral eruption. In a few instances tetanus has developed and proved fatal. A question of special importance with reference to vaccination is the transmission of other diseases. For a time physicians were unwilling to acknowledge that constitutional disorders could be transmitted by vaccina- tion, but it is now universally recognized that such transmission may take place, and this has emphasized the scrupulous care which should be taken in the performance of the operation. SPECIFIC INFECTIOUS DISEASES. Vaccino-Syphilis.—For a knowledge of this most serious of all accidents during vaccination we are largely indebted to Jonathan Hutchinson. It is a true instance of a mixed infection. The vaccine vesicles take as a rule their usual course, and it is not until they have healed or are in process of healing that the local changes characteristic of syphilis are manifested. The fact that syphilis may be transmitted in this way should put the prac- titioner on his guard in selecting humanised lymph. He should take it only from subjects with whose constitution he is perfectly familiar. Fortunately, the instances are extremely rare. They are, in fact, much less frequent than is usually supposed, and in a majority of the cases in which vaccino-syphilis is suspected the condition is really that of inflamed and indurated vaccinal ulcer. As the subject is of daily interest to the practitioner, and one which he may at any moment be called upon to de- cide, I here insert a table of differential features between vaccinal ulcers and vaccino-syphilis, and between the vaccination rashes and the secondary syphilitic eruptions, compiled by C. E. Shelly * from Fournier’s lectures. VACCINO-SYPHILIS. VACCINATION ULCERS. Chancre developed on the site of usually one or two only of the vac- cination punctures. Ulceration affects all the punct- ures as a rule. Inflammation is slight. Inflammation and ulceration se- vere. Loss of substance superficial only. Ulcer deeply excavated. Suppuration scanty or absent, scabs or crusts formed. Much suppuration. Border of chancre smooth, slight- ly elevated, gradually merging into floor. Margin of ulcer irregular, as in “ soft chancre.” Surface of floor smooth. Floor of ulcer uneven, suppurat- ing. Induration “ parchment - like ” and specific, not merely inflammatory. Induration inflammatory only. Inflammatory areola very slight. Areola inflammatory and ery- sipelatous in character. Gland swelling constant, indo- lent (syphilitic) bubo. Gland swelling often absent; if present, merely inflammatory. Complications rare. Complications—sloughing, ery- sipelas, etc.—often present. Chancre never developed before the fifteenth day after vaccination ; usually not until after three to five weeks; still in its earlier stage twenty days after vaccination. Ulceration is present twelve or fifteen days after vaccination and is fully developed by the twentieth day after vaccination. * Fowler’s Dictionary of Medicine. Article Vaccination. VACCINIA—VACCINATION. 67 SECONDARY SYPHILITIC ERUPTION due to true vaccino-syphilis. (including roseola vaccinalis, miliaria vaccinalis, vaccinia bullosa, vaccinia hasmorrhagica); also accidental erup- tions — rubeola, scarlatina, lichen, urticaria, etc. VACCINATION RASHES Appears, at the earliest, nine or ten weeks after vaccination. A true vaccinal rash appears be- tween the ninth and fifteenth day after vaccination. Requires, in every case, the pre- existence of a specific ulcer (chancre) at the site of vaccination. Absence of inoculation chancre. Exhibits the characters of a true specific eruption. Eruption does not exhibit spe- cific characters. Fever often slight. Lasts for a long time. Fever always present. Evanescent. Usually accompanied by specific appearances on mucous membranes. VACCINO-SYPHILIS. HEREDITARY SYPHILIS SHOWING ITSELF ABOUT THE TIME OF VACCINATION'. Begins with a local infection, chancre and indolent bubo. No chancre; begins with gen- eral phenomena. Typical development in four stages, viz., incubation, chancre, second incubation, generalization (secondary eruptions, etc.). Has no typical development in connection with vaccination. Never appears earlier than the ninth or tenth week after vaccina- tion. Time of development quite inde- pendent of vaccination. Is attended by the characteristic syphilitic bodily aspect. Other manifestations of heredi- tary syphilis may be present. The history may indicate syphilis. Choice of Lymph.—Humanised lymph should be taken on the eighth day and only from perfectly formed, unbroken vesicles, which have had a typical course. Pricking or scratching the surface, the greatest care being taken not to draw blood, allows the lymph to ex- ude, and it may then be collected on ivory points or in capillary tubes. The child from which the lymph is taken should be healthy, strong, and known to be of good stock, free from tuberculous or syphilitic taint. Under these circumstances humanised lymph, one or two re- 68 SPECIFIC INFECTIOUS DISEASES. moves from the calf, is usually very satisfactory in its action and is per- fectly reliable. In the case of the calf the most scrupulous care should be exercised in the vaccine farms to secure animals which are healthy and strong. The risk, however, that the calf has any disease which can be transmitted to man is exceedingly slight, as tuberculosis is very rare in cattle when young. Unquestionably, however, there may be risk in the case of a calf born of tuberculous parents, and special care should be taken in the selection of proper animals. There is no essential difference in the pocks which fol- low humanised lymph and bovine lymph. It was, I believe, a common experience in Montreal that children inoculated with bovine lymph had more constitutional disturbance and often sorer arms than those vaccinated with humanised lymph at one or two removes. In the performance of the operation that part of the arm about the in- sertion of the deltoid is usually selected. Mothers “ in society ” prefer to have girl babies vaccinated on the leg. The skin should be cleansed and put upon the stretch. Then, with a lancet or the ivory point, cross- scratches should be made in one or more places. When the lymph has dried on the points it is best to moisten it in warm water. The clothing of the child should not be adjusted until the spot has dried, and it should be protected for a day or two with lint or a soft handkerchief. If erysipe- las is prevalent, or if there are cases of suppuration in the same house, it is well to apply a pad of antiseptic cotton. Vaccination is usually per- formed at the second or third month. If unsuccessful, it should be re- peated from time to time. A person exposed to the contagion of small- pox should always be revaccinated. This, if successful, will usually pro- tect ; but not always, as there are many instances in which, though the vaccination takes, variola also appears. The Value of Vaccination.—Vaccination is not claimed to be an invariable and permanent preventive of small-pox, but in an immense ma- jority of cases successful inoculation renders the person for many years insusceptible. Communities in which vaccination and revaccination are thoroughly and systematically carried out are those in which small-pox has the fewest victims. On the other hand communities in which vacci- nation and revaccination are persistently neglected are those in which epi- demics are most prevalent. In the German army the practice of revaccina- tion has stamped out the disease. Nothing in recent times has been more instructive in this connection than the fatal statistics of Montreal. The epidemic which started in 1870-’71 was severe in Lower Canada, and per- sisted in Montreal until 1875. A great deal of feeling had been aroused among the French Canadians by the occurrence of several serious cases of ulceration, possibly of syphilitic disease, following vaccination ; and several agitators, among them a French physician of some standing, aroused a popular and wide-spread prejudice against the practice. There were in- deed vaccination riots. The introduction of animal lymph was distinctly VACCINIA—VACCINATION'. 69 beneficial in extending the practice among the lower classes, but compul- sory vaccination could not be carried out. Between the years 1876 and 1884 a considerable unprotected population grew up and the materials were ripe for an extensive epidemic. The soil had been prepared with the greatest care and it only needed the introduction of the seed, which in due time came as already stated with the Pullman-car conductor from Chicago, on the 28th of February, 1885. Within the next ten months thousands of persons were stricken with the disease, and 3,164 died. Although the effects of a single vaccination may wear out, as we say, and the individual again become susceptible to small-pox, yet the mortal- ity in such cases is very much lower than in persons who have never been vaccinated. The mortality in persons who have been vaccinated is from 6 to 8 per cent, whereas in the unvaccinated it is at least 35 per cent. Marson pointed out some years ago that there is a definite ratio between the number of deaths and the number of good vaccination marks in post- vaccinal small-pox. With good marks the mortality is between 3 and 4 per cent, and with indifferent marks at least 10 or 11 per cent. W. M. Welch’s statistics of 5,000 cases on this point give with good cicatrices 8 per cent; with fair cicatrices, 14 per cent; with poor cicatrices, 27 per cent; post-vaccinal cases, 16 per cent; unvaccinated cases, 58 per cent. VI. VARICELLA {Chicken-pox). Definition.—An acute contagious disease of children, characterised by an eruption of vesicles on the skin. Etiology.—The disease occurs in epidemics, but sporadic cases are also met with. It may prevail at the same time as small-pox or may fol- low or precede epidemics of this disease. An attack of chicken-pox is no protection against small-pox. It is a disease of childhood ; a majority of the cases occur between the second and sixth years. It is rarely seen in adults. The specific germ has not yet been discovered. There can be no question that varicella is an affection quite distinct from variola and without at present any relation whatever to it. An at- tack of the one does not confer immunity from an attack of the other. The case which Sharkey reported is of special importance in this connec- tion. A boy, aged five, was admitted to St. Thomas’ Hospital with a vesicular eruption, and was isolated in a ward on the same floor as the small-pox ward. The disease was pronounced chicken-pox, however, by Sir Eisdon Bennett and Dr. Bristowe. The patient was then removed and vaccinated, with a result of four vesicles which ran a pretty normal course. On the eighth day from the vaccination the child became fever- ish. On the following day the papules appeared and the child had a well- developed attack of small-pox with secondary fever. Symptoms.—After a period of incubation of ten or fifteen days the child becomes feverish and in some instances has a slight chill. There 70 SPECIFIC INFECTIOUS DISEASES. may be vomiting and pains in the back and legs. Convulsions are rare. The eruption usually develops within twenty-four hours. It is first seen upon the trunk, either on the back or on the chest. It may begin on the forehead and face. At first in the form of raised red papules, they are in a few hours transformed into hemispherical vesicles containing a clear or turbid fluid. As a rule there is no umbilication, but in rare instances the pocks are flattened, and a few may even be umbilicated. They are often ovoid in shape and look more superficial than the variolous vesicles. The skin in the neighborhood is neither infiltrated nor hyperasmic. At the end of thirty-six or forty-eight hours the contents of the vesicles are purulent. They begin to shrivel and during the third and fourth days are converted into dark brownish crusts, which fall off and as a rule leave no scar. Fresh crops appear during the first two or three days of the ill- ness, so that on the fourth day one can usually see pocks in all stages of development and decay. They are always discrete and the number may vary from eight or ten to several hundreds. As in variola, a scarlatinal rash occasionally precedes the development of the eruption. There are one or two modifications of the rash which are interesting. The vesicles may become very large and develop into regular bullse, look- ing not unlike ecthyma or pemphigus (varicella bullosa). The irritation of the rash may be excessive, and if the child scratches the pocks ulcerat- ing sores may form, which on healing leave ugly scars. Indeed, cicatrices after chicken-pox are not so very uncommon. They are in my experi- ence more common than after varioloid. The fever in varicella is slight, but it does not as a rule disappear with the appearance of the rash. The course of the disease is in a large majority of the cases favorable and no ill effects follow. The disease may recur in the same individual. There are instances in which a person has had three attacks. In delicate children, particularly the tuberculous, gangrene (varicella escharotica) may occur about the vesicles (Hutchinson); or in other parts, as the scrotum. Cases have been described (Andrew) of haemorrhagic varicella with cutaneous ecchymoses and bleeding from the mucous membranes. Nephritis may occur. Infantile hemiplegia has developed during an attack of the disease. Death has followed in an uncomplicated case from extensive involvement of the skin (Nisbet). The diagnosis is as a rule easy, particularly if the patient has been seen from the outset. When a case comes under observation for the first time with the rash well out, there may be considerable difficulty. The abundance of the rash on the trunk in varicella is most important. The pocks in varicella are more superficial, more bleb-like, have not so deeply an infiltrated areola about them, and may usually be seen in all stages of development. They rarely at the outset have the hard, shotty feeling of small-pox. The general symptoms, the greater intensity of the onset, the prolonged period of invasion, and the more frequent occurrence of prodro- mal rashes in small-pox are important points in the diagnosis. SCARLET FEVER. 71 No special treatment is required. If the rash is abundant on the face great care should be taken to prevent the child from scratching the pus- tules. A soothing lotion should be applied on lint. VII. SCARLET FEVER. Definition.—An infectious disease characterised by a diffuse exan- them and an angina of variable intensity. Etiology.—We owe the recognition of scarlet fever as a distinct dis- ease to Sydenham, before whose time it was confounded with measles. It is a wide-spread affection, occurring in nearly all parts of the globe and attacking all races. The disease occurs sporadically from time to time, and then under unknown conditions becomes wide-spread. Epidemics vary in severity. Among predisposing factors age is most important. A large propor- tion of the cases occur before the tentli year. Of an enormous number of fatal cases tabulated by Murchison over 90 per cent occurred in children under this age. Adults, however, are by no means exempt. Very young infants are rarely attacked. A certain number exposed to the contagion escape. In a family of children all more or less exposed one or two may not take the disease, whereas, as a rule, all exposed to measles take it. The susceptibility seems to vary in families, and we meet occasionally with sad instances in which three or more members of a family succumb in rapid succession. Males and females are equally affected. Epidemics prevail at all seasons, but perhaps with greater intensity in autumn and winter. The contagion of scarlet fever is probably not developed until the erup- tion appears, and is particularly to be dreaded during desquamation. No doubt the poison is spread largely by the fine scaly particles which are diffused with the dust throughout the room. Even late in the disease, after desquamation has been apparently completed, a patient has con- veyed the contagion. The poison clings with great persistence to cloth- ing of all kinds and to articles of furniture in the room. In no disease is a greater tenacity displayed. Bedding and clothes which have been put away for months or even for years may, unless thoroughly disinfected, convey contagion. Physicians, nurses, and others in contact with the sick may carry the poison to persons at a distance. It is remarkable that in the case of physicians this does not more frequently occur. I know of but one instance in which I carried the contagion of this disease. The poison probably is not widely spread in the atmosphere. Observations have been recently made which indicate that the poison may be conveyed in milk. The epidemic investigated by Power and Klein in London in 1885 was traced by them to milk obtained from a dairy at Hendon, in which the cows were found to be suffering from a vesicular affection of SPECIFIC INFECTIOUS DISEASES. the udder. The nature of this disease of the cow is doubtful, however. Crookshank maintains that it was cow-pox, and had nothing to do with scarlet fever. Some writers maintain that scarlet fever may be associated with de- fective house-drainage. Possibly the virus may occasionally gain entrance in this way. The attack does not necessarily protect permanently. There are in- stances of a second and even a third attack. Surgical and puerperal scarlatinas, so called, demand a word under this section. While scarlet fever may attack a person after operation, or a woman in childbed, the majority of the cases described as such represent I believe, only the red rash of septicaemia. In the cases which I have seen the rash was rarely so widespread as in scarlet fever; the tongue had not the special features, nor was the throat affected. Desquamation is no cri- terion, as it occurs whenever hyperaemia of the skin persists for any length of time. It is interesting to note that these cases have become rare with the gradual disappearance of septicaemia. I. E. Atkinson suggests that these rashes are in many cases due to quinine. The specific germ of the disease is still unknown. Streptococci are found in the skin, in the blood sometimes, and in the organs of fatal cases. It has even been urged that the disease is only a form of strep- tococcus infection. Throat lesions of the most malignant type may occur without the presence of the Loeffler bacillus, but in the infec- tious pavilions of hospitals the scarlet fever cases are very apt to be complicated with true diphtheria; much more so than in private prac- tice. The streptococcus pyogenes is the common organism of the otitis media. Morbid Anatomy.—Except in the liasmorrhagic form, the skin after death shows no traces of the rash. There are no specific lesions. Those which occur in the internal organs are due partly to the fever and partly to infection with pus-organisms. The anatomical changes in the throat are those of simple inflamma- tion, follicular tonsillitis, and, in extreme grades, of pseudo-membranous angina. In severe cases there is intense lymphadenitis and much inflam- matory oedema of the tissues of the neck, which may go on to suppuration, or even to gangrene. Streptococci are found abundantly in the glands and in the areas of suppuration. Of changes in the digestive organs, a catarrhal state of the gastro-intestinal mucosa is not uncommon. The liver may show interstitial changes (Klein). The spleen is often enlarged. Endocarditis and pericarditis are not infrequent. Myocardial changes are less common. The renal changes are the most important, and have been thoroughly studied by Coats, Klebs, Wagner, and others. The spe- cial nephritis of the disease will be considered with the diseases of the kidney. Affections of the respiratory organs are not frequent. When death SCARLET FEVER. 73 results from the pseudo-membranous angina, broncho-pneumonia is not uncommon. Cerebro-spinal changes are rare. Symptoms.—Incubation.—“ From one to seven days, oftenest two to four.” Invasion.—The onset is as a rule sudden. It may be preceded by a slight, scarcely noticeable, indisposition. An actual chill is rare. Vomit- ing and, in. young children, convulsions are common. The fever is in- tense ; rising rapidly, it may on the first day reach 104° or even 105°. The skin is unusually dry and to the touch gives a sensation of very pun- gent heat. The tongue is furred, and as early as the first day there may be complaint of dryness of the throat. Cough and catarrhal symptoms are uncommon. The face is often flushed and the patient has all the ob- jective features of an acute fever. Eruption.—Usually on the second day, in some instances within twen- ty-four hours, the rash develops in the form of scattered red points on a deep subcuticular flush. It appears first on the neck and chest, and spreads so rapidly that by the evening of the second day it may have in- vaded the entire skin. In pronounced cases the rash at its height has a vivid scarlet hue, quite distinctive and unlike that seen in any other eruptive disease. It is entirely hyperagmic, and the anaemia produced by pressure instantly disappears. In some cases the rash does not become uniform but remains patchy, and intervals of normal skin separate large hyperaemic areas. Tiny papular elevations may sometimes be seen, but they are not so common as in measles. At the height of the eruption sudaminal vesicles may develop, the fluid of which may become turbid. The entire skin may at the same time be covered with small yellow vesi- cles on a deep red background. Pronounced cases of this type were called by the older writers scarlatina miliaris. The blood shows an early leuco- cytosis, which is often extreme in fatal cases. Occasionally there are petechiae, which in the malignant type of the disease become wide-spread and large. The eruption does not always ap- pear upon the face. There may be a good deal of swelling of the skin which feels uncomfortable and tense. The itching is variable; not as a rule intense at the height of the eruption. After persisting for two or three days the rash gradually fades. The rash can often be seen on the mucous membranes of the palate, the cheeks and the tonsils, giving to these parts a vivid red, punctiform appearance. The tongue at first is red at the tip and edges, furred in the centre; and through the white fur are often seen the swollen red papillae, which give the so-called “ strawberry ” appearance to the tongue. In a few days the “ fur ” desquamates and leaves the surface red and rough, and it is this condition which some writers call the “ strawberry,” or, better, the “ raspberry ” tongue. The breath often has a very heavy, sweet odor. The pharyngeal symptoms vary extremely. There may be— 1. Slight redness, with swelling of the pillars of the fauces and of the tonsils. 74 SPECIFIC INFECTIOUS DISEASES. 2. A more intense grade of swelling and innitration of these parts with a follicular tonsillitis. 3. Membranous angina with intense inflammation of all the pharyn- geal structures and swelling of the glands below the jaw, and in very se- vere cases a thick brawny induration of all the tissues of the neck. The fever, which sets in with such suddenness and in- tensity, may reach 105° or even 106°. It persists with slight morning remissions, gradually declining with the disappear- ance of the rash. In mild cases the temperature may not reach 103°; on the other hand, in very severe cases there may be hyperpyrexia, the thermometer registering 108° or even before death 109°. The pulse presents the ordi- nary febrile characters, ranging in children from 120° to 150°, or even higher. The respirations show an increase proportionate to the intensity of the fever. The gastro-intestinal symptoms are not marked after the initial vomiting, and food is usually well taken. In some instances there are abdominal pains. The edge of the spleen may be palpable. The liver is not often enlarged. With the initial fever nervous symptoms are present in a majority of the cases ; but as the rash comes out the headache and the slight nocturnal wandering dis- appear. The urine has the ordinary febrile characters, being scanty and high colored. Albuminuria is by no means infrequent during the stage of eruption, but the amount is slight. Careful examination of the urine should be made every day. There is no cause for alarm in the slight trace of albumen which is so often present, not even if it is associated with a few tube-casts. Desquamation.—With the disappearance of the rash.and the fever the skin looks somewhat stained, is dry, a little rough, and gradually the up- per layer of the cuticle begins to separate. The process usually begins about the neck and chest, and flakes are gradually detached. The degree and character of the desquamation bear some relation to the intensity of the eruption. When the latter has been very vivid and of long-standing, large flakes may be detached. In rare instances the hair and even the nails have been shed. It must not be forgotten that there are cases in which the desquamation has been prolonged, according to Trousseau, even to the seventh or eighth week. The entire process lasts from ten to fifteen or even twenty days. There are cases of exceptional mildness in which the rash may be 1 23456789 Chart VITI.—Scarlet fever (Strurapell). Eruption. SCARLET FEVER. 75 scarcely perceptible. During epidemics, when several children of a house- hold are affected, it sometimes happens that a child sickens as if of scarlet fever, and has a sore throat and the “ strawberry tongue ” without the de- velopment of any rash. This is the so-called scarlatina sine eruptione. These slight cases of scarlet fever may be followed by the severest at- tacks of nephritis. MALIGNANT SCARLET FEVER. Atactic Form.—This presents all the characteristics of an acute intoxi- cation. The patient overwhelmed by the intensity of the poison may die within twenty-four or thirty-six hours. The disease sets in with great severity—high fever, extreme restlessness, headache, and delirium. The temperature may rise to 107° or even 108°, and rare cases have been ob- served in which the thermometer has registered even higher. Convulsions may occur in children. The initial delirium rapidly gives place to coma. The dyspnoea may be urgent; the pulse is very rapid and feeble. Hsemorrhagic Form.—In some instances haemorrhages occur into the skin. There are haematuria and epistaxis. In the erythematous rash there are at first scattered petechiae, which gradually become more extensive, and ultimately the skin may be universally involved. Death may take place on the second or on the third day. While this form is perhaps more common in enfeebled children, I have twice known it to attack per- sons apparently in full health. Anginose Form.—The throat symptoms may appear early and progress rapidly. The fauces and tonsils are swollen. Membranous exudation forms. It may extend to the posterior wall of the pharynx, forward into the mouth, and upward into the nostrils. The glands of the neck rapidly enlarge. Necrosis occurs in the tissues of the throat, the fcetor is extreme, the constitutional disturbance profound, and the child dies with the clinical picture of a malignant diphtheria. Occasionally the mem- brane extends into the trachea and the bronchi. The Eustachian tubes and the middle ear are usually involved. In cases in which death does not take place rapidly from toxaemia there may be extensive abscess forma- tion in the tissues of the neck and sloughing. In the separation of deep sloughs about the tonsils the carotid artery may be opened, causing fatal haemorrhage. Complications and Sequelae.—(a) Nephritis.—At the height of the fever there is often a slight trace of albumin in the urine, which is not of special significance. In a majority of cases the kidneys escape without greater damage than occurs in other acute febrile affections. Nephritis is most common in the second or third week and may de- velop after a very mild attack. It may be delayed until the third or fourth week. As a rule, the earlier it develops in the disease the more intense it is. It varies greatly in intensity, and three grades of cases may be recognized : 76 SPECIFIC INFECTIOUS DISEASES. 1. Very severe cases with suppression of urine or the passage of a small quantity of dark bloody urine laden with albumin and tube-casts. Vomiting is constant, there are convulsions, and the child dies with the symptoms of acute uraemia. 2. Less severe cases without any serious acute symptoms. There is a puffy appearance of the eyelids, with slight oedema of the feet; the urine is diminished in quantity, smoky in appearance, and contains albumin and tube-casts. The kidney symptoms then dominate the entire case, the dropsy persists, and there may be effusion into the serous sacs. The case may drag on and become chronic, or the patient may succumb to uraemic accidents. Fortunately, in a majority of the cases the disease yields to judicious treatment and recovery takes place. 3. Cases so mild that they can scarcely be termed nephritis. The urine contains albumin, and a few tube-casts, but rarely blood. The oedema is extremely slight or transient, and the convalescence is scarcely interrupted. Occasionally, however, in these mild attacks serious symp- toms may supervene. (Edema of the glottis may prove rapidly fatal, and in one case of the kind a child under my care died of acute effusion into the pleural sacs. There are instances of oedema without albuminuria or signs of nephri- tis. Possibly in some of these cases the oedema may be hsemic and due to the anaemia; but there are instances in which marked changes have been found in the kidney after death, even when the urine did not show the features characteristic of nephritis. (b) Arthritis.—During the subsidence of the fever, rarely at its height, pains and swellings in the joints may develop and present all the characteristics of acute rheumatism. In all probability it is not however true rheumatism, but is analogous to gonorrhoeal synovitis. The disease may pass on to suppuration, in which case it most commonly involves only a single joint. (c) Cardiac Complications.—Simple endocarditis is not uncommon, and many cases of chronic valvular disease originate probably in a latent endocarditis during this disease. Malignant endocarditis is rare. Peri- carditis is probably not more frequent, but is less likely to be overlooked than endocarditis. It usually develops during convalescence; the effu- sion may be sero-fibrinous or purulent. The cardiac complications are sometimes found in association with arthritis. Myocarditis is not un- common. (d) Pleurisy may follow pneumonia, though this is rare. More often it occurs during convalescence, is insidious in its course, and as a rule purulent. This serious complication of scarlet fever is not sufficiently recognized. It was one upon which my teacher, R. P. Howard,* in Mont- real, specially insisted in his lectures. Sheriff, in a number of the same * Canada Medical and Surgical Journal, December, 1872. SCARLET FEVER. journal, reports two cases, occurring at the same time in brothers, one of whom died suddenly after a slight exertion. (e) Ear Complications.—These are common and serious. They are due to extension of the inflammation from the throat through the Eu- stachian tubes. It is one of the most frequent causes of deafness. The severe forms of membranous angina are almost always associated with in- flammation of the middle ear, which goes on to suppuration and to per- foration of the drum. The suppuration may extend to the labyrinth and rapidly produce deafness. In other instances there is suppuration in the mastoid cells. In the necrosis which follows the middle-ear disease, the facial nerve may be involved and paralysis follow. Later, still more serious complications may follow the otitis; such as thrombosis of the lateral sinus, meningitis, or abscess of the brain. (/) Adenitis.—In comparatively mild cases of scarlet fever the sub- maxillary lymph-glands may be swollen. In severer cases the swelling of the neck becomes extreme and extends beyond the limits of the glands. Acute phlegmonous inflammations may occur, leading to wide-spread de- struction of tissue, in which vessels may be eroded and fatal hajmorrhage ensue. The suppurative processes may also involve the retro-pharyngeal tissues. The swelling of the lymph-glands usually subsides, and within a few weeks even the most extensive enlargement gradually disappears. There are rare instances, however, in which the lymphadenitis becomes chronic, and the neck remains with a glandular collar which almost obliterates its outline. This may prove intractable to all ordinary measures of treat- ment. A case came under my observation in which, two years after scar- let fever, the neck was enormously enlarged and surrounded by a mass of firm brawny glands. (g) Nervous Complications.—Chorea occasionally develops in connec- tion with the arthritis and endocarditis. Sudden convulsions followed by hemiplegia may occur. Two instances of progressive paralysis of the limbs with wasting came under my observation at the Philadelphia In- firmary for Nervous Diseases. The history was that of subacute, ascend- ing spinal paralysis, but it is probable that they tvere instances of multiple neuritis. Mental symptoms, mania and melancholia, ha\Te been described. (h) Other rare complications and sequelae are cedema of the eyelids, without nephritis (S. Philips), symmetrical gangrene, enteritis, noma, and perforation of the soft palate (Goodall). Diagnosis.—The diagnosis of scarlet fever is not difficult, but there are cases in A\rhich the true nature of the disease is for a time doubtful. The following are the most common conditions with which it may be confounded : 1. Acute Exfoliating Dermatitis.—This pseudo-exanthem simulates scarlet fever very closely. It has a sudden onset, with fever. The erup- tion spreads rapidly, is uniform, and after persisting for five or six days SPECIFIC INFECTIOUS DISEASES. 78 begins to fade. Even before it has entirely gone, desquamation usually begins. Some of these cases cannot be distinguished from scarlet fever in the stage of eruption. The throat symptoms, however, are usually absent, and the tongue rarely shows the changes which are so marked in scarlet fever. In the desquamation of this affection the hair and nails are com- monly affected. It is, too, a disease liable to recur. Some of the instances of second and third attacks of scarlet fever have been cases of this form of dermatitis. 2. Measles, which is distinguished by the longer period of invasion, the characteristic nature of the prodromes, and the later appearance of the rash. The greater intensity of the measly rash upon the face, the more papular character, the irregular crescentic distribution, are distinguishing features in a majority of the cases. Other points are the absence in measles of the sore throat, the peculiar character of the desquamation, and the absence of leucocytosis. 3. Rotheln.—The rash of rubella is sometimes strikingly like that of scarlet fever, but in the great majority of cases the mistake could not arise. In cases of doubt the general symptoms are our best guide. 4. Septicaemia.—As already mentioned, the so-called puerperal or sur- gical scarlatina shows an eruption which may be identical in appearance with that of true scarlet fever. 5. Diphtheria.—The practitioner may be in doubt whether he is deal- ing with a case of scarlet fever with intense membranous angina, a true diphtheria with an erythematous rash, or coexisting scarlet fever and diphtheria. In the angina occurring early in, and during, the course of scarlet fever, though the clinical features may be those of true diphtheria, Loeffler’s bacilli are rarely present. On the other hand, in the membra- nous angina occurring during convalescence, bacilli are usually present. The rash in diphtheria is, after all, not so common, is limited usually to the trunk, is not so persistent, and is generally darker than the scarlatinal rash. Scarlatina and diphtheria may coexist, but in a case presenting wide- spread erythema and extensive membranous angina with Loeffler’s bacilli, it would puzzle Hippocrates to say whether the two diseases coexisted, or whether it was only an intense scarlatinal rash in diphtheria. Desquama- tion occurs in either case. The streptococcus angina is not so apt to ex- tend to the larynx, nor are recurrences so common; but it is well to bear in mind that general infection may occur, that the membrane may spread downward with great rapidity, and, lastly, that all the nervous sequel* of the Klebs-Loeffler diphtheria may follow the streptococcus form. 6. Drug Rashes.—These are partial, and seldom more than a transient hypersemia of the skin. Occasionally they are diffuse and intense, and in such cases very deceptive. They are not associated, however, with the characteristic symptoms of invasion. There is no fever, and with care the distinction can usually be made. They are most apt to follow the use of belladonna, quinine, and iodide of potassium. SCARLET FEVER. Prognosis.—Epidemics differ in severity and the death-rate is ex- tremely variable. Among the better classes the death-rate is much less than in hospital practice. There are physicians who have treated consecu- tively a hundred or more cases without a death. On the other hand, in hospitals and among the poorer classes the death-rate is considerable, ranging from 5 to 10 per cent in mild epidemics to 20 or 30 per cent in the very severe. The younger the child the greater the danger. In infants under one year the death-rate is very high. The great proportion of fatal cases occurs in children under six years of age. The unfavorable symptoms are very high fever, early mental disturb- ance with great jactitation, the occurrence of hasmorrhages (cutaneous or visceral), intense membranous angina with cervical bubo, and signs of laryngeal obstruction. Nephritis is always a serious complication and when setting in with suppression of the urine may quickly prove fatal. It is noteworthy, how- ever, that a large majority of the cases of scarlatinal nephritis recover. Treatment.—The disease cannot be cut short. In the presence of the severer forms we are still too often helpless. There is no disease in which the successful issue and the avoidance of complications depends more upon the skilled judgment of the physician and the care with which his instructions are carried out. The child should be isolated and placed in charge of a competent nurse. The temperature of the room should be constant and the ventila- tion thorough. The child should wear a light flannel night-gown, and the bedclothing should not be too heavy. The diet should consist of milk, broths, and fresh fruits; and water should be freely given. With the fall of the temperature, the diet may be increased and the child may gradually return to ordinary fare. When desquamation begins the child should be thoroughly rubbed every day, or every second day, with sweet oil, or carbolated vaseline, or a 5-per-cent hydro-naphthol soap, which prevents the drying and the diffusion of the scales. An occasional warm bath may then be given. At any time during the attack the skin may be sponged with warm water. The patient may be allowed to get up after the temperature has been normal for ten days, but for at least three weeks from this time great care should be exercised to prevent exposure to cold. It must not be forgotten, also, that the renal complications are very apt to develop during the convalescence, and after all danger is apparently past. Ordinary cases do not require any medicine, or at the most a simple fever mixture, and during convalescence a bitter tonic. The bowels should be carefully regulated. Special symptoms in the severe cases call for treatment. When the temperature is above 103° the extremities may be sponged with tepid water. In severe cases, with the temperature rapidly rising, this will not suffice, and more thorough measures of hydrotherapy should be 80 SPECIFIC INFECTIOUS DISEASES. practised. With pronounced delirium and nervous symptoms the cold- pack should be used. When the temperature is rising rapidly but the child is not delirious, he should be placed in a warm bath, the temperature of which can be gradually lowered. The bath at a temperature of 80° is beneficial. In giving the cold-pack a rubber sheet and a thick layer of blanket should be laid upon a sofa or a bed, and upon this a sheet, wrung out of cold water. The naked child is then laid upon it and wrapped -in the blankets. An intense glow of heat quickly follows the preliminary chilling, and from time to time the blankets may be unfolded and the child sprinkled with cold water. The good effects which follow this plan of treatment are often striking, particularly in allaying the delirium and jactitation, and procuring quiet and refreshing sleep. Parents will object less, as a rule, to the warm bath gradually cooled than to any other form of hydrotherapy. The child may be removed from the warm bath, placed upon a sheet wrung out of tolerably cold water, and then folded in blankets. The ice-cap is very useful and may be kept constantly applied in cases in which there is high fever. Medicinal antipyretics are not of much service in comparison with cold water. The throat symptoms, if mild, do not require much treatment. If severe, the local measures mentioned under diphtheria should be used. Cold applications to the neck are to be preferred to hot, though it is some- times difficult to get a child to submit to them. In connection with the throat symptoms the ears should be specially looked after, and a careful disinfection of the throat by suitable antiseptic solutions should be prac- tised. When the inflammation extends through the tubes to the middle ear, the practitioner should either himself daily examine the condition of the drum, or, when available, a specialist should be called in to assist him in the case. The careful watching of this membrane day by day and the puncturing of it if the tension becomes too great may save the hearing of the child. With the aid of cocaine the drum is readily punctured. The operation may be repeated at intervals if the pain and distention return. No complication of the disease is more serious than this extension of the inflammatory process to the ear. The nephritis should be dealt with as in ordinary cases, and indications for treatment will be found under the appropriate section. It is worth mentioning, however, that Jaccoud insists upon the great value of milk diet in scarlet fever as a preventive of nephritis. Among other indications for treatment in the disease is cardiac weak- ness, which is usually the result of the direct action of the poison, and is best met by stimulants. Many specifics have been vaunted in scarlet fever, but they are all useless. MEASLES. 81 VIII. MEASLES. Definition.—An acute, highly infectious disorder, characterised by an initial coryza and a rapidly spreading eruption. Etiology.—The infection of measles is very intense and immunity against attack not nearly so common as in scarlet fever. It is a disease of childhood, but unprotected adults are liable to the infection. Indeed, measles is more frequent in adults than is scarlet fever. Within the first six months of life the liability is not so marked, though I have known in- fants of a month and of six weeks to be attacked. The sexes are equally affected. The contagion is communicated by the breath and by the secre- tions, particularly those of the nose. It may be conveyed by a third per- son and by fomites. The disease is practically endemic in large centres of population, and from time to time spreads and prevails epidemically. It occurs at all sea- sons, but prevails more extensively during the colder months. There is no infectious disease in which recurrence is more frequent. There may be a second, third, or even a fourth attack. The contagion of the disease is unknown. No one of the various or- ganisms which have been described meets the requirements of Koch’s law. Morbid Anatomy.—Measles itself rarely kills, but the complica- tions and sequelae combine to make it a very fatal affection in children. There are no characteristic post-mortem appearances. The skin changes are those associated with an intense hyperaemia. There is a catarrhal condition of the mucous membranes, particularly of the bronchi. The fatal cases show almost invariably either broncho- pneumonia, capillary bronchitis with patches of collapse, or less frequently lobar pneumonia. The bronchial glands are invariably swollen. Pleurisy is less common. During convalescence from measles there is a special lia- bility to tuberculous invasion, and tuberculous broncho-pneumonia claims a large number of victims. The bronchial glands may also be affected. The gastro-intestinal mucosa may be hypersemic. Swelling of Peyer’s glands is not at all uncommon and may reach a very intense grade in the patches. Symptoms.—Incubation.—“From seven to eighteen days; oftenest fourteen.” The disease has been frequently inoculated. In such cases the incubation period is less than ten days. Invasion.—The disease usually begins with symptoms of a feverish cold. There are shiverings (not often a definite chill), marked coryza, sneezing, running at the nose, redness of the eyes and lids, with photo- phobia, and within twenty-four hours cough. These early catarrhal symptoms are more marked in measles than in any other infectious disease of children. There may be the symptoms so commonly associated with an on-coming fever—nausea, vomiting, and headache. The tongue is 82 SPECIFIC INFECTIOUS DISEASES. furred. Examination of the throat may show a reddish hyperaim ia or in some instances a distinct punctiform rash. Occasionally this spreads over the whole mucous membrane of the mouth with the exception of the tongue. The temperature at this stage is usually high, reach- ing from 103° to 104°, ascending gradually through the second and third days. Eruption. — Usually on the fourth day, when the fever and general symptoms have reached their height, the rash appears upon the cheeks or forehead in the form of small red papules, which increase in size and spread over the neck and thorax. When the eruption becomes well devel- oped the face is swollen and cov- ered with reddish blotches, which often have rounded or crescentic out- lines. Here and there is an intervening portion of unaffected skin. At this stage the cervical lymph-glands may be slightly swollen and sore; sometimes also the glands in the groins, axillae, and at the elbows. The papules can now be felt with the finger. Sometimes they are quite shotty, but do not extend deep into the skin. On the trunk and extremities the swelling of the skin is not so noticeable, the color of the rash not so in- tense and often less uniform. The mottled, blotchy character of the rash appears most clearly on the chest or the abdomen. The rash is hyperaemic and disappears on pressure, but in the more malignant cases it may be- come haemorrhagic. The general symptoms do not abate with the occur- rence of the eruption. They persist until the end of the fifth or the sixth day, when in the majority of the cases all the symptoms become miti- gated. Among the peculiarities of the rash may be mentioned the de- velopment of numerous miliary vesicles and the occurrence of petechia?, which are seen occasionally even in cases of moderate severity. Desquamation.—After persisting for two or three days the rash gradu- ally fades and desquamation occurs in the form of very fine branny scales, which may be difficult to see and are wholly unlike the coarse exfoliation in scarlet fever. The catarrhal symptoms gradually disappear and convalescence is rapidly established. In epidemics of measles atypical cases are common. The rash may appear early, within thirty-six hours of the onset of the symptoms; or, on the other hand, it may be delayed until the sixth day. As in other exan- thems, when many cases occur in a household, one of the children may 1 2 3 4 5 6 7 8 Initial Fever. Chart IX.—Measles (Striimpell). Eruptive Fever. Eruption. MEASLES. 83 have all the initial symptoms and “ sicken for the disease,” as it is said, but no eruption appear. The most serious variety of measles is that in which haemorrhages oc- cur—the morbilli hcemorrhagici. In general practice these cases are very uncommon. Occasionally in institutions, particularly when the hygienic surroundings are bad, one or two cases develop during an epidemic. It has been frequently seen in camps and when the disease is freshly im- ported into a native population, as in the Fiji Islands. During the civil war, as shown by Smart’s statistics, some cases occurred. In this form the disease sets in with much greater intensity, the rash becomes petechial, haemorrhages occur from the mucous membranes, the constitutional depression is very great, and death occurs early from tox- aemia. Complications and Sequelae.—These are met with chiefly in the respiratory system. The danger comes from the existing bronchitis, which is apt to extend into the smaller tubes and lead to collapse and broncho-pneumonia. When limited in extent this causes only aggrava- tion of the cough and persistence of the fever (symptoms which gradually abate), and convalescence is rapid; but in debilitated children, more par- ticularly in institutions and among the lower classes, this complication is extremely grave and is responsible for the high death-rate from measles in the community. In some instances the clinical picture is that of a suffocative catarrh, the result of a wide-spread involvement of the smaller tubes. The description of the condition will be found under the section Broncho-pneumonia. Lobar pneumonia is less common and perhaps less dangerous. Laryngitis is not uncommon : the voice becomes husky and the cough croupy in character. (Edema of the glottis is very rare. Pseudo-mem- branous inflammation of the pharynx and larynx may occur and prove fatal. In debilitated infants severe stomatitis, cancrum oris, or ulcerative vulvitis may develop. Catarrhal inflammation of the middle ear is not very uncommon, and may proceed to suppuration and to perforation of the drum. The con- junctival catarrh rarely leads to further trouble, though occasionally the inflammation becomes purulent. Intestinal catarrh is common in some epidemics, and there may be the symptoms of acute colitis. Nephritis is an exceedingly rare complication. Of the sequelae of measles, tuberculosis is the most important—either an involvement of the bronchial glands, a miliary tuberculosis, or a tuber- culous broncho-pneumonia. Among the rarer sequelae of measles are paralyses. Hemiplegia is very rare, but cases of paraplegia have been described. Thomas Barlow * * Medico-Chirurgical Society’s Transactions, 1887. 84 SPECIFIC INFECTIOUS DISEASES. reports a fatal case in which the symptoms occurred early, the paraly- sis extended rapidly and involved the upper limbs, and death took place on the eleventh day. Marked vascular changes were found in the gray matter of the spinal cord, and were believed to depend on an early dissemi- nated myelitis. Examination of the peripheral nerves was not made. Similar cases are met with in the literature, and they probably come under the division of the post-febrile polyneuritis, though of course it is not im- possible that some of them, such as Barlow’s case, may be due to a rapidly ascending myelitis. Diagnosis.—From scarlet fever, with which it is most likely to be confounded, measles is distinguished by the longer initial stage with char- acteristic symptoms, and the blotchy irregular character of the rash, which is so unlike the diffuse uniform erythema of scarlet fever. Occa- sionally in measles, when the throat is very sore and the eruption pretty diffuse, there may at first be difficulty in determining which disease is present, but a few days should suffice to make the diagnosis clear. As a rule there is no leucocytosis. It may be extremely difficult to distinguish from rotheln. I have more than once known practitioners of large ex- perience unable to agree upon a diagnosis. The shorter prodromal stage, the slighter fever in many cases, are perhaps the most important features. It is difficult to speak definitely about the distinctions in the rash, though perhaps the more uniform distribution and the absence of the crescentic arrangement are more constant in rotheln. The conditions under which measles may be mistaken for small-pox have already been described. Of drug eruptions, that induced by copaiba is very like measles, but is readily distinguished by the absence of fever and catarrh. Prognosis.—The mortality bills of large cities show what a serious disease measles is in a community. Among the eruptive fevers it ranks third in the death-rate. The mortality from the disease itself is not high, but the pulmonary complications render it one of the most serious of the diseases of children. In some epidemics the disease is of great severity. In institutions and in armies the death-rate is often high. The fever itself is rarely a source of danger. The extension of the catarrhal symptoms to the finer tubes is the most serious indication. Treatment.—Confinement to bed in a well-ventilated room and a milk diet are the only measures necessary in cases of uncomplicated measles. The fever rarely reaches a dangerous height. If it does it may be lowered by sponging or by the tepid bath gradually reduced. If the rash does not come out well, warm drinks and a hot bath will hasten its maturation. The bowels should be freely opened. If the cough is dis- tressing, paregoric and a mixture of ipecacuanha wine and squills should be given. The patient should be kept in bed for a few days after the fever subsides. During desquamation the skin should be oiled daily, RUBELLA. 85 and warm baths given to facilitate the process. The convalescence from measles is the most important stage of the disease. Watchfulness and care may prevent serious pulmonary complications. The frequency with which the mothers of children with simple or tuberculous broncho- pneumonia tell us that “ the child caught cold after measles,” and the contemplation of the mortality bills should make us extremely careful in our management of this affection. IX. R U B E L LA (Rotheln, German Measles). This exanthein has also the names of rubeola notha, or epidemic rose- ola, and, as it is supposed to present features common to both, has been also known as hybrid measles or hybrid scarlet fever. It is now generally re- garded, however, as a separate and distinct affection. Etiology.—It is propagated by contagion and spreads with great rapidity. It frequently attacks adults, and the occurrence of either measles or scarlet fever in childhood is no protection against it. The epidemics of it are often very extensive. Symptoms.—These are usually mild, and it is altogether a less seri- ous affection than measles. Very exceptionally, as in the epidemics studied by Cheadle, the symptoms are severe. The stage of incubation ranges from ten to twelve da.ys. In the stage of invasion there are chilliness, headache, pains in the back and legs, and coryza. There may be very slight fever. In 30 per cent of Edwards’s cases the temperature did not rise above 100°. The duration of this stage is somewhat variable. The rash usually appears on the first day, some writers say on the second, and others again give the duration of the stage of invasion as three days. Griffith places it at two days. The eruption comes out first on the face, then on the chest, and gradually extends so that within twenty-four hours it is scattered over the whole body. It may be the first symptom noted by the mother. The eruption consists of a number of round or oval, slightly raised spots, pink- ish-red in color, usually discrete, but sometimes confluent. The color of the rash is somewhat brighter than in measles. The patches are less distinctly crescentic. After persisting for two or three days (sometimes longer), it gradually fades and there is a slight fur- furaceous desquamation. The rash persists as a rule longer than in scar- let fever or measles, and the skin is slightly stained after it. The lym- phatic glands of the neck are frequently swollen, and, when the eruption is very intense and diffuse, the lymph-glands in the other parts of the body. There are no special complications. The disease usually progresses favorably; but in rare instances, as in those reported by Cheadle, the symptoms are of greater severity. Albuminuria may occur and even SPECIFIC INFECTIOUS DISEASES. 86 nephritis. Pneumonia and colitis have been present in some epidemics. Icterus has been seen. Diagnosis.—The mildness of the case, the slightness of the prodromal symptoms, the mildness or the absence of the fever, the more diffuse character of the rash, its rose-red color, and the early enlargement of the cervical glands, are the chief points of distinction between rotheln and measles. The treatment is fhat of a simple febrile affection. It is well to keep the child in bed, though this may be difficult, as the patient rarely feels ill. X. EPIDEMIC PAROTITIS (Mumps). Definition.—An infectious disease, characterized by inflammation of the parotid gland. The testes in males and the ovaries and breasts in females are sometimes involved. Etiology.—The nature of the virus is unknown. The affection has all the characters of an epidemic disease. It is said to be endemic in certain localities, and probably is so in large centres of population. At certain seasons, particularly in the spring and autumn months, the number of cases increases rapidly. It is met most frequently in childhood and adolescence. Very young infants and adults are seldom attacked. Males are somewhat more frequently affected than females. In institutions and schools the disease has been known to attack over 90 per cent of all the children. It may be curiously localized in a city or district. The disease is contagious and spreads from patient to patient. A remarkable idiopathic, non-specific parotitis may follow injury or disease of the abdominal or pelvic organs. Stephen Paget* has collected 101 cases of this kind, the majority of which were not associated with septic processes (see Diseases of the Salivary Glands). Symptoms.—The period of incubation is from two to three weeks, and there are rarely any symptoms during this stage. The invasion is marked by fever, which is usually slight, rarely rising above 101°, but in exceptionally severe cases going up to 103° or 104°. The child com- plains of pain just below the ear on one side. Here a slight swelling is noticed, which increases gradually, until, within forty-eight hours, there is great enlargement of the neck and side of the cheek. The swelling passes forward in front of the ear, and back beneath the sterno-cleido muscle. The other side usually becomes affected within a day or two. The submaxil- lary glands may also be involved. The greatest inconvenience is experi- enced in taking food, for the patient is unable to open the mouth, and even speech and deglutition become difficult. There may be an increase in tbe secretion of the saliva, but the reverse is sometimes the case. There * British Medical Journal, March 19, 1887. EPIDEMIC PAROTITIS. 87 is seldom great pain, but, instead, an unpleasant feeling of tension and tightness. There may be earache and slight impairment of hearing. After persisting for from seven to ten days, the swelling gradually subsides and the child rapidly regains his strength and health. Relapse rarely if ever occurs. Occasionally the disease is very severe and characterized by high fever, delirium, and great prostration. The patient may even lapse into a typhoid condition. One of the most remarkable features of the disease is a tendency to involvement of the testes, usually as the affection of the salivary glands subsides. One or both testicles may be involved. The swelling may be great, and occasionally effusion takes place into the tunica vaginalis. The orchitis may develop before the parotitis, or in rare instances may be the only manifestation of the infection (orchitis pcirotidea). The in- flammation increases for three or four days, and resolution takes place gradually. Occasionally there may be a muco-purulent discharge from the urethra. In severe cases atrophy may follow, fortunately as a rule only in one organ; occurring in both before puberty the natural devel- opment is usually checked. The proportion of cases of orchitis varies in different epidemics; 211 cases occurred in 699 cases, and 103 cases of atrophy followed 163 instances of orchitis (Comby). Orchitis is rarely seen before puberty. A vulvo-vaginitis sometimes occurs in girls, and the breasts may be- come enlarged and tender. Mastitis has been seen in boys. Involvement of the ovaries is rare. Complications and Sequelae.—Of these the cerebral affections are perhaps the most serious. As already mentioned, there may be de- lirium and high fever. In rare instances meningitis has been found. Hemiplegia and coma may also occur. A majority of the fatal cases are associated with meningeal symptoms. These, of course, are very rare in comparison with the frequency of the disease; yet, in the Index Catalogue, under this caption, there are six fatal cases mentioned. In some epi- demics the cerebral complications are much more marked than in others. Acute mania has occurred, and there are instances on record of insanity following the disease. Arthritis, albuminuria, with convulsions, acute uraemia, endocarditis, and peripheral neuritis are occasional complications. Suppuration of the gland is an extremely rare complication in genuine idiopathic mumps. Gangrene has occasionally occurred. The special senses may be seriously involved. Many cases of deafness have been de- scribed in connection with or following mumps. It, unfortunately, may be permanent. Affections of the eye are rare, but atrophy of the optic nerve has been described. The lachrymal glands may be involved. The diagnosis of the disease is usually easy. The position of the swelling in front of and below the ear and the elevation of the lobe on the 88 SPECIFIC INFECTIOUS DISEASES. affected side definitely fix the locality of the swelling. In children in- flammation of the parotid, apart from ordinary mumps, is excessively rare. Treatment.—It is well to keep the patient in bed during the height of the disease. The bowels should be freely opened, and the patient given a light liquid diet. No medicine is required unless the fever is high, in which case aconite may be given. Cold compresses may be placed on the gland, but children, as a rule, prefer hot applications. A pad of cotton wadding covered with oiled silk is the best application. Suppuration is almost unknown, and need not be dreaded, even though the gland be- come very tense. Should redness and tenderness develop, leeches may be used. With delirium and head symptoms the ice-cap may be applied. In a robust subject, unless the signs of constitutional depression are ex- treme, a free venesection may do good. For the orchitis, rest, with sup- port and protection of the swollen gland with cotton-wool, is usually sufficient. XI. WHOOPING-COUGH. Definition.—A specific affection characterized by convulsive cough and a long-drawn inspiration, during which the “ whoop”is produced. Etiology.—The disease occurs in epidemic form, but sporadic cases appear in a community from time to time. It is directly contagious from person to person; but dwelling-rooms, houses, school-rooms, and other localities may be infected by a sick child. It is, however, in this way less infectious than other diseases, and is probably most often taken by direct contact. The nature of the virus is still doubtful, many organisms hav- ing been described in the sputum. The observations of Afanassjew in 1887 have been the most satisfactory. He has cultivated a short bacillus, which grows with well-marked characters, and, when inoculated into the trachea of animals, produces a catarrhal condition of the mucous mem- brane. Cornil and Babes conclude that the organism has not character- istics sufficiently pronounced, or an influence on animals sufficiently characteristic, to enable us to say that it is specific. None of the more recent observations are more conclusive. Epidemics prevail for two or three months, usually during the winter and spring, and have a curious relation to other diseases, often preceding or following measles, less fre- quently scarlet fever. Children between the first and second dentitions are commonly affected. Sucklings are, however, not exempt, and I have seen very severe attacks in infants under six weeks. It is stated that girls are more subject to the disease than boys. Adults and old people are sometimes attacked, and in the aged it may be a very serious affection. Many persons possess immu- nity against the disease, and, though frequently exposed, escape. As a rule, one attack protects. Delicate anaemic children with nasal or bron- chial catarrh are more subject to the disease than others. According to WHOOPING-COUGH. 89 the United States Census Eeports, the disease is more than twice as fatal in the negro race than in others. Morbid Anatomy.—Whooping-cough itself has no special patho- logical changes. In fatal cases pulmonary complications, particularly broncho-pneumonia, are usually present. Collapse and compensatory em- physema, vesicular and interstitial, are found, and the tracheal and bron- chial glands are enlarged. Symptoms.—Catarrhal and paroxysmal stages can be recognized. There is a variable period of incubation of from seven to ten days. In the catarrhal stage the child has the symptoms of an ordinary cold, which may begin with slight fever, running at the nose, injection of the eyes, and a bronchial cough, usually dry, and sometimes giving indi- cations of a spasmodic character. The fever is usually not high, and slight attention is paid to the symptoms, which are thought to be those of a simple catarrh. After lasting for a week or ten days, instead of subsiding, the cough becomes worse and more convulsive in char- acter. The paroxysmal stage, marked by the characteristic cough, dates from the first appearance of the “ whoop.” The fit begins with a series of from fifteen to twenty short coughs of increasing intensity, and then with a deep inspiration the air is drawn into the lungs, making the “ whoop,” which may be heard at a distance and from which the disease takes its name. This loud inspiratory sound may sometimes precede the series of spasmodic expiratory efforts. Several coughing-fits may succeed each other until a tenacious mucus is expectorated. This may be small in amount, but after a series of coughing-fits a considerable quantity may be expec- torated. Not infrequently it is brought up by vomiting or by a combina- tion of cough and regurgitation. There may be only four or five of these attacks in the day, or in severe cases they may recur every half-hour. During the attack the thorax is very strongly compressed by the powerful expiratory efforts, and, as very little air passes in through the glottis, there are signs of defective aeration of the blood ; the face becomes swollen and congested, the veins are prominent, the eyeballs protrude, and the con- junctivse become deeply engorged. Suffocation indeed seems imminent, when with a deep, crowing inspiration air enters the lungs and the color is quickly restored. Children are usually terrified at the onset, and run at once to the mother or nurse to be supported during the attack. Few diseases are more painful to witness. In severe paroxysms vomiting is frequent and the sphincters may be opened. The urine is said to be of high specific gravity (1022-1032), pale yellow, and to contain much uric acid. An ulcer under the tongue is a very common event, and was thought at one time to be the cause of the disease. During the attack, if the chest be examined, the resonance is defective in the expiratory stage, full and clear during the deep, crowing inspiration ; 90 SPECIFIC INFECTIOUS DISEASES. but on auscultation during the latter there may be no vesicular murmur heard, owing to the slowness with which the air passes the narrowed glot- tis. Bronchial rales are occasionally heard. Among circumstances which precipitate an attack are emotion, such as crying, and any irritation about the throat. Even the act of swallowing sometimes seems sufficient. In a close dusty atmosphere the coughing- fits are more frequent. After lasting for three or four weeks the attacks become lighter and finally cease. In cases of ordinary severity the course of the disease is rarely under six weeks. The complications .and sequelse of whooping-cough are important. During the extensive venous congestion haemorrhages are very apt to occur in the form of petechias, particularly about the forehead, eccliymo- sis of the conjunctivae, epistaxis, and occasionally haemoptysis. Haemor- rhage from the bowels is rare. Convulsions are not very uncommon, due perhaps to the extreme engorgement of the cerebral cortex. Very rarely hemiplegia or monoplegia follows. Sudden death has been caused by extensive subdural haemorrhage. Whooping-cough must be regarded as a very unusual cause of cerebral palsy in children. It was associated with three cases of my series of one hundred and twenty cases, but in none of them did the hemiplegia come on during the paroxysm, as in a case reported by S. West. The persistent vomiting may induce marked anaemia and wasting. The pulmonary complications which follow whooping-cough are extremely serious. During the severe cougliing-spells interstitial emphysema maybe induced, more rarely pneumothorax. I saw one instance in which rupture occurred, evidently near the root of the lung, and the air passed along the trachea and reached the subcutaneous tissues of the neck, a condition which has been known to become general. Broncho-pneumonia, with its accompanying collapse, is the most frequent pulmonary complication and carries off a large number of children. It may be simple, but in a con- siderable proportion of the cases the process is tuberculous. Pleurisy is sometimes met with and occasionally lobar pneumonia. Enlargement of the bronchial glands is very common in whooping-cough and has been thought to cause the disease. It may sometimes be sufficient to produce dulness upon the manubrium. During the spasm the radial pulse is small, the right heart engorged, and during and after the attack the cardiac action is very much disturbed. Serious damage may result, and possibly some of the cases of severe valvular disease in children who have had neither rheumatism nor scarlet fever may be attributed to the terrible heart strain during a prolonged attack of whooping-cough. Koplik re- gards the swelling about the face and eyes as an important sign of the heart strain. Serious renal complications are very uncommon, but albu- min not infrequently and sugar occasionally are found in the urine. Diagnosis.—So distinctive is the “ whoop ” of the disease that the diagnosis is very easy; but occasionally there are doubtful cases, particu- WHOOPING-COUGH. 91 larly during epidemics, in which a series of expiratory coughs occurs with- out any inspiratory crow. Prognosis.—Taken with its complications, whooping-cough must be regarded as a very fatal affection. According to Dolan, it ranks third among the fatal diseases of children in England, where the death-rate per million from this disease is five thousand annually. The younger the infant the greater is the probability of serious complications. The deaths are chiefly among • children of the poor and among delicate in- fants. Treatment.—Parents should be warned of the serious nature of whooping-cough, the gravity of which is scarcely appreciated by the pub- lic. Particular care should be taken that children suspected of the disease are not sent to the public schools or exposed in any way so that other chil- dren can become contaminated. There is more reprehensible neglect in connection with this than with any other disease. The patient should be isolated, and if the paroxysms are at all severe, at rest in bed. Fresh air, night and day, is a most essential element in the treatment of the disease. The medicinal treatment of whooping-cough is most unsatisfactory. In the catarrhal stage when there is fever the child should be in bed and a saline fever mixture administered. If the cough is distressing, ipecacuanha wine and paregoric may be given. For the paroxysmal stage a suspiciously lorg list of remedies has been recommended, twenty-two in one popular text-book on therapeutics. If the disease is due, as seems probable, to a germ growing upon and irritating the bronchial mucosa, a germicidal plan of treatment seems highly rational and persistent attempts should be made to discover a suitable remedy. Quinine is one of the best remedies. One sixth of a grain may be given three times a day for each month of age, and one grain and a half for each year in children under five years. Resorcin in one-per-cent solutions, swabbed frequently on the throat; two or three grains of iodoform to an ounce of starch powder; a spray of carbolic acid —have all been warmly recommended. J. Lewis Smith advises the use of the steam atomizer with a solution of carbolic acid, chloride of potassium and bromide of potassium in glycerin. Bromoform, in doses of one to five minims suspended in syrup, has been warmly recommended of late. Jacobi regards belladonna as the most satisfactory remedy. He gives it in full doses, as much as one sixth of a grain of the extract to a child of six or eight months three times a day. It should be given in sufficient doses to produce the cutaneous flush. For the nervous element in the disease anti- pyrin has been used with apparent success. After the severity of the attack has mitigated and convalescence has begun, the child should be watched with the greatest care. It is just at this period that the fatal broncho-pneumonias are apt to develop. The cough sometimes persists for months and the child remains weak and deli- cate. Change of air should be tried. Such a patient should be fed with care, and given tonics and cod-liver oil. 92 SPECIFIC INFECTIOUS DISEASES. XII. INFLUENZA {La Grippe). Definition.—An infectious disease characterized by great prostration and often catarrh of the mucous membranes, particularly the respiratory and gastro-intestinal. There is a marked liability to serious complications, particularly pneumonia. Epidemics appear at intervals and spread with extraordinary rapidity, so that in a few weeks an entire continent may be involved. The dis- ease has been known for several centuries, and there have been within the past fifty years several extensive outbreaks, notably those of 1833,1847-’48, and the epidemic of 1889-’90, which has recurred each year with varying severity, lessening last winter (1894-’95). Many of the epidemics have started in Russia, hence the name Russian fever. In October of 1889 it prevailed extensively in St. Petersburg. During November and December it spread to Germany, France, and western Europe, appearing in London about the end of December. Cases appeared in this country about Christ- mas, and the disease rapidly became epidemic. The elaborate report of the Verein f. innere Medicin (1892), the report of Parsons (Local Govern- ment Board’s Report, 1892-’93), and the work of Pfeiffer, from Koch’s Institute, are the three most notable productions of the last visitation. Etiology.—The disease is highly contagious, and probably is spread only from the sick to the sound. Independent of all meteorological con- ditions, like other rapidly spreading affections it is conveyed along lines of travel. The bacillus isolated by Pfeiffer, which is accepted by leading authori- ties as the cause of the disease, is a small, non-motile, organism which stains well in Loeffler’s methylene blue, or in a dilute, pale-red solution of carbol-fuchsin in water. On culture media it grows only in the presence of luemoglobin. The bacilli are present in enormous numbers in the nasal and bronchial secretions of patients, in the latter almost in pure cultures. They persist often after the severe symptoms have subsided. Morbid Anatomy.'—Uncomplicated cases recover. In the delicate and aged alone do we see fatal results, and then only from the intensity of the fever or the profound depression. Injection and swelling of the pharyngeal and laryngeal mucosa, bronchitis, and a catarrhal condition of the stomach and intestines may be present. The complications are very varied. Severe bronchitis, lobar and lobu- lar pneumonia, and nephritis may exist. Symptoms.—The period of incubation is “from one to four days; oftenest three to four days.” In many cases the attack closely resembles an ordinary catarrh with slight fever, dryness and swelling of the nasal mucosa, and then increase in the secretion. In the severer cases the coryza is subsidiary or absent, and the symptoms are those of an infection of varying grades of severity. Headache, pain in the back and legs, and a general soreness as if bruised or beaten, are more pronounced in influ- INFLUENZA. 93 enza than in any other disorders except dengue and small-pox. Delirium may be marked. Associated with these are a prostration and cardiac weak- ness out of proportion to the intensity of the fever, and sometimes very alarming. The pulse is feeble, small, and intermittent. Death may result directly from heart-failure, as in cases mentioned by Wilks. Endocarditis and pericarditis are rare complications. Persistent irregularity of the heart’s action, bradycardia, tachycardia, and pseudo-angina attacks have been frequent sequelae. Herpes is common; diffuse erythema sometimes occurs, and a few in- stances of purpura have been observed. Albuminuria and cystitis may develop. Conjunctivitis is a frequent event; iritis, and in rare instances optic neuritis, have been observed. Acute otitis is a common complication. Serious nervous complications are marked delirium and meningitis, the latter usually in association with pneumonia. Bristovve has reported several cases of abscess of the brain following influenza. Peripheral neu- ritis is not very uncommon. Severe and persistent vertigo is a distressing sequel. Mental disorders are not infrequent. Inaptitude for mental exertion, depression of spirits, even insanity, may follow an attack. Affections of the respiratory organs are the most serious. Many cases present an intense bronchitis, involving the large and small tubes and coming on with high fever, sometimes with delirium. The sputum is viscid, and brought up in little lumps or balls. In children the bronchitis may be complicated with broncho-pneumonia. By far the most serious and fatal complication is pneumonia, which may follow the bronchitis, or set in with well-characterized symptoms. Sometimes the symptoms are at first obscure and the pneumonia atypical. Thus, after an initial rigor, with some dyspnoea and high fever, the local signs may be masked, and it may not be until the third or fourth day, or even later, that the physical signs of a pneumonia are detected. The sputa may not be rusty until the fourth or fifth day. The crisis may be deferred or the defervescence may be by lysis. A considerable proportion of the cases, however, run a normal course. In the aged and weak a broncho-pneumonia of the lower lobes, without high fever, is a not infrequent complication. Abscess of the lung may follow. Pleurisy is not an uncommon complication, and empyema may develop. The gastro-intestinal symptoms may be marked ; thus, with the initial fever, there may be nausea and vomiting. Diarrhoea is not uncommon; indeed, the brunt of the entire process may fall upon the gastro-intes- tinal mucosa. The diagnosis of the disease offers no difficulties when it occurs in epi- demic form. Coryza is not always present, and the symptoms may be those of general fever with great prostration. In other instances the bron- chitis may be an important feature. The severe prostration, fever, de- lirium, with the initial bronchitis, and occasionally epistaxis, may lead to the diagnosis of typhoid fever. The complications are, as a rule, readily recognized, though at first the symptoms of the pneumonia may be some- 94 SPECIFIC INFECTIOUS DISEASES. what indefinite. The bacteriological diagnosis can sometimes be made by examining the bronchial sputum, but cultures are as a rule necessary. Treatment.—Isolation should be practised when possible, and old people should be guarded against all possible sources of infection. The secretions, nasal and bronchial, should be thoroughly disinfected. In every case the disease should be regarded as serious, and the patient should be con- fined to bed until the fever has completely disappeared. In this way alone can serious complications be avoided. From the outset the treatment should be supporting, and the patient should be carefully fed and well nursed. The bowels should be opened by a dose of calomel or a saline draught. At night ten grains of Dover’s powder may be given. At the onset a warm bath is sometimes grateful in relieving the pain in the back and limbs, but great care should be taken to have the bed well warmed, and the patient should be given after it a drink of hot lemonade. If the fever is high and there is delirium, small doses of antipyrin may be given and an ice-cap applied to the head. The medicinal antipyretics should be used with caution, as profound prostration sometimes develops in these cases. Too much stress should not be laid upon the mental features. Delirium may be marked even with slight fever. In the cases with great cardiac weakness stimulants should be given freely, and during convalescence strychnia in full doses. The intense bronchitis, pneumonia, and other complications should receive their appropriate treatment. The convalescence requires careful management, and it may be weeks or months before the patient is restored to full health. A good nutritious diet, change of air, and pleasant sur- roundings are essential. The depression of spirits following this disease is one of its most unpleasant and obstinate features. XIII. DENGUE. Definition.—An acute infectious disease of tropical and subtropical regions, characterized by febrile paroxysms, pains in the joints and mus- cles, and sometimes a cutaneous rash. . The disease was first noted in Java. During this century many epi- demics of it have been reported, particularly in India, Africa, and the southern United States. S. II. Dickson gave the most satisfactory account of the disease as it appeared in Charleston in 1828. Since that time there have been three or four wide-spread epidemics, confined chiefly to the Gulf States and rarely extending beyond the 32d parallel. Etiology.—Many observers regard it as contagious. The disease spreads from place to place, and is conveyed by ships and along railroads. It is remarkable among epidemics as practically affecting all members in a community who have not been protected by a previous attack. Matas, in his excellent account, states that one attack does not protect from subsequent infection. It attacks all races equally. The disease is stated to attack animals. McLaughlin, of Texas, has found in the blood of patients a micrococcus, which he regards as the special agent and has been able to cultivate. DENGUE. 95 As the disease is never fatal, no observations have been made upon its pathological anatomy. Symptoms.—The period of incubation is from three to five days, during which the patient feels well. The attack sets in suddenly with headache, chilly feelings, and intense aching pains in the joints and mus- cles. The fever rises gradually and may reach as high as 106° or 107°. The pulse is rapid and there are the other phenomena associated with acute fever—loss of appetite, coated tongue, slight nocturnal delirium, and concentrated urine. In the initial stage there may be an erythematous rash. In a majority of the cases the pains in the muscles, joints and bones are of a most aggravated character, and the patients speak of them as of a boring or breaking character, hence the popular name “ break-bone fever.” The large and small joints are affected, sometimes in succession, and they become swollen, red, and painful. The pains shift about, and in some cases cutaneous hyperaesthesia has been noted. In some instances there is a tendency to haemorrhage, from either the nose, lungs, stomach, or bow- els. Eugene Foster speaks of having seen black vomit, similar to that of yellow fever, and in three instances alarming haemorrhage from the bow- els, which in one case persisted for three months and caused death. The fever gradually reaches its height by the third or fourth day, and the patient enters upon the apyretic period, which may last from two to four days, and in which he feels prostrated and stiff. At this time, in a large number of cases, an eruption is common which, judging from the description, has nothing distinctive, being at times macular, like measles, at others, diffuse and scarlatiniform, or papular, or lichen-like. In other instances the rash has been described as urticarial, or even vesicular. A second paroxysm of fever then occurs, and the pains return. Certain writers describe inflammation and hyperasmia of the mucous membrane of the nose, mouth, and pharynx. Enlargement of the lymph-glands is not uncommon, and may persist for weeks after the disappearance of the fever. Convalescence is often protracted, and there is a degree of mental and physical prostration out of all proportion to the severity of the primary attack. By far the most distressing symptom is the pain, which all who have experienced the disease speak of as agonising and in- tolerable, and more severe than that experienced in any other acute fever. Complications are rare. Insomnia and occasionally delirium, resem- bling somewhat the alcoholic form, have been observed. A relapse may occur even as late as two weeks. Briefly, the course of the disease may be described as consisting of a febrile paroxysm of three or four days; a re- mission of variable duration, which may be wanting ; and a second parox- ysm of about three days. The average duration of a moderate attack is from seven to eight days. The diagnosis of the disease rarely offers any special difficulties, pre- vailing as it does in epidemic form, and attacking all classes indiscrimi- nately. Isolated cases might be mistaken at first for acute rheumatism. 96 SPECIFIC INFECTIOUS DISEASES. Southern physicians say that occasionally yellow fever and dengue may be confounded. Treatment.—This is entirely symptomatic. Quinine is stated to be a prophylactic, but on insufficient grounds. Hydrotherapy may be em- ployed to reduce the fever. The salicylates or antipyrin may be tried for the pains, which usually, however, require opium. During convalescence iodide of potassium is recommended for the arthritic pains, and tonics are indicated. XIV. CEREBRO-SPINAL MENINGITIS. Definition.—A specific infectious disease, occurring sporadically and in epidemics, characterised by inflammation of the cerebro-spinal menin- ges and a clinical course of great irregularity. The affection is known by the names of malignant purpuric fever, petechial fever, and spotted fever. Etiology.—Since its recognition in Geneva in the early part of this century, numerous epidemics have been described. Stille’s monograph (1867), and the elaborate section (pp. 409-553) in Volume I of Joseph Jones’s works, give full details of the American epidemics. In Europe it is remarkable with what frequency the disease has occurred in garrisons. In this country the disease was first seen in Massachusetts in 1806, since which date there have been epidemics in various localities at irregular in- tervals. During the civil war, according to Smart’s report, comparatively few deaths were caused by this disease. Sporadic cases occur from time to time in the larger cities and country districts on this continent. After the first epidemic in Montreal in 1873 occasional cases occurred. In Philadelphia, since its appearance in 1863, there have been cases reported every year in the mortality bills. Without autopsy the diagnosis of many of these cases is extremely doubtful; but there can be no question that the disease, though rare, still lingers. Judg- ing from my own experience in three of the hospitals of that city, and from the fact that in five years I saw only three instances, I would regard it as very much less frequent than the reports of the Health Office would seem to indicate. The disease has broken out simultaneously in regions far distant from each other. The epidemics occur most frequently in winter and spring. Neither soil nor locality has any special influence. The concentration of indi- viduals, as in large barracks, seems to be specially favorable. Children are much more susceptible to the disease than adults, though the susceptibility has differed in different epidemics. In certain places CEREBRO-SPINAL MENINGITIS. 97 children alone have been affected; in others the disease has been chiefly among adults. It attacks males and females alike. Certain epidemics have been most prevalent in country districts. In 1873 the disease prevailed along the valley of the Ottawa, in villages and country places, much more severely than in the cities of Montreal and Ottawa. Over-exertion, prolonged marching in the heat, depressing mental or bodily surroundings, and the misery and squalor of the large tenement- houses in cities are predisposing causes. The disease is not directly contagious; it is probably not transmitted by clothing or the excretions. We are still ignorant of the conditions favoring the occurrence of epi- demics. The existence of the micrococcus lanceolatus in sporadic as well as in epidemic forms has led to the belief that the disease may be due to this organism, the morbid manifestations of which are so varied, and which is present in so large a percentage of all persons. Striimpell has suggested that there may be some connection with coryza and epidemic meningitis, the infection occurring directly from the nose. Flexner and Barker suggest that the intestine may be the infection-atrium ; but neither of these views explain the rapid development of epidemics, dependent ap- parently upon local conditions. Morbid Anatomy.—In malignant cases there may be no charac- teristic changes, for the patient may die before exudation occurs. In well-marked cases the meninges of the brain and cord are inflamed. The following abstract of one of the Montreal cases, in which death occurred about the fifth day, gives a good idea of the condition in this disease: The brain contained an excessive amount of blood. The dural sinuses and all the veins and arteries were engorged. Some of the veins of the pia were as large as goose-quills. On the cortex there was much lymph beneath the arachnoid on either side of the longitudinal fissure— more on the right than on the left hemisphere. At the base there was a purulent exudate about the chiasma and inner parts of the Sylvian fissure, but none on the pons or medulla. There was no fibrin in the course of the middle cerebral arteries. The ventricles contained serous exudate; the walls were not softened. The gray matter of the brain Avas deeply congested, but presented neither haemorrhages, spots, nor softening. In the spinal cord the veins of the pia were engorged. On the posterior surface, from the cervical enlargement to the cauda equina, was a thick layer of grayish-yellow, lympho-purulent exudation, which in places produced irregular bulging of the arachnoid membrane. There Avere no changes in the thoracic or abdominal viscera. Foci of haemor- rhage and of encephalitis occur in some cases. The formation of abscess has been occasionally described. The involvement of the ventricles is less than in tuberculous meningitis. In the cases which I have seen the exu- dation, as is usual in the secondary meningeal inflammations, Avas most 98 SPECIFIC INFECTIOUS DISEASES. abundant on the cortex. The exudation may extend along the lymph- sheaths of the cranial nerves, particularly the auditory and optic. In long-standing cases the inflammatory processes appear more chronic. There are thickening and adhesion of the membranes, areas of cortical softening or of atrophy, and, in some instances, hydrocephalus. The changes in the other organs are those associated with fever. In the ma- lignant cases there may be hasmorrhages into the skin and on the serous membranes. Pneumonia, pleurisy, endocarditis, dysentery and nephritis have been described. The spleen varies in size according to the period of the disease at which death has occurred. When the fever has been intense it is enlarged- Symptoms.—Cases differ remarkably in their characters. Many different forms have been described. These are perhaps best grouped into three classes: 1. Malignant Form.—This fulminant or apoplectic type occurs with variable frequency in epidemics. It may occur sporadically. The onset is sudden, usually with violent chills, headache, somnolence, spasms in the muscles, great depression, moderate elevation of temperature, and feeble pulse, which may fall to fifty or sixty in the minute. Usually a purpuric rash develops. In a Philadelphia case in 1888 a young girl, apparently quite well, died within twenty hours of this form. There are cases on record in which death has occurred within a shorter time. Stille tells of a child of five years, in whom death occurred after an illness of ten hours; and refers to a case reported by Gordon, in which the entire duration of the illness was only five hours. 2. Ordinary Form.—The stage of incubation is not known. The dis- ease usually sets in suddenly. There may be premonitory symptoms: headache, pains in the back, and loss of appetite. More commonly, the onset is with headache, severe chill, and vomiting. The temperature rises to 101° or 102°. The pulse is full and strong. An early and important symptom is a painful stiffness of the muscles of the neck. The headache increases, and there are photophobia and great sensitiveness to noises. Children become very irritable and restless. In severe cases the contrac- tion of the muscles of the neck sets in early, the head is drawn back, and, when the muscles of the back are also involved, there is orthotonos, which is more common than opisthotonos. The pains in the back and in the limbs may be very severe. The motor symptoms are most characteristic. Tremor of the muscles may be present, with tonic or clonic spasms in the arms or legs. Rigidity of the muscles of the back or neck is very com- mon, and the patient lies with the body stiff and the head drawn so far back that the occiput may be between the shoulder-blades. Except in early childhood convulsions are not common. Strabismus is a frequent and important symptom. Spasm of the muscles of the face may also occur. Cases have been described in which the general rigidity and stiff- ness was such that the body could be moved like a statue. Paralysis of CEREBRO-SPINAL MENINGITIS. 99 the trunk muscles is rare, but paralysis of the muscles of the eye and the face is not uncommon. Of sensory symptoms, headache is the most dominant and persists from the outset. It is chiefly in the back of the. head, and the pain ex- tends into the neck and back. There may be great sensitiveness along the spine, and in many cases there is marked hypera3stliesia. The psychical symptoms are marked. Delirium occurs at the onset, occasionally of a furious and maniacal kind. The patient may display at the start marked erotic symptoms. The delirium gives place in a few days to stupor, which, as the effusion increases, deepens to coma. The temperature is irregular and variable. Remissions occur fre- quently, and there is no uniform or typical curve during the disease. In some instances there has been little or no fever. In other cases the tem- perature may reach 105° or 106°, or, before death, 108°. The pulse may be very rapid in children; in adults it is at first usually full and strong. In some cases it is remarkably slow, and may not be more than fifty or sixty in the minute. Sighing respirations and Cheyne-Stokes breathing are met with in some instances. Unless there is pneumonia the respira- tions are not often increased in frequency. The cutaneous symptoms of the disease are important. Herpes occurs with even greater frequency than in pneumonia or in intermittent fever. The petechial rash, which has given the name spotted fever to the disease, is very variable. Stille states that of ninety eight cases in the Philadel- phia Hospital, no eruption was observed in thirty-seven. In the Montreal cases petechiae and purple spots were common. They appear to have been more frequent in the epidemics on this continent than in Europe. The petechiae may be numerous and cover the entire skin. An erythema or dusky mottling may be present. In some instances there have been rose- colored hyperaemic spots like the typhoid rash. Urticaria or erythema no- dosum, ecthyma, pemphigus and in rare instances gangrene of the skin have been noted. There is a leucocytosis, a point which may help in the diagnosis from typhoid fever. As already stated, vomiting may be a special feature at the onset; but, as a rule, it gradually subsides. In some instances, however, it persists and becomes the most serious and distressing of the symptoms. Diarrhoea is not common. The bowels are usually confined. The abdomen is not tender. In acute cases the spleen is usually enlarged. The urine is sometimes albuminous and the quantity may be increased. Glycosuria has been noted in some instances, and in the malignant forms haematuria. The course of the disease is extremely variable. Hirsch rightly states that it may range between a few hours and several months. More than half of the deaths occur within the first five days. In favorable cases, after the symptoms have persisted for five or six days, improvement is in- 100 SPECIFIC INFECTIOUS DISEASES. dicated by a lessening of the spasm, reduction of the fever, and a return of the intelligence. Sudden fall in the temperature is of bad omen. Con- valescence is extremely tedious, and may be interrupted by complications and sequelae to be noted, 3. Anomalous Forms. (a) Abortive Type.—The attack sets in with great severity, but in a day or two the symptoms subside and convalescence is rapid. Strumpell would distinguish between this*abortive variety, which sets in with such intensity, and the mild ambulant cases described by certain writers. He reports a case in which the meningeal symptoms set in with the greatest intensity and persisted for four days, the temperature rising to 40*9° C. On the fifth day the patient entered upon a rapid and satisfactory con- valescence. In the mild cases, as distinguished from the abortive, the pa- tients complain of headache, nausea, sensations in the back and limbs, and stiffness in the neck. There is little or no fever, and only moderate vomiting. These cases could be recognized only during the prevalence of an epidemic. (&) An Intermittent Type has been observed in many epidemics, and is recognized by von Ziemssen and Stille. It is characterized by exacerba- tions of fever, which may recur daily or every second day, or follow a curve of an intermittent or remittent character. The pyrexia resembles that of pyaemia rather than malaria. (c) Chronic Form.—Heubner states that this is a relatively frequent form, though it does not seem to be recognized by many writers on the subject. An attack may be protracted for from two to five or even six months, and may cause the most intense marasmus. The attack consists of a series of recurrences of the fever, and may present the most complex symptomatology. It is not improbable that these protracted cases depend upon chronic hydrocephalus or abscesses of the brain. This form differs distinctly from the intermittent type. A very remarkable instance of it is described by Worthington, in which the disease lasted for fourteen weeks. Complications.—Pleurisy and pericarditis and parotitis are not uncommon. Pneumonia is described as frequent in certain epidemics. Immer- mann found, during the Erlangen epidemic, many instances of the com- bination of pneumonia with meningitis, but it does not seem possible to determine whether, in such instances, pneumonia is the primary disease and the meningitis secondary, or vice versa. The frequency with which inflammation of the meninges of the brain complicates pneumonia has already been mentioned. It is not impossible that the pneumococcus is responsible for both affections. Arthritis has been the most frequent complication in certain epidemics. Many joints are affected simulta- neously, and there are swelling, pain, and exudation, sometimes serous, sometimes purulent. This was first observed by James Jackson, Sr., in the epidemic which he described. Enteritis has been observed. CEREBRO-SPINAL MENINGITIS. 101 Among the important sequelse are those affecting the special senses. Blindness may result from optic neuritis with atrophy. Keratitis with ulceration may develop. This may also occur in the meningitis follow- ing pneumonia. Iritis is less common. Still more serious are the ear symptoms, particularly in children. Deafness very often follows inflammation of the labyrinth; the result, no doubt, of the direct extension of the inflammation along the auditory nerve. In children this not infrequently leads to deaf-mutism. Von Ziemsseu states that in the deaf and dumb institutions of Bamberg and Nuremberg, in 1874, a majority of the pupils had become deaf from epi- demic cerebro-spinal meningitis. Headache may persist for months or years after an attack. Chronic hydrocephalus develops in certain instances in children. The symptoms of this are “ paroxysms of severe headache, pains in the neck and ex- tremities, vomiting, loss of consciousness, convulsions, and involuntary discharges of fasces and urine” (von Ziemssen). Von Ziemssen regards chronic hydrocephalus as by no means a rare sequela. Mental feebleness and aphasia have occasionally been noted. Paralysis of individual cranial nerves or of the lower extremities may persist for some time. In some of these cases unquestionably there may be peripheral neuritis, as Mills suggested. Diagnosis.—There are several affections with which cerebro-spinal meningitis is likely to be confounded : (a) Tuberculous Meningitis.—In sporadic cases it is sometimes impos- sible to determine the nature of a case in the absence of local tuberculous disease. Retraction of the neck and spasms of the muscles of the arms and legs are not nearly so marked and prominent in tuberculous menin- gitis. Herpes also is rare, and the pulse is more irregular. There is rarely petechial eruption. When the disease is prevailing epidemically this fac- tor is of the greatest help in the diagnosis. (5) Pneumonia.—The meningeal complication of this disease is most commonly confined to the cerebrum. As the cortex is chiefly involved, there may be a good deal of motor spasm and tremor, but rarely is there retraction of the muscles of the neck or opisthotonos. In sporadic cases, as has been said, it may be quite impossible to decide whether the pneu- monia has complicated the meningitis or the meningitis the pulmonary affection. The bacteriological examination gives no clue, as the pneumo- coccus is found in both situations. (c) With other Acute Infectious Diseases.—Both typhus and typhoid present symptoms which closely simulate cerebro-spinal meningitis. On several occasions at the Montreal General Hospital cases have been sent into the ward with the diagnosis of cerebro-spinal fever. These cases showed high fever, delirium, retraction of the neck, spasm, and tremor of the muscles, and had not the post-mortem examination revealed typhoid lesions and only cerebro-spinal congestion the diagnosis would not have 102 SPECIFIC INFECTIOUS DISEASES. been corrected. I am sure that many of the cases sent into the health offices as cerebro-spinal fever are instances of the cerebral form of typhoid. I have already referred to the fact that the malignant form of small- pox may be mistaken for cerebro-spinal meningitis. It could scarcely be possible to confound tetanus with this disease. Prognosis.—Ilirsch states that the mortality has ranged in various epidemics from 20 to 75 per cent. In children the death-rate is much higher than in adults. Cases with deep coma, repeated convulsions, and high fever rarely recover. The outlook in the protracted cases is not good, though Heubner gives an instance of a lad of seven, who was ill from the end of February until the end of June, with repeated recur- rences, was worn to a skeleton, and yet completely recovered. Treatment.—The high rate of mortality which has existed in most epidemics indicates the futility of the various therapeutical agents which have been recommended. When Ave consider the nature of the local dis- ease and the fact that, so far as we know, simple or tuberculous cerebro- spinal meningitis is invariably fatal, we may wonder rather that recovery follows in any well-developed case. In strong robust patients the local abstraction of blood by wet cups on the nape of the neck relieves the pain. General bloodletting is rarely indicated. Cold to the head and spine, which was used in the first epi- demics by New England physicians, is of great service. A bladder of ice to the head, or an ice-cap, and the spinal ice-bag may be continuously em- ployed. The latter is very beneficial. Judging from the beneficial effects of the general bath in typhoid with pronounced cerebro-spinal symptoms, hydrotherapy should be systematically employed if the temperature is above 102|°. In private practice the cold-pack or sponging may be sub- stituted. If any counter-irritation is thought necessary, the skin of the back of the neck may be lightly touched with the Paquelin thermo- cautery. Blisters, which have been used so much, are of doubtful benefit and should not be employed. Of internal remedies opium may be given freely, best as morphia hypodermically. Stille recommends either a grain of opium every hour in severe cases or every two hours in cases of mod- erate severity; von Ziemssen advises the hypodermic of morphia, from one third to one half grain in adults. Mercury has no special influence on meningeal inflammation. Iodide of potassium is warmly recom- mended by some writers. Quinine in large doses, ergot, belladonna and Calabar bean have had advocates. Bromide of potassium may be employed in the milder cases, but it is not so useful as morphia to control the spasms. The diet should be nutritious, consisting of milk and strong broths while the fever persists. Many cases are very difficult to feed, and Heub- ner recommends forced alimentation with the stomach-tube. These cases seem to bear stimulants well, and whisky or brandy may be given freely when there are signs of a failing heart. DIPHTHERIA. 103 XV. DIPHTHERIA. Definition.—A specific infectious disease, characterized by a local fibrinous exudate, usually upon a mucous membrane, and by constitu- tional symptoms due to toxins produced at the site of the lesion. The presence of the Klebs-Loeffler bacillus is the etiological criterion by which true diphtheria is distinguished from other forms of membranous inflam- mation. The clinical and bacteriological conceptions of diphtheria are at pres- ent not in full accord. On the one hand, there are cases of simple sore throat which the bacteriologists, finding the Klebs-Loeffler bacillus, call true diphtheria. On the other hand, cases of membranous, sloughing angina, diagnosed by the physician as diphtheria, are called by the bac- teriologists, in the absence of the Klebs-Loeffler bacillus, pseudo-diph- theria or diphtheroid angina. The term diphtheroid may be used for the present to designate those forms in which the Klebs-Loeffler bacillus is not present. Though usu- ally milder, severe constitutional disturbance, and. even paralysis, may fol- low these so-called pseudo-diphtheritic processes. Historical Note.—The disease was known to Aretaeus and to Galen. Epidemics occurred throughout the middle ages. It appeared early among the settlers of New England, and accounts are extant of epidemics *in this country in the seventeenth and eighteenth centuries. Huxham and Fothergill gave excellent descriptions of the disease. An admirable account was given by Samuel Bard,* of New York, whose essay is one of the most solid contributions made to medicine in America. It was reserved for Pierre Bretonneau, of Tours, to grasp the fact that angina suffocativa, “ cynanche maligna,” the “ putrid,” and other forms of malignant sore throat, were one and the same disease, to which he gave the name “diphtherite''’ Etiology.—The disease is endemic in the larger centres of popula- tion, and becomes epidemic at certain seasons of the year. While other contagious diseases have diminished within the past decade, diphtheria has increased, particularly in cities. It has prevailed also with great severity in country districts, in which indeed the affection seems to be specially virulent. A close relation between imperfect drainage or a pol- luted water-supply and diphtheria has not been determined. Diphtheria is a highly contagious disease, readily communicated from person to person. The bacilli may be received, “ (1) from the mem- branous exudate or discharges from diphtheria patients; (2) from the secretions of the nose and throat of convalescent cases of diphtheria in which the virulent bacilli persist; (3) from the throats of healthy indi- viduals who have acquired the bacilli from being in contact with others * Transactions of the American Philosophical Society, yoI. i, Philadelphia, 1770. 104 SPECIFIC INFECTIOUS DISEASES. having virulent germs on their person or clothing: in such cases the bacilli may sometimes live and develop for days or weeks in the throat without causing any lesion ” (Park and Beebe). In the tenement dis- tricts of New York these authors recognized two varieties of local epi- demics. In one, the cases were evidently from neighborhood infection ; while in the other, the infection was derived from schools, since a whole district would suddenly become the seat of scattered cases. “ At times in a certain area of the city, from which several schools drew their scholars, all the cases of diphtheria would occur (as investigation showed) in fami- lies whose children attended one school, the children of the other schools being for the time exempt.” No disease of temperate regions proves more fatal to physicians and nurses. There seems to be particular danger in the examination and swabbing of the throat, for in the gagging, coughing, and spluttering efforts the patient may cough mucus and flakes of membrane into the physician’s face. The virus attaches itself to the clothing, the bedding, and the room in which the patient has lived, and has in many instances displayed great tenacity. It has been found to live on blood serum for one hundred and fifty-five days, in gelatin for eighteen months, dried on silk threads for one hundred and seventy-two days, on a child’s plaything which had been kept in a dark place for five months, in bits of dried membrane for from fourteen to twenty weeks. They have been found, too, in the dust of a diphtheria pavillion, and in the hair and clothing of the nurses in attendance upon diphtheria babies (Wright and Emerson). The disease may be transmitted by inoculation. Calves, cats, and fowls are subject to contagious membranous diseases, which are, however, not identical with diphtheria in man and are not communicable to him. As in other infectious disorders, individual susceptibility plays an im- portant role. Not only do very many of those exposed escape, but even of those in whose throats the bacilli lodge and grow. Of predisposing causes age is one of the most important. Very young children are rarely attacked, but Jacobi states that he has seen three instances of the disease in the newly born. Between the second and the fifteenth year a large majority of the cases occur. In this period the great- est number of deaths is between the second and the fifth years. Girls are attacked in larger numbers than boys, probably because they are brought into closer contact with the sick. Adults are frequently affected. The disease is most prevalent in the cold autumn weather. The secondary pseudo-membranous inflammations, caused usually by the streptococcus, attack debilitated persons, the subjects of fevers, particularly of scarlet fever, typhoid, and measles. Caille regards as special predisposing elements in children enlarged tonsils, chronic naso-pharyngeal catarrh, carious teeth, and an unhealthy condition of the mucous membrane of the mouth and throat. DIPHTHERIA. 105 Epidemics vary in intensity. While in some the affection is mild and rarely fatal, in others it is characterized by wide extension of the mem- brane, and shows a special tendency to attack the larynx. The Klebs-Loeffler bacillus occurs in a large percentage of all suspected cases. It is found chiefly in the false membrane, and does not extend into the subjacent mucosa. In the majority of instances the affec- tion is local, and only a few organisms penetrate into the interior. In exceptional instances the bacilli are found in the blood and in the internal organs. It may be the predominating organism in the broncho-pneu- monia so common in the disease. Besides the throat, the common site of its morbid action, the Klebs-Loeffler bacillus has been found in diph- theritic conjunctivitis, in otitis media, sometimes in wound diphtheria, in fibrinous rhinitis, and by Howard in a case of ulcerative endocar- ditis. Morphological Characters.—The bacillus is non-motile, varies from 2-5 to 3 fjL in length, and from 0-5 to 08 //, in thickness. It appears as a straight or slightly bent rod with rounded ends; irregular, bizarre forms, such as rods with one or both ends swollen, are not uncommon. The bacillus stains in sections or on the cover-glass by the Gram method. It grows best upon a mixture of glucose bouillon and blood serum (Loeffler), forming large, elevated, grayish-white colonies with opaque cen- tres. It grows also upon all the ordinary culture media. The growth usually ceases at temperatures below 20° C. The bacillus is very resistant, and cultures have been made from a bit of membrane preserved for five months in a dry cloth. Variation in Virulence.—For testing the virulence the guinea-pig is used, being most susceptible to the poison. An amount of a forty-eight hour bouillon culture equalizing one half per cent of the weight of the animal is injected subcutaneously. “ A fully virulent culture is one which causes the death of a guinea-pig within three days or less; a culture of medium virulence one which causes the death of the animal in from three to five days. Cultures which only produce local necrosis and ulceration or death after a greater number of days may be considered as of slight virulence ” (J. H. Wright). At the seat of the inoculation there is local necrosis with fibrinous exudate wfflich contains the bacilli, and there is also a more or less extensive oedema of the subcutaneous tissue. The Klebs-Loeffler bacillus evidently has very varying grades of virulence down even to com- plete absence of pathogenic effects. The name pseudo-bacillus of diph- theria should not be given to this organism. The Presence of the Klebs-Loeffler Bacillus in Non-membranous Angina and in Healthy Throats.—The bacillus has been isolated from cases which show nothing more than a simple catarrhal angina, of a mild type without any membrane, with diffuse redness, and perhaps huskiness and signs of catarrhal laryngitis. In other cases the anatomical picture may be that of a lacunar tonsillitis. 106 SPECIFIC INFECTIOUS DISEASES. During the prevalence of an epidemic the organisms may be met with in perfectly healthy throats, particularly in persons in the same house, or the ward attendants and nurses in fever hospitals. Following an attack of diphtheria the bacilli may persist in the throat after all the membrane has disappeared for weeks or months. Schafer notes a case in which they were present six months after the attack, and in a nurse in my ward the bacilli persisted for eighty-four days. Toxine of the Klebs-Loeffler Bacillus.—Itoux and Yersin showed that a fatal result following the inoculation with the bacillus was not caused by any extension of the micro-organisms within the body; and they were enabled in bouillon cultures to separate the bacilli from the poison. The toxine so separated killed with very much the same effects as those caused by the inoculation of the bacilli. These results were confirmed by many observers, particularly by Sidney Martin, who separated a toxic albumose. The precise composition of the body is still doubtful. Production of Immunity.—Susceptible animals may be rendered im- mune from diphtheria by injection of the diphtheria toxine, at first weak- ened by chemical agents, and then given in full strength in gradually increasing doses. In this way an animal may become insusceptible to many times the lethal dose of the toxine. This form of immunity is called antitoxic immunity, as the blood and other fluids of the immuni- lied animal have acquired the property of neutralizing the effects of the toxine. The Bacteria associated with the Diphtheria Bacillus.—The most common is the streptococcus pyogenes. Others, in addition to the organ- isms constantly found in the mouth, are the micrococcus lanceolatus, the bacillus coli communis, and the staphylococcus albus and aureus. Of these, probably the streptococcus pyogenes is the most important, as cases of general infection with this organism have been found in diphtheria. The suppuration in the lymph-glands and the broncho-pneumonia are usu- ally (though not always) caused by this organism. Pseudo-Diphtheria Bacillus.—As mentioned above, the Klebs-Loeffler bacillus varies very much in its virulence, and it exists in a form entirely devoid of pathogenic properties. This organism should not be designated the pseudo-diphtheria bacillus. The name “should be confined to bacilli which, though resembling the diphtheria bacillus, differ from it not only by absence of virulence, but also by cultural peculiarities, the most im- portant of the latter being greater luxuriance of growdh on agar, and the preservation of the alkaline reaction of the bouillon cultures” (Welch). Diphtheroid Inflammations.—Under the term diphtheroid may be grouped those membranous inflammations which are not associated with the Klebs-Loeffler bacillus. It is perhaps a more suitable designation than pseudo-diphtheria or secondary diphtheria. As in a great majority of cases the streptococcus pyogenes is the active organism, the term “ strep- tococcus diphtheritis ” is often used. The name “ diphtheritis ” is best DIPHTHERIA. 107 used in an anatomical sense to designate an inflammation of a mucous membrane or integumentary surface characterized by necrosis and a fibrin- ous exudate, whereas the term “diphtheria” should be limited to the dis- ease caused by the Klebs-Loeffler bacillus. The proportion of cases of diphtheroid inflammation varies greatly in the different statistics. Of the large number of observations made by Park and Beebe (5,611) in New York, 40 per cent were diphtheroid. Figures from other sources do not show so high a percentage. It is not to be inferred from these statistics that any considerable number of the cases which present the appearances of typical and char- acteristic primary diphtheria are due to other micro-organisms than the Klebs-Loeffler bacillus. Nearly all such cases, when carefully examined by a competent bacteriologist, are found to be due to the diphtheria bacil- lus. It is the less characteristic cases, with more or less suspicion of diph- theria, which are most likely to be caused by other bacteria than the Klebs-Loeffler bacillus. It is also to be remembered that in the routine examination of a large number of cases for boards of health and diph- theria wards of hospitals, some cases of genuine diphtheria may escape recognition by lack of such repeated and thorough bacteriological tests as are sometimes required for the detection of cases presenting unusual difficulties. Conditions under which the Diphtheroid Affection occurs.—Of 450 cases (Park and Beebe), 300 occurred in the autumn months and 150 in the spring; 198 of the cases occurred in children from the first to the seventh year. In a large proportion of all the cases the disease de- velops in children, and can only be differentiated from diphtheria proper by the bacteriological examination. In many of the cases it is simply an acute catarrhal angina with lacunar tonsillitis. The diphtheroid inflammations are particularly prone to develop in connection with the acute fevers. (a) Scarlet Fever.—In a large proportion of the cases of angina in scarlet fever the Klebs-Loeffler bacillus is not present. Booker has re- ported 11 cases complicating scarlet fever, in all of which the strepto- cocci were the predominant organisms. Of the 450 cases of Park and Beebe, 42 complicated scarlet fever. The angina of this disease is not always, however, due to the streptococcus. Where diphtheria is prevalent and opportunities are favorable for exposure, a large proportion of the cases of membranous throats in scarlet fever may be genuine diphtheria, as is shown by the statistics of Williams and Morse in the Boston City Hospital. Here, of 97 cases of scarlet fever, membranous angina was present in 35; in 12 with the Klebs-Loeffler bacillus, and in 23 other organisms. Morse reports 99 cases of angina in scarlet fever in which 76 were diphtheroid. This large proportion of cases in which scarlet fever was associated with true diphtheria is attributed to local conditions in the hospital. 108 SPECIFIC INFECTIOUS DISEASES. (b) Measles.—Membranous angina is much less common in this dis- ease. It occurred in 6 of the 450 diphtheroid cases in New York. Of 4 cases with severe membranous angina at the Boston City Hospital, one only presented the Klebs-Loeffler bacillus. (c) Whooping-cough may also be complicated with membranous an- gina. The bacteriological examinations have not been very numerous. Escherich gives four cases, in all of which the Klebs-Loeffler bacillus was found. (d) Typhoid Fever.—Membranous inflammations in this disease are not very infrequent, and they may occur in the throat, the pelvis of the kidney, the bladder, or the intestines. The complication may be caused by the Klebs-Loeffler bacillus, which was present in four cases described by Morse. It is frequently, however, a streptococcus infection. Ernst Wagner has remarked upon the greater frequency of these membranous inflammations in typhoid fever when diphtheria is pre- vailing. Clinical Features of the Diphtheroid Affection.—The cases, as a rule, are milder, and the mortality is low, only 25 per cent in the 450 cases of Park and Beebe. The diphtheroid inflammations complicating the spe- cific fevers are, however, often very fatal, and a general streptococcus infection is by no means infrequent. As in the Klebs-Loeffler angina, there may be only a simple catarrhal process. In other instances the tonsils are covered with a creamy, pultaceous exudate, without any actual membrane. An important group may begin as a simple lacunar tonsilli- tis, while in others the whole fauces and tonsils are covered by a continu- ous membrane, and there is a foul sloughing angina with intense consti- tutional disturbance. Are the diphtheroid cases infectious? General clinical experience warrants the statement that the membranous angina associated with the fevers is rarely communicated to other patients. The health depart- ment of New York does not keep the diphtheroid cases under super- vision. Their investigation of the 450 diphtheroid cases seems to jus- tify this conclusion. Park and Beebe say that “it did not seem that the secondary cases were any less liable to occur where the primary case was isolated than when it was not.” Sequelee of the Diphtheroid Angina.—The milder type is in part, no doubt, due to the less frequent systemic invasion. Some of the worst forms of general streptococcus infection are, however, seen in this dis- ease. There are no peculiarities, local or general, which can be in anv way regarded as distinctive; and if the observation of Bourges should be corroborated, even the most extensive paralysis may follow an angina qaused by it. Morbid Anatomy.—A majority of the cases die of the faucial or of the laryngeal disease. The exudation may occur in the mouth and cover the inner surfaces of the cheeks; it may even extend beyond the DIPHTHERIA. 109 lips on to the skin. This was met once in thirty autopsies at the Mont- real General Hospital. The amount of exudation varies in different cases. Usually the tonsils and the pillars of the fauges are swollen and covered with the false membrane. More commonly, in the fatal cases, the exuda- tion is very extensive, involving the uvula, the soft palate, the posterior nares, and the lateral and posterior walls of the pharynx. These parts are covered with a dense pseudo-membrane, in places firmly adherent, in others beginning to separate. In extreme cases the necrosis is advanced and there is a gangrenous condition of the parts. The membrane is of a dirty greenish or gray color, and the tonsils and palate may be in a state of necrotic sloughing. The erosion may be deep enough in the tonsils to open the carotid artery, or a false aneurism may be produced in the deep tissues of the neck. The nose may be completely blocked by the false membrane, which may also extend into the conjunctivae and through the Eustachian tubes into the middle ear. In cases of laryngeal diphtheria the exudate in the pharynx may be extensive. In many cases, however, it is slight upon the tonsils and fauces and abundant upon the epiglottis and the larynx, which may be completely occluded by false membrane. In severe cases the exudate extends into the trachea and to the bronchi of the third or fourth dimension. This occurred in nearly half of my thirty Montreal autopsies. In all these situations the membrane varies very much in consistency, depending greatly upon the stage at -which death happens. If death has occurred early, it is firm and closely adherent; if late, it is soft, shreddy, and readily detached. When firmly adherent it is torn off with difficulty and leaves an abraded mucosa. In the most extreme cases, in which there is extensive necrosis, the parts look gangrenous. In fatal cases the lym- phatic glands of the neck are enlarged, and there is a general infiltration of the tissues with serum; the salivary glands, too, maybe swollen. In rare instances the membrane extends to the gullet and stomach. On inspection of the larynx of a child dead of membranous croup, the rirna is seen filled with mucus or with a shreddy material wrhich, when washed off carefully, leaves the mucosa covered by a thin grayish-yellow membrane, which may be uniform or in patches. It covers the ary-epi- glottic folds and the true cords, and may be continued into the ventricles or even into the trachea. Above, it may involve the epiglottis. It varies much in consistency. I have seen fatal cases in which the exudation was not actually membranous, but rather friable and granular. It may form a thick, even stratified membrane, which fills the entire glottis. The ex- udation may extend down the trachea and into the bronchi, and may pass beyond the epiglottis to the fauces. Usually it can be readily stripped off from the mucous membrane of the larynx and leaves exposed the swollen and injected mucosa. On examination it is seen that the fibrinous mate- rial has involved chiefly the epithelial lining and has not greatly infiltrated the subjacent tissues. 110 SPECIFIC INFECTIOUS DISEASES. Histological Changes.—We owe largely to the labors of Wagner, Wei- gert, and more particularly to the splendid work of Oertel, our knowledge of the minute changes which take place in diphtheria. The following is a brief abstract of the views of the last-named author: The diphtheritic poison induces first a necrosis or death of cells with which it comes in contact, particularly the superficial epithelium and the leucocytes. The deeper cells of the mucosa and of the other parts reached by the poison may also be affected. The second change is hyaline trans- formation of the dead cells, or, as Weigert terms it, the production of co- agulation-necrosis. The bacilli excite inflammation with the migration of leucocytes, which are destroyed by the poison and undergo the hyaline change. The superficial epithelial layers undergo a similar alteration, and what we know as the false membrane represents in large part an aggrega- tion of dead cells, most of which have undergone the transformation into hyaline material, and have become much distorted in shape. Genuine fibrinous exudate is, however, associated with this coagulation-necrosis of cells. This is in all probability a conservative process by which, in a meas- ure, the poison is localized and prevented from reaching the deeper struc- tures. The laminated condition of the exudate is probably produced by the inflammation of different layers. The formation of these foci of necrobiosis, starting from the epithelium and proceeding inward, is, ac- cording to Oertel, the distinguishing characteristic of diphtheria. The action of the poison is by no means confined to the superficial mucosa on which the bacilli grow. Although they do not themselves pene- trate deeply, the contiguous bronchial glands show extensive foci of necrosis. In severe cases these necrotic areas are found in the internal organs, in the solitary glands of the intestines, and in the mesenteric glands. The blood-vessels may themselves be much altered and the capillaries may show extensive hyaline degeneration. Every one of the histological changes described by Oertel in human diphtheria may be paralleled in the experimental disease induced by the Klebs-Loeffler bacillus. Welch and Flexner have shown that similar foci of necrosis with nuclear fragmenta- tion in lymphatic glands, the liver, spleen, intestinal mucosa, and other parts, occur in the experimental diphtheria of guinea-pigs, and they have demonstrated that these necroses are due to the so-called tox-albumin of the diphtheria bacillus. The local exudate is caused by the bacilli them- selves and cannot be produced by the tox-albumin alone. The changes in the other organs are variable. When death has oc- curred from asphyxia there is general congestion of the viscera. Capillary bronchitis, areas of collapse, and patches of broncho-pneu- monia are almost constantly found in fatal cases. The broncho-pneumo- nia complicating diphtheria often contains the Klebs-Loeffler bacillus, but usually in combination with the streptococcus pyogenes or the diplococcus pneumoniae. These latter organisms, particularly the streptococcus, are DIPHTHERIA. the most frequent cause of the pulmonary complications of diphtheria. In very malignant cases the blood may be fluid. Fibrinous coagula may be found in the heart, but the wide-spread idea that they may cause sud- den death is erroneous. Myocardial changes are not infrequent, and in certain cases sudden death is due to heart-failure in consequence of degen- eration of the muscle-fibres. Endocarditis is extremely rare. It was not present in one of my thirty autopsies. The serous membranes often show ecchymoses. The kidneys present parenchymatous changes, such as are associated with acute febrile affections. There may, however, be acute nephritis. The spleen and liver show the usual febrile changes. The spleen is not always enlarged. General streptococcus septicaemia or lesions of internal organs due to localizations of the streptococcus pyo- genes are common and most dangerous complications of diphtheria. The Klebs-Loeffler bacillus may be found at autopsy in the blood and internal organs, but usually only in small number. Symptoms.—The period of incubation is “ from two to seven days, oftenest two.” The initial symptoms are those of an ordinary febrile attack—slight chilliness, fever, and aching pains in the back and limbs. In mild cases these symptoms are trifling, and the child may not feel ill enough to go to bed. Usually the temperature rises within the first twenty-four hours to 102-5° or 103° ; in severe cases to 104a. In young children there may be convulsions at the outset. Pharyngeal Diphtheria.—In a typical ease there is at first redness of the fauces, and the child complains of slight difficulty in swallowing. The membrane first appears upon the tonsils, and it may be a little diffi- cult to distinguish a patchy diphtheritic pellicle from the exudate of the tonsillar crypts. The pharyngeal mucous membrane is reddened, and the tonsils themselves are swollen. By the third day the membrane has covered the tonsils, the pillars of the fauces, and perhaps the uvula, which is thickened and cedematous, and may fill completely the space between the swollen tonsils. The membrane may extend to the posterior wall of the pharynx. At first grayish-white in color, it ehanges to a dirty gray, often to a yellow white. It is firmly adherent, and when removed leaves a bleeding, slightly eroded! surface, which is soon covered by fresh exudate. The glands in the neck are swollen, and may be tender. The general condition of a patient in a ease of moderate severity is usually good ; the temperature not very high in the absence of complications ranging from 102° to 103°. The pulse range is from 100 to 120. The local condition of the throat is not of great severity, and the constitutional depression is slight. The symptoms gradually abate, the swelling of the neck dimin- ishes, the membranes separate, and from the seventh to the tenth day the throat becomes clear and convalescence sets in. Clinically atypical forms are extremely common, and I follow here Koplik’s division: 112 SPECIFIC INFECTIOUS DISEASES. («) There may be no local manifestation of membrane, but a simple catarrhal angina associated sometimes with a croupy cough. The detec- tion in these cases of the Klebs-Loeffler bacillus can alone determine the diagnosis. Such cases are of great moment, inasmuch as they may com- municate the severer disease to other children. (b) There are cases in which the tonsils are covered by a pultaceous exudate, not a consistent membrane. (c) Cases presenting a punctate form of membrane, isolated, and usually on the surface of the tonsils. (d) Cases which begin and often run their entire course with the local picture of a typical lacunar amygdalitis. They may be mild, and the local exudate may not extend, but in other cases there are rapid develop- ment of membrane, and extension of the disease to the pharynx and the nose, with severe septic and constitutional symptoms. (e) Under the term “latent diphtheria” Heubner has described cases, usually secondary, occurring chiefly in hospital practice, in young persons the subject of wasting affections, such as rickets and tuberculosis. There are fever, naso-pharyngeal catarrh, and gastro-intestinal disturbances. Diphtheria may not be suspected until severe laryngeal complications develop, or the condition may not be determined until post mortem. Systemic Infection.—The constitutional disturbance in mild diphtheria is very slight. There are instances, too, of extensive local disease without grave systemic symptoms. As a rule, the general features of a case bear a definite relation to the severity of the local disease. There are rare instances in which from the outset the constitutional prostration is ex- treme, the pulse frequent and small, the fever high, and the nervous phenomena pronounced; the patient may sink in two or three days overwhelmed by the intensity of the toxaemia. There are cases of this sort in which the exudation of the throat may be slight, but usually the nasal symptoms are pronounced. The temperature may be very slightly raised or even subnormal. More commonly the severe systemic symp- toms appear at a later date when the pharyngeal lesion is at its height. They are constantly present in extensive disease, and when there is a sloughing, foetid condition. The lymphatic glands become greatly en- larged ; the pallor is extreme; the face has an ashen-gray hue; the pulse is rapid and feeble, and the temperature sinks below normal. In the most aggravated forms there are gangrenous processes in the throat, and in rare instances, when life is prolonged, extensive sloughing of the tis- sues of the neck. Escherich accounts for the discrepancy sometimes observed between the severity of the constitutional disturbance and the intensity of the local process, by assuming varying degrees of susceptibility to the diph- theria bacillus on the one hand, and to its poison on the other hand. With high local susceptibility of a part to the action of the bacillus, with little general susceptibility to the toxine, there is extensive local exudate DIPHTHERIA. 113 with mild constitutional symptoms, or vice versa, severe systemic disturb- ance with limited local inflammation. A leucocytosis is present in diphtheria. Morse does not think it of any prognostic value, since it is present and may be pronounced in mild cases. Nasal Diphtheria.—In cases of pharyngeal diphtheria the Klebs-Loef- fler bacillus is found oil the mucous membrane of the nose and in the secretions, even when no membrane is present, but it may apparently produce two affections similar enough locally but widely differing in their general features. In membranous or fibrinous rhinitis, a very remarkable affection seen usually in children, the nares are occupied by thick membranes, but there is an entire absence of any constitutional disturbance. The condition has been studied very carefully by Park, Abbott, Gerber and Podack, and others. Ravenel has collected seventy-seven cases (Medical News, 1895, I), in forty-one of which a bacteriological examination wras made, and in thirty-three the Klebs-Loeffler bacillus was present. All the cases ran a benign course, and in all but a few the membrane was limited to the nose, and the constitutional symptoms were either absent or very slight. Remarkable and puzzling features are that the disease runs a benign course, and that infection of other children in the family is ex- tremely rare. On the other hand, nasal diphtheria is apt to present a most malignant type of the disease. The infection may be primary in the nose, and in a case recently in my wards there was otitis media, and the Klebs-Loeffler bacillus was separated from the discharge before the condition of nasal diphtheria was suspected. While some cases are of mild character, others are very intense, and the constitutional symptoms most profound. The glandular inflammation is usually very intense, due, as Jacobi points out, to the great richness of the nasal mucosa in lymphatics. From the nose the inflammation may extend through the tear-ducts to the conjunctiva and into the antra. Laryngeal Diphtheria.—Membranous Croup.—With a very large pro- portion of all the cases of membranous laryngitis the Klebs-Loeffler bacillus is associated ; in a much smaller number other organisms, particu- larly the streptococcus, are found. Membranous croup, then, may be said to be either genuine diphtheria or diphtheroid in character. Of 286 cases in which the disease was confined to the larynx or bronchi, in 229 the Klebs-Loeffler bacilli were found. In 57 they were not present, but 17 of these cultures were unsatisfactory (Park and Beebe). The strepto- coccus cases are more likely to be secondary to other acute diseases. Symptoms.—Naturally, the clinical symptoms are almost identical in the non-specific and specific forms of membranous laryngitis. The affection begins like an acute laryngitis with slight hoarseness and rough cough, to which the term croupy has been applied. After these symptoms have lasted for a day or two with varying intensity, the child 114 SPECIFIC INFECTIOUS DISEASES. suddenly becomes worse, usually at night, and there are signs of impeded respiration. At first the difficulty in breathing is paroxysmal, due proba- bly to more or less spasm of the muscles of the glottis. Soon the dyspnoea becomes continuous, inspiration and expiration become difficult, particularly the latter, and with the inspiratory movements the epigastrium and lower intercostal spaces are retracted. The voice is husky and may be reduced to a whisper. The color gradually changes and the imperfect aeration of the blood is shown in the lividity of the lips and finger-tips. Restlessness comes on and the child tosses from side to side, vainly trying to get breath. Occasionally, in a severer paroxysm, portions of membrane are coughed out. The fever in membranous laryngitis is rarely very high and the condition of the child is usually very good at the time of the onset. The pulse is always increased in frequency and if cyanosis be present is small. In fav- orable cases the dyspnoea is not very urgent, the color of the face remains good, and after one or two paroxysms the child goes to sleep and wakes in the morning, perhaps without fever and feeling comfortable. The attack may recur the following night with greater severity. In unfavorable cases the dyspnoea becomes more and more urgent, the cyanosis deepens, the child, after a period of intense restlessness, sinks into a semi-comatose state, and death finally occurs from poisoning of the nerve centres by car- bon dioxide. In other cases the onset is less sudden and is preceded by a longer period of indisposition. As a rule, there are pharyngeal symptoms. The constitutional disturbance may be more severe, the fever higher, and there may be swelling of the glands of the neck. Inspection of the fauces may show the presence of false membranes on the pillars or on the tonsils. Bacteriological examination can alone determine whether these are due to the Klebs-Loeffler bacillus or to the streptococcus. Fagge held that non- contagious membranous croup may spread upward from the larynx just as diphtheritic inflammation is in the habit of spreading downward from the fauces. Ware, of Boston, whose essay on croup is perhaps the most solid contribution to the subject made in this country, reported the presence of exudate in the fauces in 74 out of 75 cases of croup. These observations were made prior to 1840, during periods in which diphtheria was not epidemic to any extent in Boston. In protracted cases pulmonary symp- toms may develop, which are sometimes due to the difficulty in expelling the muco-pus from the tubes; in others, the false membrane extends into the trachea and even into the bronchial tubes. During the paroxysm the vesicular murmur is scarcely audible, but the laryngeal stridor may be loudly communicated along the bronchial tubes. Diphtheria of Other Parts.—Primary diphtheria occurs occasionally in the conjunctiva. It follows in some instances the affection of the nasal mucous membrane. Some of the cases are severe and serious, but it has been shown by C. Frankel and others that the diphtheria bacilli may be present in a conjunctivitis catarrhal in character, or associated with only slight croupous deposits. DIPHTHERIA. 115 Diphtheria of the external auditory meatus is seen in rare instances in which there are diphtheritic otitis media and extension through the tympanic membrane. Diphtheria of the shin is most frequently seen in the severer forms of pharyngeal diphtheria, in which the membrane extends to the mouth and lips, and invades the adjacent portions of the skin of the face. The skin about the anus and genitals may also be attacked. Pseudo-membranous inflammation is not uncommon on ulcerated surfaces and wounds. In very many of these cases it is a streptococcus infection, but in a majority, perhaps, in which the patient is suffering with diphtheria, the Klebs-Loef- fler bacillus will be found in the fibrinous exudate. As proposed by Welch, the term “ wound diphtheria ” should be limited to infection of a wound by the Klebs-Loeffler bacillus. This “ may manifest itself as a simple inflammation, or inflammation with superficial necrosis, or inflammation with more or less adherent pseudo-membrane. The conditions as regards varying intensity and character of the infection, association with other bacteria, particularly streptococci, and the necessity of a bacteriological examination to establish the diagnosis, are in no way different in the diphtheria of wounds from those in diphtheria of mucous membranes. Wound diphtheria may occur without demonstrable connection with cases of diphtheria and without affection of the throat in the individual at- tacked, but such occurrences are rare” (Welch). Paralysis may follow wound diphtheria. Pseudo-membranous inflammations of w'ounds are caused more frequently by other micro-organisms, particularly the strep- tococci pyogenes, than by the Klebs-Loeffler bacillus. The fibrinous membrane so common in the neighborhood of the tracheotomy wound in diphtheria is rarely associated with the Klebs-Loeffler bacillus. Complications and Sequelae.—Of local complications, haemor- rhage from the nose or throat may occur in the severe ulcerative cases. Skin rashes are not infrequent, particularly the diffuse erythema. Occa- sionally there is urticaria and in the severe cases purpura. The pulmonary complications are extremely important. Fatal cases almost invariably show capillary bronchitis with broncho-pneumonia and large patches of collapse. In very bad cases, with extensive sloughing, the septic particles may reach the bronchi and excite gangrenous processes which may lead to severe and fatal haemorrhage. Penal complications are common. Albuminuria is present in all severe cases. It may cause with the usual tests only a slight turbidity of the urine, the ordinary febrile albuminuria. In others there is a large amount of albumin, curdy in character. It is only when the albumin is in considerable quantity and associated with epithelial or blood casts that the condition indicates parenchymatous nephritis and is alarming. The nephritis may be quite early in the disease. It sets in occasionally with complete suppression of the urine. In comparison with scarlet fever the renal changes lead less frequently to general dropsy. Mention has already 116 SPECIFIC INFECTIOUS DISEASES. been made of the frequency and gravity of septicaemia and local infection of internal parts due to invasion of the streptococcus pyogenes, which is nearly a constant attendant of the Klebs-Loeffler bacillus in the human body. Of the sequelae of diphtheria, paralysis is by far the most important. This can be experimentally produced in animals, as already noted, by the inoculation of the toxic material produced by the bacilli. The paralysis occurs in a variable proportion of the cases, ranging from 10 to 15 and even to 20 per cent. It is strictly a sequel of the disease, coming on usu- ally in the second or third week of convalescence. Occasionally it comes as early as the seventh or eighth day of the disease. It may follow very mild cases; indeed, the local disease may be so trifling that the onset of the paralysis alone calls attention to the true nature of the trouble. It is proportionately less frequent in children than in adults. The disease is a toxic neuritis, due to the absorption of the poison, and, like other forms of multiple neuritis, has an extremely complex symp- tomatology, according to the nerves which are affected. The paralysis may be local or general. Of the local paralyses the most common is that which affects the pal- ate. This gives a nasal character to the voice, and, owing to a return of liquids through the nose, causes a difficulty in swallowing. These may be the only symptoms. The palate is seen to be relaxed and motionless, and the sensation in it is also much impaired. The affection may extend to the constrictors of the pharynx, and deglutition become embarrassed. Within two or three weeks or even a shorter time the paralysis disappears. In many cases the affection of the palate is only part of a general neuritis. Of other local forms perhaps the most common are paralysis of the eye- muscles, intrinsic and extrinsic. There may be strabismus, ptosis, and loss of power of accommodation. Facial paralysis may develop. The neuritis may be confined to the nerves of one limb, though more commonly the legs or the arms are affected together. Very often with the palatal paral- ysis is associated a weakness of the legs without definite palsy but with loss of the knee-jerk. Heart symptoms are not uncommon. There may be great retardation, even to thirty beats in the minute. Bradycardia and tachycardia may alternate in the same patient. Heart-failure and fatal syncope may occur at the height of the disease or during convalescence. If they occur during the fever, the child, perhaps after an exaggeration of symptoms, presents an unusual pallor. The pulse becomes weak and rapid, but may fall to fifty, forty, or even lower. The extremities are cold, the temperature sinks, and death takes place, with all the features of collapse, within a few hours. More frequently the fatal collapse comes during convalescence, even as late as the sixth or seventh week after apparent recovery. The attack may set in abruptly, perhaps following a sudden exertion. More com- monly there have been symptoms pointing to disturbed cardiac rhythm, DIPIITIIEKIxV. 117 or even fainting-spells. In some instances vomiting has preceded the serious cardiac attack. There may be no physical signs other than slight increase in the cardiac dulness and a gallop-rhythm indicating dilatation. These symptoms were formerly ascribed to cardiac thrombosis or to endo- carditis. Possibly in some of the cases the result is due, as pointed out by Mosler and Leyden, to an infectious myocarditis, but in a majority of the cases the symptoms are probably due to a neuritis of the cardiac nerves. The multiple form of diphtheritic neuritis is not uncommon. It may begin with the palatal affection, or with loss of power of accommodation and loss of the tendon reflexes. This last is an important sign, which, as Bernhardt, Buzzard, and K. L. MacDonnell have shown, may occur early, but is not necessarily followed by other symptoms of neuritis. There is paraplegia, which may be complete or involve only the extensors of the feet. The paralysis may extend and involve the arms and face and render the patient entirely helpless. The muscles of respiration may be spared. The chief danger in these severer forms comes from the involvement of the heart and of the muscles of respiration; but the outlook is in many cases not so bad as the patient’s condition would indicate. Of thirteen cases collected by Cadet de Gassicourt six died. The sphincters may be involved, though they are often spared. Diagnosis.—The presence of the Klebs-Loeffler bacillus is regarded by bacteriologists as the sole criterion of true diphtheria, and as this or- ganism may be associated with all grades of throat affections, from a simple catarrh to a sloughing, gangrenous process, it is evident that in many instances there will be a striking discrepancy between the clinical and the bacteriological diagnosis. One inestimable value of the recent studies has been the determination of the diphtherial character of many of the milder forms of tonsillitis and pharyngitis. The bacteriological diagnosis is simple. The plan adopted by the New York Health Department is a model which may be followed with advantage in other cities. Outfits for making cultures, consisting of a box containing a tube of blood-serum and a sterilized swab in a test-tube, are distributed to about forty stations at convenient points in the city. A list of these places is published, and a physician can obtain the outfit free of cost. The directions are as follows: “ The patient should be placed in a good light, and, if a child, properly held. In cases where it is possible to get a good view of the throat, depress the tongue and rub the cotton swab gently but freely against any visible exudate. In other cases, including those in which the exudate is confined to the larynx, avoiding the tongue, pass the swab far back and rub it freely against the mucous membrane of the pharynx and tonsils. Without laying the swab down, withdraw the cotton plug from the culture-tube, insert the swab, and rub that portion of it which has touched the exudate gently but thoroughly all over the surface of the blood-serum. Do not push the 118 SPECIFIC INFECTIOUS DISEASES. swab into tlie blood-serum, nor break the surface in any way. Then re- place the swab in its own tube, plug both tubes, put them in the box, and return the culture outfit at once to the station from which it was ob- tained.” The culture-tubes which have been inoculated are kept in an incubator at 37° C. for twelve hours and are then ready for examination. Some prefer a method by which the material from the throat collected on a sterile swab, or, as recommended by von Esmarch, on small pieces of sterilized sponge, is sent to the laboratory where the cultures and micro- scopical examination are made by a bacteriologist. An immediate diagnosis without the use of cultures is often possible by making a smear preparation of the exudate from the throat. The Klebs-Loeffler bacilli may be present in sufficient numbers, and may be quite characteristic to an expert. In this connection may be given the following statement by Park, who has had such an exceptional experi- ence : “ The examination by a competent bacteriologist of the bacterial growth in a blood-serum tube which has been properly inoculated and kept for fourteen hours at the body temperature can be thoroughly relied upon in cases where there is visible membrane in the throat, if the culture is made during the period in which the membrane is forming, and no antiseptic, especially no mercurial solution, has lately been applied. In cases in which the disease is confined to the larynx or bronchi, surpris- ingly accurate results can be obtained from cultures, but in a certain pro- portion of cases no diphtheria bacilli will be found in the first culture, and yet will be abundantly present in later cultures. We believe, there- fore, that absolute reliance for a diagnosis cannot be placed upon a single culture from the pharynx in purely laryngeal cases.” Where a bacteriological examination cannot be made, the practitioner must regard as suspicious all forms of throat affections in children, and carry out measures of isolation and disinfection. In this way alone can serious errors be avoided. It is not, of course, in the severer forms of membranous angina that mistake is likely to occur, but in the various lighter forms, many of which are in reality due to the Klebs-Loeffler bacillus. A large proportion of the cases of diphtheroid inflammation of the throat are due to the streptococcus pyogenes. They are usually milder, and the liability to general infection is less intense; still, in scarlet fever and other specific fevers some of the most virulent cases of throat disease which we see, with intense systemic infection, are caused by this micro- organism. These streptococcus cases are probably much less numerous than the figures which I have given would indicate. The more careful examinations in the diphtheria pavilions of hospitals, particularly in Europe, have shown that in the large majority of cases admitted the Klebs-Loeffler bacillus is present. I have already referred, under the sec- tion on scarlet fever, to the question of the diagnosis between scarlet fever with severe angina and diphtheria. DIPHTHERIA. 119 Prognosis.—In hospital practice the disease is very fatal, the per- centage of deaths ranging from thirty to fifty. This is due in great part to the admission only of the severer forms. In country places the disease may display an appalling virulence. In cases of ordinary severity the out- look is usually good. Death results from involvement of the larynx, sep- tic infection, sudden heart-failure, diphtheritic paralysis, occasionally from uraemia, and sometimes from broncho-pneumonia developing during convalescence. Prophylaxis.—Isolation of the sick, disinfection of the clothing and of everything that has come in contact with the patient, careful scru- tiny of the milder cases of throat disorder, and more stringent surveillance in the period of convalescence are the essential measures to prevent the spread of the disease. Suspected cases in families or schools should be at once isolated or removed to a hospital for infectious disorders. When a death has occurred from diphtheria, the body should be wrapped in a sheet which has been soaked in a corrosive-sublimate solution (1 to 3,000), and placed in a closely sealed coffin. The funeral should always be private. In cases of well-marked diphtheria these precautions are usually car- ried out, but the chief danger is from the milder cases, particularly the ambulatory form, in which the disease has perhaps not been suspected. Mixing with susceptible children the disease is thus conveyed. The healthy children in a family in which diphtheria exists may carry the dis- ease to their school-fellows. A striking illustration of the way in which diphtheria is spread is given by Park and Beebe: “ The child of a man who kept a candy store developed diphtheria; there were four other chil- dren in the family, and these were in no way isolated from the sick, yet none of them developed diphtheria; but children who bought candy at the store, and other children coming in contact with these in school, developed diphtheria. The secondary cases ceased to develop so soon as the candy store had been closed.” A very important matter in the prophylaxis relates to the period of convalescence. It has been shown by numerous observations that, after all the membrane has cleared away, virulent bacilli may persist in the throat from periods ranging from six weeks to six months, or even longer. There is evidence to show that the disease may be communicated by such cases, so that isolation should be continued in any given case until the bacteriological examination shows that the throat is free. It .cannot be too strongly emphasized that the important elements in the prophylaxis of diphtheria are the rigid scrutiny of the milder types of throat affection, and the thorough isolation and disinfection of the individual patients. Careful attention should be given to the throats and mouths of chil- dren, particularly to the teeth and tonsils, as Caille has urged. Swollen and enlarged tonsils should be removed. In persons exposed, the anti- 120 SPECIFIC INFECTIOUS DISEASES. septic mouth washes, such as corrosive sublimate (1 to 10,000), chlorine water (1 to 1,100), or swabbing the throat with a diluted Loeffler’s solu- tion, should be employed. Treatment.—The important points are hygienic measures to pre- vent the spread of the malady, local treatment of the throat to destroy the bacilli, medication, general or specific, to counteract the effects of the toxines, and, lastly, to treat the complications and sequelae. (a) Hygienic Measures.—The patient should be in a room from which the carpets, curtains, and superfluous furniture have been removed. The temperature should be about 68°, and thorough ventilation should be secured. The air may be kept moist by a kettle or a steam-atomizer. If possible, only the nurse, the child’s mother, and the doctor should come in contact with the patient. During the visit the physician should wear a linen overall, and on leaving the room he should thoroughly wash his hands and face in a corrosive-sublimate solution. The strictest quaran- tine should be employed against other members in the house. (b) Local Treatment.—In mild cases the throat symptoms are alone prominent. Vigorous local treatment from the outset should be carried out, taking especial care in all instances to avoid mechanical injury to the tissues. A very large number of solutions have been recommended. They are best employed with a swab of cotton-wool or a soft sponge, or irrigation may be employed with hot antiseptic solutions. The direct application with a swab of cotton-wool or spongev is, as a rule, effect- ive. In many young children it is really a most trying procedure to carry out the treatment, and sometimes one is compelled to desist. The nurse should hold the child on her knees, well wrapped in a shawl, with its head resting on her shoulder. The nose is then held, and so soon as the child opens its mouth a cork should be placed between the molar teeth. The local application can then be made, or thorough irri- gation carried out. In infants the disinfecting fluids are sometimes better applied through the nostrils. The following solutions may be employed : Loeffler’s solution: Menthol, 10 grammes dissolved in toluol to 36 c. c. Liq. Ferri sesquichlorati, 4 c. c. ; alcohol absol., 60 c. c. Corrosive sublimate, 1 to 1,000, either alone or with tartaric acid, five grammes to the litre. Carbolic acid, 3 per cent in 30 per cent alcohol solution, is much employed; some prefer to touch the small spots of exudate with pure carbolic acid. Other solution is: The tincture of the perchloride of iron, a drachm and a half, in glycerine, one ounce, water one ounce, with from 15 to 20 minims of carbolic acid. Chlorine water, boric acid, peroxide of hydro- gen, iodoform, lactic acid, trypsin, and papain are also recommended. Loeffler’s solution, which has recently been given a very thorough trial, is perhaps the most satisfactory. DIPHTHERIA. 121 Nasal diphtheria requires prompt and thorough disinfection of the passages. Jacobi recommends chloride of sodium, saturated boric acid, or one part of bichloride of mercury, thirty-five of chloride of sodium, and one thousand of water, or the one-per-cent solution of carbolic acid. Loeffler’s solution may be used. It may be applied with a syringe or a spray. To be effectual the injection must be properly given. The nurse should be instructed to pass the nozzle of the syringe horizontally, not vertically; otherwise the fluid will return through the same nostril. When the larynx becomes involved, a steam tent may be arranged upon the bed, so that the child may breathe an atmosphere saturated with moisture. If the dyspnoea becomes urgent, an emetic of sulphide of zinc or ipecacuanha may be given. When the signs of obstruction are marked there should be no delay in the performance of intubation or tracheotomy. Hot applications to the neck are usually very grateful, particularly to young children, though in the case of older children and adults the ice poultices are to be preferred. (c) General Measures.—The food should be liquid—milk, beef juices, barley water, albumen water, and soups. The child should be encouraged to drink water freely. When the pharyngeal involvement is very great and swallowing painful, nutritive enemata should be used. In cases with severe constitutional symptoms stimulants should be given early. Medicines given internally are of very little avail in the disease. There is still a wide-spread belief in the profession that forms of mercury are beneficial. The tincture of the perchloride of iron is also very warmly recommended. We are still, however, without remedies which can directly counteract the tox-albumins of this disease, and we must rely on general measures of feeding and stimulants to support the strength. The convalescence of the disease is not without its dangers, and pa- tients should be very carefully watched, particularly if there are signs of heart weakness. The diphtheritic paralysis requires rest in bed, and in those cases in which the heart rhythm is disturbed the avoidance of sudden exertion. In the chronic forms with wasting, massage, electricity, and strychnine are invaluable aids. If swallowing becomes very difficult, the patient must be fed with the stomach-tube, which is very much preferable to feeding per rectum. (cl) Antitoxine Treatment.—As above mentioned, animals may be ren- dered immune against diphtheria, and the blood of an animal so treated when introduced into another animal protects it from infection with the bacilli of the disease. The observations of Behring, Roux, and others have shown that the use of the blood-serum of animals rendered arti- ficially immune against diphtheria has an important healing influence upon diphtheria spontaneously acquired in man. In preparing the blood- serum it is very desirable, of course, to have a uniform standard of strength. 122 SPECIFIC INFECTIOUS DISEASES. One tenth of one cubic centimetre of what Behring calls his normal serum will counteract ten times the minimum of diphtheria poison fatal for a guinea-pig weighing 300 grammes. One cubic centimetre of this normal serum he calls an antitoxine unit. The serum prepared by his method comes labelled in three strengths: No. 1 is sixty times the strength of the normal serum ; No. 2 is one hundred times as strong; and No. 3 is one hundred and forty times as strong. As a rule, in ordinary cases a flask of the No. 1 serum of Behring, containing sixty antitoxine units, is first used. The injection may be made into the skin of the side of the buttock or flank. On the following day, if the condition has not improved, a flask of the No. 2 serum should be used. If the case is very severe or not seen until late, it is best to use the stronger No. 3 solution at once. A large number of preparations are now on the market, and some caution has to be exercised by the practitioner as to the serum which he employs. In favorable cases the effects of the serum are seen in a marked amel- ioration of both the local and general symptoms. Within twenty-four hours the swelling of the fauces subsides and the membrane begins to dis- appear. At the same time the temperature falls, the pulse becomes slower, and the general condition of the patient improves in every way. In cases of moderate severity, when the injections are employed early, the improve- ment in both the throat and constitutional symptoms is certainly very striking. The earlier the cases come under treatment the better are the results. There are cases, however, of great severity, in which the anti- toxine has been employed early and yet has not saved life. Among the untoward effects of the treatment may be the development of a local abscess, which, however, is rare, diffuse erythema and urticaria, and albuminuria. None of these are serious, and the evidence is not con- clusive that the incidence of albuminuria is greater in the cases treated with antitoxine. The beneficial effects of the treatment are seen in the great reduction of the mortality from the disease. The following figures may be quoted in illustration: The mortality in Berlin during 1894 was 39 per cent; after the introduction of the antitoxine treatment, in 1,390 cases the mor- tality was only 21 per cent. The figures from Baginsky’s clinic in Berlin are still more confirma- tive. In the four years preceding the introduction of the antitoxine treat- ment the average mortality had been 41*1 per cent. In 525 cases corre- sponding to the period during which the antitoxine was employed the mortality was only 15-81 per cent. The figures given at the Congress for Internal Medicine at Munich in 1895 were on the whole very favorable. At the Boston City Hospital 305 cases were treated with seventy-nine deaths—a mortality of 25-9 per cent. The mortality for the same period last year was 44-5 per cent. ERYSIPELAS. 123 A very much larger number of cases must be treated over a long period before final judgment can be reached ; meanwhile the treatment should be adopted in the cases of true diphtheria. The question of immunizing those exposed to the disease is a very practical one. It has been carried out on a large scale in some institu- tions with satisfactory results. An injection of the No. 1 Behring is given, and if thought proper repeated in a few days. The immunity ap- pears to be transient, only persisting for a few weeks. XVI. ERYSIPELAS. Definition.—An acute, contagious disease, characterized by a special inflammation of the skin caused by streptococci. Etiology.—Erysipelas is a wide-spread affection, endemic in most communities, and at certain seasons epidemic. We are as yet ignorant of the atmospheric or telluric influences which favor the diffusion of the poison. It is particularly prevalent in the spring of the year. Of 2,012 cases collected by Anders, 1,214 occurred during the first five months of the year. April had the largest number of cases. The affection prevails extensively in old, ill-ventilated hospitals and institutions in which the sanitary conditions are defective. With the improved sanitation of late years the number of cases has materially diminished. It has been ob- served, however, to break out in new institutions under the most favorable hygienic circumstances. Erysipelas is both contagious and inoculable ; but, except under special conditions, the poison is not very virulent and does not seem to act at any great distance. It can be conveyed by a third person. The poison certainly attaches itself to the furniture, bedding, and walls of rooms in which patients have been confined. The disposition to the disease is wide-spread, but the susceptibility is specially marked in the case of individuals with wounds or abrasions of any sort. Recently delivered women and persons who have been the sub- ject of surgical operations are. particularly prone to it. A wound, how- ever, is not necessary, and in the so-called idiopathic form, although it may be difficult to say that there was not a slight abrasion about the nose or lips, in very many cases there certainly is no observable external lesion. Chronic alcoholism, debility, and Bright’s disease are predisposing agents. Certain persons show a special susceptibility to the disease, and it may recur in them repeatedly. There are instances, too, of a family predisposition to the disease. The specific agent of the disease is the streptococcus pyogenes, with which the streptococcus erysipelatos appears to be identical. The fever and constitutional symptoms are due in great part to the toxins; the more serious visceral complications are the result of secondary infection. 124 SPECIFIC INFECTIOUS DISEASES. Morbid Anatomy.—Erysipelas is a simple inflammation. In its uncomplicated forms there is seen, post mortem, little else than inflamma- tory oedema. Investigations have shown that the cocci are found chiefly in the lymph-spaces and most abundantly in the zone of spreading inflam- mation. In the uninvolved tissue beyond the inflamed margin the mi- crococci are to be found in the lymph-vessels, and it is here, according to Metschnikoff and others, that an active warfare goes on between the leuco- cytes and the cocci (phagocytosis). In more extensive and virulent forms of the disease there is usually suppuration. It is stated that the inflam- mation may pass inward from the scalp through the skull to the meninges. This I have never seen, but in one case I traced the extension from the face along the fifth nerve to the meninges, where an acute meningitis and thrombosis of the lateral sinus were excited. The visceral complications of erysipelas are numerous and important. The majority of them are of a septic nature. Infarcts occur in the lungs, spleen, and kidneys, and there may be the general evidences of pyaemic infection. Some of the worst cases of malignant endocarditis are secondary to erysipelas; thus, of twenty-three cases, three occurred in connection with this disease. Septic pericarditis and pleuritis also occur. As just mentioned, the disease may in rare cases extend and involve the meninges. Pneumonia is not a very common complication. Acute nephritis is also met with; it is often ingrafted upon an old chronic trouble. Symptoms.—The following description applies specially to erysipelas of the face and head, the form of the disease which the physician is most commonly called upon to treat. The incubation is variable, probably from three to seven days. The stage of invasion is often marked by a rigor, and followed by a rapid rise in the temperature and all the characters of an acute fever. When there is a local abrasion, the spot is slightly reddened ; but if it is idiopathic, there is seen within a few hours slight redness over the bridge of the nose and on the cheeks. The swelling and tension of the skin increase and within twenty-four hours the external symptoms are well marked. The skin is smooth, tense, and cedeinatous. It looks red, feels hot, and the superficial layers of the epidermis may be lifted as small blebs. The patient complains of an unpleasant feeling of tension in the skin; the swelling rapidly increases; and during the second day the eyes are usually closed. The first-affected parts gradually become pale and less swollen as the disease extends at the periphery. When it reaches the forehead it progresses as an advancing ridge, perfectly well defined and raised; and often, on palpation, hardened extensions can be felt beneath the skin which is not yet reddened. Even in a case of moderate severity, the face is enormously swollen, the eyes are closed, the lids greatly mdematous, the ears thickened, the scalp is swollen, and the patient’s ERYSIPELAS. 125 features are quite unrecognizable. The formation of blebs is common on the eyelids, ears, and forehead. The cervical lymph-glands are swollen, but are usually masked in the oedema of the neck. The temperature keeps high without marked remissions for four or five days and then deferves- cence takes place by crisis. Leucocytosis is present. The general condi- tion of the patient varies much with his previous condition of health. In old and debilitated persons, particularly in those addicted to alcohol, the constitutional depression from the outset may be very great. Delirium is present, the tongue becomes dry, the pulse feeble, and there is marked tendency to death from toxaemia. In the majority of cases, however, even with extensive disease, the constitutional disturbance, considering the height of the fever range, is slight. The mucous membrane of the mouth and throat may be swollen and reddened. The erysipelatous inflammation may extend to the larynx, but the severe oedema of this part occasionally met with is commonly due to the extension of the inflammation from without inward. There are cases in which the inflammation extends from the face to the neck, and over the chest, and may gradually migrate or wander over the greater part of the body (E. migrans). The close relation between the erysipelas coccus and the pus organisms is shown by the frequency with which suppuration occurs in facial ery- sipelas. Small cutaneous abscesses are common about the cheeks and forehead and neck, and beneath the scalp large collections of pus may accumulate. Suppuration seems to occur more frequently in some epi- demics than in others, and at the Philadelphia Hospital one year nearly all the cases in the erysipelas wards presented local abscesses. Complications.—Meningitis is rare. The cases in which death occurs with marked brain symptoms do not usually show, post mortem, meningeal affection. The delirium and coma are due to the fever, or to toxaemia. Pneumonia is an occasional complication. Ulcerative endocarditis and septicaemia are more common. Albuminuria is almost constant, particularly in persons over fifty. True nephritis is occasionally seen. Da Costa has called attention to curious irregular returns of the fever which occur during convalescence without any aggravation of the local condition. The diagnosis rarely presents any difficulty. The mode of onset, the rapid rise in fever, and the characters of the local disease are quite dis- tinctive. Acute necrosis of bone may sometimes be regarded as erysipelas, a mistake which I once saw made in connection with the lower end of the femur. Prognosis.—Healthy adults rarely die. The general mortality in hospitals is about 7 per cent, in private practice about 4 per cent (Anders). In the new-born, when the disease attacks the navel, it is almost always fatal. In drunkards and in the aged erysipelas is a seri- 126 SPECIFIC INFECTIOUS DISEASES. ous affection, and death may result either from the intensity of the fever or, more commonly, from toxasmia. The wandering or ambulatory erysipelas, which has a more protracted course, may cause death from exhaustion. Treatment.—Isolation should be strictly carried out, particularly in hospitals. A practitioner in attendance upon a case of erysipelas should not attend cases of confinement. The disease is self-limited and a large majority of the cases get well without any internal medication. I can speak definitely on this point, having, at the Philadelphia Hospital, treated many cases in this way. The diet should be nutritious and light. Stimulants are not required except in the old and feeble. For the restlessness, delirium, and insomnia, chloral or the bromides may be given ; or, if these fail, opium. When fever is high the patient may be bathed or sponged, or, in private practice, if there is an objection to this, antipyrin or antifebrin may be given. Of internal remedies believed to influence the disease, the tincture of the perchloride of iron has been highly recommended. At the Montreal General Hospital this wras the routine treatment, and doses of half a drachm to a drachm were given every three or four hours. I am by no means convinced that it has any special action; nor, so far as I know, has any medicine, given internally, a definite control over the course of the disease. Of local treatment, the injection of antiseptic solutions at the margin of the spreading areas has been much practised. Two-per-cent solutions of carbolic acid, the corrosive sublimate and the biniodide of mercury have been much used. The injection should be made not into but just a little beyond the border of the inflamed patch. F. P. Henry has treated a large number of cases at the Philadelphia Hospital with the latter drug, and this mode of practice is certainly most rational. Of local applications, ichthyol is at present much used. The inflamed region may be covered with salicylate of starch. Perhaps as good an ap- plication as any is cold water, which was highly recommended by Hip- pocrates. XVII. SEPTICEMIA AND PYEMIA. In these days of asepsis physicians see many more cases of septicaemia and pyaemia than do the surgeons. For one case in the post-mortem room with the anatomical diagnosis of septiccemia which comes from the surgical or gynaecological departments of the Johns Hopkins Hospital, at least fifteen or twenty come from my medical wards. Certain terms must first be defined. An infection is the morbid process induced by the invasion and growth in the body of pathogenic micro-organisms. An infection may be local, as in a boil, or general, as in some cases of anthrax. SEPTICAEMIA AND PYAEMIA. 127 An intoxication is the morbid condition caused by the absorption of the toxines, in large part derived from the pathogenic organisms. The term saprcemia is the equivalent of septic intoxication. A hard-and-fast line cannot be drawn between an infection and an intoxication, but agents of infection alone are capable of reproduction, whereas those of intoxication are chemical poisons produced by the agency of bacteria, or by vegetable and animal cells. Infectious diseases which are communicated directly from one person to another are termed con- tagious, and the infecting agent is sometimes spoken of as a contagium. “ Whether or not an infectious disease is contagious in the ordinary sense depends upon the nature of the infectious agent, and especially upon the manner of its elimination from and reception by the body. Most but not all contagious diseases are infectious. Scabies is a contagious disease, but it is not infectious” (Welch). There are three chief clinical types infection. 1. LOCAL INFECTIONS WITH THE DEVELOPMENT OF TOXINES. This is the common mode of invasion of many of the diseases which we have already considered. Erysipelas, diphtheria, pneumonia, tetanus, typhoid fever, and anthrax are diseases which have sites of local infection in which the pathogenic organisms develop; but the constitutional effects are caused by the absorption of the poisonous products. The diphtheria toxine produces all the general symptoms, the tetanus toxine every feature, of the disease without the presence of their respective bacilli. Certain of the symptoms following the absorption of the toxines are general to all; others are special and peculiar, according to the organism which produces them. A chill, fever, general malaise, prostration, rapid pulse, restless- ness, and headache are the most frequent. With but few exceptions the febrile disturbance is the most common feature. The most serious effects are seen upon the nervous system and upon the heart, and the gravity of the symptoms on the part of these organs is to some extent a measure of the intensity of the intoxication. The organisms of certain local infec- tions produce poisons which have special actions; thus the diphtheria toxine, besides having the effects already referred to, is especially prone to attack the nervous system and to cause peripheral neuritis. The tetanus toxine has a specific action on the motor neurons. 2. SEPTICAEMIA. Formerly, and in a surgical sense, the term “ septicaemia ” was used to designate the invasion of the blood and tissues of the body by the organ- isms of suppuration, but in the medical sense the term may be applied to any condition in which, with or without a local site of infection, there is microbic invasion of the blood and tissues, but in which there are no foci of suppuration. 128 SPECIFIC INFECTIOUS DISEASES. (a) Progressive Septicaemia from Local Infection.—The common strep- tococcus and staphylococcus infection is as a rule first local, and the toxines alone pass into the blood. In other instances the cocci appear in the blood and throughout the tissues, causing a wide-spread septicaemia which intensifies greatly the severity of the case. Other infections in which the bacterial invasion, local at first, may become general are pneu- monia, typhoid fever, anthrax, gonorrhcea, and puerperal fever. The clinical features of this form are well seen in the cases of puerpe- ral septicaemia or in dissection wounds, in which the course of the infec- tion may be traced along the lymphatics. The symptoms usually set in within twenty-four hours, and rarely later than the third or fourth day. There is a chill or chilliness, with moderate fever at first, which gradually rises and is marked by daily remissions and even intermissions. The pulse is small and compressible, and may reach 120 or higher. Gastro- intestinal disturbances are common, the tongue is red at the margin, and the dorsum is dry and dark. There may be early delirium'or marked mental prostration and apathy. As the disease progresses there may be pallor of the face or a yellowish tint. Capillary heemorrhages are not uncommon. The outlook is serious in streptococcus cases. Death may occur within twenty-four hours, and in fatal cases life is rarely prolonged for more than seven or eight days. On post-mortem examination there may be no focal lesions in the viscera, and the seat of infection may present only slight changes. The spleen is enlarged and soft, the blood may be extremely dark in color, and haemorrhages are common, particularly on the serous surfaces. Neither thrombi nor emboli are found. Many instances of septicaemia are combined infections; thus in diph- theria streptococcus septicaemia is a common, and the mo£t serious, event. The local disease and the symptoms produced by absorption of the tox- ines dominate the clinical picture; but the features are usually much aggravated by the systemic invasion. A similar infection may develop in typhoid fever and in tuberculosis, and may obscure the typical picture, leading to serious errors in diagnosis. The septicaemia is not always due to the streptococcus. (b) General Septicaemia without Recognizable Local Infection.— Cryp- togenetic Septiccemia.—This is a group of very great interest to the physician, the full importance of which we are only now beginning to recognize. The subjects when attacked may be in perfect health; more com- monly they are already weakened by acute or chronic illness. The patho- genic organisms are varied. The streptococcus pyogenes is the most com- mon ; the forms of staphylococcus more rare. Others capable of inducing it are the micrococcus lanceolatus (pneumococcus), the proteus, and the bacillus pyocyaneus. Between May 1, 1892, and June 1, 1895, there were sent to the post-mortem room from my wards 21 cases of general SEPTICAEMIA AND PYAEMIA. 129 infection, of which 13 were due to the streptococcus pyogenes, 2 to the staphylococcus pyogenes, and 6 to the pneumococcus. In 19 of these cases the patients were already the subjects of some other malady, which was aggravated, or in most instances terminated, by the general septicaemia. The symptoms vary somewhat with the character of the micro-organisms. In the streptococcus cases there may be chills with high, irregular fever, and a more characteristic septic state than in the pneumococcus infection. Most of these cases come correctly under the term “ cryptogenetic septi- caemia ” as employed by Leube, inasmuch as the local focus of infection is not evident during life, and may not he found after death. It is well to bear in mind that there are instances of this type of affection coming on in apparently healthy persons. The fever may be extremely irregular, characteristically septic, and persist for many weeks. Foci of suppuration may not develop, and may not be found even at autopsy. I have on sev- eral occasions met with cases of an intermittent pyrexia persisting for weeks, in which it seemed impossible to give any explanation of the phe- nomena, and cases which ultimately recovered, and in which tuberculosis and malaria oould be almost positively excluded. These cases require to be carefully studied bacteriologically. Dreschfeld has described them as idiopathic intermittent fever of pyaemic character. Local symptoms may be absent, though in three of his cases there was enlargement of the liver, and in two the condition was a diffuse suppurative hepatitis. 3. SEPTICO-PYAEMIA. The pathogenic micro-organisms which invade the blood and tissues may settle in certain foci and there cause suppuration. When mul- tiple abscesses are thus produced in connection with a general infection, the condition is known as pyaemia or, perhaps better, septico-pyaemia. There are no specific organisms of suppuration, and the condition of pyaemia may be produced by organisms other than the streptococci and staphylococci, though these are the most common. Other forms which may invade the system and cause foci of suppuration are the micrococcus lanceolatus, the gonococcus, the bacillus coli communis, the bacilli typhi abdominalis, the proteus, and the bacillus pyocyaneus, and very probably the bacillus aerogenes capsulatus. In a large proportion of all cases of pyaemia there is a focus of infection, either a suppurating external wound, an osteo-myelitis, a gonorrhoea, an otitis media, an empyaema, an area of suppuration in a lymph-gland or about the appendix. In a large majority of all these cases the common pus cocci are present. In a suppurating wound, for example, the pus organisms induce coagu- lation-necrosis in the smaller vessels with the production of thrombi and purulent phlebitis. The entrance of pus organisms in small numbers into the blood does not necessarily produce pyaemia. Commonly the transmission to various parts from the local focus takes place by the frag- ments of thrombi which pass as emboli to different parts, where, if the 130 SPECIFIC INFECTIOUS DISEASES. conditions are favorable, the pus organisms excite suppuration. A throm- bus which is not septic or contaminated, when dislodged and impacted in a distant vessel, produces only a simple infarction; but, coming from an infected source and containing pus microbes, an independent centre of infection is established wherever the embolus may lodge. These inde- pendent suppurative centres in pyaemia, known as embolic or metastatic abscesses, have the following distribution : (a) In external wounds, in osteo-myelitis, and in acute phlegmon of the skin, the embolic particles very frequently excite suppuration in the lungs, producing the well-known wedge-shaped pyaemie infarcts; but in some cases the infected particles pass through the lungs, and there are foci of inflammation in the heart and kidneys. (b) Suppurative foci in the territory of the portal system, particularly in the intestines, produce metastatic abscesses in the liver with or without suppurative pyle-phlebitis. Endocarditis is an event which is very liable to occur in all forms of septicaemia, and modifies materially the character of the clinical features. Streptococci and staphylococci are the most common organisms present in the vegetations, but the pneumococci, gonococci, tubercle bacilli, ty- phoid bacilli, anthrax bacilli, and other forms have been isolated. The vegetations which develop at the site of the valve lesion become covered with thrombi, particles of which may be dislodged and carried as emboli to different parts of the body, causing' multiple abscesses or infarcts. Symptoms of Septico-pyaemia.—In a case of wound infection, prior to the onset of the characteristic symptoms, there may be signs of local trouble, and, if a discharging wound, the pus may change in charac- ter. The onset of the disease is marked by a severe rigor, during which the temperature rises to 103° or 104° and is followed by a profuse sweat. These chills are repeated at intervals, either daily or every other day. In the intervals there may be slight pyrexia. The constitutional disturb- ance is marked and there are loss of appetite, nausea, and vomiting, and, as the disease progresses, rapid emaciation. Transient erythema is not uncommon. Local symptoms usually develop. If the lungs become in- volved there are dyspnoea and cough. The physical signs may be slight. Involvement of the pleura and pericardium is common. The tint of the skin is changed; at first pale and white, it subsequently becomes bile- tinged. The spleen is enlarged, and there may be intense pain in the side, pointing to perisplenitis from embolism. Usually in the rapid cases a typhoid state gradually develops, and the patient dies comatose. In the chronic cases the disease may be prolonged for months ; the chills recur at long intervals, the temperature is irregular, and the condi- tion of the patient varies from month to month. The course is usually slow and progressively downward. Diagnosis.—Pyaemia is a disease frequently overlooked and often mistaken for other affections. SEPTICAEMIA AND PYAEMIA. 131 Cases following a wound, an operation, or parturition are readily rec- ognized. On the other hand, the following conditions may be over- looked : Osteo-myelitis.—Here the lesion may be limited, the constitutional symptoms severe, and the course of the disease very rapid. The cause of the trouble may be discovered only post mortem. So, too, acute septico-pyaemia may follow gonorrhoea or a prostatic abscess. Cases are sometimes confounded with typhoid fever, particularly the more chronic instances, in which there are diarrhoea, great prostration, delirium, and irregular fever. The spleen, too, may be enlarged. The marked leucocytosis is an important differential point. In some of the instances of ulcerative endocarditis the diagnosis is very difficult, particularly in what is known as the typhoid, in contradis- tinction to the septic, type of this disease. In acute miliary tuberculosis the symptoms occasionally resemble those of septicaemia, more commonly those of typhoid fever. The post-febrile arthritides, such as occur after scarlet fever and gon- orrhoea, are really instances of mild septic infection. The joints may sometimes proceed to suppuration and pyaemia develop. So, also, in tuber- culosis of the kidneys and calculous pyelitis recurring rigors and sweats due to septic infection are common. In this latitude septic and pyaemic processes are too often confounded with malaria. In early tuberculosis, or even when signs of excavation are present in the lungs, and in cases of suppuration in various parts, particularly empyema and abscess of the liver, the diagnosis of malaria is made. The practitioner may take it as a safe rule, to which he will find very few exceptions, that an hitermittent fever which resists quinine is not malaria. Other conditions associated with chills which may be mistaken for pyaemia are profound anaemia, certain cases of Hodgkin’s disease, the hepatic intermittent fever associated with the lodgment of gall-stone at the orifice of the common duct, rare cases of essential fever in nervous women, and the intermittent fever sometimes seen in rapidly developing cancer. Treatment.—The treatment of septicaemia and pyaemia is largely a surgical problem. The cases which come under the notice of the physi- cian usually have visceral abscesses or ulcerative endocarditis, conditions which are irremediable. We have no remedy which controls the fever. Quinine and the new antipyretics may be tried, but they are of little serv- ice. Quinine is probably better than antipyrin and antifebrin, wdiich lower the temperature for a time, but when a careful two-hourly twenty- four-hour chart is taken, it is often found that the depression under the influence of the drug is made up at some other period of the day; a morn- ing may be substituted for an afternoon fever. The brilliant and remarkable results which follow complete evacuation 132 SPECIFIC INFECTIOUS DISEASES. of the pus with thorough drainage give the indication for the only suc- cessful treatment of this condition. Unfortunately, in too many cases which the physician is called upon to treat, the region of suppuration is not accessible, and we have to be content with the employment of general measures for the support of the patient’s strength. TERMINAL INFECTIONS. It may seem paradoxical, but there is truth in the statement that per- sons rarely die of the disease with which they suffer. Secondary infec- tions, or, as we are apt to call them in hospital work, terminal infections, carry off many of the incurable cases in the wards. These may be local or general. The former are extremely common, and are found in a large proportion of all cases of Bright’s disease, arterio- sclerosis, heart disease, cirrhosis of the liver, and other chronic disorders. Affections of the serous membranes (acute pleurisy, acute pericarditis, or peritonitis), meningitis, and endocarditis are the most frequent lesions. It is perhaps safe to say that the majority of cases of advanced arterio- sclerosis and of Bright’s disease succumb to these intercurrent infections. The infective agents are very varied. The streptococcus pyogenes is per- haps the most common, but the bacillus diphtherias, the pneumococcus, the proteus, and the bacillus pyocyaneus are also met with. Particular mention may be here made of the terminal form of acute miliary tuberculosis. It is surprising in how many instances of arterio- sclerosis, of chronic heart disease, of Bright’s disease, and more particu- larly of cirrhosis of the liver, the fatal event is determined by an acute tuberculosis of the peritonaeum or pleura. The general terminal infections are not so common, but in Hodgkin’s disease, leukaemia, Bright’s disease, and tuberculosis there may be a ter- minal pneumococcus or streptococcus septicaemia without local lesion, and to which the patients succumb. And, lastly, probably of the same nature is the terminal entero-colitis so frequently m£t with in chronic disorders. XVIII. CHOLERA AS1ATICA, Definition.—A specific, infectious disease, caused by the comma ba- cillus of Koch, and characterized clinically by violent purging and rapid collapse. Historical Summary.—Cholera has been endemic in India from a remote period, but only within the present century has it made inroads into Europe and America. An extensive epidemic occurred in 1832, in which year it was brought in immigrant ships from Great Britain to Quebec. It travelled along the lines of traffic up the Great Lakes, and finally reached CHOLERA ASIATICA. 133 as far west as the military posts of the upper Mississippi. In the same year it entered the United States by way of New York. There were re- currences of the disease in 1835-’36. In 1848 it entered the country through New Orleans, and spread widely up the Mississippi Valley and across the continent to California. In 1849 it again appeared. In 1854 it was introduced by immigrant ships into New York and prevailed widely throughout the country. In 1866 and in 1867 there were less serious epi- demics. In 1873 it again appeared in the United States, but did not pre- vail widely. In 1884 there was an outbreak in Europe, and again in 1892 and 1893. Although occasional cases have been brought by ship to the quarantine stations in this country, the disease has not gained a foothold here since 1873. Etiology.—In 1884 Koch announced the discovery of the specific organism of this disease. Subsequent observations have confirmed his statement that the comma bacillus, as it is termed, occurs constantly in the true cholera, and in no other disease. It has the form of a slightly bent rod, which is thicker, but not more than about half the length of the tubercle bacillus, and sometimes occurs in an S form. It is not a true bacillus, but really a spirochaete. The organism grows upon a great variety of media and displays distinctive and characteristic appearances. Koch found them in the water-tanks in India, and also in the water during the Hamburg epidemic of 1892. During epidemics virulent bacilli may be found in the faeces of healthy persons. The bacilli are found in the intestine, in the stools from the earliest period of the dis- ease, and very abundantly in the characteristic rice-water evacuations, in which they may be seen as an almost pure culture. They very rarely occur in the vomit. Post mortem, they are found in enormous numbers in the intestine. In acutely fatal cases they do not seem to invade the intestinal wall, but in cases with a more protracted course they are found in the follicles and even in the deeper tissues. Modes of Infection.—As in other diseases, individual peculiarities count for much, and during epidemics virulent cholera bacilli have been isolated from the normal stools of healthy men. Cholera cultures have also been swallowed with impunity. The disease is not highly contagious ; physicians, nurses, and others in close contact with patients are not often affected. On the other hand, washerwomen and those who are brought into very close contact with the linen of the cholera patients, or with their stools, are particularly prone to catch the disease. There have been several instances of so-called “ labora- tory cholera,” in which students have been accidentally infected while working at the cultures. Vegetables which have been washed in the infected water, particularly lettuces and cresses, may convey the disease. Milk may also be contami- nated. The bacilli live on fresh bread, butter, and meat, for from six to eight days. In regions in which the disease prevails the possibility of the 134 SPECIFIC INFECTIOUS DISEASES. infection of food by flies should be borne in mind, since it has been shown that the bacilli may live for at least three days in their intestines. Infection through the air is not to be much dreaded, since the germs when dried die rapidly. The disease is propagated chiefly by contaminated water used for drinking, cooking, and washing. The virulence of an epidemic in any region is in direct proportion to the imperfection of its water supply. In India the demonstration of the connection between drinking-water and cholera infection is complete. The Hamburg epidemic is a most remark- able illustration. The unfiltered water of the Elbe was the chief supply, although taken from the river in such a situation that it was of necessity directly contaminated by sewage. It is not known accurately from what source the contagion came, whether from Russia or from France, but in August, 1892, there was a sudden explosive epidemic, and within three months nearly 18,000 persons were attacked, with a mortality of 42-3 per cent. The neighboring city of Altona, which also took its water from the Elbe, but which had a thoroughly well-equipped modern filtration system, had only in the same period 516 cases. Two main types of epidemics of cholera are recognized : the first, in which many individuals are attacked simultaneously, as in the Hamburg outbreak, and in which no direct connection can be traced between the individual cases. In this type there is wide-spread contamination of the drinking-water. In the other type the cases occur in groups, so-called cholera nests; individuals are not attacked simultaneously but success- ively. xl direct connection between the cases may be very difficult to trace. Again, both these types may be combined, and in an epidemic which has started in a wide-spread infection through water, there may be other outbreaks, which are examples of the second or chain-like type. Pettenkofer, on the other hand, denies the truth of this drinking- water theory, and maintains that the conditions of the soil are of the greatest importance ; particularly a certain porosity, combined with moist- ure and contamination with organic matter, such as sewage. He holds that germs develop in the subsoil moisture during the warm months, and that they rise into the atmosphere as a miasm. The disease is always spread along the lines of human travel. In India it has, in many notable cases, been widely spread by pilgrims. It is carried also by caravans and in ships. It is not conveyed through the atmosphere. Places situated at the sea-level are more prone to the disease than inland towns. In high altitudes the disease does not prevail so exten- sively. A high temperature favors the development of the disease, but in Europe and America the epidemics have been chiefly in the late sum- mer and in the autumn. The disease affects persons of all ages. It is particularly prone to attack the intemperate and those debilitated by want of food and by bad CHOLERA ASIATICA. 135 surroundings. Depressing emotions, such as fear, undoubtedly have a marked influence. It is doubtful whether an attack furnishes immunity against a second one. Morbid Anatomy.—There are no characteristic anatomical changes in cholera; but a post-mortem diagnosis of the nature of the disease could be made by any competent bacteriologist, as the micro-organisms are specific and distinctive. The body has the appearances associated with profound collapse. There is often marked post-mortem elevation of temperature. The rigor mortis sets in early and may produce displace- ment of the limbs. The lower jaw has been seen to move and the eyes to rotate. Various movements of the arms and legs have also been seen. The blood is thick and dark, and there is a remarkable diminution in the amount of water and salts. The peritonaeum is sticky, and the coils of intestines are congested and look thin and shrunken. There is nothing special in the appearance of the stomach. The -small intestine usually contains a turbid serum, similar in appearance to that which was passed in the stools. The mucosa is, as a rule, pale and swollen and often con- gested about the Peyer’s patches. Post mortem the epithelial lining is sometimes denuded, but this is probably not a change which takes place during life. In the stools, however, large numbers of columnar epithelial cells have been described by many observers. The bacilli are found in the contents of the intestine and in the mucous membrane. The spleen is usually small. The liver and kidneys show cloudy swelling, and the latter extensive coagulation-necrosis and destruction of the epithelial cells. The heart is flabby ; the right chambers are distended with blood and the left chambers are usually empty. The lungs are collapsed, and congested at the bases. The above appearances are those met with in cases which prove rapidly fatal. When the patient survives and death occurs during reaction, there may be more definite inflammatory appearances in the intestines and more pronounced changes in the kidneys and liver. Symptoms.—A period of incubation of uncertain length, probably not more than from two to five days, precedes the development of the symptoms. Three stages may be recognized in the attack : the preliminary diar- rhoea, the collapse stage, and the period of reaction. {a) The preliminary diarrhoea may set in abruptly without any pre- vious indications. More commonly there are, for one or two days, colicky pains in the abdomen, with looseness of the bowels, perhaps vomiting, with headache and depression of spirits. There may be no fever. (b) Collapse Stage.—The diarrhoea increases, or, without any of the preliminary symptoms, sets in with the greatest intensity, and profuse liquid evacuations succeed each other rapidly. There are in some in- stances griping pains and tenesmus. More commonly there is a sense of exhaustion and collapse. The thirst becomes extreme, the tongue is 136 SPECIFIC INFECTIOUS DISEASES. white ; cramps of great severity occur in the legs and feet. Within a few hours vomiting sets in and becomes incessant. The patient rapidly sinks into a condition of collapse, the features are shrunken, the skin of an ashy gray hue, the eyeballs sink in the sockets, the nose is pinched, the cheeks are hollow, the voice becomes husky, the extremities are cyauosed, and the skin is shrivelled, wrinkled, and covered with a clammy perspiration. The temperature sinks. In the axilla or in the mouth it may be from five to ten degrees below normal, but in the rectum and in the internal parts it may be 103° or 104°. The pulse becomes extremely feeble and flickering, and the patient gradually passes into a condition of coma, though con- sciousness is often retained until near the end. The faeces are at first yellowish in color, from the bile pigment, but soon they become grayish white and look like turbid whey or l’ice-water; whence the term “ rice-water stools.” There are found in it numerous small flakes of mucus and granular matter, and at times blood. The reaction is usually alkaline. The fluid contains albumen and the chief mineral ingredient is chloride of sodium. Microscopically, mucus and epithelial cells and innumerable bacteria are seen, the majority of the latter being the comma bacilli. The condition of the patient is largely the result of the concentration of the blood consequent upon the loss of serum in the stools. There is almost complete arrest of secretion, particularly of the saliva and the urine. On the other hand, the sweat-glands increase in activity, and in nursing women it has been stated that the lacteal flow is unaffected. This stage may not last more than two or three hours, but more com- monly lasts from twelve to twenty-four. There are instances in which the patient dies before purging begins—the so-called cholera sicca. (c) Reaction Stage.—When the patient survives the collapse, the cyanosis gradually disappears, the warmth returns .to the skin, which may have for a time a mottled color or present a definite erythematous rash. The heart’s action becomes stronger, the urine increases in quantity, the irritability of the stomach disappears, the stools are at longer intervals, and there is no abdominal pain. In the reaction the temperature may not rise above normal. Not infrequently this favorable reaction is inter- rupted by a recurrence of severe diarrhoea and the patient is carried off in a relapse. Other cases pass into the condition of what has been called cholera-typhoid, a state in which the patient is delirious, the pulse rapid and feeble, and the tongue dry. Death finally occurs with coma. These symptoms have been attributed to uraemia. During epidemics attacks are found of all grades of severity. There are cases of diarrhoea with griping pains, liquid, copious stools, vomiting, and cramps, with slight collapse. The term cholerine has been applied to these cases. They resemble the milder cases of cholera nostras. At the opposite end of the series there are the instances of cholera sicca, in which death may occur in a few hours after the attack, without diarrhoea. There CHOLERA ASIATICA. 137 are also cases in which the patients are overwhelmed with the poison and die comatose, without the preliminary stage of collapse. Complications and Sequelae.—The typhoid condition has al- ready been referred to. The consecutive nephritis rarely induces dropsy. Diphtheritic colitis has been described. There is a special tendency to diphtheritic inflammation of the mucous membranes, particularly of the throat and genitals. Pneumonia and pleurisy may develop, and destruc- tive abscesses may occur in different parts. Suppurative parotitis is not very uncommon. In rare instances local gangrene may develop. A troublesome symptom of convalescence is cramps in the muscles of the arms and legs. Diagnosis.—The only affection with which Asiatic cholera could be confounded is the cholera nostras, the severe choleraic diarrhoea which occurs during the summer montfcs in temperate climates. The clinical picture of the two affections is identical. The extreme collapse, vomiting, and rice-water stools, the cramps, the cyanosed appearance, are all seen in the worst forms of cholera nostras. In enfeebled persons death may occur within twelve hours. It is of course extremely important to be able to' diagnose between the two affections. This can only be done by one thor- oughly versed in bacteriological methods, and conversant with the diversified flora of the intestines. The comma bacillus is present in the dejections of a great majority of the cases and can be seen on cover-glass preparations. Though the eye of the expert may be able to differentiate between the bacillus of true cholera and that which occurs in cholera nostras, cultures should be made, from which alone positive results can be obtained. Attacks very similar to Asiatic cholera are produced in poisoning by arsenic, corrosive sublimate, and certain fungi; but a difficulty in diag- nosis could scarcely arise. The prognosis is always uncertain, as the mortality ranges in different epidemics from 30 to 80 per cent. Intemperance, debility, and old age are unfavorable conditions. The more rapidly the collapse sets in, the greater is the danger, and as Andral truly says of the malignant form, “ It begins where other diseases end—in death.” Cases with marked cyanosis and very low temperature rarely recover. Prophylaxis.—Preventive measures are all-important, and isolation of the sick and thorough disinfection have effectually prevented the dis- ease entering England or the United States since 1873. On several occa- sions since that date cholera has been brought to various ports in Amer- ica, but has been checked at quarantine. During epidemics the greatest care should be exercised in the disinfection of the stools and linen of the patients. When an epidemic prevails, persons should be warned not to drink water unless previously boiled. Errors in diet should be avoided. As the disease is not more contagious than typhoid fever, the chance of a person passing safely through an epidemic depends very much upon how far he is able to carry out thoroughly prophylactic measures. Digestive 138 SPECIFIC INFECTIOUS DISEASES. disturbances are to be treated promptly, and particularly the diarrhoea, which so often is a preliminary symptom. For this, opium and acetate of lead and large doses of bismuth should be given. Ilaffkine has obtained a protective virus which has been used on a large scale in India. During 189-3 and 1894 about 32,000 people were inoculated. The results -on the whole are encouraging, as the percent- age attacked of the inoculated was very considerably smaller than in unprotected individuals. Medicinal Treatment.—During the initial stage, when the diar- rhoea is not excessive but the abdominal pain is marked, opium is the most efficient remedy, and it should be given hypodermically as morphia. It is advisable to give at once a full dose, which may be repeated on the return of the pain. It is best not to attempt to give remedies by the mouth, as they disturb the stomach. I#e should be given, and brandy or hot coffee. In the collapse stage, writers speak strongly against the use of opium. Undoubtedly it must be given with caution, but, judging from its effects in cholera nostras, I should say that collapse per se was not a contra-indication. The patient may be allowed to drink freely. For the vomiting, which is very difficult to check, cocaine may be tried, and lav- age with hot water. Creasote, hydrocyanic acid, and creolin have been found useless. Rumpf advises calomel (gr. every two hours. External applications of heat should be made and a hot bath may be tried. Warm applications to the abdomen are very grateful. Hypoder- mic injections of ether will be found serviceable. Irrigation of the bowel—enteroclysis—with warm water and soap, or tannic acid (2 per cent), should be used. With a long, soft-rubber tube, as much as three or four litres may be slowly injected. Not only is the colon cleansed, but the small bowel may also be reached, as shown by the fact that the tannic-acid solutions have been vomited. Owing to the profuse serous discharges the blood becomes concen- trated, and absorption takes place rapidly from the lymph-spaces. To meet this, intravenous injections have been practised. My preceptor, Bo veil, first practised the intravenous injections of milk in Toronto, in the epidemic of 1854. A litre of salt solution at 107° may be injected, and repeated in a few hours if no reaction follows. Less risky and equally efficacious is the subcutaneous injection of a saline solution. For this, common salt should be used in the proportion of about four grammes to the litre. With rubber tubing, a cannula from an aspirator, or even with a hypodermic needle, the warm solution may be allowed to run by pres- sure beneath the skin. It is rapidly absorbed, and the process may be continued until the pulse shows some sign of improvement. This is really a valuable method, thoroughly physiological, and should be tried in all severe cases. In the stage of reaction special pains should be taken to regulate the diet and to guard against recurrences of the severe diarrhoea. YELLOW FEVER. 139 XIX. YELLOW FEVER. Definition.—An acute febrile disease of tropical and subtropical countries, characterized by jaundice and haemorrhages, and due to the action of a specific virus, the nature of which is yet unknown. Etiology.—The disease prevails endemically in the West Indies and in certain sections of the Spanish Main. From these regions it occasionally extends and, under suitable conditions, prevails epidemically in the Southern States. Now and then it is brought to the large seaports of the Atlantic coast. Formerly it occurred extensively in the United States. In the latter part of the last century and the beginning of this, frightful epi- demics prevailed in Philadelphia and other Northern cities. The epidemic of 1793, so graphically described by Matthew Carey, was the most serious that has ever prevailed in any city of the Middle States. The mortality, as given by Carey, during the months of August, September, October, and November, was 4,041, of whom 3,435 died in the months of September and October. The population of the city at the time was only 40,000. Epidem- ics occurred in the United States in 1797, 1798, 1799, and in 1802, when the disease prevailed slightly in Boston and extensively in Baltimore. In 1803 and 1805 it again appeared ; then for many years the outbreaks were slight and localized. In 1853 the disease raged throughout the Southern States. In New Orleans alone there was a mortality of nearly eight thou- sand. In 1867 and 1873 there were moderately severe epidemics. In 1878 the last extensive epidemic occurred, chiefly in Louisiana, Alabama, and Mississippi. The total mortality was nearly sixteen thousand. In Europe it has occasionally gained a foothold, but there have been no wide-spread epidemics except in the Spanish ports. The disease exists on the west coast of Africa. It is sometimes carried to ports in Great Britain and France, but it has never extended into those countries. The history of the disease and its general symptomatology are exhaustively treated in the classical work of Rene La Roche. Guiteras recognizes three areas of infection : (1) The focal zone in which the disease is never absent, including Havana, Yera Cruz, Rio, and other Spanish-American ports. (2) Perifocal zone or regions of periodic epidemics, including the ports of the tropical Atlantic in America and Africa. (3) The zone of accidental epidemics, between the parallels of 45° north and 35° south latitude. The epidemics are invariably due to the introduction of the poison either by patients affected with the disease or through infected articles. Unquestionably the poison may be conveyed by fomites. Individuals of all ages and races are attacked. The negro is much less susceptible than the white, but he does not enjoy an immunity. Residents in southern countries, in which the disease is prevalent, are not so susceptible as stran- gers and temporary residents. Males are more frequently affected and the mortality is greater among them, owing probably to greater exposure. 140 SPECIFIC INFECTIOUS DISEASES. Very young children usually escape; but in the epidemics of large cities the number under five attacked is large, since they constitute a con- siderable proportion of the population unprotected by previous attack. Guiteras states that the “ foci of endemicity of yellow fever are essentially maintained by the creole infant population.” Immunity is acquired by passing through an attack or by prolonged residence in a locality in which it is endemic. The statement so often made that the creoles are exempt from yellow fever has been abundantly disproved. They certainly are not so susceptible, but in severe epidemics they die in numbers. The evidence in favor of inherited immunity is not conclusive. Conditions favoring the Development of Epidemics.—Yellow fever is a disease of the sea-coast, and rarely prevails in regions with an eleva- tion above one thousand feet. Its ravages are most serious in cities, par- ticularly when the sanitary conditions are unfavorable. It is always most severe in the badly drained, unhealthy portions of a city, where the popu- lation is crowded together in ill-ventilated, badly drained houses. The disease prevails during the hot season. In Havana the death-rate is great- est during the months of June, July, and August. The epidemics in the United States have always been in the summer and autumn months. The specific germ of the disease has not yet been discovered. Stern- berg, in his last report to the United States Government, concludes that the specific cause of yellow fever has not yet been demonstrated. With this statement Cornil and Babes * agree, and they do not accept the organ- isms described by Freire, Carmona, and Gibier. Morbid Anatomy.—The skin is more or less jaundiced. Cutane- ous haemorrhages may be present. No specific or distinctive internal lesions have been found. The blood-serum contains haemoglobin, owing to destruction of the red cells, just as in pernicious malaria. The heart sometimes, not invariably, shows fatty change; the stomach presents more or less hyperaemia of the mucosa with catarrhal swelling. It contains the material which, ejected during life, is known as the black vomit. The essential ingredient in this is transformed blood-pigment. In the two specimens which I have had an opportunity of examining it differed in no respect from the material found in other affections associated with haema- temesis. There is no proof that this black material depends upon the growth of a micro-organism. The liver is usually of a pale yellow or brownish-yellow color, and the cells are in various stages of fatty degen- eration. From the date of Louis’s observations at Gibraltar in 1828, the appearances of this organ have been very carefully studied, and some have thought the changes in it to be characteristic. Councilman has described remarkable appearances in the liver-cells which he believes are distinctive and peculiar. Fatty degeneration and regions of necrosis are present in all cases. The kidneys often show traces of diffuse nephritis. The epi- * Les Bacteries, 1890. YELLOW FEVER. 141 thelium of the convoluted tubules is swollen and very granular; there may also he necrotic changes. In both liver and kidneys bacteria of vari- ous sorts have been described. Symptoms.—The incubation is usually three or four days, but it may be less than twenty-four hours and prolonged to seven days. The onset is sudden; as a rule, without preliminary symptoms. An initial chill is common, and with it are usually associated headache and pains in the back and limbs. The fever rises rapidly and the skin feels very hot and dry. The face is flushed ; the tongue furred, but moist; the throat sore. Nausea and vomiting are present, and become more intense on the second or third day. The bowels are usually constipated. The urine is reduced in amount and may be albuminous from the outset. The pulse, at first, has the usual febrile characters, but quickly becomes feeble and, as the jaundice develops, may become slow. This stage of invasion, or the febrile stage, lasts from a few hours to two or three days. It is succeeded by a remission, or, as it has sometimes been called, the stage of calm, during which the temperature falls and the sever- ity of the symptoms abates. In favorable cases the fever now subsides and convalescence sets in. In such cases jaundice may not develop. In the third stage, or that of the febrile reaction, the temperature rises again and the symptoms become aggravated. The jaundice develops rapidly, the vomiting increases, and, in a considerable proportion of the cases, black vomit occurs. This consists of blood and gastric mucus altered by the acid juices of the stomach. Though usually regarded as distinctive and characteristic of the disease, material identical with it is brought up under other febrile conditions in which vomiting of blood occurs. Altered blood-corpuscles, epithelial cells, portions of food, and various fungi are found in the fluid. The vomiting may be accompanied by great abdominal pain. The stools are often tarry from the presence of altered blood. In mild cases the vomiting ceases during the first stage of the disease. Black vomit is not necessarily a fatal symptom, though it is present only in the severer cases of the disease. Jaundice occurs in a limited number of the cases which recover, and is present in almost all the fatal cases. From the character of the disease it is probably haematoge- nous in its origin. Bleeding may occur from the kidneys or from the gums, and haemorrhages into the skin are not uncommon. As would be expected in a fever of this nature, the urine is albuminous; the amount varying a good deal with the intensity of the fever, and with the grade of jaundice. Febrile icterus, from whatever cause, is almost invariably associated with albuminuria and tube-casts, and the evidences of a diffuse nephritis. Relapses occasionally occur. Among the varieties of the disease it is important to recognize the mild cases. These are characterized by slight fever, continuing for one or two days, and succeeded by a rapid convales- cence. Such cases would not be recognized as yellow fever in the absence of a prevailing epidemic. Cases of greater severity have high fever and 142 SPECIFIC INFECTIOUS DISEASES. the features of the disease are well marked—vomiting, prostration, and haemorrhages. And lastly there are malignant cases in which the patient is overwhelmed by the intensity of the fever, and death takes place in two or three days.* In severe cases convalescence may be complicated by the occurrence of parotitis, abscesses in various parts of the body, and diarrhoea. An attack confers an immunity which persists, as a rule, through life. Diagnosis.—Mild cases, and even severe cases in the early period of an epidemic, are very difficult to recognize. The disease simulates closely, and may be mistaken for ordinary malarial remittent fever. It is not un- common for physicians, in regions in which yellow fever is occasionally epidemic, to call the milder cases malarial fever, reserving the name of yellow fever for the severer forms with jaundice and black vomit. The only disease with which these cases could be confounded is malaria in its remittent and pernicious forms. But yellow fever can now be defi- nitely and at once separated by the examination of the blood. The clinical picture in certain cases of malarial remittent and yellow fever may be almost identical. The presence of albumen in the urine, upon which some writers lay such stress as a distinguishing feature in yellow fever, is far too common a symptom in all forms of malaria to be worth much as a guide. Guiteras states that there may be difficulty for a time in recognizing the difference between mild cases of thermic fever and yellow fever. Prognosis.—In its graver forms, yellow fever is one of the most fatal of epidemic diseases. The mortality has ranged, in various epidem- ics, from 15 to 85 per cent. In heavy drinkers and those who have been exposed to hardships the death-rate is much higher than among the bet- ter classes. In the epidemic of 1878, in New Orleans, while the mortality in hospitals was over 50 per cent of the white and 21 per cent of the col- ored patients, in private practice the mortality was not more than 10 per cent among the white patients. Favorable symptoms are a low grade of fever, slight jaundice, absence of haemorrhages, and a free secretion of urine. If the temperature rises above 103° or 104° during the first two days, the outlook is serious. Black vomit is not an invariably fatal symp- tom. Cases with suppression of urine, delirium, coma, and convulsions rarely recover. Prophylaxis.—The measures to be taken are— (a) “Exclusion of the exotic germ of the disease by the sanitary super- vision, at the port of departure, of ships sailing from infected ports, and thorough disinfection at the port of arrival, Avhen there is evidence or rea- sonable suspicion that they are infected; (b) isolation of the sick on ship- * For a full discussion of the morbid anatomy and symptomatology of the disease the student is referred to the works of Joseph Jones, of New Orleans, and to his recent papers in the Journal of the American Medical Association, 1895,1. YELLOW FEVER. 143 board, at quarantine stations, and, so far as practicable, in recently infected places; (c) disinfection of excreta, and of the clothing and bedding used by the sick, and of localities into which cases have been introduced, or which have become infected in any way; (d) depopulation of infected places—i. e., the removal of all susceptible persons whose presence is not necessary for the care of the sick ” (Sternberg). During an epidemic, individuals who must remain in the locality should avoid the regions in which the disease prevails most; they should live temperately, avoiding all excesses, and should be careful not to get overheated, either in the sun or by exercise. It is very doubtful whether the preventive inoculations in- troduced by Freire in Brazil and Carmona in Mexico are of any value. Treatment.—Careful nursing and a symptomatic plan of treatment probably give the best results. Bleeding has long since been abandoned. How much patients will stand in this disease is illustrated by Kush’s prac- tice, which was of the most heroic character. He says: “ From a newly arrived Englishman I took 144 ounces, at twelve bleedings, in six days; four were in twenty-four hours. I gave within the course of the same six days nearly 150 grains of calomel, with the usual proportions of jalap and gamboge ” * With the courage of his convictions this modern Sangrado himself submitted to two bleedings in one day, and had his infant of six weeks old bled twice. Neither emetics nor purgatives are now employed. Of special remedies quinine is warmly recommended, and, when haemor- rhage sets in, the perchloride of iron. Digitalis, aconite, and jaborandi have been employed. Sternberg advises the following mixture: Bicar- bonate of soda, 150 grains; bichloride of mercury, grain; pure water, 1 quart. Three tablespoonfuls to be given every hour. This is given on the view that the specific agent is in the intestine, and that its growth may possibly be restrained by this antacid and antiseptic mixture. The fever is best treated by hydrotherapy. There are several reports of the good effects of cold baths, sponging, and the application of ice-cold water to the head and the extremities in this disease. Vomiting is a very difficult symptom to control. Morphia hypodermically and ice in small quantities are probably the best remedies. Medicines given by the mouth for this purpose are said to be rarely efficacious. We have no reliable medicine which can be depended upon to check the haemorrhages. Ergot and acetate of lead and opium are recommended. The uraemic symptoms are best treated by the hot bath. Stimulants should be given freely during the second stage, when the heart’s action becomes feeble and there is a tendency to collapse. The patient should be carefully fed ; but when the vomiting is incessant it is best not to irritate the stom- ach, but to give nutritive enemata until the gastric irritation is allayed. * Manuscript letter to Redman Coxe. 144 SPECIFIC INFECTIOUS DISEASES. XX. THE BUBONIC PLAGUE. A specific, contagious disease, characterized by fever, inflammatory swelling of the lymphatic glands, and haemorrhages. This terrible malady, known also as the black-death, or the Oriental plague, has gradually disappeared from Europe, but is still met with in parts of Asia. A short but severe epidemic in May, 1894, at Hong Kong, was rendered memorable by the discovery of the bacillus. In severe epidemics the disease may kill within a few hours. As a rule it comes on suddenly after an incubation period of from two to five days. There is usually intolerable headache and excessively severe pain in the back and limbs. There is early delirium, and the temperature rises. In two or three days buboes appear, forming the most characteristic symptom of the disease. In about seventy-five per cent of the cases the inguinal glands enlarge. Involvement of the cervical and axillary glands is less frequent. Resolution may occur, or the glands pass on to suppuration. In the very severe cases the affected glands may become gangrenous. Carbuncles also occur on the skin. Haemorrhages are common in certain epidemics, and gave to the disease the name of “ black-death.” The bacillus discovered by Kitasato is a short rod with rounded ends, resembling the bacillus of chicken-cholera. It grows in a perfectly char- acteristic manner. The conclusions appended to Kitasato’s report on the IIong-Kong epidemic are as follows : 1. “ In the plague, bacilli are found in the blood, glands and viscera. 2. “ This particular bacillus is not found in any other disease. 3. “ Obtained in pure culture it is capable of producing in inoculated animals the same effects as in human beings. 4. “ It gains entrance into the body through (a) the respiratory tract, (b) excoriations of the surface, (c) the digestive tract. “The disease prevails especially under faulty hygienic conditions; it is therefore urged that general hygienic measures be carried out. Proper receptacles for sewage should be provided ; a pure water supply afforded ; houses and streams are to be cleansed ; all persons sick of the disease iso- lated ; the furniture of the sick-room washed with a two-per-cent carbolic solution in milk of lime; old clothes and bedding are to be steamed at 100° C. for at least one hour, or exposed for a few hours to sunlight. If feasible, all infected articles should be burned. The evacuations of the sick are to be mixed with milk of lime; and those who die of the disease are to be buried at a depth of three metres, or, preferably, cremated. After recovery the patient is to be kept in isolation at least one month. All contact with the sick is to be avoided, and great care is to be exer- cised with reference to food and drink.” DYSENTERY. 145 XXI. DYSENTERY. Definition.—Under this clinical term several different forms of in- testinal flux are described, which are characterized by frequent stools, and in the acute stage are accompanied by tormina and tenesmus. Anatomi- cally there are inflammation and usually ulceration of the large bowel. Etiology.—Dysentery is one of the four great epidemic diseases of the world. In the tropics it destroys more lives than cholera, and it has been more fatal to armies than powder and shot. While especially severe in the tropics, sporadic cases constantly occur in more temperate climates, and under favoring circumstances epidemics are found even in the more northern countries, such as Canada and Nor- way. It has become less frequent of late years, owing to improved sani- tary conditions. The statistics of the Montreal General Hospital, for the twenty years ending May 1, 1889, show a remarkable decrease in the dis- ease. In the decade ending May, 1879, 150 cases were admitted; whereas in the last ten years there have been only 31 cases admitted. There has been a similar decrease at the Pennsylvania Hospital. In the Southern cities of this country dysentery is more prevalent; even when not epidemic, sporadic cases are common. In Baltimore it prevails every summer, and has on several occasions been epidemic. Epidemics of dysentery have occurred in the United States for more than a century, and Woodward has collected the data which show the various outbreaks. Perhaps the most serious was that which prevailed in various localities from 1847 to 1856. During the war of secession the dis- ease existed to an alarming extent in both armies. According to Wood- ward’s report,* there were in the Federal service in all 259,071 cases of acute and 28,451 cases of chronic dysentery. Probably a considerable pro- portion of the 182,586 cases of chronic diarrhoea should also come in this category. The decennial census reports since 1850 show a progressive de- crease in the total number of deaths from this disease. It prevails most extensively in the summer and autumn. Sudden changes of temperature appear more harmful than variations in moisture. The effluvia from de- composing animal matter have been thought by some to predispose to or even to cause the disease. That dysenteric affections are more frequent in malarial localities has long been known, and is probably connected with external conditions favoring their development. With reference to the influence of drinking-water, Woodward is doubtless correct in stating that the effects of dissolved mineral matters have been greatly exaggerated. On the other hand, from the days of the old Greek physicians, it has been held that the impurities in the stagnant water of marshy districts and * Medical and Surgical History of the War of the Rebellion, Medical, vol. ii; the most exhaustive treatise extant on intestinal fluxes—an enduring monument to the in- dustry and ability of the author. 146 SPECIFIC INFECTIOUS DISEASES. ponds may give rise to diarrhoea and dysentery. Here, however, it is prob- ably not the vegetable impurities which are directly causative, but the or- ganic matter renders the water a more favorable medium for the develop- ment of organisms which may cause disease. Dyspeptic conditions, particularly those caused by the ingestion of bad food and unripe fruit, seem to predispose to the disease. Great stress has been laid by German authorities on the importance of constipation as a causal factor in dysentery. Dysentery occurs at all ages. There is no race immunity. The con- tagiousness of the disease is doubtful. The experience of the civil war is decidedly against it, but the possibility, as with typhoid fever, must be acknowledged. Clinical Forms.—(a) Acute Catarrhal Dysentery.—This may occur sporadically or endemically, and is the variety most frequently found in temperate climates. Morbid Anatomy.—The lesions are confined to the large bowel, and sometimes the ileum also is involved. The mucous membrane is injected, swollen, and often covered with tenacious blood-stained mucus. The most striking feature is the enlargement of the solitary follicles, which stand out prominently from the mucous membrane. In very acute forms, as in children, the picture is that of an acute follicular colitis. In more protracted cases the follicles suppurate or are capped with an area of necrotic tissue. In other instances the sloughs have separated and the entire colon presents numerous ulcers, most of which have developed from the follicles, and others have resulted from necrosis and sloughing of the intervening tissue. Symptoms.—There may be preliminary dyspepsia or slight pains in the abdomen. Chills are rare. Diarrhoea is the most constant initial symp- tom, and at first is not painful. Usually within thirty-six hours the char- acteristic features of the disease develop—abdominal pain of a colicky, griping character, frequent stools, which are passed with straining and tenesmus; the constitutional disturbance is variable, and in mild cases may be slight. The temperature range is not high, but at the outset the fever may rise to 102° or 103°. The tongue is furred and moist, and as the disease progresses becomes red and glazed. Nausea and vomiting may be present, but as a rule the patient retains nourishment. The constant desire to go to stool and the straining or tenesmus are the most distressing symptoms. The abdomen may be flat and hard. The thirst is often exces- sive. The stools in this variety of dysentery have the following characters : During the first twenty-four or forty-eight hours they consist of more or less clear mucus and blood mixed with small fajcal scybala. After this they become purely gelatinous and bloody, and are small and frequent, from fifteen to two hundred in twenty-four hours, according to the severity of the case. About the end of the first week the mucus becomes opaque, the proportion of blood diminishes, and grayish or brownish shreddy material DYSENTERY. 147 appears in the stools, which become gradually reduced in frequency. Some of the stools at this time may be wholly composed of a greenish pul- taceous material and mucus. As the disease subsides, faecal matter again appears in the stools, increasing in amount until fully formed faeces are passed, containing no mucus or blood. Microscopical examination of the glairy bloody stools shows red blood-corpuscles, few or many leucocytes, and constantly large, swollen, round or oval epithelioid cells, containing fat-drops and vacuoles. Bacteria are scarce ; occasionally the cercomonas intestinalis is seen in large numbers. Course of the Disease.—The milder cases run a course, as Flint has shown, of about eight days; severer ones rarely terminate within four weeks. The affection occasionally becomes chronic. Peritonitis and liver abscess are extremely rare. (b) Tropical Dysentery—Amoebic Dysentery.—This form of intestinal flux is characterized by irregular diarrhoea and the constant presence in the stools of the amoeba coli (Losch), amoeba clysenterice (Councilman and La- fleur). It is this variety which prevails extensively in the tropical and sub- tropical regions, and which proves so fatal in epidemic form. The amoeba is a unicellular, protoplasmic, motile organism, from fifteen to thirty mi- cromillimetres in diameter, consisting of a clear outer zone, ectosarc, and a granular inner zone, endosarc, containing a nucleus and one or more vacuoles. It was first described by Lambl in 1859, and subsequently by Losch, who considered it the cause of the disease. In the endemic dysen- tery of Egypt, Kartulis, in 1883, found these amoebae constantly in the stools, in the intestines, and in the liver abscesses. He was afterward enabled to cultivate them in straw infusion, and to produce the disease artificially in cats and dogs. In 1890 I reported a case of dysentery with abscess of the liver originating in Panama, in which the amoebae were found in the stools and in the pus from the abscess; and Council- man and Lafleur * have described the clinical features and anatomical lesions in a series of cases of this form of dysentery in my wards. Dock has demonstrated their presence in a number of cases in Galveston, and Musser has found them in Philadelphia. Amoebae are occasionally found in the stools of healthy men. Quincke and Roos recognize three forms of parasitic amoebae, two of which are pathogenic. The disease is very com- mon in tropical and subtropical countries. It is, however, found more or less widely distributed throughout Europe and North America. The sources of infection are not known, but it seems probable that one of them is drinking-water. Morbid Anatomy.—The lesions are found in the large intestine, some- times in the lower portion of the ileum. Abscess of the liver is a common sequence. Perforation into the right lung is not infrequent. Intestines.—The lesions consist of ulceration, produced by preceding * Johns Hopkins Hospital Reports, vol. ii. 148 SPECIFIC INFECTIOUS DISEASES. infiltration, general or local, of the submucosa, the general infiltration being due to an cedematous condition, the local to multiplication of the fixed cells of the tissue. In the earliest stage these local infiltrations appear as hemispherical elevations above the general level of the mucosa. The mucous membrane over these soon becomes necrotic and is cast off, exposing the infiltrated submucous tissue as a grayish-yellow gelatinous mass, which at first forms the floor of the ulcer, but is subsequently cast off as a slough. The individual ulcers are round, oval, or irregular, with infiltrated, undermined edges. The visible aperture is often small compared to the loss of tissue beneath it, the ulcers undermining the mucosa, coalescing, and forming sinuous tracts bridged over by apparently normal mucous membrane. According to the stage at which the lesions are observed, the floor of the ulcer may be formed by the submucous, the muscular, or the serous coat of the intestine. The ulceration may affect the whole or some portion only of the large intestine, particularly the caecum, the hepatic and sigmoid flexures, and the rectum. In severe cases the whole of the intestine is much thickened and riddled with ulcers, with only here and there islands of intact mucous membrane. The disease advances by progressive infiltration of the connective-tissue layers of the intestine, which produces necrosis of the overlying structures. Thus, in severe cases there may be in different parts of the bowel slough- ing en masse of the mucosa or of the muscularis, and the same process is observed, but not so conspicuously, in the less severe forms. In some cases a secondary diphtheritic inflammation complicates the original lesions. Healing takes place by the gradual formation of fibrous tissue in .the floor and at the edges of the ulcers, which may ultimately result in partial and irregular strictures of the bowel. Microscopical examination shows a notable absence of the products of purulent inflammation. In the infiltrated tissues polynuclear leucocytes are seldom found, and never constitute purulent collections. On the other hand, there is proliferation of the fixed connective-tissue cells. Amoebas are found more or less abundantly in the tissues at the base of and around the ulcers, in the lymphatic spaces, and occasionally in the blood-vessels. The lesions in the liver are of two kinds: firstly, local necroses of the parenchyma, scattered throughout the liver and possibly due to the action of chemical products of the amoebae; and, secondly, abscesses. These may be single or multiple. When single they are generally in the right lobe, either toward the convex surface near its diaphragmatic attachment, or on the concave surface in proximity to the bowel. Multiple abscesses are small and generally superficial. In an early stage the abscesses are grayish- yellow, with sharply defined contours, and contain a spongy necrotic ma- terial, with more or less fluid in its interstices. The larger abscesses have DYSENTERY". 149 ragged necrotic walls, and contain a more or less viscid, greenish-yellow or reddish-yellow purulent material mixed with blood and shreds of liver- tissue. The older abscesses have fibrous walls of a dense, almost carti- laginous toughness. A section of the abscess wall shows an inner necrotic zone, a middle zone in which there is great proliferation of the connective- tissue cells and compression and atrophy of the liver-cells, and an outer zone of intense hyperaemia. There is the same absence of purulent inflam- mation as in the intestine, except in those cases in which a secondary in- fection with pyogenic organisms has taken place. The material from the abscess cavity shows chiefly fatty and granular detritus, few cellular ele- ments, and more or less numerous amoebae. Amoebae are also found in the abscess walls, chiefly in the inner necrotic zone. Cultures are usually sterile. Lesions in the lungs are seen when an abscess of the liver—as so frequently happens—points toward the diaphragm and extends by conti- nuity through it into the lower lobe of the right lung. The gross and microscopical appearances are similar to those of the liver. Symptoms.—The onset may be sudden, as in catarrhal dysentery, or gradual, beginning as a trifling and perhaps transient diarrhoea. In severe gangrenous cases the abrupt onset is more common. The subsequent course is a very irregular diarrhoea, marked by exacerbations and inter- missions, and progressive loss of strength and flesh. There is moderate fever as a rule, but many cases are afebrile throughout the greater part of their course. Abdominal pain and tenesmus are frequently present at the onset, especially in severe cases, but may be entirely absent, and vomiting and nausea are only occasionally observed. The stools vary very much in frequency and appearance in different cases and at different periods in the same cases. They may be very frequent, bloody, and mucoid at the out- set, as in catarrhal dysentery; but their main characteristic, when the disease is well established, is fluidity. From six to twelve yellowish-gray liquid stools, containing mucus and occasionally blood in varying propor- tions, are passed daily for weeks. Actively moving amoebae are found in these stools, more abundantly during exacerbations of the diarrhoea, and disappear gradually as the stools become formed. Abscess of the liver, and especially of the liver and lung, is a frequent and formidable complication. In India it occurs once in every four or five cases. The duration of the disease in uncomplicated cases varies from six to twelve weeks. Recovery is tedious, owing to anaemia and muscular weak- ness, often delayed by relapses, and there is in all cases a constant tend- ency to chronicity. The mortality is much higher than in catarrhal dysentery. A fatal issue is due either to the initial gravity of the intes- tinal lesions, to exhaustion in prolonged cases, or to involvement of the liver. (c) Diphtheritic Dysentery.—A form of colitis or entero-colitis in which areas of necrosis occur in the mucous membranes, "which on sepa- 150 SPECIFIC INFECTIOUS DISEASES. ration leave ulcers. This occurs: (a) As a primary disease coming on acutely and sometimes proving fatal. In its milder grades the tops of the folds of the colon are capped with a thin, yellow exudate. In se- verer forms the colon is enormously enlarged, the walls are thickened, stiff, and infiltrated, and the mucosa, from the ileo-csecal valve to the rectum, represented by a tough, yellowish material, in which on section no trace of the glandular elements can be seen. It is an extensive necrosis of the mucosa. There are cases in which this necrosis is su- perficial, involving only the upper layers of the mucous membrane; but in the most advanced forms it may be, as in the description by Roki- tansky, “ a black, rotten, friable, charred mass.” The areas of necrosis may be more localized, and large sloughs are formed which may be a half to three fourths of an inch in thickness and extend to the serosa. There are instances in which this condition is confined to the lower por- tion of the large bowel. A sailor from the Mediterranean was admitted to the Montreal General Hospital under my care with symptoms resem- bling typhoid fever. The autopsy showed enormous sloughs in the rectum and in the sigmoid flexure, but scarcely any disease in the transverse or ascending colon. In cases which last for many weeks the sloughs separate and may be thrown off, sometimes in large tubular pieces. (b) Secondary Diphtheritic Dysentery.—This occurs as a terminal event in many acute and chronic diseases. It is not infrequent in chronic heart affections, in Bright’s disease, and in cachectic states generally. In acute diseases it is, as pointed out by Bristowe, most frequently associated with pneumonia. Anatomically there may be only a thin, superficial infil- tration of the upper layer of the mucosa in localized regions, particularly along the ridges and folds of the colon, often extending into the ileum. In severer forms the entire mucosa may be involved and necrotic, some- times having a rough, granular appearance. In the secondary colitis of pneumonia the exudation may be pseudo-membranous and form a firm, thin, white pellicle which seems to lie upon, not within, the mucous mem- brane. Symptoms.—The clinical features of diphtheritic dysentery are very varied. In the acute primary cases the patient from the outset is often extremely ill, with high fever, great prostration, pain in the abdomen, and frequent discharges. Delirium may be early and the clinical features may closely resemble severe typhoid. I have, on more than one occasion, known this mistake to be made. The abdomen is distended and often tender. The discharges are frequent and diarrheeal in character, and tenesmus may not be a striking symptom. Blood and mucus may be found early, but are not such constant features as in the follicular disease. This primary form is very fatal, but the sloughs may separate and the condition become chronic. In the secondary form there may have been no symptoms to attract attention to the large bowel. In a majority of the cases the patient has a diarrhoea—three, four, or more movements in the DYSENTERY. 151 day, which are often profuse and weakening. A little blood and mucus may be passed at first, but they are not specially characteristic elements in the stools. In all forms of dysentery death usually results from asthenia. The pulse becomes weaker and more rapid, the tongue dry, the face pinched, the skin cool and covered with sweat, and the patient falls into a drowsy, torpid condition. Consciousness may be retained until the last, hut in the protracted cases there is a low delirium deepening into collapse. (d) Chronic Dysentery.—This usually succeeds an acute attack, though the amoebic form may be subacute from the outset and not present an acute period. Anatomical changes in the large intestine in chronic dysentery are variable. There may be no ulceration, and the entire mucosa presents a rough, irregular puckered appearance, in places slate-gray or blackish in color. The submucosa is thickened and the muscular coats are hyper- trophied. There may be cystic degeneration of the glandular elements, as is beautifully figured in Woodward’s volume. Ulcers are usually present, often extensive and deeply pigmented, in places perhaps healing. The submucous and muscular coats are thick- ened and the calibre of the bowel may be reduced. Stricture, however, is very rare. The symptoms of chronic dysentery are by no means definite, and it is not always possible to separate the cases from those of chronic diarrhoea. Many of the characteristic symptoms of the acute disease are absent. Tenesmus and severe griping pains rarely occur except in acute exacerba- tions. The character of the stools varies very much. Blood and necrotic shreddy tissue are not often found. Mucus is passed in variable amounts. On a mixed diet the faeces are thin, often frothy, and contain particles of food. The motions vary from four or five to twelve or more in the twenty-four hours. There are cases in which marked constipation alter- nates with attacks of diarrhoea, and scybala may be passed with much mucus. In many cases the faeces have a semi-fluid consistency, and a yel- lowish or brown color depending on the amount of bile. Fragments of undigested food may be found, and the discharges have the character of what is termed a lienteric diarrhoea. Indeed, variations in the bile and in the food give at once corresponding variations in the character of the stools. In chronic dysentery recurrences are common in which blood and mucus again appear in the stools, accompanied perhaps by pus. Flatu- lence is in some cases distressing, and there is always more or less ten- derness along the course of the colon. The appetite is capricious, the digestion disordered, and unless the patient is on a strictly regulated diet the number of stools is greatly increased. The tongue is not often furred ; it is more commonly red, glazed, and beefy, and becomes dry and cracked toward the end in protracted cases. There is always anaemia and the emaciation may be extreme; with the exception of gastric cancer, we rarely see such ghastly faces as in patients with prolonged dysentery. 152 SPECIFIC INFECTIOUS DISEASES. The complications are those already referred to in the acute form. The greater debility renders the patient more liable to the intercurrent af- fections, such as pneumonia and tuberculosis. Ulceration of the cornea was frequently noted during the civil war. Complications and Sequelae.—A local peritonitis may arise by extension, or a diffuse inflammation may follow perforation, which is usually fatal. When this occurs about the caecal region, perityphlitis re- sults ; when low down in the rectum, periproctitis. In one hundred and eight autopsies collected by Woodward perforation occurred in eleven. By far the most serious complication is abscess of the liver, which occurs fre- quently in the tropics and is not very uncommon in this country. It was not, however, a frequent complication in dysentery during the civil war. In this latitude it is certainly not uncommon, as we have had five cases, within two years, in the Johns Hopkins Hospital. It usually comes on insidiously. The symptoms will be discussed in connection with hepatic abscess. It is stated that malaria is a complication, but with one exception the cases which I have seen with intermittent pyrexia were invariably associ- ated with suppuration. In extensive epidemics, however, Woodward states that cases of ordinary dysentery occur associated with all the phenomena of malaria. With reference to typhoid fever, as a complication, this au- thor mentions that the combination was exceedingly frequent during the civil war, and characteristic lesions of both diseases coexisted. In civil practice it must be extremely rare Sydenham noted that dysentery was sometimes associated with rheu- matic pains, and in certain epidemics joint swellings have been especially prevalent. They are probably not of the nature of true rheumatism, but are rather analogous to gonorrhoeal arthritis. In severe, protracted cases there may be pleurisy, pericarditis, endocarditis, and occasionally pyaemic manifestations, among which may be mentioned pylephlebitis. Chronic Bright’s disease is also an occasional sequel. In protracted cases there may be an anaemic oedema. An interesting sequel of dysentery is paraly- sis. Woodward reports eight cases. Weir Mitchell mentions it as not uncommon, occurring chiefly in the form of paraplegia. As in other acute fevers, this is due to a neuritis.* Intestinal stricture is a rare sequence— so rare that no case was reported at the Surgeon-General’s office during the war. Among the sequelae of chronic dysentery, in persons who have recovered a certain measure of health, may be mentioned persistent dys- pepsia and irritability of the bowels. Diagnosis.—The recognition of the acute follicular form is easy; the frequency of the passages, the presence of blood and mucus, and the tenesmus forming a very characteristic picture. Local affections of the rectum, particularly syphilis and epithelioma, may produce tenesmus with * Pugibet, Revue de Medecine, February, 1888. DYSENTERY. 153 the passage of mucoid and bloody stools. The acute diphtheritic form, coming on with great intensity and with severe constitutional .disturb- ances, is not infrequently mistaken for typhoid fever, to which indeed in many cases the resemblance is extremely close. The higher grade of fever, the more pronounced intestinal symptoms, the presence, particularly in the early stage, of a small amount of blood in the stools, the absence of enlargement of the spleen and the rose rash should lead to a correct diag- nosis. In the amoebic form the diagnosis can readily be made by ex- amination of the stools. A characteristic feature of these cases is their irregular, chronic course. A patient may be about and in fairly good condition, with well-formed stools and very slight intestinal disturbance, in whose faeces the amoebae may still be discovered, and in whom the disease is at any time likely to recur with intensity. In some cases, com- plicated by abscess of the liver and lung discharging through a bronchus, the diagnosis may rest on the detection of amoebae in the sputa, when they cannot be found in the stools owing to the latency of the intestinal dis- turbance. Three such cases occurred in my wards in 1890.* Treatment.—Flint has shown that sporadic dysentery is, in its slighter grades at least, a self-limited disease, which runs its course in eight or nine days. Reading a report of his cases, one is struck, however, with their comparative mildness. The enormous surface involved, amounting to many square feet, the con- stant presence of irritating particles of food, and the impossibility of get- ting absolute rest, are conditions which render the treatment of dysentery peculiarly difficult. Moreover, in the severer cases, when necrosis of the mucosa has occurred, ulceration necessarily follows, and cannot in any way be obviated. When a case is seen early, particularly if there has been con- stipation, a saline purge should be given. The free watery evacuations produced by a dose of salts cleanse the large bowel with the least possible irritation, and if necessary, in the course of the disease, particularly if scybala are present, the dose may be repeated. Purgatives are, as a rule, objectionable, and the profession has largely given up their use. Of medi- cines given by the mouth which are supposed to have a direct effect upon the disease, ipecacuanha still maintains its reputation in the tropics. It did not, however, prove satisfactory during the civil war; nor can I say that in cases of sporadic dysentery I have ever seen the marked effect described by the Anglo-Indian surgeons. The usual method of adminis- tration is to give a preliminary dose of opium, in the form of laudanum or morphia, and half an hour after from twenty to sixty grains of ipecacuanha. If rejected by vomiting, the dose is repeated in a few hours. Minute doses of corrosive sublimate, one hundredth of a grain every two hours, are warmly recommended by Ringer. Large doses of bismuth, half a drachm to a drachm every two hours, so that the patient may take * For details see monograph of Councilman and Lafleur. 154 SPECIFIC INFECTIOUS DISEASES. from twelve to fifteen drachms in a day, have in many cases had a bene- ficial effect. To do good it must be given in large doses, as recommended by Monneret, who gave as high as seventy grammes a day. It certainly is more useful in the chronic than the acute cases. It is best given alone. Opium is an invaluable remedy for the relief of the pain and to quiet the peristalsis. It should be given as morphia, hypodermically, according to the needs of the patient. The treatment of dysentery by topical applications is by far the most rational plan. A serious obstacle, however, in the acute cases, is the ex- treme irritability of the rectum and the tenesmus which follows any attempt to irrigate the colon. A preliminary cocaine suppository or the injection of a small quantity of the four-per-cent solution will sometimes relieve this, and then with a long tube the solution can be allowed to flow in slowly. The patient should be in the dorsal position with a pillow under the hips, so as to get the effect of gravitation. Water at the tem- perature of 100° is very soothing, but the irritability of the bowel is such that large quantities can rarely be retained for any time. When the acute symptoms subside, the injections are better borne. Various astringents may be used—alum, acetate of lead, sulphate of zinc and copper, and nitrate of silver. Of these remedies the nitrate of silver is the best, though I think not in very acute cases. In the chronic form it is per- haps the most satisfactory method of treatment which we have. It is useless to give it in the small injections of two or three ounces with one to two grains of the salt to the ounce. It must be a large irrigating in- jection, which will reach all parts of the colon. This plan was introduced by Hare, of Edinburgh, and is highly recommended by Stephen Mac- Kenzie and II. C. Wood. The solution must be fairly strong, twenty to thirty grains to the pint, and if possible from three to six pints of fluid must be injected. To begin with it is well to use not more than a drachm to the two pints or two and a half pints, and to let the warm fluid run in slowly through a tube passed far into the bowel. It is at times intensely painful and is rejected at once. In the cases of amoebic dysen- tery we have been using at the Johns Hopkins Hospital with great benefit warm injections of quinine in strength of 1 to 5,000, 1 to 2,500, and 1 to 1,000. The amoebae are rapidly destroyed by it. These large injections are not without a certain degree of danger. Brayton Ball reports the case of a child in whom general peritonitis followed the injections. I have never seen any ill effects, even with the very large amounts. When there is not much tenesmus, a small injection of thin starch with half a drachm to a drachm of laudanum gives great relief, but for the tormina and tenesmus, the two most distressing symptoms, a hypodermic of morphia is the only satisfactory remedy. Local applications to the abdomen, in the form of light poultices or turpentine stupes, are very grateful. The diet in acute cases must be restricted to milk, whey, and broths, MALARIAL FEVER. 155 and during convalescence the greatest care must be taken to provide only the most digestible articles of food. In chronic dysentery, diet is perhaps the most important element in the treatment. The number of stools can frequently be reduced from ten or twelve in the day to two or three, by placing the patient in bed and restricting the diet. Many cases do well on milk alone, but the stools should be carefully watched and the amount limited to that which can be digested. If curds appear, or if much oily matter is seen on microscopical examination, it is best to reduce the amount of milk and to supplement it with beef-jnice or, better still, egg- albumen The large doses of bismuth seem specially suitable in the chronic cases, and the injections of nitrate of silver, in the way already mentioned, should always be given a trial. XXII. MALARIAL FEVER. Definition.—An infectious disease characterized by: (a) paroxysms of intermittent fever of quotidian, tertian, or quartan type; (&) a continued fever with marked remissions; (c) certain pernicious, rapidly fatal forms ; and (d) a chronic cachexia, with anaemia and an enlarged spleen. With the disease are invariably associated the haematozoa described by Laveran. Etiology.—(1) Geographical Distribution.—In Europe, southern Rus- sia and certain parts of Italy are now the chief seats of the disease. It is not widely prevalent in Germany, France, or England, and the foci of epidemics are becoming yearly more restricted. In America it is now rare on the Atlantic coast above the latitude of Philadelphia. From New England, where it once prevailed extensively, it has gradually disappeared, but there has of late years been a slight return in some places. In the city of New York genuine malaria is rare except as an imported disease. In Philadelphia and along the valleys of the Delaware and Schuylkill Rivers, formerly hot-beds of malaria, the disease has become much restricted. Except in the low-lying southern portions of the city it rarely devel- ops, and the majority of cases admitted into hospital are of the poorer class, who have returned from picking cranberries and peaches in Dela- ware and New Jersey. In Baltimore a few cases develop in the autumn, but a majority of the patients seeking relief are from the outlying dis- tricts and one or two of the inlets of Chesapeake Bay. Though prevalent in certain regions on this bay, the disease is yearly becoming less wide- spread and less severe. In the Southern States there are on the seaboard many isolated regions in which malaria prevails; but here, too, there has everywhere been a marked diminution in the prevalence and intensity of the disease. W. W. Johnston states that in the Gulf district there are places in which the disease is increasing. The percentage of cases admit- ted to the Marine Hospital Service in 1876 was 18-4, and 23-4 in 1887. , SPECIFIC INFECTIOUS DISEASES. But this may be due to the development of the shipping trade and to the greater number of sailors who carry the infection from the West Indian ports, and those of Mexico and Central America. In the interior of Louisiana, Mississippi, Arkansas, and Texas malaria is endemic, and the severe types are not infrequent. At irregular periods epidemics of the most severe forms occur. In the Northwestern States malaria is almost unknown. It is rare on the Pacific coast. In the region of the Great Lakes malaria prevails only in the Lake Erie and Lake St. Clair regions. It has practically disappeared from Lake Ontario, whereas in the upper Huron and Lake Superior basins it is unknown. The St. Lawrence River region remains free from the disease. In Montreal a patient with malaria is invariably questioned as to his latest residence. (2) Telluric Conditions.—The importance of the state of the soil in the etiology of malaria is universally recognized. It is seen particularly in low, marshy regions which have an abundant vegetable growth. Estu- aries, badly drained, low-lying districts, the course of old river-beds, tracts of land which are rich in vegetable matter, and particularly districts such as the Roman Campagna, which have been allowed to fall out of cultiva- tion, are favorite localities for the development of the malarial poison. These conditions are most frequently found, of course, in tropical and subtropical regions, but nothing can be truer than the fact that reeking marshes of the most pestilent appearance may be entirely devoid of the poison, and the disappearance of the disease from a locality is not neces- sarily associated with any material improvement in the condition of the marshes or of the soil. Thus, in New England and in parts of western Canada, in which malaria formerly was very prevalent, the increased salu- brity is usually attributed to the clearing of the forests and the better drainage of the ground; but these improvements alone can scarcely ex- plain the disappearance, since in many districts there are marshy tracts and low-lying lands in every respect like those in which, even at the same latitude, the disease still prevails. Compare, for example, a swampy tract on the northern shore of Lake Erie and a similar tract on the southern shore of Lake Ontario; the flora and fauna of the two districts are prac- tically identical, but in the former the conditions under which the mala- rial virus develops still exist, whereas in the latter they have gradually disappeared. In short, it is impossible to ascertain from the nature of the soil and climate in any given place whether it is malarial or not. In the absence of accurate knowledge as to the habitat of the haematozoa, the only means of deciding this point is by noticing the effect of residence in such a place on the human subject, preferably one of the Caucasian race. (3) Season.—Even in the tropics, where malaria constantly prevails, there are minimal and maximal periods; the former corresponding to the summer and winter, the latter to the spring and autumn months. In temperate regions, like the central Atlantic States, there are only a few MALARIAL FEVER. 157 cases in the spring, usually in the month of May, and a large number of cases in September and October, and sometimes in November. In the tropics, too, the cases are most numerous in the autumn months. (4) Meteorological Conditions.—(a) Ileat.—A tolerably high tempera- ture is one of the essential conditions for the development of the virus. It is more prevalent after prolonged hot summers. (b) Moisture.—In the tropics the malarial fevers are most prevalent in the rainy seasons. In the temperate climates the relation between the rainfall and malaria is not so clear, and cases are more numerous after a dry summer; but if either heat or moisture is excessive, the development of the virus is checked for a time. (c) Winds.—Many facts are on record which seem to indicate that the poison may be carried to some distance by winds. The planting of trees has been held to interfere with the transmission by prevailing winds. Possibly, however, the quickly growing trees, such as the Eucalyptus globu- lus, have acted more beneficially by drying the soil. (5) Specific Gravity.—That the distribution of the poison of malaria is influenced by gravity has long been conceded. Persons dwelling in the upper stories, or in buildings elevated some distance above the ground, are exempt in a marked degree. The Specific Germ.—As Hirsch correctly remarks, the late J. K. Mitch- ell “ was the first to approach in a scientific spirit the nature of infec- tive disease and particularly in malarial fever.” Many attempts were made to discover a constant and characteristic organism. Klebs and Tommasi-Crudeli in 1879 announced the discovery of a bacillus malarice, but their observations have not been confirmed. In 1880 Laveran, a French army surgeon, now professor at the Medical School at Yal de Grace, announced the discovery of a parasite in the blood of patients at- tacked by malarial fever. During the next three years he published nine additional communications, but for a time these observations attracted little attention. The Italian observers Marchiafava, Celli, and Golgi corroborated Laveran’s statements. Councilman carefully studied the question in this country, and Laveran’s statements were confirmed by my- self in Philadelphia, by Walter James in New York, and more recently by Dock in Galveston, Koplik in New York. The whole question has been considered recently in an extensive monograph by my assistants, Thayer and Hewetson, in Baltimore.* In India, Vandyke Carter has pub- lished an elaborate monograph on the parasites. In France, Germany, and England, owing in great part to the absence of cases of malaria, the value of Laveran’s observations was at first overlooked, but recently the confirmation has been published from many of the German clinics, while valuable observations have recently been made in Southern Russia. So far as I know, not a single observer, who has had the necessary training * The Malarial Fevers of Baltimore, J. H. H. Reports, vol. v. 158 SPECIFIC INFECTIOUS DISEASES. and the material at his command, has failed to demonstrate the existence of these parasites. The bodies which have been found invariably associated with all forms of malarial fevers belong to the protozoa and to a group of organisms known as the hcematozoa, the precise affinities of which have not yet been definitely determined. Parasites of the red blood-corpuscles have been met with abundantly in the blood of fish, turtles, and many species of birds. One of the best and most readily studied examples is the Drepa- nidium ranarum, a common parasite in the red blood-corpuscles of the frog.* These organisms are generally placed among the sporozoa; their further classification is still a matter of dispute. The parasites are true hsemocy- tozoa, existing and pursuing their cycle of existence within the red blood- corpuscles of the infected individual. The youngest forms, small, hyaline, amoeboid bodies, enter the red blood-corpuscles and develop, accumulating, as they increase in size, fine granules of dark pigment, which is formed at the expense of the haemoglobin of the including corpuscle. When the organisms have reached their full development and destroyed their hosts, the pigment granules gather into a central clump or block, and the para- sites break up into a number of small round or ovoid hyaline bodies, each one of which represents a fresh young organism ready to attack a new cor- puscle and begin again a cycle of existence. Several varieties of the parasite have been separated, each of which is associated with a characteristic type of fever. These varieties are: (1) The parasite of tertian fever; (2) the parasite of quartan fever; (3) the parasite associated with the more irregular fevers occurring in temperate climates, in the later summer and autumn—the “ sestivo-autumnal fever ” of the Italians. Gfolgi first pointed out the remarkable fact that the para- sites of the regularly intermittent fevers—the tertian and quartan para- sites—exist in the blood in great groups, all the members of which are ap- proximately at the same stage of development. Thus an entire group of myriads of parasites undergoes sporulation within a period of several hours. The sporulation of such a group of parasites is always followed by the malarial paroxysm, which very possibly depends upon some toxic sub- stance which is developed at the time of sporulation. The tertian para- site requires about forty-eight hours to accomplish its cycle of develop- ment and undergo sporulation. Thus with infections with a single group of tertian parasites, sporulation occurs every other day, resulting, as might be expected, in tertian paroxysms. More often, however, infections with two groups of tertian parasites are seen—groups reaching maturity on alternate days, and causing quotidian paroxysms. Very rarely infections with multiple groups of the parasite may be seen. * For an excellent account of these hjematozoa and their development, see Celli, in Fortschritte der Medicin, 1891. MALARIAL FEVER. 159 The cycle of existence of the quartan parasite lasts about seventy-two hours, and if but one group of organisms be present, typical quartan fever results. The presence of two groups—double quartan infection—is asso- ciated with paroxysms on two successive days, followed by a day of inter- mission ; the presence of three groups gives rise to quotidian paroxysms. Very rarely more than three groups may be present. The parasite of the autumnal type possesses a cycle of development the exact duration of which is still a subject of dispute; it probably vari- able, lasting from twenty-four hours or less to forty-eight hours or even more, the variations depending upon conditions not wholly known.* While at the beginning of the infection the arrangement of the parasites in groups may be made out, this regular arrangement often disappears, and organisms at different stages of development may be found at the same time. Segmentation may thus occur at irregular intervals, sometimes almost continuously. The resulting fever may be regularly intermittent, but is often irregular and sometimes almost continuous. The parasite of tertian fever begins its cycle of development as a small, hyaline, amoeboid body. This rapidly accumulates fine brown pig- ment granules which are thrown into active motion; the including cor- puscle becomes expanded and decolorized as the parasite grows. The full- grown tertian organism is about the size of a normal red corpuscle. In sporulation the segments number from fifteen to twenty, or even more. The parasite of quartan fever is very similar in its appearance to the tertian organism. The amoeboid movements are, however, slower, and the pigment granules are coarser, darker, and in less active motion. The fully developed parasite is smaller, while the corpuscle in which the or- ganism develops, instead of becoming expanded and decolorized, as in the tertian infections, rather shrinks about the parasite and assumes a deeper, greenish, somewhat brassy color. In sporulation the segments are fewer, from five to ten in number. They are arranged with great regularity about the central pigment clump or block, forming the most beautiful “ rosettes.” The parasite of the autumnal malarial fever is considerably smaller than the other varieties; at full development it is often less than one half the size of a red blood-corpuscle. The pigment is much scantier, often consisting of a few minute granules, f Only the earlier stages of devel- opment, small, hyaline bodies, sometimes with one or two pigment gran- ules, are to be found in the peripheral circulation; the later stages are ordinarily only to be sehn in the blood of certain internal organs, the * Marchiafava and Bignami distinguish two varieties of the aestivo-autumnal para- site, a quotidian and a tertian. These observations we have not as yet been able to confirm. f Segmenting bodies have been described which were quite free from pigment. 160 SPECIFIC INFECTIOUS DISEASES. spleen and bone marrow particularly. The corpuscles containing the parasites become not infrequently shrunken, crenated, and brassy-col- ored. After the process has existed for about a week, larger, refractive, crescentic, ovoid, and round bodies, with central clumps of coarse pig- ment granules, begin to appear. These bodies are characteristic of aestivo- autumnal fever. Their significance is a matter of dispute. From the full-grown tertian and quartan parasites, and from the round bodies with central pigment clumps in aestivo-autumnal infections, long, actively moving flagella may develop; these may at times break loose and move about free among the corpuscles. Their significance has not been wholly determined. The general symptoms and morbid anatomy of malaria are in har- mony with the changes which these parasites induce. The remarkable periodicity of the manifestations of paludism are well explained when we consider the relations which these manifestations bear to the life history of the parasite. The destruction of the red blood-corpuscles by the organ- ism can be traced in all stages. The presence of pigment in the blood and viscera so characteristic of malaria results from the transformation of the hemoglobin by the parasites. The anaemia is a direct consequence of the wide-spread destruction of the corpuscles themselves. The severe cere- bral symptoms in pernicious cases, as well as the occasional cases of chol- eriform malaria, have been shown to be associated with the special local- ization of the parasites in capillaries of the brain, or in the mucous membrane of the gastro-intestinal tract. There are, however, many gaps in our knowledge. While by hypo- dermic or intravenous inoculation malarial infection may be transferred from one individual to another, the same type always appearing in the inoculated individual, yet we are quite ignorant of the form in which the parasite exists outside of the human body. All experiments at cultiva- tion of the parasites have failed. We are therefore also ignorant as to the manner of infection. The evidence appears to suggest that this occurs generally through the respiratory tract, though the proof of this supposi- tion is wanting. That infection may occur hypodermically is proved by the inoculation experiments. Repeated attempts to bring about infection through the gastro-intestinal tract have all failed. Meantime, awaiting further knowledge, advantage may be taken of the constant presence of the parasite in malaria. This alone, without refer- ence to the true nature of the organism, is a fact of the highest impor- tance. To be able, everywhere and under all circumstances, to differenti- ate between malaria and other forms of fever is one of the most important advances which has been made of late years in practical medicine; one which will revolutionize the study of fevers in tropical and subtropical countries, and should within a short time bring some order out of the chaos which at present exists regarding the different forms which there prevail. MALARIAL FEVER. 161 Morbid Anatomy.—The changes result from the disintegration of the red blood-corpuscles, accumulation of the pigment thereby formed, and possibly the influence of toxic materials produced by the parasite. Cases of simple malarial infection, the ague, are rarely fatal, and our knowledge of the morbid anatomy of the disease is drawn from the pernicious mala- ria or the chronic cachexia. Rupture of the enlarged spleen may occur spontaneously, but more commonly from trauma. A case of the kind was admitted under my colleague, Halsted, in June, 1889, and Dock has recently reported two cases. (1) Pernicious Malaria.—The blood is hydraemic and the serum may even be tinged with haemoglobin. The red blood-corpuscles present the endoglobular forms of the parasite and are in all stages of destruction. The spleen is enlarged, often only moderately; thus, of two fatal cases recently in my wards the spleens measured 13 X 8 ctm. and 14 X 8 ctm. respectively. If a fresh infection, the spleen is usually very soft, and the pulp lake-colored and turbid. In cases of intense reinfection the spleen may be enlarged and firm. The amount of pigment in the spleen elements is greatly increased. The pulp contains large num- bers of red corpuscles containing parasites. Enormous numbers of phagocytes, large and small, are to be seen, some of the larger being ne- crotic. The liver is swollen and turbid. In very acute cases there is not necessarily any macroscopic pigmentation, though microscopically the capillaries may be stuffed with phagocytes, which may almost occlude the vessels. Parasites may be present in considerable numbers, usually within the red corpuscle. Areas of disseminated necrosis closely similar to those observed in typhoid fever, diphtheria, and other acute infectious diseases, have been described by Guarni£re, Bignami, and Barker.* In association with these areas, Barker describes capillary thrombosis. Peri- vascular (portal) infiltration has been found in a very acute case in a young man (Dock). The brain usually shows interesting changes. In severe cases of some duration the tissue is stained, sometimes chocolate- colored. In mild cases the discoloration is present, but less marked. The blood-vessels, especially the arterioles and capillaries, contain large numbers of parasites, with partial or total destruction of red blood-cor- puscles, and phagocytes. Occlusions of arterioles by means of parasites are often seen, together with perivascular infection and punctate haemor- rhages. In some instances changes of this sort occurring in special areas have given rise to focal symptoms. Anaemia and oedema are commoner than congestion. The kidneys show analogous conditions. In some acute pernicious cases with choleraic symptoms, the capillaries of the gastro-intestinal mucosa may be stuffed with parasites. (2) Malarial Cachexia.—A patient, the subject of chronic paludism, usually dies of anaemia or of haemorrhage associated with it. The most * Morbid Anatomy of Malaria, J. H. H. Reports, vol. v. SPECIFIC INFECTIOUS DISEASES. characteristic cases of the kind which have come under my observation have been in the workmen returning from the Panama Canal, victims of the so-called Chagres fever. The anaemia is profound, particularly if the patient has died of fever. The spleen is greatly enlarged, and may weigh from seven to ten pounds. If the disease has persisted for any length of time, it is firm and resists cutting. The capsule is thickened, the parenchyma brownish or yel- lowish-brown, with areas of pigmentation, or in very protracted cases it is extremely melanosed, particularly in the trabeculae and about the vessels. The liver may be greatly enlarged; but, as a rule, the increase in size is moderate in proportion to that of the spleen. It may present to the naked eye a grayish-brown or slate color due to the large amount of pig- ment. In the portal canals and beneath the capsule the connective tissue is impregnated with melanin. Varying with the duration of the disease, the shade of color of the liver ranges from a light gray to a deep slate-gray tint. The texture is firm, but there is not necessarily any great increase in the connective tissue. Histologically, the pigment is seen in the Kupffer’s cells and the perivascular tissue. The kidneys may be enlarged and present a grayish-red color, or areas of pigmentation may be seen. The pigment may be diffusely scattered and particularly marked about the blood-vessels and the Malpighian bodies, or it is often abundant in the cells of the convoluted and collecting tubules. The peritonaeum is usually of a deep slate-color. The mucous membrane of the stomach and intestines may have the same hue, due to the pigment in and about the blood-vessels. In some cases this is confined to the lymph nodules of Peyer’s patches, causing the shaven-beard appear- ance. (3) The Accidental and Late Lesions of Malarial Fever. (a) The Liver.—Paludal hepatitis plays a very important role in the history of malaria, as described by French writers. Kelsch and Kiener devote over sixty pages to a description of the various forms, parenchym- atous and interstitial, describing under the latter three different varie- ties. The perusal of this section of their work by no means carries con- viction that all the forms which they describe are associated definitely with malaria. Many of the patients were the subjects of chronic alcohol- ism, and the most important diagnostic point upon which they seem to have placed reliance was melanosis of the spleen, sometimes with pig- mentation of Gflisson’s sheath. The existence of a cirrhosis dependent upon the irritation of large quantities of pigment in the liver is unques- tioned, but only those cases in which the history of chronic malaria is definite, and in which the melanosis of both liver and spleen coexist, should be regarded as of paludal origin. The affection in this country is of extraordinary rarity. In the post-mortem room of the Philadelphia Hospital I have frequently seen, in subjects in whom the spleen was MALARIAL FEVER. 163 deeply pigmented, the portal sheaths of the liver stained, and a slight increase in the connective tissue; but it is begging the question to say that in such patients, who have almost certainly been habitual consumers of bad whisky, the condition of the liver was due to malaria. No instance of malarial cirrhosis has been shown at the Philadelphia Pathological Society since its foundation. Welch tells me he knows of but one speci- men which has been shown in New York, and that was from an Algerian. (b) Pneumonia is believed by many authors to be common in malaria, and even to depend directly upon the malarial poison, occurring either in the acute or in the chronic forms of the disease. I have no personal knowledge of such a special pneumonia. It certainly does not occur in the intermittent or remittent fevers which prevail in Philadelphia and Baltimore. The two diseases may be concurrent. Inflammation of the lungs may develop during a simple intermittent, and the quinine may check the chills without influencing in any way the pneumonia. There were two cases among the 616 analyzed by Thayer and Hewetson. (c) Nephritis.—Acute inflammation of the kidneys is rare in the milder forms. Albumin in the urine is not infrequent during the chill, and in the course of the continued or remittent fevers. Kelsch and Kiener describe several forms of nephritis. No instance of chronic Bright’s disease resulting directly from paludism has come under my notice. Clinical Forms of Malarial Fever.—(1) The Regularly Inter- mittent Fevers.—(a) Tertian fever; (b) quartan fever. These forms are characterized by recurring paroxysms of what are known as ague, in which, as a rule, chill, fever, and sweat follow each other in orderly sequence. The stage of incubation is not definitely known ; it probably varies much according to the amount of the infectious material absorbed. Experimentally the period of incubation varies from six to fifteen days, being a trifle longer in quartan than in tertian infections. Attacks have been reported within a very short time after the apparent exposure. On the other hand, the ague may be, as is said, “ in the system,” and the patient may have a paroxysm months after he has removed from a mala- rial region, though I doubt if this can be the case unless he has had the disease when living there. Description of the Paroxysm.—The patient generally knows he is going to have a chill a few hours before its advent by unpleasant feelings and uneasy sensations, sometimes by headache. The paroxysm is divided into three stages—cold, heat, and sweating. Cold Stage.—The onset is indicated by a feeling of lassitude and a desire to yawn and stretch, by headache, uneasy sensations in the epigas- trium, sometimes by nausea and vomiting. Even before the chill begins the thermometer indicates slight rise in temperature. Gradually the pa- tient begins to shiver, the face looks cold, and in the fully developed rigor the whole body shakes, the teeth chatter, and the movements may often SPECIFIC INFECTIOUS DISEASES. Ward _ Admitted... Chart X. No.. MALARIAL FEVER. 1G5 Ward_ Chart X—(Continued). Admitted . No._ 166 SPECIFIC INFECTIOUS DISEASES. be violent enough to shake the bed. Not only does the patient look cold and blue, but a surface thermometer will indicate a reduction of the skin temperature. On the other hand, the axillary or rectal temperature may, during the chill, be greatly increased, and, as shown in the chart, the fever may rise during the chill to 105° or 10G°. Of symptoms associated with the chill, nausea and vomiting are common. There may be intense headache. The pulse is quick, small, and hard. The urine is increased in quantity. The chill lasts for a variable time, from ten or twelve min- utes to an hour, or even longer. The hot stage is ushered in by transient flushes of heat; gradually the coldness of the surface disappears and the skin becomes intensely hot. The contrast in the patient’s appearance is striking: the face is flushed, the hands are congested, the skin reddened, the pulse is full and bound- ing, the heart’s action is forcible, and the patient may complain of a throbbing headache. The rectal temperature may not increase much dur- ing this stage; in fact, by the termination of the chill the fever may have reached its maximum. The duration of the hot stage varies from half an hour to three or four hours. The patient is intensely thirsty and drinks eagerly of cold water. Sweating Stage.—Beads of perspiration appear upon the face and gradually the entire body is bathed in a copious sweat. The uncomfort- able feeling associated with the fever disappears, the headache is relieved, and within an hour or two the paroxysm is over and the patient usually sinks into a refreshing sleep. The sweating varies much. It may be drenching in character or it may be slight. Chart X is a fac-simile of a ward temperature chart in a case of tertian ague. The duration of the paroxysms on February 1st, 3d, and 5th was from twelve to sixteen hours. Quinine in two-grain doses was given on the 5th and was sufficient to prevent the on-coming paroxysms on the 7th, though the temperature rose to 100*5°. The small doses, how- ever, were not effective, and on the 9th he had a severe chill. The total duration of the paroxysm averages from ten to twelve hours, but may be shorter. Variations in the paroxysm are common. Thus the patient may, instead of a chill, experience only a slight feeling of coldness. The most common variation is the occurrence of a hot stage alone, or with very slight sweating. During the paroxysm the spleen is enlarged and the edge can usually be felt below the costal margin. In the interval or intermission of the paroxysm the patient feels very well, and, unless the disease is unusually severe, he is able to be up. Bronchitis is a common symptom. Herpes, usually labial, is perhaps as frequently seen in ague as in pneumonia. Types of the Regularly Intermittent Fevers.—As has been stated in the description of the parasites, two distinct types of the regularly inter- mittent fevers have been separated. These are (a) tertian fever and (b) quartan fever. MALARIAL FFArER. 167 (a) Tertian Fever.—This type of fever depends upon the presence in the blood of the tertian parasite, an organism which, as stated above, is usually present in sharply defined groups, whose cycle of development lasts approximately forty-eight hours, sporulation occurring every third day. In infections with one group of the tertian parasite the paroxysms occur synchronously with sporulation at remarkably regular intervals of about forty-eight hours, every third day—hence the name tertian. Very commonly, however, there may be two groups of parasites which reach maturity on alternate days, resulting thus in daily (quotidian) paroxysms —double tertian infection. Quotidian fever, depending upon double ter- tian infection, is the most frequent type in the acute intermittent fevers in this latitude. (b) Quartan Fever.—This type of fever depends upon infection with the quartan parasite, an organism which occurs in well-defined groups, whose cycle of existence lasts about seventy-two hours. In infection with one group of parasites the paroxysm occurs every fourth day; hence the term quartan. At times, however, two groups of the parasites may be present; under these circumstances paroxysms occur on two successive days, with a day of intermission following. In infection with three groups of parasites there are daily paroxysms. Thus a quotidian intermittent fever may be due to infection with either the tertian or quartan parasites. Course of the Disease.—After a few paroxysms, or after the disease has persisted for ten days or two weeks, the patient may get well without any special medication. In cases in which we have been studying the haematozoa I have repeatedly known the chills to stop spontaneously. Such cases, however, are very liable to recurrence. Persistence of the fever leads to anaemia and haematogenous jaundice, owing to the destruc- tion of the red blood-disks by the parasites. Ultimately the condition may become chronic, and will be described under malarial cachexia. The regularly intermittent fevers yield promptly and immediately to treatment by quinine. (2) The more Irregular, Remittent, or Continued Fevers.—iEstivo- autumnal Fever.—This type of fever occurs in temperate climates, chiefly in the late’r summer and fall; hence the term given to it by Marchiafava and Celli, aistivo-autumnal fever. The severer forms of it prevail in the Southern States and in tropical countries, where it is known chiefly as bilious remittent fever. The entire group of cases in- cluded under the terms remittent fever, bilious remittent, and typho- malarial fevers requires to be studied anew. This type of fever is associated with the presence in the blood of the sestivo-autumnal parasite, an organism the length of the cycle of develop- ment of which is probably subject to variations, while the existence of multiple groups of the parasite, or the absence of arrangement into defi- nite groups, is not infrequent. 168 SPECIFIC INFECTIOUS DISEASES. The symptoms are therefore, as might be expected, often irregular. In some instances there may be regular intermittent fever occurring at uncertain intervals of from twenty-four to forty-eight hours, or even more. In the cases with longer remissions the paroxysms are longer. Some of the quotidian intermittent cases may closely resemble the quotid- ian fever depending upon double tertian or triple quartan infection. Commonly, however, the paroxysms show material differences; their length averages over twenty hours, instead of from ten or twelve ; the onset occurs often without chills and even without chilly sensations. The rise in temperature is frequently gradual and slow, instead of sudden, while the fall may occur by lysis instead of by crisis. There is a marked tend- ency toward anticipation in the paroxysms, while frequently, from the anticipation of one paroxysm or the retardation of another, more or less continuous fever may result. Sometimes there is continuous fever with- out sharp paroxysms. In these cases of continuous and remittent fever the patient, seen fairly early in the disease, has a flushed face and looks ill. The tongue is furred, the pulse is full and bounding, but rarely dicrotic. The temperature may range from 102° to 103°, or is in some instances higher. The general appearance of the patient is strongly sug- gestive of typhoid fever—a suggestion still further borne out by the exist- ence of acute splenic enlargement of moderate grade. As in intermittent fever, an initial bronchitis may be present. The course of these cases is variable. The fever may be continuous, with remissions more or less marked; definite paroxysms with or without chills may occur, in which the temperature rises to 105° or 106°. Intestinal symptoms are usually absent. A slight haematogenous jaundice may develop early. Delirium of a mild type may occur. The cases vary very greatly in severity. In some the fever subsides at the end of the week, and the practitioner is in doubt whether he has had to do with a mild typhoid or a simple febric- ula. In other instances the fever persists for from ten days to two weeks; there are marked remissions, perhaps chills, with a furred tongue and low delirium. Jaundice is not infrequent. These are the cases to which the term bilious remittent and typho-malarial fevers are applied. In other instances the symptoms become grave and assume a character of the pernicious type. It is in this form of malarial fever that so much con- fusion still exists. The similarity of the cases to typhoid fever is most striking, more particularly the appearance of the facies, and the patient looks very ill. The cases develop, too, in the autumn, at the very time when typhoid fever occurs. The fever yields, as a rule, promptly to qui- nine, though here and there cases are met with—rarely indeed in my experience—in which they are refractory. It is just in this group that the observations of Laveran will be found of the greatest value. Several of the charts in Thayer and Hewetson’s report show how closely, in some instances, the disease may simulate typhoid fever. The diagnosis of malarial remittent fever may be definitely made by MALARIAL FEVER. 169 the examination of the blood. The small, actively motile, hyaline forms of the aestivo-autumnal parasite are to be found, while, if the case has lasted over a week, the larger crescentic and ovoid bodies are usually seen. Vandyke Carter, in his monograph, alludes to the value of this method in the fevers of India. In many cases here we are at first unable to distin- guish between typhoid and continued malarial fever without a blood ex- amination. A more wide-spread use of this means of diagnosis will enable us to bring some order out of the confusion which exists in the classification of the fevers of the South. At present the following febrile affections are recognized by various physicians as occurring in the sub- tropical regions of this continent: (a) Typhoid fever ; (b) typho-malarial fever—a typhoid modified by malarial infection, or the result of a com- bined infection ; (c) the malarial remittent fever; and (d) continued thermic fever (Guiteras). In these'various forms, all of which may be characterized by a continued pyrexia with remissions or with chills and sweats (for we must remember that chills and sweats in typhoid fever are by no means rare), the blood examination will enable us to discover those which depend upon the malarial poison. In many of these cases of con- tinued or remittent fever careful inquiry will show that at the beginning the patient had several intermittent paroxysms. In this latitude we have not the opportunity of seeing many of the protracted and severe cases, but I am inclined to think that future observations will show that, apart from the thermic fever, there are only two forms of these continued fevers in the South—the one due to the typhoid and the other to the malarial infection. The typhoid fever of Philadelphia and Baltimore presents no essential difference from the disease as it occurs in Montreal, a city prac- tically free from malaria. Dock has shown conclusively that cases diag- nosed in Texas as continued malarial fever were really true typhoid. Pernicious Malarial Fever.—This is fortunately rare in temperate cli- mates, and the number of cases which now occur, for example, in Phila- delphia and Baltimore, is very much less than thirty or forty years ago. Among the cases of malaria which have been under observation during the past five years there were only three of the pernicious form. Per- nicious fever is always associated with the testivo-autumnal parasite. The following are the most important types: (a) The comatose form, in which a patient is struck down with symp- toms of the most intense cerebral disturbance, either acute delirium or, more frequently, a rapidly developing coma. A chill may or may not precede the attack. The fever is usually high, and the skin hot and dry. The unconsciousness may persist for from twelve to twenty-four hours, or the patient may sink and die. After regaining consciousness a second attack may come on and prove fatal. In these instances, as has been stated, the special localization of the infection is in the brain, where actual thrombi of parasites with marked secondary changes in the sur- rounding tissues have been found. 170 SPECIFIC INFECTIOUS DISEASES. (b) Algid Form.—In this, the attack sets in usually with gastric symp- toms ; there are vomiting, intense prostration, and feebleness out of all proportion to the local symptoms. The patient complains of feeling cold, although there may be no actual chill. The temperature may be normal, or even subnormal; consciousness may be retained. The pulse is feeble and small, and the respirations are increased. There may be most severe diarrhoea, the attack assuming a choleriforrn nature. The urine is often diminished, or even suppressed. This condition may persist with slight exacerbations of fever for several days and the patient may die in a condi- tion of profound asthenia. This is essentially the same as described as the asthenic or adynamic form of the disease. In the cases with vomiting and diarrhoea, Marchiafava has shown that the gastro-intestinal mucosa is often the seat of a special invasion by the parasites, actual thrombosis of the small vessels with superficial ulceration and necrosis occurring. Simi- lar lesions were found by Barker in the gastro-intestinal tract of a case from my wards. (c) Ilcemorrhagic Forms.—In all the severe types of malarial infec- tion, especially if persistent, haemorrhage may occur from the mucous membranes. An important form is the malarial haematuria, which in some instances assumes a very malignant type. Paroxysms of ague may precede the attack, but in many cases called malarial haematuria there is no febrile paroxysm. The condition is usually hsemoglobinuria, though blood-corpuscles are present also. In severe cases there is bleeding from the mucous membranes. Jaundice is present, but to a variable extent, and is haematogenous, due to the destruction of the red blood-corpuscles. Malarial haematuria occurs in epidemic form in many regions of the Southern States, and in some seasons proves very fatal. Many different forms of pernicious malarial fever—diaphoretic, synco- pal, pneumonic, pleuritic, choleraic, cardiac, gastric, and gangrenous—all of which depend upon some special symptom, have been described. Malarial Cachexia.—The symptoms of chronic malarial poisoning are very varied. It may follow the frequent recurrence of ordinary inter- mittent fever, a common sequence in this country. A patient has chills for several weeks, is improperly or imperfectly treated, and on exposure the chills recur. This may be repeated for several months until the pa- tient presents the two striking features of malarial cachexia—namely, anaemia and an enlarged spleen. Cases developing without chills or with- out febrile paroxysms are almost unknown in this region. They may occur, however, in intensely malarial districts, but in such cases the pa- tients have fever, though chills may not supervene. The most pronounced types of malarial cachexia which we meet with here are in sailors from the West Indies and Central America. There is profound anaemia; the blood count may be as low as one million per cubic millimetre; the skin has a saffron-yellow or lemon tint, not often the light yellow tint of pernicious anaemia, but a darker, dirtier yellow. The spleen is greatly enlarged, MALARIAL FEVER. 171 firm, and hard. It rarely reaches the dimensions of the large leuksemic organ, but comes next to it in size. The general symptoms are those of ordinary anmmia—breathlessness on exertion, oedema of the ankles, haemorrhages, particularly into the retina, as noted by Stephen Mackenzie. Occasionally the bleeding is severe, and I have twice known fatal liaematemesis to occur in association wdth the enlarged spleen. The fever is variable. The temperature may be low for days, not reaching above OQ’S0. In other instances there may be irreg- ular fever, and the temperature rises gradually to 102 5° to 103°. The cases in fact present a picture of splenic anaemia. With careful treatment the outlook is good, and a majority of cases recover. The spleen is gradually reduced in size, but it may take several months or, indeed, in some instances, several years before the ague-cake entirely disappears. Among the rarer symptoms which may develop as a result of ma- larial intoxication may be mentioned paraplegia, cases of which have been described by Gibney, Suckling, and others. Some of the cases are doubtful, and have been attributed to malaria simply because the paralysis was intermittent. It is a condition of extreme rarity. No case is men- tioned by Kelsch and Kiener. Suckling’s case had had several attacks of malaria, the last of which preceded by about two weeks the onset of the nervous symptoms, which were headache, giddiness, loss of speech, and paraplegia. The attack was transient, but he had a subsequent attack which also followed an ague-fit. The patient was an old soldier who had had syphilis, a point which somewhat complicated the case. Orchitis has been described as developing in malaria by Charvot in Algiers and Fedeli in Rome. Diagnosis.—The blood, as one might expect, shows marked changes in malarial fever. In the regularly intermittent fevers there is a loss in red corpuscles after each paroxysm, which may be considerable, but which is rapidly compensated during the intermissions. In asstivo-autumnal fever the losses are oftener greater and more permanent. In any case of malaria which has existed for any length of time there is always considerable anaemia. The haemoglobin, as in all secondary anaemias, is diminished, usually in greater proportion than the corpuscles. The leucocytes are almost invariably diminished in number in malarial fever. The reduc- tion is greatest just after the paroxysms, the number increasing slightly at the beginning of the febrile paroxysm. The differential count shows a relative diminution in polynuclear leucocytes, with a relative increase in the large mononuclear forms, exactly the same condition that is seen in typhoid fever. Sometimes in fatal post-malarial anaemia the blood shows all the characteristics of true pernicious anaemia; in other instances of fatal anaemia, where the blood during life has shown an absence of leuco- cytosis, or of nucleated red corpuscles, the marrow of the long bones has been found to be perfectly yellow, no evidence of regenerative activity. 172 SPECIFIC INFECTIOUS DISEASES. The diagnosis of the various forms of malaria is usually easy. The continued remittent and certain of the pernicious cases offer diffi- culties, which, however, are now greatly lessened or entirely overcome since Laveran’s researches have given us a positive diagnostic indication. Many forms of intermittent pyrexia are mistaken for malarial fever, particularly the initial chills of tuberculosis and of septic infection. In these instances the blood shows leucocytosis, which is rare in malaria. If the practitioner will take to heart the lesson that an intermittent fever which resists quinine is not malarial, lie will avoid many errors in diag- nosis. In the so-called masked intermittent or dumb ague, the febrile manifestations are more irregular and the symptoms less pronounced ; but occasionally chills occur, and the therapeutical test usually removes every doubt in the diagnosis. The malarial poison is supposed to influence many affections in a re- markable way, giving to them a paroxysmal character. A whole series of minor ailments and some more severe ones, such as neuralgia, are attrib- uted to certain occult effects of paludism. The more closely such cases are investigated the less definite appears the connection with malaria. Practitioners in districts entirely exempt from the disease have to deal with ailments which present the same odd periodicity, and which the phy- sicians of the Atlantic coast attribute to a “ touch of malaria.” Treatment.—We do not know as yet how the poison reaches the sys- tem. Infection seems most liable to occur at night. In regions in which the disease prevails extensively the drinking-water may be boiled, though all experiments tend to show that the virus does not enter through the gastro- intestinal tract. Persons going to a malarial region should take about ten grains of quinine daily, though Richard found that two or three grains three times a day was a sufficient protection against the disease. During the paroxysm the patient should, in the cold stage, be wrapped in blankets and given hot drinks. The reactionary fever is rarely dangerous even if it reaches a high grade. The body may, however, be sponged. In quinine we possess a specific remedy against malarial infection. Experiment has shown that the parasites are most easily destroyed by quinine at the stage when they are free in the circulation—that is, during and just after sporu- lation. While in most instances the parasites of the regularly intermittent fevers may be destroyed, even in the intra-corpuscular stage, in aestivo-au- tumnal fever this is much more difficult. It should, then, be our object, if we wish to most effectually eradicate the infection, to have as much quinine in circulation at the time of the paroxysm and shortly before as is possible, for this is the period at which sporulation occurs. In the regu- larly intermittent fevers from ten to thirty grains in divided doses through- out the day will in many instances prevent any fresh paroxysms. If the patient comes under observation shortly before an expected paroxysm, the administration of a good dose of quinine just before its onset may be ad- visable to obtain a maximum effect upon that group of parasites. The MALARIAL FEVER. 173 quinine will not prevent the paroxysm, but will destroy the greater part of the group of organisms and prevent its further recurrence. It is safer to give at least twenty to thirty grains daily for the first three days, and then to continue the remedy in smaller doses for the next two or three weeks. In aestivo-autumnal fever larger doses may be necessary, though in relatively few instances is it necessary to give more than thirty to forty grains in the twenty-four hours. The quinine should be ordered in solution or in capsules. The pills and compressed tablets are more uncertain, as they may not be dissolved. A question of interest is the efficient dose of quinine necessary to cure the disease. I have a number of charts showing that grain doses three times a day will in many cases prevent the paroxysm, but not ahvays with the certainty of the larger doses. In cases of aestivo-autumnal fever with pernicious symptoms it is necessary to get the system under the influence of quinine as rapidly as possible. In these instances the drug should be administered hypodermically as the bisulphate in thirty-grain doses, with five grains of tartaric acid, every two or three hours. The muriate of quinine and urea is also a good form in which to administer the drug hy- podermically ; ten, fifteen, or twenty grain doses may be necessary. In the most severe instances some observers advise the intravenous adminis- tration of quinine. For extreme restlessness in these cases opium is indi- cated, and cardiac stimulants, such as alcohol and strychnine, are neces- sary. If in the comatose form the internal temperature is raised, the patient should be put in a bath and doused with cold water. For malarial anaemia, iron and arsenic are indicated. SPECIFIC INFECTIOUS DISEASES. XXIII. ANTHRAX. (Malignant Pustule ; Splenic Fever ; Charbon ; Wool-sorter's Disease.) Definition.—An acute infectious disease caused by the bacillus an- thracis. It is a wide-spread affection in animals, particularly in sheep and cattle. In man it occurs sporadically or as a result of accidental absorp- tion of the virus. Etiology.—The infectious agent is a non-motile, rod-shaped organ- ism, the bacillus anthracis, which has, by the researches of Pollender, Da- vaine, Koch, and Pasteur, become the best known perhaps of all patho- genic microbes. The bacillus has a length of from two to ten times the diameter of a red blood-corpuscle,; the rods are often united. They mul- tiply by fission with great rapidity and grow with facility on various cult- ure media, extending into long filaments which interlace and produce a dense mycelium. The spore formation is seen with great readiness in these filaments. The bacilli themselves are readily destroyed, but the spores are very resistant, and survive after prolonged immersion in a five- per-cent solution of carbolic acid, and resist for some minutes a tempera- ture of 212° Fahr. They are capable also of resisting gastric digestion. Outside the body the spores are in all probability very durable. Geographically and zoologically the disease is the most wide-spread of all infectious disorders. It is much more prevalent in Europe and in Asia than in America. The ravages among the herds of cattle in Russia and Siberia, and among sheep in certain parts of Europe, are not equalled by any other animal plague. In this country the disease is rare. So far as I know it has never prevailed on the ranches in the Northwest, but cases were not infrequent about Montreal. A protective inoculation with a mitigated virus has been introduced by Pasteur, and has been adopted in certain anthrax regions. Hankin has isolated from the cultures an albumose which renders animals immune against the most intense virus. In animals the disease is conveyed sometimes by direct inoculation, as by the bites and stings of insects, by feeding on carcasses of animals which have died of the disease, but more commonly by feeding in pastures in which the germs have been preserved. Pasteur believes that the earth- worm plays an important part in bringing to the surface and distributing the bacilli which have been propagated in the buried carcass of an in- fected animal. Certain fields, or even farms, may thus be infected for an indefinite period of time. It seems probable, however, that if the carcass is not opened or the blood spilt, spores are not formed in the buried animal. Animals vary in susceptibility: herbivora in the highest degree, then ANTHRAX. 175 the omnivora, and lastly the carnivora. The disease does not occur spon- taneously in man, but always results from infection, either through the skin, the intestines, or in rare instances through the lungs. The disease is found in persons whose occupations bring them into contact with ani- or animal products, as stablemen, shepherds, tanners, butchers, and those who work in wool and hair. Various forms of the disease have been described, and two chief groups may be recognized: the external anthrax, or malignant pustule, and the internal anthrax, of which there are pulmonary and intestinal forms. Symptoms.—(l) External Anthrax. [a) Malignant Pustule.—The inoculation is usually on an exposed surface—the hands, arms, or face. At the site of inoculation there are, within a few hours, itching and uneasiness. Gradually a small papule develops, which becomes vesicular. Inflammatory induration extends around this, and within thirty-six hours, at the site of inoculation there is a dark brownish eschar, at a little distance from which there may be a series of small vesicles. The brawny induration may be extreme. The oedema produces very great swelling of the parts. The inflammation ex- tends along the lymphatics, and the neighboring lymph-glands are swollen and sore. The temperature at first rises rapidly, and the febrile phenom- ena are marked. Subsequently the fever falls, and in many cases becomes subnormal. Death may take place in from three to five days. In cases which recover the constitutional symptoms are slighter, the eschar gradu- ally sloughs out, and the wound heals. The cases vary much in severity. In the mildest form there may be only slight swelling. At the site of in- oculation a papule is formed, which rapidly becomes vesicular and dries into a scab, which separates in the course of a few days. (b) Malignant Anthrax (Edema.—This form occurs in the eyelid, and also in the head, hand, and arm, and is characterized by the absence of the papule and vesicle forms, and by the most extensive oedema, which may follow rather than precede the constitutional symptoms. The oedema reaches such a grade of intensity that gangrene results, and may involve a considerable surface. The constitutional symptoms then become extremely grave, and the cases invariably prove fatal. In a recent case, in a hair-picker, there was most extensive enteritis, peritonitis, and endocarditis, which latter lesion has been described by Eppinger. A feature in both these forms of malignant pustule, to which many writers refer, is the absence of feeling of distress or anxiety on the part of the patient, whose mental condition may be perfectly clear. He may be without any apprehension, even though his condition is very critical. The diagnosis in most instances is readily made from the character of the lesion and the occupation of the patient. When in doubt, the exami- nation of the fluid from the pustule may show the presence of the an- thrax bacilli. Cultures should be made, or a mouse or guinea-pig inocu- SPECIFIC INFECTIOUS DISEASES. lated. It is to be remembered that the blood may not show the bacilli in numbers until shortly before death. (2) Internal Anthrax. («) Intestinal Form, Mycosis intestinalis.—In these cases the infec- tion is through the stomach and intestines, and results from eating the flesh or drinking the milk of diseased animals. The symptoms are those of intense poisoning. The disease may set in with a chill, followed by vomiting, diarrhoea, moderate fever, and pains in the legs and back. In acute cases there are dyspnoea, cyanosis, great anxiety and restlessness, and toward the end convulsions or spasms of the muscles. Haemorrhage may occur from the mucous membranes. Occasionally there are small phlegmonous areas on the skin, or petechiae develop. The spleen is en- larged. The blood is dark and remains fluid for a long time after death. Late in the disease the bacilli may be found in the blood. This is one of the forms of acute poisoning which may affect many in- dividuals together. Thus Butler and Karl Huber describe an epidemic in which twenty-five persons were attacked after eating the flesh of an animal which had had anthrax. Six died in from forty-eight hours to seven days. (b) Wool-sorter's Disease.—This important form of anthrax is found in the large establishments in which wool or hair is sorted and cleansed. The hair and wool imported into Europe from Russia and South America appear to have induced the largest number of cases. Many of these cases show no external lesion. The infection has been swallowed or inhaled with the dust. There are rarely premonitory symptoms. The patient is seized with a chill, becomes faint and prostiated, has pains in the back and legs, and the temperature rises to 102° to 103°. The breathing is rapid, and he complains of much pain in the chest. There may be a cough and signs of bronchitis. So prominent in some instances are these bronchial symptoms that a pulmonary form of the disease has been described. The pulse is feeble and very rapid. There may be vomiting, and death may occur within twenty-four hours with symptoms of pro- found collapse and prostration. Other cases are more protracted, and there may be diarrhoea, delirium, and unconsciousness. The cerebral symptoms may be most intense; in at least four cases the brain seems to have been chiefly affected, and its capillaries stuffed with bacilli (Mer- kel). The recognition of wool-sorter’s disease as a form of anthrax is due to J. II. Bell, of Bradford, England. In certain instances these profound constitutional symptoms of internal anthrax are associated with the external lesions of malignant pustule. The rag-picker's disease has been made the subject of an exhaustive study by Eppinger (Die Iladernkrankheit, Jena, 1894), who has shown that it is a local anthrax of the lungs and pleura, with general infection. The diagnosis of internal anthrax is by no means easy, unless the history points definitely to infection in the occupation of the individual, HYDROPHOBIA. 177 Treatment.—In malignant pustule the site of inoculation should be destroyed by the caustic or hot iron, and powdered bichloride of mercury may be sprinkled over the exposed surface. The local development of the bacilli about the site of inoculation may be prevented by the subcuta- neous injections of solutions of carbolic acid or bichloride of mercury. The injections should be made at various points around the pustule, and maybe repeated two or three times a day. The internal treatment should be confined to the administration of stimulants and plenty of nutritious food. Davies-Colley advises ipecacuanha powder in doses of from five to ten grains every three or four hours. In malignant forms, particularly the intestinal cases, little can be done. Active purgatives may be given at the outset, so as to remove the infect- ing material. Quinine in large doses has been recommended. XXIV. HYDROPHOBIA. {Lyssa; Rabies.) Definition.—An acute disease of animals, dependent upon a specific virus, and communicated by inoculation to man. Etiology.—In man the disease is very variously distributed. In Russia it is common. In North Germany it is extremely rare, owing to the wise provision that all dogs shall be muzzled ; in England and France it is much more common. In this country the disease is very rare. Dulles could collect only 78 cases in the five and a half years ending Dec. 31, 1893. Canines are specially liable to the disease. It is found most frequently in the dog, the wolf, and the cat. All animals are, however, susceptible; and it is communicable by inoculation to the ox, horse, or pig. The disease is propagated chiefly by the dog, which seems specially susceptible. In the Western States the skunk is said to be very liable to the disease. The nature of the poison is as yet unknown. It is contained chiefly in the nervous system and is met with in the secretions, particularly in the saliva. A variable time elapses between the introduction of the virus and the appearance of the symptoms. Horsley states that this depends upon the following factors : “ (a) Age. The incubation is shorter in children than in adults. For obvious reasons the former are more frequently attacked. (b) Part infected. The rapidity of onset of the symptoms is greatly de- termined by the part of the body which may happen to have been bitten. Wounds about the face and head are especially dangerous; next in order in degrees of mortality come bites on the hands, then injuries on the other parts of the body. This relative order is, no doubt, greatly de- pendent upon the fact that the face, head, and hands are usually naked, while the other parts are clothed, (c) The extent and severity of the wound. Puncture wounds are the most dangerous; the lacerations are fatal in proportion to the extent of the surface afforded for absorption of SPECIFIC INFECTIOUS DISEASES. the virus. (d) The animal conveying the infection. In order of decreas- ing severity come: first, the wolf; second, the cat; third, the dog; and fourth, other animals.” Only a limited number of those bitten by rabid dogs become affected by the disease ; according to Horsley, not more than fifteen per cent. On the other hand, the death-rate of those persons bitten by wolves is higher, not less than forty per cent. The incubation period in man is extremely variable. The average is from six weeks to two months. In a few cases it has been under two weeks. It may be prolonged to three months. It is stated that the incu- bation may be prolonged for a year or even two years, but this has not been definitely settled. Symptoms.—Three stages of the disease are recognized: (1) Premonitory stage, in which there may be irritation about the bite, or pain or numbness. The patient is depressed and melancholy; and complains of headache and loss of appetite. He is very irritable and sleepless, and has a constant sense of impending danger. There is often greatly increased sensibility. A bright light or a loud voice is distressing. The larynx may be injected and the first symptoms of difficulty in swal- lowing are experienced. The voice also becomes husky. There is a slight rise in the temperature and the pulse. (2) Stage of Excitement.—This is characterized by great excitability and restlessness, and an extreme degree of hyperaesthesia. “ Any afferent stimulant—i. e., a sound or a draught of air, or the mere association of a verbal suggestion—will cause a violent reflex spasm. In man this symp- tom constitutes the most distressing feature of the malady. The spasms, which affect particularly the muscles of the larynx and mouth, are exceed- ingly painful and are accompanied by an intense sense of dyspnoea, even when the glottis is widely opened or tracheotomy has been performed ” (Horsley). Any attempt to take water is followed by an intensely painful spasm of the muscles of the larynx and of the elevators of the hyoid bone. It is this which makes the patient dread the very sight of water and gives the name hydrophobia to the disease. These spasmodic attacks may be associated with maniacal symptoms. In the intervals between them the patient is quiet and the mind unclouded. The temperature in this stage is usually elevated and may reach from 100° to 103°. In some in- stances the disease is afebrile. The patient rarely attempts to injure his attendants, and in the intense spasms may be particularly anxious to avoid hurting any one. There are, however, occasional fits of furious mania, and the patient may, in the contractions of the muscles of the larynx and pharynx, give utterance to odd sounds. This stage lasts from a day and a half to three days and gradually passes into the— (3) Paralytic Stage.—In rodents the preliminary and furious stages are absent, as a rule, and the paralytic stage may be marked from the out- set—the so-called dumb rabies. This stage rarely lasts longer than from six to eighteen hours. The patient then becomes quiet; the spasms no HYDROPHOBIA. 179 longer occur ; there is gradual unconsciousness ; the heart’s action becomes more and more enfeebled, and death occurs by syncope. Morbid Anatomy.—The lesions are in the cerebro-spinal system. The blood-vessels are congested; there is perivascular exudation of leuco- cytes ; and there are minute hgemorrhages. According to Gowers, these are particularly intense in the medulla. The pharynx is congested, the mucous membrane of the stomach is hyperaemic, and not infrequently covered with a blood-stained mucus. The larynx, trachea, and bronchi show acute congestion. There are no special changes in the abdominal or thoracic viscera. The inoculation experiments show that the virus is not present in the liver, spleen, or kidneys, but is abundant in the spinal cord and brain. Treatment.—Prophylaxis is of the greatest importance, and by a systematic muzzling of dogs the disease can be, as in Germany, practically eradicated. The bites should be carefully washed and thoroughly cauterized with caustic potash or concentrated carbolic acid. It is best to keep the wound constantly open for at least five or six weeks. When once established the disease is hopelessly incurable. No measures have been found of the slightest avail, consequently the treatment must be palliative. The pa- tient should be kept in a darkened room, in charge of not more than two careful attendants. To allay the spasm, chloroform may be administered and morphia given hypodermically. It is best to use these powerful reme- dies from the outset, and not to temporize with chloral, bromide of potas- sium, and other less potent drugs. By the local application of cocaine, the sensitiveness of the throat may be diminished sufficiently to enable the patient to take liquid nourishment. Sometimes he can swallow read- ily. Nutrient enemata should be administered. Preventive Inoculation.—Pasteur has found that the virus, when propa- gated through a series of rabbits, increases rapidly in its virulence; so that whereas subdural inoculation from the brain of a mad dog takes from fif- teen to twenty days to produce the disease, in successive inoculations in a series of rabbits the incubation period is gradually reduced to seven days. The spinal cord of these rabbits contains the virus in great intensity, but when preserved in dry air the virus gradually diminishes in intensity. If now dogs are inoculated with cords preserved for from twelve to fifteen days, and then with cords preserved for a shorter period, i. e., with a pro- gressively stronger virus, they gradually acquire immunity against the dis- ease. A dog treated in this way will resist inoculation with material from a perfectly fresh cord from a rabid rabbit, which otherwise would inevi- tably have proved fatal. Belying upon these experiments, Pasteur began inoculations in the human subject using, on successive days, material from cords in which the virus was of varying degrees of intensity. There is still much discussion as to the full value of this method, but if the protective inoculation can be successfully performed in dogs, 180 SPECIFIC INFECTIOUS DISEASES. there is no reason why the same should not hold good for man ; and the figures published annually from the Pasteur Institute show that in per- sons bitten by animals known to have been rabid, the mortality after in- oculation is only about 0-60 per cent. Pseudo-hydrophobia (Lyssophobia).—This is a very interesting affection, which may closely resemble hydrophobia, but is really nothing more than a neurotic or hysterical manifestation. A nervous person bitten by a dog, either rabid or supposed to be rabid, develops within a few months, or even later, symptoms somewhat resembling the true disease. He is irri- table and depressed. He constantly declares his condition to be serious and that he will inevitably become mad. He may have paroxysms in which he says he is unable to drink, grasps at his throat, and becomes emotional. The temperature is not elevated and the disease does not progress. It lasts much longer than the true rabies, and is amenable to treatment. It is not improbable that a majority of the cases of alleged recovery in this disease have been of this hysterical form. In a case which Burr reported from my clinic a few years ago the patient had paroxysmal attacks in which he could not swallow. He was greatly excited and alarmed at the sight of water and was extremely emotional. The attack lasted for a couple of weeks and yielded to treatment with powerful electrical currents. XXV. TETANUS. Definition.—An infectious malady characterized by tonic spasms of the muscles with marked exacerbations. The virus is produced by a bacillus which occurs in earth and sometimes in putrefying fluids and manure. Etiology.—It occurs as an idiopathic affection or follows trauma. It is frequent in some localities and has prevailed extensively in epidemic form among new-born children, when it is known as tetanus or trismus neonatorum. It is more common in hot than in temperate climates, and in the colored than in the Caucasian race. This is particularly the case with tetanus following confinement and in tetanus neonato- rum. In certain of the West India Islands more than one half of the mortality among the negro children has been due to this cause. In a ma- jority of the cases there is an injury which may be of the most trifling character. It is more common after punctured and contused than after incised wounds, and frequently follows those of the hands and feet. The disease usually appears within two weeks of the injury. In some military campaigns tetanus has prevailed extensively, but in others, as in the late civil war, the cases have been comparatively few. Idiopathic tetanus is rare in man, but it has sometimes followed exposure to cold or after sleep- ing on the damp ground. (Lockjaw.) TETANUS. 181 The infectious nature of tetanus was suggested by its endemic occur- rence and from the manner of its behavior in certain institutions. Vet- erinarians have long been of this belief, as cases are apt to occur together in horses in one stable. In the United States attention was early called to this feature by the prevalence of the disease in the eastern end of Long Island. The Tetanus Bacillus.—The observations of Rosenbach, Nicolai'er, and Kitasato have demonstrated that there is in connection with the disease a specific organism which can be isolated and cultivated. The bacillus forms a slender rod with rounded ends and may grow into long threads. It is motile, grows at ordinary temperatures, and is anaerobic. The bacilli de- velop at the site of the wound (and do not invade the blood and organs), where alone the toxine is manufactured. With small quantities of the cul- ture the disease may be transmitted to animals, which die with symptoms of tetanus. The poison is a tox-albumin of extraordinary potency, which has been separated by Brieger and Cohn in a state of tolerable purity. It is perhaps the most virulent poison known. Whereas the fatal dose of strychnine for a man weighing 70 kilos is from 30 to 100 milligrammes, that of the tetanus toxine is estimated at 0*23 milligrammes. Every fea- ture of the disease can be produced by it experimentally without the pres- ence of the bacilli. The symptoms do not develop immediately, as in the case of ordinary poisons, but slowly, and it has been suggested that it acts by producing a kind of fermentation. Another point of interest is the fact that immunity can be procured by inoculating an animal with the blood of another which has had the disease. The organism has been found in the earth and in putrefying fluids, and Nicolai'er has caused the disease by inoculating with different sorts of surface soil. Morbid Anatomy.—No characteristic lesions have been found in the cord or in the brain. Congestions occur in different parts, and peri- vascular exudations and granular changes in the nerve-cells have been found. The condition of the wound is variable. The nerves are often found injured, reddened, and swollen. In the tetanus neonatorum the umbilicus may be inflamed. Symptoms.—After an injury the disease sets in usually within ten days. In Yandell’s statistics in at least two fifths, and in Joseph Jones’s in four fifths, the symptoms occurred before the fifteenth day. The pa- tient complains at first of slight stiffness in the neck, or a feeling of tightness in the jaws, or difficulty in mastication. Occasionally chilly feelings or actual rigors may precede these symptoms. Gradually a tonic spasm of the muscles of these parts develops, producing the condition of trismus or lockjaw. The eyebrows may be raised and the angles of the mouth drawn out, causing the so-called sardonic grin—risus sardoni- cus. In children the spasm may be confined to these parts. Sometimes the attack is associated with paralysis of the facial muscles and difficulty in swallowing—the head tetanus of Rose, which has most commonly fol- 182 SPECIFIC INFECTIOUS DISEASES. lowed injuries in the neighborhood of the fifth nerve. Gradually the process extends and involves the muscles of the body. Those of the back are most affected, so that during the spasm the unfortunate victim may rest upon the head and heels—a position known as opisthotonos. The rectus abdominalis muscle has been torn across in the spasm. The en- tire trunk and limbs may be perfectly rigid—orthotonos. Flexion to one side is less common—pleurosthotonos ; while spasm of the muscles of the abdomen may cause the body to be bent forward—emprosthotonos. In very violent attacks the thorax is compressed, the respirations are rapid, and spasm of the glottis may occur, causing asphyxia. The paroxysms last for a variable period, but even in the intervals the relaxation is not complete. The slightest irritation is sufficient to cause a spasm. The paroxysms are associated with agonizing pain, and the patient may be held as in a vise, unable to utter a word. Usually he is bathed in a pro- fuse sweat. The temperature may remain normal throughout, or show only a slight elevation toward the close. In other cases the pyrexia is marked from the outset; the temperature reaches 105° or 106°, and be- fore death 109° or 110°. In rare instances the temperature may reach a still higher point. Death either occurs during the paroxysm from heart- failure or asphyxia, or is due to exhaustion. The cephalic tetanus (Kopftetanus of Rose) originates usually from a wound on one side of the head, and is characterized by stiffness of the muscles of the jaw and paralysis of the facial muscles on the same side as the wound, with difficulty of swallowing. The prognosis is good. In the chronic cases only eight of thirty-two died, but in the acute form, of forty- five cases, only four recovered (Willard). Diagnosis.—Well-developed cases following a trauma could not be mistaken for any other disease. The spasms are not unlike those of strychnia-poisoning, and in the celebrated Palmer murder trial this was the plea for the defence. The jaw-muscles, however, are never involved early, if at all, and between the paroxysms in strychnia-poisoning there is no rigidity. In tetany the distribution of the spasm at the extremi- ties, the peculiar position, the greater involvement of the hands, and the condition under which it occurs, are sufficient to make the diag- nosis clear. In doubtful cases cultures should be made from the pus of the wound. Prognosis.—Two of the Hippocratic aphorisms express tersely the general prognosis even at the present day: “ The spasm supervening on a wound is fatal,” and “ such persons as are seized with tetanus die within four days, or if they pass these they recover.” The mortality in the traumatic cases is not less than eighty per cent (Conner); in the idiopathic cases it is under fifty per cent. According to Yandell, the mortality is greatest in children. Favorable indications are: late onset of the attack, localization of the spasms to the muscles of the neck and jaw, and an absence of fever. TETANUS. 183 Treatment.—Local treatment of the wound is essential, as the poi- son is manufactured here. Tizzoni advises nitrate of silver as the best germicide for the tetanus bacillus. Thorough excision and antiseptic treatment should be carried out. The patient should be kept in a dark- ened room, absolutely quiet, and attended by only one person. All pos- sible sources of irritation should be avoided. Veterinarians appreciate the importance of this complete seclusion, and in well-equipped infirmaries there may be seen a brick padded chamber in which the horses are treated. When the lockjaw is extreme it may be impossible to feed the patient, under which circumstances it is best to use rectal injections, or to feed by a catheter passed through the nose. The spasm should be controlled by chloroform, which may be repeatedly given at intervals. It is more satis- factory to keep the patient thoroughly under the influence of morphia given hypodermically. Chloral hydrate, bromide of potassium, Calabar bean, curara, Indian hemp, belladonna, and other drugs have been recom- mended, and recovery occasionally follows their use. It is very difficult to estimate the value of the blood-serum therapy in this disease. Tizzoni and Cantani have used an antitoxine prepared from the blood-serum of immunized animals. The material, which is now to be obtained from Merck, is in the dried state, and comes in tubes containing four to five grammes. It can be obtained in this country from his agents. An anti- toxine serum is also prepared by Behring and by Roux. Of the fluid serum 20 to 30 c. c. may be used for the first dose and 15 to 20 c. c. every five or ten hours after. Tizzoni advises 2-25 grammes of his antitoxine for the first dose and 0*6 grammes for subsequent doses. According to Hewlett, of fifty cases treated with antitoxine, only sixteen died. Kanthack has made an elaborate analysis (Medical Chronicle, May, 1895) of all the recorded cases, fifty-four in number, with twenty deaths. He concludes that the method is still on trial, and that no really acute or otherwise hopeless case has yet been cured by it. 184 SPECIFIC INFECTIOUS DISEASES. XXVI. SYPHILIS. Definition.—A specific disease of slow evolution, propagated by inoculation (acquired syphilis), or by hereditary transmission (congenital syphilis). In the acquired form the site of inoculation becomes the seat of a special tissue change—primary lesion. After an interval of two or three months constitutional symptoms develop, with affections of the skin and mucous membranes—secondary lesions. And, finally, after a period of three, four, or more years, granulomatous growths develop in the viscera, muscles, bones, or skin—tertiary lesions. I. General Etiology and Morbid Anatomy. The nature of the virus is still doubtful. Lustgarten found in the hard chancre and in gummata a rod-shaped bacillus of 3 or 4 /x in length, which he claims is specific and peculiar to the disease. This organism closely resembles the smegma bacillus, which is found beneath the pre- puce, but from its occurrence in gummatous growths it is hardly possible that they can be identical. Further observations are required before the question can be considered settled. Syphilis is peculiar to man, and cannot be transmitted to the lower animals. All are susceptible to the contagion, and it occurs at all ages. Modes of Infection.— (1) In a large majority of all cases the disease is transmitted by sexual congress, but the designation venereal disease (lues venerea) is not always correct, as there are many other modes of inocula- tion. (2) Accidental Infection.—In surgical and in midwifery practice phy- sicians are not infrequently inoculated. It is surprising that infection from these sources is not more common. I have known personally of six cases. Midwifery chancres are usually on the fingers, but I have met with one instance on the back of the hand. The lip chancre is the most common of these erratic or extra-genital forms, and may be acquired in many ways apart from direct infection. Mouth and tonsillar sores result as a rule from improper practices. Wet-nurses are sometimes infected on the nipple, and it occasionally happens that relatives of the child are accidentally contaminated. One of the most lamentable forms of acci- dental infection is the transmission of the disease in humanized vaccine lymph. This, however, is extremely rare. The conditions under which it occurs have been already referred to (see Vaccination). (3) Hereditary Transmission.—This may be, and is, most common SYPHILIS. 185 from (a) the father, the mother being healthy (sperm inheritance). It is, unfortunately, an every-day experience to see cases of congenital syphilis in which the infection is clearly paternal. A syphilitic father may, how- ever, beget a healthy child, even when the disease is fresh and full-blown. On the other hand, in very rare instances, a man may have had syphilis when young, undergo treatment, and for years present no signs of disease, and yet his first-born may show very characteristic lesions. Happily, in a large majority of instances, when the treatment has been thorough, the offspring escape. The closer the begetting to the primary sore, the greater the chance of infection. A man with tertiary lesions may beget healthy children. As a general rule it may be said that with judicious treatment the transmissive power rarely exceeds three or four years. (b) Maternal transmission (germ inheritance). It is a remarkable and interesting fact that a woman who has borne a syphilitic child is her- self immune, and cannot be infected, though she may present no signs of the disease. This is known as Colles’s law, and was thus stated by the distinguished Dublin surgeon: “ That a child born of a mother who is without obvious venereal symptoms, and which, without being exposed to any infection subsequent to its birth, shows this disease when a few weeks old, this child will infect the most healthy nurse, whether she suckle it, or merely handle and dress it; and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue.” In a majority of these cases the mother has received a sort of protective inoculation, without having had actual manifestations of the disease. A woman with acquired syphilis is liable to bear infected children. The father may not be affected. In a large number of instances both parents are diseased, the one having infected the other, in which case the chances of foetal infection are greatly increased. (c) Placental transmission. The mother may be infected after con- ception, in which case the child may be, but is not necessarily, born syph- ilitic. Morbid Anatomy.—The primary lesion, or chancre, shows: (a) A dif- fuse infiltration of the connective tissue with small, round cells. (b) Larger epithelioid cells. (c) Giant cells. (d) The Lustgarten bacilli, in small numbers. (e) Changes in the small arteries, chiefly thickening of the intima, and alterations in the nerve-fibres going to the part (Berkeley). The sclerosis is due in part to this acute obliterative endarteritis. Asso- ciated with the initial lesions are changes in the adjacent lymph-glands, which undergo hyperplasia, and finally become indurated. The secondary lesioris of syphilis are too varied for description here. They consist of condylomata, skin eruptions, affections of the eye, etc. The tertiary lesions consist of circumscribed tumors known as gum- mata, and of an arteritis, which, however, is not peculiar to the disease. Gummata.—Syphilomata develop in the bones or periosteum—here 186 SPECIFIC INFECTIOUS DISEASES. they are called nodes—in the muscles, skin, brain, lung, liver, kidneys, heart, testes, and adrenals. They vary in size from small, almost micro- scopic, bodies to large, solid tumors from three to five centimetres in diam- eter. They are usually firm and hard, but in the skin and on the mucous membranes they tend to break down rapidly and ulcerate. On cross-sec- tion a medium-sized gumma has a grayish-white, homogeneous appear- ance, presenting in the centre a firm, caseous substance, and at the pe- riphery a translucent, fibrous tissue. Often there are groups of three or more surrounded by dense sclerotic tissue. They are usually very firm and hard. Histologically, a small gumma consists of a granulation tissue composed of rounded cells. Owing to insufficient blood-supply, coagula- tion necrosis takes place in the centre with the formation of a fibro-caseous material, while the growth extends at the margins with the gradual pro- duction of fibre-cells. Ultimately the central caseous part may be ab- sorbed, and healing takes place with the development of a fibrous scar. The arteritis will be considered in a separate section. II. Acquired Syphilis. Primary Stage.—This extends from the appearance of the initial sore until the onset of the constitutional symptoms, and has a variable dura- tion of from six to twelve weeks. The initial sore appears within a month after inoculation, and it first shows itself as a small red papule, which gradually enlarges and breaks in the centre, leaving a small ulcer. The tissue about this becomes indurated so that it ultimately has a gristly, car- tilaginous consistence—hence the name, hard or indurated chancre. The size attained is variable, and when small the sore may be overlooked, par- ticularly if it is just within the urethra. The glands in the lymph-district of the chancre enlarge and become hard. Suppuration both in the initial lesion and in the glands may occur as a secondary change. The general condition of the patient in this stage is good. There may be no fever and no impairment of health. Secondary Stage.—The first constitutional symptoms are usually mani- fested within three months of the appearance of the primary sore. They rarely develop earlier than the sixth or later than the twelfth week. The symptoms are: (a) Fever, slight or intense, and very variable in charac- ter. A mild continuous pyrexia is not uncommon, the temperature not rising above 101°. The fever may have a distinctly remittent character; but the most remarkable and puzzling type of syphilitic fever is the inter- mittent, which often leads to error in diagnosis. The fever may come on within a month after exposure and rise to 104° or 105°, with oscillations of five or six degrees (Yeo) A remarkable case is reported by Sidney Phillips, in which pyrexia persisted for months, with paroxysms resem- bling in all respects tertian ague, and which resisted quinine and yielded promptly to mercury and potassium iodide. Although usually a secondary manifestation, the fever of syphilis may occur late in the disease. SYPHILIS. 187 (b) Ancemia.—In many cases the syphilitic poison causes a pronounced anaemia which gives to the face a muddy pallor, and there may even be a light-yellow tingeing of the conjunctivae or of the skin, an haeinatogenous icterus. This syphilitic cachexia may in some instances be extreme. The red blood-corpuscles do not show any special alterations. The blood- count may fall to three millions per cubic millimetre, or even lower, and the haemoglobin to forty or fifty per cent (Hayem). No characteristic organisms have been found in the blood. {c) Cutaneous Lesions.—Skin eruptions of all forms may develop. The earliest and most common is a rash—macular syphilide or syphilitic roseola—which occurs on the abdomen, the chest, and on the front of the arms. The face is often exempt. The spots, which are reddish-brown and symmetrically arranged, persist for a week or two. Next in frequency is a papular syphilide, which may form acne-like indurations about the face and trunk, often arranged in groups. Other forms are the pustular rash, which may so closely simulate variola that the patient may be sent to a small-pox hospital. A squamous syphilide occurs, not unlike ordi- nary psoriasis, except that the scales are less abundant. The rash is more copper-colored and not specially confined to the extensor surfaces. In the moist regions of the skin, such as the perinaeum and groins, the axillae, between the toes, and at the angles of the mouth, the so-called mucous patches develop, which are flat, warty outgrowths, with well-defined margins and surfaces covered with a grayish secretion. They are among the most distinctive lesions of syphilis. Frequently the hair falls out (alopecia), either in patches or by a general thinning. Occasionally the nails become affected (syphilitic onychia). (d) Mucous Lesions.—With the fever and the roseolous rash the throat and mouth become sore. The pharyngeal mucosa is hypersemic, the ton- sils are swollen and often present small, kidney-shaped ulcers with gray- ish-white borders. Mucous patches are seen on the inner surfaces of the cheeks and on the tongue and lips. Sometimes on the tongue there are whitish spots (leucomata), which are seen most frequently in smokers, and which Hutchinson regards as the joint result of syphilitic glossitis and the irritation of hot tobacco-smoke. Hypertrophy of the papillae in various portions of the mucous membrane produces the syphilitic warts or condy- lomata which are most frequent about the vulva and anus. (e) Other Lesions.—Iritis is common, and usually affects one eye be- fore the other. It develops in from three to six months after the chancre. There may be only slight ciliary congestion in mild cases, but in severer forms there is great pain, and the condition is serious and demands care- ful management. Choroiditis and retinitis are rare secondary symptoms. Ear affections are not common in the secondary stage, but instances are found in which sudden deafness develops, which may be due to labyrinth- ine disease ; more commonly the impaired hearing is due to the extension 188 SPECIFIC INFECTIOUS DISEASES. of inflammation from the throat to the middle ear. Epididymitis and parotitis are occasional secondary lesions. Tertiary Stage.—No hard and fast line can be drawn between the lesions of the secondary and those of the tertiary period; and, indeed, in exceptional cases, manifestations which usually appear late may set in even before the primary sore has properly healed. The special affections of this stage are certain skin eruptions, gummatous growths in the viscera, and amyloid degenerations. (a) The late syphilides show a greater tendency to ulceration and destruction of the deeper layers of the skin, so that in healing scars are left. They are also more scattered and seldom symmetrical. One of the most characteristic of the tertiary syphilides is rupia, the dry stratified crusts of which cover an ulcer which involves the deeper layers of the skin and in healing leaves a scar. (b) Gummata.—These may develop in the skin, subcutaneous tissue, muscles, or internal organs. The general character has been already described. When they develop in the skin they tend to break down and ulcerate, leaving ugly sores which heal with difficulty. In the solid organs they undergo fibroid transformation and produce puckering and deformity. On the mucous membranes these tertiary lesions lead to ulceration, in the healing of which cicatrices are formed; thus, in the larynx great narrowing may result, and in the rectum ulceration with fibroid thickening and retraction may lead to stricture. (c) Amyloid Degeneration.—Syphilis plays a most important role in the production of this affection. Of 244 instances analyzed by Fagge, 76 had syphilis, and of these 42 had no bone lesions. It follows the acquired form and is very common in association with rectal syphilis in women. In congenital lues amyloid degeneration is rare. (d) Parasyphilitic Affections.—Certain disorders not actually syphi- litic, yet so closely connected that a large proportion of the cases have had the disease, are termed by Fournier parasyphilitic (Les Affections Parasyphilitiques, 1894). These affections are not exclusively and neces- sarily caused by syphilis, and they are not influenced by specific treatment. The chief of them are locomotor ataxia, dementia paralytica, certain types of epilepsy, and, we may add, arterio-sclerosis. With the exception of the primary sore, every feature of the acquired disease may be seen in the congenital form. The intra-uterine conditions leading to the death of the foetus do not here concern us. The child may be born healthy-looking, or with well- marked evidences of the disease. In the majority of instances the former is the case, and within the first month or two the signs of the disease appear. Symptoms.—(a) At Birth.—When the disease exists at birth the III. Congenital Syphilis. SYPHILIS. 189 child is feebly developed and wasted, and a skin eruption is usually present, commonly in the form of bullae about the wrists and ankles, and on the hands and feet (pemphigus neonatorum). The child snuffles, the lips are ulcerated, the angles of the mouth fissured, and there is en- largement of the liver and spleen. The bone symptoms may be marked, and the epiphyses may even be separated. In such cases the children rarely survive long. (t>) Early Manifestations.—When born healthy the child thrives, is fat and plump, and shows no abnormity whatever; then from the fourth to the eighth week, rarely later, a nasal catarrh develops, syphilitic rhinitis, which impedes respiration, and produces the characteristic symptom which has given the name snuffles to the disease. The dis- charge may be sero-purulent or bloody. The child nurses with great difficulty. In severe cases ulceration takes place with necrosis of the bone, leading to a depression at the root of the nose and a deformity characteristic of congenital syphilis. This coryza may be mistaken at first for an ordinary catarrh, but the coexistence of other manifestations usually makes the diagnosis clear. The disease may extend into the Eustachian tubes and middle ears and lead to deafness. The cutaneous lesions develop with or shortly after the onset of the snuffles. The skin often has a sallow, earthy hue. The eruptions are first noticed about the nates. There may be an erythema or an eczematous condition, but more commonly there are irregular reddish-brown patches with well-defined edges. A papular syphilide in this region is by no means uncommon. Fissures develop about the lips, either at the angles of the mouth or in the median line. These rhagades, as they are called, are very characteristic. There may be marked ulceration of the muco- cutaneous surfaces. The secretions from these mouth lesions are very virulent, and it is from this source that the wet-nurse is usually infected. Not only the nurse, but members of the family, may be contaminated. There are instances in which other children have been accidentally inocu- lated from a syphilitic infant. The hair of the head or of the eyebrows may fall out. The syphilitic onychia is not uncommon. Enlargement of the glands is not so frequent in the congenital as in the acquired disease. When the cutaneous lesions are marked, the contiguous glands can usually be felt. As pointed out by Gee, the spleen is enlarged in many cases. The condition may persist for a long time. Enlargement of the liver, though often present, is less significant, since in infants it may be due to various causes. These are among the most constant symptoms of con- genital syphilis, and usually develop between the third and twelfth weeks. Frequently they are preceded by a period of restlessness and wake- fulness, particularly at night. Some authors have described a peculiar syphilitic cry, high-pitched and harsh. Among rarer manifestations are haemorrhages—the syphilis hcemorrhagica neonatorum. The bleeding may be subcutaneous, from the mucous surfaces, or, when early, from the 190 SPECIFIC INFECTIOUS DISEASES. umbilicus. All of such cases, however, are not syphilitic, and the disease must not be confounded with the acute haemoglobinuria of new-born in- fants, which Winckel describes as occurring in epidemic form, and which is probably an acute infectious disorder. (c) Late Manifestations.—Children with congenital syphilis rarely thrive. Usually they present a wizened, wasted appearance, and a pre- maturely aged face. In the cases which recover, the general nutrition may remain good and the child may show no further manifestations of the disease; commonly, however, at the period of second dentition or at puberty the disease reappears. Although the child may have recovered from the early lesions, it does not develop like other children. Growth is slow, development tardy, and there are facial and cranial characteristics which often render the disease recognizable at a glance. A young man of nineteen or twenty may neither look older nor be more developed than a boy of ten or twelve. Fournier describes this condition as infantilism. The forehead is prominent, the frontal eminences are marked, and the skull may be very asymmetrical. The bridge of the nose is depressed, the tip retrousse. The lips are often prominent, and there are striated lines running from the corners of the mouth The teeth are deformed and may present appearances which Jonathan Hutchinson claims are specific and peculiar. The upper central incisors of the permanent set are the teeth which give information. The specific alterations are—the teeth are peg-shaped, stunted in length and breadth, and narrower at the cutting edge than at the root. On the anterior surface the enamel is well formed, and not eroded or honeycombed. At the cutting edge there is a single notch, usually shallow, sometimes deep, in which the dentine is exposed. Among late manifestations, particularly apt to appear about puberty, is the interstitial keratitis, which usually begins as a slight steaminess of the corneas, which present a ground-glass appearance. It affects both eyes, though one is attacked before the other. It may persist for months, and usually clears completely, though it may leave opacities, which pre- vent clear vision. Iritis may also occur. Of ear affections, apart from those which develop as a sequence of the pharyngeal disease, a form occurs about the time of puberty or earlier, in which deafness comes on rapidly and persists in spite of all treatment. It is unassociated with obvious lesions, and is probably labyrinthine in character. Bone lesions, occurring oftenest after the sixth year, are not rare among the late manifestations of hereditary syphilis. The tibiae are most frequently attacked. It is really a chronic gummatous periostitis, which gradually leads to great thicken- ing of the bone. The nodes of congenital syphilis, which are often mis- taken for rickets, are more commonly diffuse and affect the bones of the upper and lower extremities. They are generally symmetrical and rarely painful. They may develop late, even after the twenty-first year. Joint lesions are rare. Clutton has described a symmetrical synovitis SYPHILIS. 191 of the knee in hereditary syphilis. Enlargement of the spleen, sometimes with the lymph-glands, may be one of the late manifestations, and may occur either alone or in connection with disease of the liver. At the University Hospital, Philadelphia, I had under observation for more than a year a girl of thirteen, small and feebly developed, with a luetic facies, whose spleen reached as low as the level of the navel. The condition was not thought to be due to inherited syphilis until she developed osseous lesions. Chronic enlargement of the salivary glands may also occur. Gummata of the liver, brain, and kidneys have been found in late hereditary syphilis. IV. Visceral Syphilis. a. Syphilis of the Brain and Cord.—The following lesions occur: (1) Gummata, forming definite tumors, ranging in size from a pea to a walnut. They are usually multiple and attached to the pia mater, some- times to the dura. Very rarely they are found unassociated with the meninges. When small they present a uniform, translucent appearance, but when large the centre undergoes a fibro-caseous change, while at the periphery there is a firm, translucent, grayish tissue. They may closely resemble large tuberculous tumors. The growths are most common in the cerebrum. They may be multiple and may even attain a consid- erable size without becoming caseous. Occasionally gummata undergo cystic degeneration. In the cord large gummatous growths are not so common. In an instance recently reported by me a tumor, from three eighths to one fourth of an inch in diameter, was completely within the cord opposite the fourth cervical nerve, and there were numerous gum- mata in the cauda equina. (2) Gummatous Meningitis.—This constantly occurs in the neighbor- hood of the larger growths, and there may be local meningeal thickening several centimetres in extent, in which the pia is infiltrated and the ar- teries greatly thickened. This by no means uncommon form may run a subacute or a chronic course. (3) Gummatous Arteritis.—The lesions may be confined to the arteries which present the nodular tumors to be described hereafter. (4) Foci of sclerosis, which Lancereaux holds may be distinguished from non-specific forms by a much greater tendency of the neuroglia ele- ments to undergo fatty transformation, and by the secondary alterations, as areas of softening, which occur in the neighborhood. Neither the dif- fuse nor the nodular cerebral sclerosis, met with particularly in children, appears to have any special relation to inherited syphilis. (5) Whether a localized encephalitis or myelitis can result from the action of the syphilitic poison without involvement of the blood-vessels is doubtful. In a case of multiple arterial gummata recently in my ward, Thomas found in the lumbar region of the cord foci of inflammatory soft- ening. 192 SPECIFIC INFECTIOUS DISEASES. Secondary Changes.—In the brain gummatous arteritis is one of the common causes of softening, which may be extensive, as when the middle cerebral artery is involved, or when there is a large patch of syphilitic meningitis. In such instances the process is really a meningo-encepha- litis, and the symptoms are due to the secondary changes in the brain-sub- stance, not directly to the gumma. In the neighborhood of a gummatous growth intense encephalitis or myelitis may develop, and within a few days change the clinical picture. Gummatous arteritis may lead to weak- ening of the wall of the vessel and rupture with meningeal haemorrhage. Syphilitic disease of the nerve-centres may occur in the inherited or acquired form, most commonly in the latter. In the congenital cases the tumors usually develop early, but may be as late as the twenty-first year (Ii. 0. Wood). In the acquired form the nerve lesions belong, as a rule, to the late manifestations, and patients may have quite forgotten the ex- istence of a primary infection, and in very many instances the secondary manifestations have been slight. Heubner, to whom we owe so much in connection with this subject, has seen them as late as the thirtieth year. On the other hand, in exceptional instances, they may occur very early, and severe convulsions with hemiplegia have been reported within three months of the primary sore. The recent discussion at the Royal Medical and. Chirurgical Society (B. M. J., 1895, vol. i), and Lydston’s paper {Jour. Am. Med. Assoc., 1895, vol. i), show that various affections of the nervous sys- tem are by no means uncommon during the secondary stage of the disease. Symptoms.—The chief features of cerebral syphilis are those of tumor, which will be considered subsequently under that section. They may be classified here as follows : (1) Psychical features. A sudden and violent onset of delirium may be the first symptom. In other instances prior to the occurrence of delirium there have been headache, alteration of character, and loss of memory. The condition may be accompanied by convulsions. There may be no neuritis, no palsy, and no localizing symptoms. (2) More commonly following headache, giddiness, or an excited state which may amount to delirium, the patient has an epileptic seizure or de- velops hemiplegia, or there is involvement of the nerves of the base. Some of these cases display a prolonged torpor, a special feature of brain syphi- lis to which both Buzzard and Heubner have referred, which may persist for as long as a month. II. C. Wood describes with this a state of au- tomatism occurring particularly at night, in which the patient behaves like “ a restless nocturnal automaton rather than a man.” (3) A clinical picture of general paralysis—dementia paralytica. The question is still in dispute whether this syphilitic encephalopathy, which so closely resembles general paralysis, is a distinct and independent affec- tion. Mickle, who has carefully reviewed the subject, concludes that syphilis may directly produce the inflammatory changes in the brain, while in other instances it directly predisposes to this affection. It is a some- SYPHILIS. 193 what remarkable feature that the cases which present the clinical picture of general paresis are most frequently those which have not had any local- izing symptoms, and they may not have convulsions until the disease is well advanced. (4) Many cases of cerebral syphilis display the symptoms of brain tumor—headache, optic neuritis, vomiting, and convulsions. Of these symptoms convulsions are the most important, and both Fournier and Wood have laid great stress on the value of this symptom in persons over thirty. The first symptoms may, however, rather resemble those of em- bolism or thrombosis; thus there may be sudden hemiplegia, with or without loss of consciousness. The symptoms of spinal syphilis are extremely varied and may be caused by large gummatous growths attached to the meninges, in which case the features are those of tumor; by gummatous arteritis with second- ary softening; by meningitis with secondary cord changes; or by scleroses developing late in the disease, the relation of which to syphilis is still ob- scure. A full resume by Mickle of the recent progress in this department will be found in Brain of the current year. Erb’s syphilitic myelitis will be considered under the spastic paraplegias. Diagnosis.—The history is of the first importance, but it may be ex- tremely difficult to get a reliable account. Careful examination should be made for traces of the primary sore, for the cicatrices of bubo, for scars of the skin eruption or throat ulcers, and for bone lesions. The character of the symptoms is often of great assistance. They are multiform, vari- able, and often such as could not be explained by a single lesion; thus there may be anomalous spinal symptoms or involvement of the nerves of the brain on both sides. And lastly the result of treatment has a definite bearing on the diagnosis, as the symptoms may clear up and disappear with the use of antisyphilitic remedies. b. Syphilis of the Lung. This is a very rare disease. During twenty years I have not seen more than half a dozen specimens in which there was no question as to the nature of the trouble. Early in my professional life I learned to recognize the disease from the teaching of Wilks, and became familiar with the ex- cellent specimens preserved at Guy‘s Hospital. In my ten years’ work in Montreal not a single specimen was recognized at the dissections at the General Hospital. In 1878 and 1884 I saw several characteristic examples in London and Germany. During five years in Philadelphia, for the greater part of which time I was connected with the Philadelphia Hospi- tal, which has perhaps as rich luetic material as is to be found anywhere, only one or two specimens were seen. Three admirable illustrations of pulmonary gummata have occurred at the Johns Hopkins Hospital during the past two years. I mention these details because the subject is one which has always interested me, and I have been constantly on the lookout for the disease. It has been a continual surprise that it should be so com- 194 SPECIFIC INFECTIOUS DISEASES. mon in certain localities, but I find that my experience as to its compara- tive rarity tallies very closely with that of pathologists and hospital physi- cians in this country and in Europe. The literature of the subject is extensive, but from the clinical aspect largely worthless, as it preceded Koch’s discovery of the bacillus tuberculosis. Etiology and Morbid Anatomy.—Syphilis of the lung occurs under the following forms: (1) The white pneumonia of the foetus. This may affect large areas or an entire lung, which then is firm, heavy and airless, even though the child may have been horn alive. On section it has a grayish-white appear- ance—the so-called white hepatization of Virchow. The chief change is in the alveolar walls, which are greatly thickened and infiltrated, so that, as Wagner expressed it, the condition resembles a diffuse syphiloma. In the early stages, for example, in a seven or eight months’ foetus, there may be scattered miliary foci of this induration chiefly about the arteries. The air-cells are filled with desquamated and swollen epithelium. (2) In the form of definite gummata, which vary in size from a pea to a goose-egg. They occur irregularly scattered through the lung, hut, as a rule, are more numerous toward the root. They present a grayish-yellow caseous appearance, are dry and usually imbedded in a translucent, more or less firm, connective tissue. In a case from my wards recently described by Councilman, there was extensive involvement of the root of the lungs. Bands of connective tissue passed inward from the thickened pleura and between these strands and surrounding the gummata there was in places a mottled red pneumonic consolidation. In the caseous nodules there is typical hyaline degeneration. Councilman describes as the primary lesion, atrophy of the alveolar walls with hyaline degeneration of the capil- laries ; not the syphilitic endarteritis, which is well marked, and to which the lesions are attributed. The bronchi are usually involved, and sur- rounding the gummata there may be a diffuse broncho-pneumonia, which does not appear to have any peculiar characters. (3) A majority of authors follow Virchow in recognizing the fibrous interstitial pneumonia at the root of the lung and passing along the bron- chi and vessels as probably syphilitic. This much may be said, that in cer- tain cases gummata are associated with these fibroid changes. Again, this condition alone is found in persons with well-marked syphilitic history or with other visceral lesions. It seems in many instances to be a purely sclerotic process, advancing sometimes from the pleura, more commonly from the root of the lung, and invading the interlobular tissue, gradually producing a more or less extensive fibroid change. It rarely involves more than a portion of a lobe or portions of the lobes at the root of the lung. The bronchi are often dilated. Symptoms.—Is there a syphilitic phthisis, an ulcerative and destruc- tive disease, due to lues ? Personally I have no knowledge of such an affection, either clinically or anatomically, and the cases which I have seen SYPHILIS. 195 demonstrated do not seem to me to have characters distinctive enough to separate them from ordinary tuberculous phthisis. Certain French writers recognize not only a chronic syphilitic phthisis but an acute syphilitic pneumonia in adults, simulating acute pneumonic phthisis. Clinically, pulmonary syphilis is not of much importance, as the cases can rarely be diagnosed, and the symptoms which arise are usually those of bronchi- ectasis or of chronic interstitial pneumonia. The white pneumonia is usually found in the still-born. Diagnosis.—It is to be borne in mind, in the first place, that hospital physicians and pathologists the world over bear witness to the extreme rarity of lung syphilis. In the second place, the therapeutic test upon which so much reliance is placed is by no means conclusive. With pul- monary tuberculosis there should now be no confusion, owing to the readi- ness with which the presence of bacilli is determined. Bronchiectasy in the lower lobe of a lung, dependent upon an interstitial pneumonia of syphilitic origin, could not be distinguished from any other form of the disease. In persons with well-marked syphilitic lesions elsewhere, when obscure pulmonary symptoms occur, or if there are signs of chronic inter- stitial pneumonia with dilated bronchi, and no tubercle bacilli are present, the condition may possibly be due to syphilis. So far as my experience goes, tuberculous phthisis occurring in a syphilitic subject has no special peculiarities. The lesions of syphilis and tuberculosis could of course co- exist in a lung. Since writing the above, the recent paper of Satterthwaite has appeared, but not one of the cases upon which it is based could prop- erly be regarded as syphilitic in the absence of an examination for tuber- cle bacilli. Much more suggestive of true syphilitic phthisis is Case I of McLane Tiffany’s series, but it too may have been tuberculous. It is quite possible that a large caseous gumma may break down and form a cavity, but the existence of an extensive ulcerative and destructive disease of the lungs (comparable to tuberculosis) due to syphilis has not yet been proved. c. Syphilis of the Liver. This occurs in three forms : (a) Diffuse Syphilitic Hepatitis.—This is most common in cases of congenital syphilis. The liver preserves its form, is large, hard, and resistant. Sometimes it has a yellow look, com- pared by Trousseau to sole-leather, or an appearance not unlike the amy- loid liver. Careful inspection shows grayish or whitish points and lines corresponding to the interlobular new growth. Microscopically, great increase in the connective tissue is seen, and in many places foci of small- celled infiltration. Sometimes these nodules are visible, forming firm miliary gummata which in cicatrizing produce more or less deformity. Larger gummata may also be present. (b) Gummata.—As a result of congenital syphilis these may occur in childhood or in adult life. In acquired syphilis they rarely come on be- fore the second year after infection. In the early stage there are pale 196 SPECIFIC INFECTIOUS DISEASES. grayish nodules, varying in size from a pea to a marble. The larger, which are usually limited toward the liver tissue, present yellowish cen- tres at first; but later there is a “ pale yellowish, cheese-like nodule of irregular outline, surrounded by a fibrous zone, the outer edge of which loses itself in the lobular tissue, the lobules dwindling gradually in its grasp. This fibrous zone is never very broad; the cheesy centre varies in consistence from a gristle-like toughness to a pulpy softness; it is some- times mortar-like, from cretaceous change ” (Wilks). When numerous, the most extensive deformity of the liver is produced in the gradual heal- ing of these gummata. On the surface there are deep, scar-like depres- sions, and the entire organ may be divided into a cluster of irregular masses, held together by fibrous tissue. To this condition the term boty- roid has been given, from its resemblance to a bunch of grapes. As a rule, the gummata gradually undergo fibroid transformation. They may, however, soften and liquefy, and, according to Wilks, may form a fluctu- ating tumor. (c) Occasionally the syphilitic changes are chiefly manifested in Glis- son's sheath, in a thickening of the capsule, producing peri-liepatitis, and increase in the connective tissue in the portal canals, so that on section the organ presents a number of branching fibrous scars which may cause considerable deformity. Symptoms.—The symptoms of syphilitic hepatitis are very variable. In the new-born icterus is not uncommon, but the condition of the liver can scarcely be recognized. In the adult there are two groups of cases : The patient presents a picture of cirrhosis of the liver; there are digestive disturbances, slight icterus, loss of weight, and ascites. If signs of syphilis are present in other organs, the condition may be suspected, or if after removal of the fluid the liver is felt to be extremely irregular, the diagnosis may be made almost with certainty. These cases, with proper treatment, may get well, and they form an important contingent of the reputed recoveries in ordinary cirrhosis of the liver. In a second group of cases the patient is anasmic, passes large quan- tities of pale urine containing albumen and tube-casts; the liver is en- larged, perhaps irregular, and the spleen also is enlarged. Dropsical symp- toms may supervene, or the patient may be carried off by some intercurrent disease. Extensive amyloid degeneration of the spleen, the intestinal mu- cosa, and of the liver, with gummata, are found. The diagnosis of syphilis of the liver is very important, since upon it the proper treatment depends. If with a history of infection the liver is enlarged and irregular, and the general health fairly good, the con- dition is probably syphiloma. Occasionally tumors of a definite form may be produced by the gummata. For two years I showed repeatedly, at my clinic at the University Hospital, Philadelphia, a boy aged eleven, who had a prominent tumor in the epigastrium connected with the liver, the nature of which was obscure until well-marked bone-lesions developed. SYPHILIS. 197 In another case, a man, aged thirty, was sent to me for advice concerning the making of an exploratory incision to determine the nature of a firm, irregular tumor which occupied the epigastric region, and was evidently connected with the left lobe of the liver. It had lasted for more than a year, had increased slightly, and had not impaired, to any marked degree, the general health. This fact, together with a well-marked history of acquired syphilis, led me to place him upon a rigid antisypliilitic treat- ment, with the result that within six months the entire tumor disapjseared. d. Syphilis of the Digestive Tract. The oesophagus is very rarely affected. Stenosis is the usual result. Gummata of the stomach occur occasionally. Syphilitic ulceration has been found in the stomach, in the small intestine, and in the caecum. The most common seat of syphilitic disease in this tract is the rectum. The affection is found most commonly in women, and results from the development of gummata in the submucosa above the internal sphincter. The process is slow and tedious, and may last for years before it finally induces stricture. The symptoms are usually those of narrowing of the lower bowel. The condition is readily recognized by rectal examination. The history of gradual on-coming stricture, the state of the patient, and the fact that there is a hard, fibrous narrowing, not an elevated crater-like ulcer, usually render easy the diagnosis from malignant disease. In medi- cal practice these cases come under observation for other symptoms, par- ticularly amyloid degeneration; and the rectal disease may be entirely overlooked, and only discovered post mortem. e. Circulatory System. Syphilis of the Heart.—A. fresh, warty endocarditis due to syphilis is not recognized, though occasionally in persons dead of the disease this form is present, as is not uncommon in conditions of debility. Outgrowths on the valves in connection with gummata have been reported by Jane way and others, and in Lang’s * monograph there are thirteen cases which he reports as syphilitic endocarditis, most of them of the fibrous or sclerotic variety. . Syphilitic myocarditis appears either in the form of diffuse fibroid in- duration or as definite gummata. Lang has collected many cases from the literature, a majority of which were of the former description. Gummata, however, occur not infrequently as definite and characteristic tumors in the myocardium. Rupture may take place, as in the cases reported by Dandridge and Nalty, or sudden death, as in the cases of Cayley and Pearce Gould. Syphilis of the Arteries.—Syphilis is believed to play an important role in arterio-sclerosis and aneurism. Its connection with these processes will be considered later; here we shall refer only to the syphilitic arteri- tis. This occurs in two forms : * Die Syphilis des Herzens, Wien, 1889. 198 SPECIFIC INFECTIOUS DISEASES. (a) An obliterating endarteritis, characterized by a proliferation of the subendothelial tissue. The new growth lies within the elastic lamina, and may gradually fill the entire lumen; hence the term obliterating. The media and adventitia are also infiltrated with small cells. This form of endarteritis described by Heubner is not, however, characteristic of syphi- lis, and its presence alone in an artery could not be considered pathog- nomonic. If, however, there are gummata in other parts, or if the con- dition about to be described exists in adjacent arteries, the process may be regarded as syphilitic. (£) Gummatous Peri-arteritis.—With or without involvement of the intima, nodular gummata may develop in the adventitia of the artery, producing globular or ovoid swellings, which may attain considerable size. They are not infrequently seen in the cerebral arteries, which seem to be specially prone to this affection. This form is specific and distinctive of syphilis. The disease usually affects the smaller vessels and may be found in the coronary arteries, and particularly in those of the brain. f. Renal Syphilis.—Gummata occasionally develop in the kidneys, particularly in cases in which there is extensive gummatous hepatitis. They are rarely numerous, and occasionally lead to scattered cicatrices. Clinically the affection is not recognizable. g. Syphilitic Orchitis.—This affection is of special significance to the physician, as its detection frequently clinches the diagnosis in obscure internal disorders. Syphilis occurs in the testes in two forms: (a) The gummatous growth, forming an indurated mass or group of masses in the substance of the organ, and sometimes difficult to distin- guish from tuberculous disease. The area of induration is harder and it affects the body of the testes, while tubercle more commonly involves the epididymis. It rarely tends to invade the skin, or to break down, soften, and suppurate, and is usually painless. (h) There is an interstitial orchitis regarded as syphilitic, which leads to fibroid induration of the gland and gradually to atrophy. It is a slow, progressive change, coming on without pain, usually involving one organ more than another. General Diagnosis of Syphilis.—There is seldom any doubt concerning the existence of syphilitic lesions. The negative statements of the patient must be taken with extreme caution, as persons will lie deliberately with reference to primary infection, when it is in their best interest to make a straightforward truthful statement. It is to be re- membered that syphilis is common in the community, and there are prob- ably more families with a luetic than with a tuberculous taint. It is pos- sible that the primary sore may have been of trifling extent, or urethral and masked by a gonorrhoea, and the patient may not have had severe secondary symptoms, but such instances are extremely rare. Inquiries should be made into the history to ascertain if the patient has had skin rashes, sore throat, or if the hair has fallen out. Careful inspection should SYPHILIS. 199 be made of the throat and skin for signs of old lesions. Scars in the groins, the result of buboes, may be taken as positive evidence of infec- tion (Hutchinson). The cicatrices on the legs are often copper-colored, though this cannot be regarded as peculiar to syphilis. The bones should be examined for nodes. In doubtful cases the scar of the primary sore may be found, or there may be signs of atrophy or of hardening of the testes. In women, special stress has been laid upon the occurrence of frequent miscarriages, which, in connection with other circumstances, are always suggestive. In the congenital disease, the occurrence within the first three months of snuffles and skin rashes is conclusive. Later, the characters of the syphilitic facies, already referred to, often give a clew to the nature of some obscure visceral lesion. Other distinctive features are the symmetrical de- velopment of nodes on the bones, and the interstitial keratitis. In doubtful cases much stress is laid by some writers upon the thera- peutic test, by placing the patient upon antisyphilitic treatment. In the case of an obstinate skin rash of doubtful character, which has resisted all other forms of medication, this has much greater weight than in obscure visceral lesions. I have on several occasions known such marked im- provement to follow large doses of iodide of potassium that the diagnosis of syphilitic lesion was greatly strengthened, but the subsequent course and the post-mortem have shown that the disease was not syphilis. Prophylaxis.—Irregular intercourse has existed from the begin- ning of recorded history, and unless man’s nature wholly changes— and of this we can have no hope—will continue. Resisting all attempts at solution, the social evil remains the great blot upon our civilization, and inextricably blended with it is the question of the prevention of syphi- lis. Two measures are available—the one personal, the other adminis- trative. Personal purity is the prophylaxis which we, as physicians, are espe- cially bound to advocate. Continence may be a hard condition (to some harder than to others), but it can be borne, and it is our duty to urge this lesson upon young and old who seek our advice in matters sexual. Cer- tainly it is better, as St. Paul says, to marry than to burn, but if the former is not feasible there are other altars than those of Venus upon which a young man may light fires. He may practise at least two of the five means by which, as the physician Rondibilis counselled Panurge, carnal concupiscence may be cooled and quelled—hard work of body and hard work of mind. Idleness is the mother of lechery; and a young man will find that absorption in any pursuit will do much to cool passions which, though natural and proper, cannot in the exigencies of our civilization always obtain natural and proper gratification. The second measure is a rigid and systematic regulation of prostitu- tion. The state accepts the responsibility of guarding citizens against small-pox or cholera, but in dealing with syphilis the problem has been 200 SPECIFIC INFECTIOUS DISEASES. too complex and has hitherto baffled solution. On the one hand, inspec- tion, segregation, and regulation are difficult if not impossible to carry out; on the other hand, public sentiment, in Anglo-Saxon communities at least, is as yet bitterly opposed to this plan. While this feeling, though unreasonable, as I think, is entitled to consideration, the choice lies be- tween two evils—licensing, even imperfectly carried out, or wide-spread disease and misery. If the offender bore the cross alone, I would say, forbear; but the physician behind the scenes knows that in countless in- stances syphilis has wrought havoc among innocent mothers and helpless infants, often entailing life-long suffering. It is for them he advocates protective measures. Treatment.—We must admit that various constitutions react very differently to the poison of syphilis. There are individuals who, although receiving brief and unsatisfactory treatment, display for years no traces of the disease. On the other hand, there are persons thoroughly and sys- tematically treated from the outset who display from time to time well- marked indications of the disease. Certainly there are grounds for the opinion that persons who have suffered very slightly from secondary symptoms are more prone to have the severer visceral lesions of the later stage. When we consider that syphilis is one of the most amenable of all dis- eases to treatment, it is lamentable that the later stages which come under the charge of the physician are so common. This results, in great part, from carelessness of the patient, who, wearied with treatment, cannot un- derstand why he should continue to take medicine after all the symptoms have disappeared; but, in part, the profession also is to blame for not insisting more urgently in every instance that acquired syphilis is not cured in a few months, but takes at least two years, during which time the patient should be under careful supervision. The treatment of the disease is now practically narrowed to the use of two remedies, justly termed specifics—namely, mercury and iodide of potassium. The former is of special service in the secondary, the latter in the tertiary manifesta- tions of the disease; but they are often combined with advantage. Mercury may be given by the mouth in the form of gray powder, the hydrargyrum cum creta, which Hutchinson recommends to be given in pills, one-grain dose with a grain of Dover’s powder. One pill from four to six times a day will usually suffice. I warmly endorse the excellent results which are obtained by this method, under which the patient often gains rapidly in weight, and the general health improves remarkably. It may be continued for months without any ill effects. Other forms given by the mouth are the pilules of the biniodide (gr. or of the protiodide (gr. three times a day. Inunction is a still more effective means. A drachm of the ordinary mercurial ointment is thoroughly rubbed into the skin every evening for six days; on the seventh a warm bath is taken, and on the eighth the mer- SYPHILIS. 201 curial course is resumed. At least half an hour should he given to each inunction. It is well to apply it at different places on successive days. The sides of the chest and abdomen and the inner surfaces of the arms and thighs are the best positions. The mercury may be given by direct injection into the muscles. If proper precautions are taken in sterilizing the syringe, and if the injec- tions are made into the muscles, not into the subcutaneous tissue, ab- scesses rarely result. One third of a grain of the bichloride in twenty drops of water may be injected once a week, or from one to two grains of calomel in glycerin (20 minims). Still another method, greatly in vogue in certain parts of the Continent and in institutions, is fumigation. It may be carried out effectively by means of Lee’s lamp. The patient sits on a chair wrapped in blankets, with the head exposed. The calomel is volatilized and deposited with the vapor on the patient’s skin. The process lasts about twenty minutes, and the patient goes to bed wrapped in blankets without washing or dry- ing the skin. A patient under mercurial treatment should avoid stimu- lants and live a regular life, not necessarily abstaining from business. Green vegetables and fruit should not be taken. Salivation is to be avoided. The teeth should be cleansed twice a day, and if the gums be- come tender, the breath fetid, or the tongue swollen and indented, the drug should be suspended for a week or ten days. In congenital syphilis the treatment of cases born with bullae and other signs of the disease is not satisfactory, and the infants usually die within a few days or weeks. The child should be nursed by the mother alone, or, if this is not feasible, should be hand-fed, but under no circumstances should a wet-nurse be employed. The child is most rapidly and thor- oughly brought under the influence of the drug by inunction. The mer- curial ointment may be smeared on the flannel roller. This is not a very cleanly method, and sometimes rouses the suspicion of the mother. It is preferable to give the drug by the mouth, in the form of gray powder, half a grain three times a day. In the late manifestations associated with bone lesions, the combination of mercury and iodide of potassium is most suitable and is well given in the form of Gilbert’s syrup, which consists of the biniodide of mercury (gr. j), of potassium iodide ( f ss.), and water (1 ij). Of this a dose for a child under three is from five to ten drops three times a day, gradually increased. Under these measures, the cases of congenital syphilis usually improve with great rapidity. The medication should be continued at intervals for many months, and it is well to watch these patients carefully during the period of second dentition and at puberty, and if necessary to place them on specific treatment. In the treatment of the visceral lesions of syphilis, which come more distinctly within the province of the physician, iodide of potassium is of equal or even greater value than mercury. Under its use ulcers rapidly heal, gummatous tumors melt away, and we have an illustration of a spe- 202 SPECIFIC INFECTIOUS DISEASES. cific action only equalled by that of mercury in the secondary stages, by iron in certain forms of anaemia, and by quinine in malaria. It is as a rule well borne in an initial dose of ten grains, or ten minims of the satu- rated solution; given in milk the patient does not notice the taste. It should be gradually increased to thirty or more grains three times a day. In syphilis of the nervous system it may be used in still larger doses. Seguin, who has specially insisted upon the advantage of this plan, urges that the drug should be pushed, as good effects are not obtained with the moderate doses. When syphilitic hepatitis is suspected the combination of mercury and iodide of potassium is most satisfactory. If there is ascites, Addison’s or Niemeyer’s pill (as it is often called) of calomel, digitalis, and squills will be found very useful. A patient of mine with recurring ascites, on whom paracentesis was repeatedly performed and who had an enlarged and irregu- lar liver, took this pill for more than a year with occasional intermissions, and ultimately there was a complete disappearance of the dropsy and an extraordinary reduction in the volume of the liver. Occasionally the iodide of sodium is more satisfactory than the iodide of potassium. It is less depressing and agrees better with the stomach. Many patients possess a remarkable idiosyncrasy to the iodide, but as a rule it is well borne. Severe coryza with salivation, and oedema about the eyelids, are its most common disagreeable effects. Skin eruptions also are frequent. I have known patients unable to take more than from twenty to thirty grains without suffering from an erythematous rash; much more common is the acne eruption. Occasionally an urticarial rash may develop with spots of purpura. Some of these iodide eruptions may closely resemble syphilis. Hutchinson has reported instances in which they have proved fatal. Upon the question of syphilis and marriage the family physician is often called to decide. He should insist upon the necessity of two full years elapsing between the date of infection and the contracting of mar- riage. This, it should bp borne in mind, is the earliest possible limit, and there should be at least a year of complete immunity from all manifesta- tions of the disease. In relation to life insurance, an individual with syphilis can not be regarded as a first-class risk unless he can furnish evidence of prolonged and thorough treatment and of immunity for two or three years from all manifestations. Even then, when we consider the extraordinary frequency of the cerebral and other complications in persons who have had this dis- ease and who may even have undergone thorough treatment, the risk to the company is certainly increased. TUBERCULOSIS. 203 XXVII. TUBERCULOSIS. I. General Etiology and Morbid Anatomy. Definition.—An infective disease, caused by the bacillus tuberculosis, the lesions of which are characterized by nodular bodies called tubercles or diffuse infiltrations of tuberculous tissue which undergo caseation or sclerosis and may finally ulcerate, or in some situations calcify. Etiology.—1. Zoological Distribution.—Tuberculosis is one of the most wide-spread of maladies. In cold-blooded animals it is rare, owing doubtless to temperature conditions unfavorable to the development of the bacillus. Among rep- tiles in confinement it is, however, occasionally seen (Sibley). In fowls it is an extremely common disease, but recent facts indicate that there are differences in avian tuberculosis sufficient to warrant its separation from the ordinary form. Among domestic animals tuberculosis is 'widely but unevenly dis- tributed. Among ruminants, bovines are chiefly affected. The percent- age for oxen and cows at the Berlin abattoir in the year 1892-’93 was 15 T. In this country much has been done, particularly in Massachusetts and Pennsylvania, to determine the presence of the disease in the dairy herds, for which purpose the tuberculin test has been extensively employed. The results show a wide-spread prevalence of the disease. Of 5,297 cattle slaughtered in Maryland only 159 were tuberculous (A. W. Clement). Of 15,506 slaughtered at the Brighton abattoir, Boston, only 29 were tuberculous (A. Burr). In sheep the disease is very rare. In pigs it is common, but not so common in this country as in Europe. In the inspection of one thousand hogs, which was made by A. W. Clement and myself in Montreal in 1880, tuberculosis was seen only once or twice. At the Berlin abattoir in 1887-’88 there were 6,393 pigs affected with the disease. Horses are rarely attacked. Dogs and cats are not prone to the disease, but cases are described in which infection of pet animals has taken place from phthisical masters. Among the semi-domestic animals, such as the rabbit and guinea-pig, the disease under natural conditions is rare, although these animals, particularly the latter, are extremely susceptible to the disease when inoculated. Among apes and monkeys in the wild state, tuberculosis is unknown, but in confinement it is the most formi- dable disease with which they have to contend. The important etiological fact in connection with tuberculosis in ani- mals is the wide-spread occurrence of the disease in bovines, from which class we derive nearly all the milk and a very large proportion of the meat used for food. 2. Geographical Distribution.—The disease exists in all countries. It 204 SPECIFIC INFECTIOUS DISEASES. prevails more in the large cities and wherever the population is massed together. Thus, while the general death-rate from it is three per thou- sand, that of Vienna is 7’7, and of Munich and Glasgow four per thousand. Hirsch, from whose classical work these facts are taken, thinks that geo- graphical position has less influence than has been supposed. Italy and England suffer alike, and the disease is very prevalent in the West Indies and the South Sea islands. Toward the poles it is rare; but it is a common disease in Canada, and prevails extensively among the French Canadians and the English. Altitude is a more potent factor than latitude. In the high regions of the Alps and Andes, and in the central plateau of Mexico the disease is very rare. Mountainous countries, such as Switzerland, have a very low death-rate from tuberculosis. 3. Race.—No race is immune. The Indians of this continent are very prone to the disease. Matthews, whose experience with the native race is large, states that the disease is on the increase among them. He quotes the ratio from the United States census, 1880, as white 166, negroes 186, Indians 286. The death-rate in the older reservations, as in New York, is three times as great as in Dakota. In the Blood Indian Reserve of the Canadian Northwest Territories, Surgeon Kennedy (N. W. M. P.) has given me the figures for six years. In a population of about 2,000 there were 127 deaths from pulmonary consumption, twenty- three per cent of the total rate. This does not include deaths from “ diseases of infancy.” This enormous death-rate, it is to be remembered, occurs in a tribe occupying one of the finest climates of the world among the foot-hills of the Rocky Mountains, a region in which consumption is extremely rare among the white population, and in which cases of tuber- culosis from the eastern provinces do remarkably well. The negro race is very susceptible to tuberculosis, more particularly the glandular and osseous forms. Of the 427 cases of pulmonary tuberculosis at the Johns Hopkins Hospital for the two years ending June 1, 1891, there were 41 cases in the colored—i. e., about 1:10. The ratio of colored to white of all patients in the wards has been 1 to 7. 4. The Bacillus Tuberculosis.—The history of the discovery of the bacillus presents many points of interest. Confidently expected by such observers as Villemin, Chauveau, Cohnheiin, and others, and claimed to have been demonstrated by many, notably by Klebs and Aufrecht, it re- mained for Koch to demonstrate its existence and its invariable association with the disease. The investigations which he had previously made upon anthrax and experimental traumatic infections, by perfecting the methods of research, paved the way for this brilliant discovery. His preliminary article * and his more elaborate later work f should be carefully studied by any one who wishes to appreciate the value of scientific methods. It forms * Berliner klinische Wochenschrift, 1882. f Mittheilungen a. d. k. Gesundheitsamte, Bd. 2. TUBERCULOSIS. 205 one of the most masterly demonstrations of modern medicine. Its thor- oughness appears in the fact that in the twelve years which have elapsed since its announcement the innumerable workers at the subject have not, so far as I know, added a solitary essential fact to those presented by Koch. Moi’phological Characters.—The tubercle bacillus is a short, fine rod, often slightly bent or curved, and has an average length of nearly half the diameter of a red blood-corpuscle (3 to 4 g). When stained it often pre- sents a beaded appearance, which some have attributed to the presence of spores. With the basic aniline dyes it stains slowly, except at the body tem- perature, but retains the dye after treatment with acids—a characteristic which separates it from all other known forms of bacteria, with the excep- tion of the bacillus of leprosy. Modes of Growth.—It grows on blood-serum, glycerin-agar, or on po- tato—most readily on the former. The cultures must be kept at blood- heat. They grow slowly, and do not appear until about the end of the second week. The colonies form thin, grayish-white, dry, scale-like masses on the surface of the culture medium. Successive inoculations may be made from the cultures, and at the end of an indefinite series material from one of them inoculated into a guinea-pig will produce tuberculosis. Products of the Growth.—Little is yet known of the chemical charac- ters of the materials which result from the growth of the tubercle bacilli. Koch’s tuberculin is stated to be a glycerin extract of the cultures. Crook- shank and Herroun have separated an albumose and a ptomaine. Distribution of the Bacilli.—The bacilli are found in all tuberculous lesions; in some in great abundance, in others sparsely. They are par- ticularly numerous in actively developing tubercles, but in the chronic tuberculous processes of lymph-glands and of the joints they are scanty. When a tuberculous focus communicates with a vein or with lymph-ves- sels, the bacilli may be spread widely throughout the body. In old lesions they may not be found in the sections, and the demonstration of the true nature may be possible only by culture or inoculation. The Bacilli outside the Body.—Patients with advanced pulmonary tuberculosis throw off in the expectoration countless millions of the bacilli daily. Some idea of the extraordinary numbers may be gained from the studies of Nuttall.* From a patient with moderately advanced disease, the amount of whose expectoration was from seventy to a hundred and thirty cubic centimetres daily, he estimated by his method that there were in sixteen counts, between January 10th and March 1st, from one and a half to four and a third billions of bacilli thrown off in the twenty- four hours. These figures emphasize the danger associated with phthisical sputa unless most carefully dealt with. When expectorated and allowed to dry, the sputum rapidly becomes dust, and is distributed far and wide. * Johns Hopkins Hospital Bulletin, May, 1891. 206 SPECIFIC INFECTIOUS DISEASES. The observations made by Cornet under Koch’s supervision are in this connection most instructive. He collected the dust from the walls and bedsteads of various localities, and determined its virulence or innocuous- ness by inoculation into susceptible animals. Material was gathered from twenty-one wards of seven hospitals, three asylums, two prisons, from the surroundings of sixty-two phthisical patients in private practice, and from twenty-nine other localities in which tuberculous patients were only transient frequenters (out-patient departments, streets, etc.). Of one hundred and eighteen dust samples from hospital wrards or the rooms of phthisical patients, forty were infective and produced tubercu- losis. Negative results were obtained with the twenty-nine dust samples from the localities occasionally occupied by consumptives. Virulent ba- cilli were obtained from the dust of the walls of fifteen out of twenty-one medical wards. It is interesting to note that in two wards with many phthisical patients the results were negative, indicating that the dust in such regions is not necessarily infective. The infectiousness of the dust of the medical and surgical divisions of a hospital is in the proportion of 76-6 to 12-5. In a room in which a tuberculous woman had lived the dust from the wall in the neighborhood of the bed was infective six weeks after her death. No bacilli were found in the dust of an inhalation-cham- ber for consumptives. The experiments of Strauss at the Charite Hospital, Paris, are important. In the nostrils of twenty-nine assistants, nurses, and ward-tenders he placed plugs of cotton-wool to collect the dust of the wards. In nine of the twenty-nine cases these contained tubercle bacilli and proved infective to animals. The tubercle bacillus is thus a wide-spread organism in regions fre- quented by phthisical patients. 5. Modes of Infection.—(«) Hereditary Transmission.—In extremely rare instances the disease is congenital. The rarity with which it occurs may be gathered from the fact that of 15,400 calves killed at the Berlin abattoir there were only four instances of tuberculosis. Nine or ten cases of congenital tuberculosis in man have been described. Tuberculosis of the placenta has been carefully studied in recent years by Lehmann, Schmorl, and others. The bacilli may be present in a foetus which shows no signs of tubercles. Birch-IIirschfeld found portions of the viscera of such a foetus infective to guinea-pigs. There is no evidence to show that a tuberculous father can directly transmit the disease. The experimental evidence is also negative. Gart- ner (whose recent article on Heredity in Tuberculosis is the most impor- tant contribution made to the subject of late years) found that in rabbits and guinea-pigs, with artificially induced tuberculosis of the testes, and whose semen contained bacilli, the embryos were never infected. On the other hand, of 65 female guinea-pigs which had consorted with the tuber- culous bucks, 5 presented genital tuberculosis, and of 59 female rabbits under similar conditions 11 became infected. TUBERCULOSIS. 207 Baumgarten holds that in many cases the virus is transmitted, but the disease does not appear until some time after birth. He bases this opinion upon the following facts : The great frequency of tuberculosis in sucklings. Thus, in 16,581 autopsies on sucklings, Frobelius found 416 with tuberculous lesions. In 219 cases of tuberculosis in children under two, from Parrot’s clinic, there were 23 under three months, and a total of 111 under one year. It seems probable that in many of these cases the virus itself was trans- mitted. The common occurrence of tuberculosis in the bones and in the joints of children, regions to which it seems unlikely that the bacilli would be conveyed in accidental infection. To make this objection valid we should require a series of cases of bone tuberculosis in children in which exami- nation showed the lymph portals of the bronchi and the mesentery to be free from disease. He regards the late manifestation as analogous to the syphilis hereditaria tarda, and suggests that the growth of the germs is, as a rule, restrained or held in check by the ac- tively developing tissues of the child. In any series of cases of pulmonary tuberculo- sis there is a suspicious number in which the as- cendants have also been tuberculous. Thus, in 427 cases at the Johns Hopkins Hospital there were 53 in which the mother was affected, 52 in which the father had tuberculosis, and 105 in which brother or sister had had the disease. The estimates by various au- thors range from 10 per cent (Louis), 25 per cent (Walshe), to even 50 per cent. Fagge very justly remarks that it is impossible to draw a line between hereditary and acci- dental tuberculosis, and naturally the children of an affected parent are more liable to accidental contamination. Maternal is very much more common than paternal inheritance. A family tree, such as is here given, of six generations tells its own tale. It is interesting to note the almost constant transmission through the mother. A. F. FEMALE 1 783—1887 M.F. FEMALE It F. MALE M. I. F. FEMALE F.F. FEMALE M.F. FEMALE P.M. FEMALE M.V. FEMALE E,V. FEMALE ' A.L. > k FEMALEy E. V. MALE A.M. MALE P.P. FEMALEy A. G. FEMALE H.R. > FEMALEj H.P. MALE f H.Q. \ f A. L. \ Chart XI.—Heredity in pulmonary tuberculosis. 208 SPECIFIC INFECTIOUS DISEASES. (b) Inoculation.—The infective nature of tuberculosis was first demon- strated by Villemin, who showed conclusively in 18G5 that it could be trans- mitted to animals by inoculation. The question was hotly contested, and Villemin’s observations were confirmed by Simon, Andrew Clark, and others, but Burdon Sanderson, Wilson Fox, and others held that the disease could be transmitted by non-tuberculous materials. The beautiful experiments of Cohnheim and Salamonson, who produced tuberculosis in the eyes of guinea-pigs and rabbits by inoculating fresh tubercle into the ante- rior chamber, confirmed and extended Villemin’s original observations and paved the way for the reception of Koch’s announcement. It is now universally conceded that only tuberculous matter can produce, when inoculated, tuberculosis. In man tuberculosis is not often transmit- ted by inoculation, and when it does occur the disease usually remains local. This mode of infection is seen in persons whose occupation brings them in contact with dead bodies or animal products. Demonstrators of morbid anatomy, butchers, and handlers of hides are subject to a local tubercle of the skin, which forms a reddened mass of granulation tissue, usually capping the dorsal surfaces of the hands or fingers. This is the so-called post-mortem wart, the verruca necrogenica of Wilks. The dem- onstration of its nature is shown by the presence of tubercle bacilli, and by inoculation experiments in animals. The statement that Laennec contracted phthisis from this source is probably false, since he did not die until twenty years after the inocula- tion and in the interval presented no manifestations. The possibility, however, of general infection must be borne in mind. Gerber reports that after accidental inoculation of the hand from a case of phthisis he had for months a “ Leichen-tubercle,” which was excised. Shortly afterward the lymph-glands of the axilla became enlarged and pain- ful, and when removed showed characteristic tuberculous changes, with bacilli. In the performance of the rite of circumcision children have been acci- dentally inoculated. Infection in these cases is probably always associated with disease in the operator, and occurs in connection with the habit of cleansing the wound by suction. Other means of inoculation have been described: as the wearing of ear-rings, washing the clothes of phthisical patients, the bite of a tubercu- lous subject, or inoculation from a cut by a broken spit-glass of a con- sumptive ; and Czerny has reported two cases of infection by transplanta- tion of skin. It has been urged by the opponents of vaccination that tuberculosis, as well as syphilis, may be thus conveyed, but of this there is no evidence, and the lymph from the vesicles of revaccinated consumptives has been shown by many observers to be non-infective. It may be said, on the whole, that inoculation in man plays a trifling role in the transmission of tuberculosis. TUBERCULOSIS. 209 (c) Infection by Inhalation.—It has been fully proved that the ex- pired air of tuberculous patients is not infective. On the other hand, the virus is contained in enormous amounts in the sputum, which, when dried, is soon widely disseminated in the form of dust, and unless carefully sterilized constitutes a great medium of transmission. A belief in the contagiousness of pulmonary tuberculosis has existed from the days of the early Greek physicians, and has persisted among the Latin races. The investigations of Cornet afford conclusive proof that the dust of a room or other locality frequented by patients with pulmonary tubercu- losis is infective. The bacilli are attached to fine particles of dust and in this way gain entrance to the system through the lungs. The following are some of the facts in favor of this view: (1) Primary tuberculous lesions are in a majority of all cases connected with the respiratory system. The frequency with which foci are met witli in the lungs and in the bronchial glands is extraordinary, and the statis- tics of the Paris morgue show that a considerable proportion of all persons dying of accident or by suicide present evidences of the disease in these parts. The post-mortem statistics of hospitals show the same wide-spread prevalence of infection through the air-passages. Biggs reports that more than 60 per cent of his post-mortems showed lesions of pulmonary tuber- culosis. In one hundred and twenty-five post-mortems at the Foundling Hospital, New York, the bronchial glands were tuberculous in every case. In adults the bronchial glands may be infected while the individual is in good health. H. P. Loomis found in eight of thirty cases in which there were no signs of old or recent tuberculous lesions that the bronchial glands were infective to rabbits. (2) The greater prevalence of tuberculosis in institutions in which the residents are confined and restricted in the matter of fresh air and a free open life—conditions which would favor, on the one hand, the presence of the bacilli in the atmosphere, and, on the other, lower the vital resist- ance of the individual. The investigations of Cornet upon the death-rate from consumption among certain religious orders devoted to nursing give some striking facts in illustration of this. In a review of thirty-eight cloisters, embracing the average number of 4,028 residents, among 2,099 deaths in the course of twenty-five years, 1,320 (62-88 per cent) were from tuberculosis. In some cloisters more than three fourths of the deaths are from this disease, and the mortality in all the residents, up to the fortieth year, is greatly above the average, the increase being due entirely to the prevalence of tuberculosis. It has been stated that nurses are not more prone to the disease than other individuals, but Cornet says that of a hun- dred nurses deceased, sixty-three died of tuberculosis. The more perfect the prophylaxis and hygienic arrangements of an asylum or institution, the lower the mortality from tuberculosis. The mortality in prisons has been shown by Baer to be four times as great as outside. The death-rate from phthisis is estimated at 15 per cent of the total mortality, while in 210 SPECIFIC INFECTIOUS DISEASES. prisons it constitutes from 40 to 50 per cent, and in some countries, as Austria, over 60 per cent. Flick has studied the distribution of the deaths from tuberculosis in a single city ward in Philadelphia for twenty-five years. His researches go far to show that it is a house disease. About 33 per cent of infected houses have had more than one case. Less than one third of the houses of the ward became infected with tuberculosis dur- ing the twenty-five years prior to 1888. Yet more than one half of the deaths from this disease during the year 1888 occurred in those infected houses. There are, however, opposing facts. The statistics of the Bromp- ton Consumption Hospital show that doctors, nurses, and attendants are rarely attacked. Dettweiler claims that no case of tuberculosis has been contracted among his nurses or attendants at Falkenstein. On the other hand, in the Paris Hospitals tuberculosis decimates the attendants. (3) Special danger exists when the contact is very intimate, such, for instance, as between man and wife. On this point much difference of opinion exists, but the figures seem to indicate that under these circum- stances the husband or wife is much more liable subsequently to die of consumption. Of 427 cases of pulmonary tuberculosis at the Johns Hop- kins Hospital, in 25 either husband or wife had been affected with it or had died of tuberculosis. In response to a question as to contagion, asked by the Collective Investigation Committee of the British Medical Associa- tion, there were 261 replies in the affirmative, among which were 158 cases of supposed contagion through marriage. Weber’s cases are of special interest. One of his patients lost four wives in succession, one lost three, and four lost two each. (d) Infection by Milk.—The milk of an animal suffering from tuber- culosis may contain the virus, and is capable of communicating the dis- ease, as shown by Gerlacli, Bang, Bollinger, and others. Striking illustra- tions of this are sometimes afforded in the lower animals. The pigs, for instance, of a tuberculous sow have been shown to present intestinal tubercu- losis of the most exquisite form. Of late years the experimental proof has been entirely conclusive. It was formerly thought that the cow must pre- sent tuberculous disease of the udder, but Ernst has shown that the bacilli may be present and the milk be infective in a large proportion of cases in which there is no tuberculous mammitis • an observation made also by Hirschberger and others. This author states the interesting fact that an owner of a herd known to be tuberculous withdrew the milk from market and used it without boiling to fatten his pigs, which, almost with- out exception, became tuberculous, so that the whole stock had to be slaughtered. Sidney Martin could not induce the disease artificially in animals inoculated or fed with milk of tuberculous cows with healthy udders.* Butter made from the milk of tuberculous cows has proved in- * See Report of Royal Commission on Tuberculosis, 1895, and Ernst, Infectiousness of Milk, Boston, 1895. TUBERCULOSIS. 211 fective (Bang). There is no reason to believe that young children, or even adults, are less susceptible to the virus than calves or pigs, so that the danger of the disease from this source is real and serious. The great fre- quency of intestinal and mesenteric tuberculosis in children no doubt finds here its explanation. As noted in Woodhead’s analysis of one hundred and twenty-seven cases of fatal tuberculosis in children, the mesenteric glands were involved in one hundred. (e) Infection by Meat.—The meat of tuberculous animals is not neces- sarily infective. The results of experiments with the flesh of cows are not in accord. This mode of infection probably plays a minor role in the etiology of human tuberculosis, as usually the flesh is thoroughly cooked before eating. The possibility, however, must be borne in mind, and it would certainly be safer in the interests of a community to confiscate the carcasses of all tuberculous animals. Experiments in Bollinger’s labora- tory show that the flesh of tuberculous subjects is very infective to guinea- pigs. Martin suggests that when the meat is infective it commonly ac- quires this property by accidental contamination with tuberculous matter during its removal. 6. Conditions influencing Infection.—(a) Constitutional Peculiarities.— It was formerly thought that individuals of a certain habit of body, and of a certain physiognomy, the habitus phthisicus, were specially prone to tuberculous disease; but few now regard the so-called tuberculous or scrofulous diathesis as more than an indication of a certain type of con- formation, in which the tissues are more vulnerable and less capable of resisting infection. In many instances Colinheim is unquestionably cor- rect in stating that the so-called phthisical habit is not an indication of a tendency to, but actually of the existence of, tuberculosis. The belief in a special phthisical frame has existed in the profession from the days of Hippocrates, who says, “ The form of body peculiar to subjects of phthisi- cal complaints was the smooth, the whitish, that resembling the lentil; the reddish, the blue-eyed, the leuco-phlegmatic, and that with the scapulae having the appearance of wings.” Galen also wrote upon this type of chest as specially characteristic of the disease. Certainly the long, narrow, flat chest with depressed sternum is most commonly seen in tuberculous per- sons, but how common it is also to meet with patients who have well- formed, well-built chests, with wide costal angle and good pulmonary ex- pansion ! The investigations of Beneke with reference to the formation of the viscera in the subjects of phthisis are very interesting. Ilis meas- urements indicate that the heart is relatively small, the arteries are pro- portionately narrow, and the pulmonary artery is relatively wider than the aorta. This point, he suggests, would lead to increase in the blood-press- ure in the lungs and favor catarrh. The lung volume he found to be relatively greater in those affected with phthisis. Galton and Mahomed made observations upon the composite portrait- ure of phthisis. In 442 patients they separated two types of face; one SPECIFIC INFECTIOUS DISEASES. 212 ovoid and narrow, the other broad and coarse featured. This corre- sponds in an interesting way to the diathetic states formerly recognized —namely, the tuberculous, with thin skin, bright eyes, oval face, and long, thin bones; and the scrofulous, with thick lips and nose, opaque skin, large thick bones, and heavy figure. These conditions, on which so much stress was formerly laid, indicate, as Fagge states, nothing more than delicacy of constitution, incomplete growth, and imperfect develop- ment. (b) Influence of Age.—Tuberculosis occurs at all periods of life, in the suckling as well as in the octogenarian. The distribution of the lesions varies greatly at different ages. In the first decade the lymphatic glands, bones, and meninges are much more frequently affected than at subse- quent periods. Meningeal tuberculosis is most common between the third and eighth years. The mesenteric glands are specially prone to be involved in young children, as before mentioned. Of 127 cases of tuberculosis in children, Woodhead found these bodies affected in 100 instances, in 14 of which there were no tubercles in other parts of the body. The majority of these cases occur between the first and fifth years. The bronchial glands are still more frequently involved, and of 125 cases at the New York Found- ling Hospital in every one were these structures the seat of more or less extensive tuberculosis. In adults the lungs usually contain tubercle when it is present in the body (Louis’ law). (c) Soil and locality are held by many to have an important influence in tuberculosis. The observations of II. I. Bowditch in this country, and of Buchanan in England, show that pulmonary tuberculosis is more preva- lent in damp, ill-drained districts; but this increased incidence is most probably associated with a heightened vulnerability due to an increased liability to catarrhal affections of all kinds. (d) Local Conditions influencing Infection.—These are doubtless of the highest importance, and second only to the constitutional vulnera- bility. Among the more important may be mentioned : Catarrhal Inflammation.—This probably acts by lowering the resist- ance, or, in modern parlance, reducing the activity of the phagocytes and allowing the bacilli to pass the portals. The liability of infection in the cervical and bronchial glands in children is probably associated with the common occurrence of catarrhal processes in the tonsils, throat, and bronchi. The influence of bronchial catarrh in pulmonary tuberculosis is all-im- portant. How often is it said that the disease has started in a neglected cold; which means, in other words, that the bronchial catarrh has enfeebled the power of tissue-resistance, or produced conditions favorable to the growth and development of the bacilli. The subjects of congenital or acquired contraction of the orifice TUBERCULOSIS. 213 of the pulmonary artery usually, as is well known, die of tuberculosis. Prior to the development of the disease many subjects show a marked anaemia, and unquestionably chlorosis offers favoring conditions for the development of this affection. Diseases of the stomach and intes- tines, particularly chronic entero-colitis, increase the susceptibility to infection. An important part in the etiology of tuberculous processes is played by trauma. Surgeons have for years laid great stress upon this association, but the relation, though universally recognized, is by no means easy of ex- planation. Bacteriological experiments, however, indicate that in tissues which have been injured organisms, which would in health have been readily and rapidly destroyed by the action of the normal juices or cells, under these altered circumstances grow rapidly and develop. Probably in the case of tuberculosis following trauma the injured part is for a time a locus tninoris resistentice, and if bacilli are present they may by it re- ceive a stimulus to growth, or under the altered conditions be capable of multiplying. Not only in arthritis but in pulmonary tuberculosis trau- matism may play a part. The question has been thoroughly studied by Mendelsohn,* who reports nine cases in which, without fracture of the rib or laceration of the lung, tuberculosis developed shortly after contu- sion of the chest. The production of general tuberculosis is sometimes favored by opera- tion upon tuberculous lesions. Surgeons have long known that resection of a strumous joint is occasionally followed by acute tuberculosis. The question lias been carefully studied by Wartmann,f who gives statistics of 837 resections. Of these, 225 ended fatally, 26 with acute tuberculosis, the outbreak of which was directly associated with operation. The acute miliary tuberculosis which, as Litten has shown, occasion- ally follows the aspiration of the effusion in tuberculous pleurisy, may come under this division. The constant inhalation of impure air in occupations associated with a very dusty atmosphere renders the lungs less capable of resisting infec- tion. The pulmonary affection of stone-cutters and coal-miners, though non-tuberculous at the outset and often a simple chronic interstitial pneu- monia, is ultimately in a large proportion of the cases tuberculous. In manufactories metallic seems more hurtful than mineral dust. Peterson \ quotes the incidence of pulmonary tuberculosis among the trades as fol- lows: Glass-workers, 80 per cent; needle-sharpeners, 70; file-cutters, 62; and stone-cutters, 60. And, lastly, circumstances which temporarily lower the nutrition, as the specific fevers render the tissues more susceptible. In this way alone can we explain the frequent onset of tuberculosis after an * Zeitschrift f. klin. Medicin, Bd. 10. f Deutsche Zeitschrift f. Chirurgie, Bd. 24, \ Medical News, 1885. 214 SPECIFIC INFECTIOUS DISEASES. exhausting illness. Fevers, such as measles and whooping-cough, which are associated with bronchial catarrh, are more prone than others to be followed by tuberculosis. This is often only the blazing of a smoulder- ing fire. With reference to infection and the conditions which influence it the following may be stated : (a) In a few cases the disease is directly transmitted from the mother, and appears in the child at birth. (&) The primary tuberculosis of the bones, joints, kidney, spleen, liver, etc., of early youth is very possibly associated with a foetal hematogenous infection (Baumgarten, Gartner). (c) Direct paternal transmission has not been proved, and experimental evidence is strongly against it. (d) In a vast majority of all cases the infection is post-foetal—through the lungs, intestines, or skin. (e) Heredity influences the soil All are tuberculizable, to use a French expression, and very many of us actually become infected. Whether or not the seed develops depends, firstly, upon the character of the tissue-soil; and, secondly, upon the existence of special favoring cir- cumstances. (/) Immunity, a relative condition, enjoyed chiefly in consequence of inherited tissue-resistance, is lessened by all circumstances which depress nutrition, such as bad air, bad food, and imperfect hygienic surroundings. Next to the germ, a vulnerability of tissue, however brought about, whether congenital or acquired, is the most important factor in the etiology of the disease. General Morbid Anatomy and Histology of Tuberculous Lesions. (1) Distribution of the Tubercles in the Body.—The organs of the body are variously affected by tuberculosis. In adults, the lungs may be regarded as the seat of election ; in children, the lymph-glands, bones, and joints. In 1,000 autopsies there were 275 cases with tuberculous lesions. With but two or three exceptions the lungs were affected. The distribu- tion in the other organs was as follows : Pericardium, 7 ; peritonaeum, 36 ; brain, 31; spleen, 23 ; liver, 12 ; kidneys, 32 ; intestines, 65 ; heart, 4; and generative organs, 8. The tuberculosis which comes under the care of the surgeon has a dif- ferent distribution, as shown by the following figures from the Wurzburg clinic. Among 8,873 patients there wrere 1,287 tuberculous, with the fol- lowing distribution of lesions: Bones and joints, 1,037; lymph-glands, 196 ; skin and connective tissues, 77; mucous membranes, 10; genito- urinary organs, 20. (2) The Changes produced by the Tubercle Bacilli. (a) The Nodular Tubercle.—The body which we term a “ tubercle ” presents in its early formation nothing distinctive or peculiar, either in TUBERCULOSIS. 215 its components or in their arrangement. Identical structures are pro- duced by other parasites, such as the actinomyces, and by the strongylus in the lungs of sheep. The researches of Baumgarten have enabled us to follow in detail all the steps in the development of a tubercle. These are: (a) The multiplication of the fixed cells, especially those of connective tissue and the endothelium of the capillaries, and the gradual production from them of rounded, cuboidal, or polygonal bodies with ve- sicular nuclei—the epithelioid cells—inside some of which the bacilli are soon seen. (l3) From the vessels of the infected focus, leucocytes, chiefly polynu- clear, migrate in numbers and accumulate about the focus of infection. They do not subdivide. Many undergo rapid destruction. Later, as the little tubercle grows, the leucocytes are chiefly of mononuclear variety (lymphocytes), and these do not undergo the rapid degeneration of the polynuclear forms. (7) A reticulum of fibres is formed by the fibrillation and rarefaction of the connective-tissue matrix. This is most apparent, as a rule, at the margins of the growth. (6) In some, but not all, tubercles giant cells are formed by an increase in the protoplasm and in the nuclei of an individual cell, or possibly by the fusion of several cells. The giant cells seem to be in inverse ratio to the number and virulence of the bacilli. In lupus, joint tuberculosis, and scrofulous glands, in which the bacilli are scanty, the giant cells are numerous; while in miliary tubercles and all lesions in which the bacilli are abundant the giant cells are few in number. The bacilli then cause, in the first place, a proliferation of the fixed elements, with the production of epithelioid and giant cells; and, secondly, an inflammatory reaction, associated with exudation of leucocytes. How far the leucocytes attack and destroy the bacilli has not been definitely settled—MetschnikofT claiming, Baumgarten denying, an active phago- cytosis. Once formed, a tubercle undergoes caseation and sclerosis. Caseation.—At the central part of the growth, owing to the direct action of the bacilli, a process of coagulation necrosis goes on in the cells, which lose their outline, become irregular, no longer take stains, and are finally converted into a homogeneous, structureless substance. Proceed- ing from the centre outward, the tubercle may be gradually converted into a yellowish-gray body, in which, however, the bacilli are still abundant. No blood-vessels are found in them. Aggregated together these form the cheesy masses so common in tuberculosis, which may undergo (a) soften- ing ; (h) fibroid limitation (encapsulation) ; (c) calcification. Sclerosis.—With the necrosis of the cell elements at the centre of the tubercle, hyaline transformation proceeds, together with great increase in the fibroid elements; so that the tubercle is converted into a firm, hard 216 SPECIFIC INFECTIOUS DISEASES. structure. Often the change is rather of a fibro-caseous nature ; but the sclerosis predominates. In some situations, as the peritonaeum, this seems to be the natural transformation of tubercle, and it is by no means rare in the lungs. In all tubercles two processes go on: the one—caseation—destructive and dangerous ; and the other—sclerosis—conservative and healing. The ultimate result in a given case depends upon the capabilities of the body to restrict and limit the growth of the bacilli. There are tissue-soils in which the bacilli are, in all probability, killed at once—the seed has fallen by the wayside. There are others in which a lodgment is gained and more or less damage done, but finally the day is with the conservative, protecting forces—the seed has fallen upon stony ground. Thirdly, there are tissue-soils in which the bacilli grow luxuriantly, caseation and soft- ening, not limitation and sclerosis, prevail, and the day is with the in- vaders—the seed has fallen upon good ground. The action of the bacilli injected directly into the blood-vessels illus- trates many points in the histology and pathology of tuberculosis. If into the vein of a rabbit a pure culture of the bacilli is injected, the microbes accumulate chiefly in the liver and spleen. The animal dies usually with- in two weeks, and the organs apparently show no trace of tubercles. Microscopically, in both spleen and liver the young tubercles in process of formation are very numerous, and the process of karyokinesis is seen in the liver-cells. After an injection of a more dilute culture, or one whose virulence has been mitigated by age, instead of dying within a fortnight the animal survives for five or six weeks, by which time the tubercles are apparent in the spleen and liver, and often in the other organs. (b) The Diffuse Infiltrated Tubercle.—This is most frequently seen in the lungs. Only a great master like Virchow could have won the pro- fession from a belief in the unity of phthisis, which the genius of Laennec had, on anatomical ground, announced. Here and there a teacher, as Wilson Fox, protested, but the heresy prevailed, and we repeated the strik- ing aphorism of Niemeyer, “ The greatest evil which can happen to a con- sumptive is that he should become tuberculous.” It was thought that the products of any simple inflammation might become caseous and that ordi- nary catarrhal pneumonia terminated in phthisis. It was peculiarly fitting that from Germany, in which the dualistic heresy arose, the truth of Laen- nec’s views should receive incontestable proof, in the demonstration by Koch of the etiological unity of all the various processes known as tuber- culous and scrofulous. Infiltrated tubercle results from the fusion of many small foci of in- fection—so small indeed that they may not be visible to the naked eye, but which histologically are seen to be composed of scattered centres, sur- rounded by areas in which the air-cells are filled with the products of exu- dation and of the proliferation of the alveolar epithelium. Under the influence of the bacilli, caseation takes place, usually in small groups of TUBERCULOSIS. 217 lobules, occasionally in an entire lobe, or even the greater part of a lung. In the early stage of the process, the tissue has a gray gelatinous appear- ance, the gray infiltration of Laennec. The alveoli contain a sero-fibrinous fluid with cells, and the septa are also infiltrated. These cells accumulate and undergo coagulation necrosis, forming areas of caseation, the infiltra- tion tuberculeuse jaune of Laennec, the scrofulous or cheesy pneumonia of later writers. There may also be a diffuse infiltration and caseation without any special foci, a wide-spread tuberculous pneumonia induced by the bacilli. After all, the two processes are identical. As Baumgarten states: “ there is no well-marked difference between miliary tubercle and chronic caseous pneumonia. Speaking histologically, miliary tuberculosis is noth- ing else than a chronic caseous miliary pneumonia, and chronic caseous pneumonia is nothing but a tuberculosis of the lungs.” (c) Secondary Inflammatory Processes.—(1) The irritation of the bacilli invariably produces an inflammation which may, as has been de- scribed, be limited to exudation of leucocytes and serum, but may also be much more extensive, and varies with varying conditions. We find, for example, about the smaller tubercles in the lungs, pneumonia—either catarrhal or fibrinous, proliferation of the connective-tissue elements in the septa (which also become infiltrated with round cells), and changes in the blood and lymph vessels. (2) In processes of minor intensity the inflammation is of the slow reactive nature, which results in the production of a cicatricial connective tissue which limits and restricts the development of the tubercles and is the essential conservative element in the disease. It is to be remembered that in chronic pulmonary tuberculosis much of the fibroid tissue which is present is not in any way associated with the action of the bacilli. (3) Suppuration. Do the bacilli themselves induce suppuration? In so-called cold tuberculous abscess the material is not histologically pus, but a debris consisting of broken-down cells and cheesy material. It is moreover sterile—that is, does not contain the usual pus organisms. The products of the tubercle bacilli are probably able to induce suppuration, as in joint and bone tuberculosis pus is frequently produced, although this may be due to a mixed infection. Koch, it will be remembered, states that the “ tuberculin ” is one of the best agents for the production of ex- perimental suppuration. In tuberculosis of the lungs the suppuration is largely the result of an infection with pus organisms. II. Acute Tuberculosis. The truly infective nature of tubercle is best shown in this affection, which is characterized by an eruption of miliary tubercles in various parts of the body. The clinical picture varies with the general or localized dis- tribution of the growths. The tubercles are found upon the pleura and 218 SPECIFIC INFECTIOUS DISEASES. peritonaeum; in the lungs, liver, kidneys, lymph-glands, and spleen ; upon the membranes of the brain, occasionally in the choroid coat of the eye, and in the bone-marrow. They may be abundant in some organs and scanty in others. Thus, in the meninges of the brain they may be thickly set, while there are few or none in the abdominal viscera or in the lungs. On the other hand, the lungs may be stuffed with granulations while the meninges of the brain are free. In other cases, again, the distribution is uniform in all the viscera. The etiology has been in part considered, and the only additional state- ment necessary is that in a great majority of all cases it is an auto-infec- tion., arising from a pre-existing tuberculous focus, which may be latent and unsuspected. The following are the most common sources of general infection: Local disease of the lungs, which may be quite limited and un- productive of symptoms ; tuberculous affection of the lymph-glands, par- ticularly in children; and tuberculosis of the bones and of the kidneys. Of these sources perhaps the most common are the tracheal and bronchial lymph-glands, which are so often the seat of local tuberculosis. Weigert has shown that in many cases the infection results from the rupture of a caseous pulmonary nodule into a vein, or of a caseous bronchial gland into one of the pulmonary veins. A general infection may, as shown by Pon- fick, result from invasion of the thoracic duct by tubercles. With special care the source of infection can • usually be discovered at post-mortem examination. The connection between tuberculous lymph-glands and veins has often been demonstrated. In many instances it is impossible to say what determines the sudden and violent onset of the disease. It would seem sometimes as if general rather than local conditions influenced the outbreak. After certain fevers, particularly measles and whooping-cough in children—affections, it is true, which are associated with long-continued bronchitis—miliary tuberculosis is not uncommon. The prostration and constitutional weakness which follow protracted fevers frequently seem in the adult a predisposing cause. Clinical Forms.—For practical purposes the cases may be divided into those with the symptoms of acute general infection without special localization; cases with marked pulmonary symptoms; and cases with cerebral or cerebrospinal symptoms. Other forms have been recognized, but this division covers a large ma- jority of the cases. Taking any series of cases it will be found that the meningeal form of acute tuberculosis exceeds in numbers the cases with general or marked pulmonary symptoms. 1. General or Typhoid Form.—Symptoms.—The patient here presents the symptoms of an infectious disease with few if any local symptoms. The cases simulate and are frequently mistaken for typhoid fever. After a period of failing health, with loss of appetite, the patient becomes feverish and weak. Occasionally the disease sets in more abruptly, but in TUBERCULOSIS. 219 many instances the anamnesis closely resembles that of typhoid fever. Nose-bleeding, however, is rare. The temperature increases, the pulse becomes rapid and feeble, the tongue dry; delirium becomes marked and the cheeks are flushed. The pulmonary symptoms may be very slight; usually bronchitis exists, but not more severe than is common with typhoid fever. The pulse is seldom dicrotic, but is rapid in proportion to the pyrexia. Perhaps the most striking feature of the temperature is the irregularity; and if seen from the outset there is not the steady ascent noted in typhoid fever. There is usually an evening rise to 103°, some- times 104°, and a morning remission of from two to three degrees. Some- times the pyrexia is intermittent, and the thermometer may register below normal during the early morning hours. The inverse type of temperature, in which the rise takes place in the morning, is held by some writers to be more frequent in general tuberculosis than in other diseases. In rare in- stances there may be little or no fever. On two occasions I have had a patient admitted to my wards in a condition of profound debility, with a history of illness of from three to four weeks’ duration, with rapid pulse, flushed cheeks, dry tongue, and very slight elevation in temperature, in whom (post mortem) the condition proved to be general tuberculosis. In one instance there was tolerably extensive disease at the right apex. Rein- hold, from Biiumler’s clinic, has recently called attention to these afebrile forms of acute tuberculosis. In nine of fifty-two cases there was no fever, or only a transient rise. In a considerable number of these cases the respirations are increased in frequency, particularly in the early stage, and there may be signs of diffuse bronchitis and slight cyanosis. Cheyne-Stokes breathing devel- ops toward the close. Active delirium is rare. More commonly there are torpor and dullness* gradually deepening into coma, in which the patient dies. In some cases the pulmonary symptoms become more marked; in others, meningeal or cerebral features develop. Diagnosis.—The differential diagnosis between general miliary tuber- culosis without local manifestations and typhoid fever is extremely diffi- cult. A point of importance, to which reference has already been made, is the irregularity of the temperature curve. The greater frequency of the respirations and the tendency to slight cyanosis is much more com- mon in tuberculosis. There are cases, however, of typhoid fever in which the initial bronchitis is severe and may lead to dyspnoea and disturbed oxygenation. The cough may be slight or absent. Diarrhoea is rare in tuberculosis; the bowels are usually constipated; but diarrhoea may oc- cur and persist for days. In certain cases the diagnosis has been compli- cated still further by the occurrence of blood in the stools. Enlargement of the spleen occurs in general tuberculosis, but is neither so early nor so marked as in typhoid fever. In children, however, the enlargement may be considerable. The urine may show traces of albumen, and unfortu- 220 SPECIFIC INFECTIOUS DISEASES. nately Ehrlich’s diazo-reaction, which is so constant in typhoid fever, is also met with in general tuberculosis. The absence of the characteristic roseola is an important feature. Occasionally in acute tuberculosis reddish spots may develop and for a time cause difficulty, but they do not come out in crops, and rarely have the characters of the true typhoid eruption. Herpes is perhaps more common in tuberculosis. Toward the close, pete- chias may appear on the skin, particularly about the wrists. A rare event is jaundice, due possibly to the eruption of tubercles in the liver. It is to be remembered that the lesions of acute tuberculosis and of typhoid fever have been demonstrated in the same body. In a few instances the presence of tubercle bacilli has been demon- strated in the blood, which in doubtful cases should therefore be examined. The spleen has been punctured and cultivations made to determine the presence or absence of the typhoid bacilli, but in the acute splenic tumor this is a dangerous procedure. The eye-grounds should be carefully exam- ined for choroidal tubercles. The blood may show a slight leucocytosis, but in the very acute cases where there are no suppurating foci this is absent. 2. Pulmonary Form.—Symptoms.—From the outset the pulmonary symptoms are marked. The patient may have had a cough for months or for years without much impairment of health, or he may be knowm to be the subject of chronic pulmonary tuberculosis. In other instances, partic- ularly in children, the disease follows measles and whooping-cough, and is of a distinctly broncho-pneumonic type. The disease begins with the symptoms of diffuse bronchitis. The cough is marked, the expectoration muco-purulent, occasionally rusty. Haemoptysis has been noted in a few instances. From the outset dyspnoea is a striking feature and may be out of proportion to the intensity of the physical signs. There is more or less cyanosis of the lips and finger-tips, and the cheeks are suffused. Apart from emphysema and the later stages of severe pneumonia I know of no other pulmonary condition in which the cyanosis is so marked. The phys- ical signs are those of bronchitis. In children there may be defective reso- nance at the bases, from scattered areas of broncho-pneumonia; or, what is equally suggestive, areas of hyper-resonance. Indeed, the percussion note, particularly in the front of the chest, in some cases of miliary tuberculosis, is full and clear, and it will be noted (post mortem) that the lungs are unusually voluminous. This is probably the result of more or less wide- spread acute emphysema. On auscultation, the rales are either sibilant and sonorous or small, fine, and crepitant. There may be fine crepitation from the occurrence of tubercles on the pleura (Jurgensen). In children there may be high-pitched tubular breathing at the bases or toward the root of the lung. Toward the close the rales may be larger and more mu- cous. The temperature rises to 102° or 103°, and may present the inverse type. The pulse is rapid and feeble. In the very acute cases the spleen is always enlarged. The disease may prove fatal in ten or twelve days, or may be protracted for weeks or even months. TUBERCULOSIS. 221 Diagnosis.—The diagnosis of this form offers less difficulty and is more frequently made. There is often a history of previous cough, or the patient is known to be the subject of local disease of the lung, or of the lymph-glands, or of the bones. In children these symptoms following measles or whooping-cough indicate in the majority of cases acute miliary tuberculosis, with or without broncho-pneumonia. Occasionally the spu- tum contains tubercle bacilli. The choroidal tubercle occurs in a limited number of cases and may help the diagnosis. More important in an adult is the combination of dyspnoea writh cyanosis and the signs of a diffuse bronchitis. In some in- stances the occurrence of cerebral symptoms at once give a clew to the nature of the trouble. 3 Meningeal Form (Tuberculous Meningitis).—This affection, which is also known as acute hydrocephalus or “ water on the brain,” is essentially an acute tuberculosis in which the membranes of the brain, sometimes of the cord, bear the brunt of the attack. There are several special etiological factors in connection with this form. It is much more common in children than in adults. It is rare during the first year of life, more frequent between the second and the fifth years. In a majority of the cases a focus of old tuberculous disease will be found, commonly in the bronchial or mesenteric glands. In a few instances the affection seems to be primary in the meninges. It is very difficult, however, in an ordinary post-mortem to make an exhaustive search, and the lesion may be in the bones, sometimes in the middle ear, or in the genito-urinary organs. In those instances in which no primary focus has been discovered it has been suggested that the bacilli reach the meninges through the cribriform plate of the ethmoid from the upper part of the nostrils, but this is not probable. Morbid Anatomy.—Tuberculous meningitis presents a very character- istic picture. The meninges at the base are most involved, hence the term basilar meningitis. The parts about the optic chiasm, the Sylvian fissures, and the interpeduncular space are affected. There may be only slight turbidity and matting of the membranes, and a certain stickiness with serous infiltration; but more commonly there is a turbid exudate, fibrino- purulent in character, which covers the structures at the base, surrounds the nerves, extends out in the Sylvian fissures, and appears on the lateral, rarely on the upper, surfaces of the hemispheres. The tubercles may be very apparent, particularly in the Sylvian fissures, appearing as small, whitish nodules on the membranes. They vary much in number and size, and may be difficult to find. The amount of exudate bears no definite re- lation to the abundance of tubercles. The arteries of the anterior and posterior perforated spaces should be carefully withdrawn and searched, as upon them nodular tubercles may be found when not present elsewhere. In doubtful cases the middle cerebral arteries should be very carefully re- moved, spread on a glass plate with a black background, and examined SPECIFIC INFECTIOUS DISEASES. 222 with a low objective. The tubercles are then seen as nodular enlarge- ments on the smaller arteries. The lateral ventricles are dilated (acute hydrocephalus) and contain a turbid fluid; the ependyma may be soft- ened, and the septum lucidum and fornix are usually broken down. The convolutions are often flattened and the sulci obliterated owing to the increased intra-ventricular pressure. Histologically the tubercles are seen to develop in the perivascular sheaths, producing circumscribed aggrega- tions of lymphoid and epithelioid cells. The lumen of the vessel is nar- rowed and thrombosis may result. The meninges are not alone involved, but the contiguous cerebral substance is more or less oedematous and infil- trated with leucocytes, so that anatomically the condition is in reality a meningo-enceplialitis. There are instances in which the acute process is associated with chronic meningeal tuberculosis; cases which may for months present the clinical picture of brain tumor. Although in a majority of instances the process is cerebral, the spinal meninges may also be involved, particularly those of the cervical cord. There are cases indeed in which the symptoms are chiefly spinal. A sailor, who had fallen on the deck three wreeks before his death, was admitted to the Montreal General Hospital. He presented signs of meningitis, chiefly spinal, which were naturally attributed to traumatism. The post-mortem showed absence of tubercles and lymph at the base of the brain, and an extensive eruption of miliary tubercles with much turbid lymph over the entire spinal meninges. There were small cheesy masses at the apices of the lungs. Symptoms.—Tuberculous meningitis presents an extremely complex clinical picture. It will be best to describe the form found in children. Prodromal symptoms are common. The child may have been in fail- ing health for some weeks, or may be convalescent from measles or whoop- ing-cough. In many instances there is a history of a fall. The child gets thin, is restless, peevish, irritable, loses its appetite, and the dispo- sition may completely change. Symptoms pointing to the disease may then set in, either quite suddenly with a convulsion, or more commonly with headache, vomiting, and fever, three essential symptoms of the onset which are rarely absent. The pain may be intense and agonizing. The child puts its hand to its head and occasionally, when the pain becomes worse, gives a short, sudden cry, the so-called hydrocephalic cry. Some- times the child screams continuously until utterly exhausted. I saw in West Philadelphia a case of basilar meningitis in a girl of thirteen, who for three days, when not under the influence of a powerful sedative or of chloroform, screamed at the top of her voice so as to be heard a square or more away. The vomiting is without apparent cause, and is independent of taking of food. Constipation is usually present. The fever is slight, but gradually rises to 102° or 103°. The pulse is at first rapid, subse- quently irregular and slow. The respirations are rarely altered. During TUBERCULOSIS. 223 sleep the child is restless and disturbed. There may be tvvitcliings of the muscles, or sudden startings; or the child may wake up from sleep in great terror. In this early stage the pupils are usually contracted. These are the chief symptoms of the initial stage, or, as it is termed, the stage of irritation. In the second period of the disease these irritative symptoms subside; vomiting is no longer marked, the abdomen becomes retracted, boat- shaped or carinated. The bowels are obstinately constipated, the child no longer complains of headache, but is dull and apathetic, and when roused is more or less delirious. The head is often retracted and the child utters an occasional cry. The pupils are dilated or irregular, and a squint may develop. Sighing respiration is common. Convulsions may occur, or rigidity of the muscles of one side or of one limb. The temperature is variable, ranging from 100° to 102'5°. A blotchy erythema is not uncom- mon on the skin. If the finger-nail is drawn across the skin of any region a red line comes out quickly, the so-called taclie cerebrate, which, however, has no diagnostic significance. In the final period, or stage of paralysis, the coma increases and the child cannot be roused. Convulsions are not infrequent, and there are spasmodic contractions of the muscles of the back and neck. Spasms may occur in the limbs of one side. Optic neuritis and paralysis of the ocular muscles may be present. The pupils become dilated, the eyelids are only partially closed, and the eyeballs are rolled up so that the cornege are only covered in part by the upper eyelid. Diarrhoea may develop, the pulse becomes rapid, and the child may sink into a typhoid state with dry tongue, low delirium, and involuntary passages of urine and faeces. The temperature often becomes subnormal, sinking in rare instances to 93° or 94°. In some cases there is ante-mortem elevation of temperature, the fever rising to 106°. The entire duration of the disease is from a fort- night to three or four weeks. A leucocytosis is not infrequently present throughout the disease. There are cases of tuberculous meningitis which pursue a more rapid course. They set in with great violence, often in persons apparently in good health, and may prove fatal within a few days. In these instances, more commonly seen in adults, the convex surface of the brain is usually involved. There are again instances which are essentially chronic- and display symptoms of a limited meningitis; sometimes with pronounced psychical symptoms, and sometimes with those of cerebral tumor. There are certain features which call for special comment. The irregularity and slowness of the pulse in the early and middle stages of the disease are points upon which all authors agree. Toward the close, as the heart’s action becomes weaker, the pulsations are more fre- quent. The temperature is usually elevated, but there are instances in which it does not rise in the whole course of the disease much above 100°. It may be extremely irregular, and the oscillations are often as much as three or four degrees in the day. Toward the close the temperature may SPECIFIC INFECTIOUS DISEASES. 224 sink to 95°, occasionally to 94°, or there may be hyperpyrexia. In a case of Baumler’s the temperature rose before death to 43'7° C. (110-7° F.). The ocular symptoms of the disease are of special importance. In the early stages narrowing of the pupils is the rule. Toward the close, with increase in the intra-cranial pressure, the pupils dilate and are irregular. There may be conjugate deviation of the eyes. Of ocular palsies the third nerve is most frequently involved, sometimes with paralysis of the face, limbs, and hypoglossal nerve on the opposite side (syndrome of Weber), due to a lesion limited to the inferior and internal part of the crus. The changes in the eye-grounds are very important. Neuritis is the most common. According to Gowers, the disk at first becomes full colored and has hazy outlines, and the veins are dilated. Swelling and striation become pronounced, but the neuritis is rarely intense. Of twenty-six cases studied by Garlick, in six the condition was of diagnostic value. The tubercles in the choroid are rare and much less frequently seen during life than post-mortem figures would indicate. Thus Litten found them (post mortem) in thirty-nine out of fifty-two cases. They were present in only one of the twenty-six cases of tuberculous meningitis examined by Garlick. Heinzel examined with negative results forty-one cases. Among the motor symptoms convulsions are most common, but there are other changes which deserve special mention. A tetanic contraction of one limb may persist for several days, or a cataleptic condition. Tremor and athetoid movements are sometimes seen. The paralyses are either hemiplegias or monoplegias. Hemiplegia may result from disturbance in the cortical branches of the middle cerebral artery, occasionally from softening in the internal capsule, due to involvement of the central branches. Of monoplegias, that of the face is perhaps most common, and if on the right side it may occur with aphasia. In two of my cases in adults aphasia developed. Brachial monoplegia may be associated with it. In the more chronic cases the symptoms persist for months, and there may be a characteristic Jacksonian epilepsy when the tubercles involve the meninges of the motor cortex. The prognosis in this form of meningitis is always most serious. I have neither seen a case which I regarded as tuberculous recover, nor have I seen post-mortem evidence of past disease of this nature. Cases of recovery have been reported by reliable authorities, but they are extremely rare, and there is always a reasonable doubt as to the correctness of the diagnosis. The differential features and treatment will be considered in connection writh acute meningitis. III. Tuberculosis of tiie Lymph-glands {Scrofula). Scrofula is tubercle, as it has been shown that the bacillus of Koch is the essential element. It is not yet definitely settled whether the virus which produces the chronic adenitis or scrofula differs from that which produces tuberculosis in other parts, or whether it is the local conditions TUBERCULOSIS, 225 in the glands which account for the slow development and milder course. The experiments of Arloing would indicate that the virus was attenuated or milder, for he has shown that the caseous material of a lymph-gland killed guinea-pigs, while rabbits escaped. The guinea-pig, as is well known, is the more susceptible animal of the two. The observations of Lingard are still more conclusive, as showing a variation in the virulence of the tubercle bacillus. Guinea-pigs inoculated with ordinary tubercle showed lymphatic infection within the first week, and the animals died within three months; infected with material from scrofulous glands, the lymphatic enlargement did not appear until the second or third week, and the animals survived for six or seven months. lie showed, moreover, that the virulence of the infection obtained from the scrofulous glands in- creased in intensity by passing through a series of guinea-pigs. Eve’s ex- periments show that scrofulous material invariably produces tuberculosis in guinea-pigs and very often in rabbits. Tuberculous adenitis is met with at all ages. It is more common in children than in adults, but it is not infrequent in the middle period of life, and may occur in old age. The tubercle bacillus is ubiquitous. All are exposed to infection, and upon the local conditions, whether favorable or unfavorable, depend the fate of those organisms which find lodgment in our bodies. It is possible, of course, that tuberculous adenitis may be congenital, but such instances must be extremely rare. A special predisposing factor in lymphatic tuber- culosis is catarrhal inflammation of the mucous membranes, which in itself excites slight adenitis of the neighboring glands. In a child with con- stantly recurring naso-pharyngeal catarrh, the bacilli which lodge on the mucous membranes find in all probability the gateways less strictly guarded and are taken up by the lymphatics and passed to the nearest glands. The importance of the tonsils as an infection-atrium has of late been urged. In conditions of health the local resistance, or, as some would put it, the phagocytes, would be active enough to deal with the in- vaders, but the irritation of a chronic catarrh weakens the resistance of the lymph-tissue and the bacilli are enabled to develop and gradually to change a simple into a tuberculous adenitis. The frequent association of tuber- culous adenitis of the bronchial glands with whooping-cough and with measles, and the frequent development of tubercle in the mesenteric glands in children with intestinal catarrh, find in this way a rational ex- planation. After all, as Virchow pointed out, an increased vulnerability of the tissue, however brought about, is the important factor in the disease. The following are some of the features of interest in tuberculous ade- nitis : (a) The local character of the disease. Thus, the glands of the neck, or at the bifurcation of the bronchi, or those of the mesentery, may be alone involved. (b) The tendency to spontaneous healing. In a large proportion of the cases the battle which ensues between the bacilli and the tissue-cells is 226 SPECIFIC INFECTIOUS DISEASES. long; but the latter are finally successful, and we find in the calcified remnants in the bronchial and mesenteric lymph-glands evidences of vic- tory. Too often in the bronchial glands a truce only is declared and hos- tilities may break out afresh in the form of an acute tuberculosis. (c) The tendency of tuberculous adenitis to pass on to suppuration. The frequency with which, particularly in the glands of the neck, we find the tuberculous processes associated with pus is a special feature of this form of adenitis. In nearly all instances the pus is sterile. Whether the suppuration is excited by the bacilli or by their products, or whether it is the result of a mixed infection with pus organisms, which are subse- quently destroyed, has not been settled. (d) The existence of an unhealed focus of tuberculous adenitis is a constant menace to the organism. It is safe to say that in three fourths of the instances of acute tuberculosis the infection is derived from this source. On the other hand, it has been urged that scrofula in childhood gives a sort of protection against tuberculosis in adult life. We certainly do meet with many persons of exceptional bodily vigor who in childhood had enlarged glands, but the evidence which Marfan brings forward in support of this view is not conclusive. Clinical Forms.—1. General Tuberculous Lymphadenitis.—In ex- ceptional instances we find diffuse tuberculosis of nearly all the lymph- glands of the body with little or no involvement of other parts. The most extreme cases of it which I have seen have been in negro patients. Two well-marked cases occurred at the Philadelphia Hospital. In a woman, the chart from April, 1888, until March, 1889, showed persistent fever, ranging from 101° to 103°, occasionally rising to 104°. On December 16th the glands on the right side of the neck were removed. After an attack of erysipelas, on February 17th, she gradually sank and died March 5th. The lungs presented only one or two puckered spots at the apices. The bronchial, retro-peritoneal, and mesenteric glands were greatly enlarged and caseous. No intestinal, uterine, or bone disease. The continuous high fever in this case depended apparently upon the tuberculous adenitis, which was much more extensive than was supposed during life. In these instances the enlargement is most marked in the retro-peritoneal, bron- chial, and mesenteric glands, but may be also present in the groups of external glands. Occurring acutely, it presents a picture resembling Hodg- kin’s disease. In a case which died in the Montreal General Hospital this diagnosis was made. The cervical and axillary glands were enormously enlarged, and death was caused by infiltration of the larynx. In infants and children there is a form of general tuberculous adenitis in which the various groups of glands are successively, more rarely simultaneously, in- volved, and in which death is caused either by cachexia, or by an acute infection of the meninges. 2. Local Tuberculous Adenitis.—(a) Cervical—This is the most com- mon form met with in children. It is seen particularly among the poor TUBERCULOSIS. 227 and those who live continuously in the impure atmosphere of badly venti- lated lodgings. Children in foundling hospitals and asylums are specially prone to the disease. In this country it is most common in the negro race. As already stated, it is often met with in catarrh of the nose and throat, or chronic enlargement of the tonsils; or the child may have had eczema of the scalp or a purulent otitis. The submaxillary glands are first involved, and are popularly spoken of as enlarged kernels. They are usually larger on one side than on the other. As they increase in size, the individual tumors can be felt; the surface is smooth and the consistence firm. They may remain isolated, but more commonly they form large, knotted masses, over which the skin is, as a rule, freely movable. In many cases the skin ultimately be- comes adherent, and inflammation and suppuration occur. An abscess points and, unless opened, bursts, leaving a sinus which heals slowly. The disease is frequently associated with coryza, with eczema of the scalp, ear, or lips, and with conjunctivitis or keratitis. When the glands are large and growing actively, there is fever. The subjects are usually anae- mic, particularly if suppuration has occurred. The progress of this form of adenitis is slow and tedious. Death, however, rarely follows, and many aggravated cases in children ultimately get well. Not only the submaxil- lary group, but the glands above the clavicle and in the posterior cervical triangle, may be involved. In other instances the cervical and axillary glands are involved together, forming a continuous chain which extends beneath the clavicle and the pectoral muscle. With them the bronchial glands may also be enlarged and caseous. Not infrequently the enlarge- ment of the supraclavicular and axillary group of glands on one side precedes the development of a tuberculous pleurisy or of pulmonary tuberculosis. (b) Bronchial.—The mediastinal lymph-glands constitute filters in which lodge the various foreign particles which escape the normal phago- cytes of bronchi and lungs. Among these foreign particles, and probably attached to them, tubercle bacilli are not uncommon, and we find tuber- cles and caseous matter with great frequency in the mediastinal glands, particularly those about the bronchi. It is stated that this process is always secondary to a focus, however small, in the lungs, but my experi- ence does not bear out such a statement. As already mentioned, North- rup found them involved in every one of a hundred, and twenty-seven cases at the New York Foundling Hospital. This tuberculous adenitis may, in the bronchial glands, attain the dimensions of a tumor of large size. But even when this occurs there may be no pressure symptoms. In children the bronchial adenitis is apt to be associated with suppuration. A more serious danger in tuberculous disease of the bronchial glands is systemic infection, which takes place through the vessels. Local in- fection of the lungs may also occur. In the tuberculous broncho-pneu- monia of children it is usual to find the bronchial glands enormously en- 228 SPECIFIC INFECTIOUS DISEASES. larged, passing deeply into the hilus, adjoining, and in some instances even merging with, areas of caseation of the pulmonary tissue itself. There is a special danger of infection of the pericardium by tubercu- lous lymph-glands in the anterior mediastinum. (c) Mesenteric ; Tabes mesenterica.—In this affection, the abdominal scrofula of old writers, the glands of the mesentery and retro-peritonseum become enlarged and caseate ; more rarely they suppurate or calcify. A slight tuberculous adenitis is extremely common in children, and is often accidentally found (post mortem) when the children have died of other diseases. It may be a primary lesion associated with intestinal catarrh, or it may be secondary to tuberculous disease of the intestines. The primary cases are very common in children, as may be gathered from Woodhead’s figures. The general involvement of the glands inter- feres seriously with nutrition, and the patients are puny, wasted, and anae- mic. The abdomen is enlarged and tympanitic; diarrhoea is a constant feature; the stools are thin and offensive. There is moderate fever, but the general wasting and debility are the most characteristic features. The enlarged glands cannot often be felt, owing to the distended condition of the bowels. These cases are often spoken of as consumption of the bowels, but in a majority of them the intestines do not present tuber- culous lesions. In a considerable number of the cases of tabes mesen- terica the peritonaeum is also involved, and in such the abdomen is large and hard, and nodules may be felt. The condition is one to which the French have given the name carreau. In adults tuberculous disease of the mesenteric glands may occur as a primary affection, or in association with pulmonary disease. Gairdner * gives a remarkable instance of the kind in a man aged twenty-one. In- stances of this sort are not uncommon in the literature. Large tumors may exist without tuberculous disease in the intestines or in any other parts. The diagnosis of local and general tuberculous adenitis from lym- phadenoma will be subsequently considered. IV. Pulmonary Tuberculosis (Phthisis, Consumption). Three clinical groups may be conveniently recognized: (1) tuberculo- pneumonic phthisis—acute phthisis; (2) chronic ulcerative phthisis ; and (3) fibroid phthisis. According to the mode of infection there are two distinct types of lesions: (a) When the bacilli reach the lungs through the blood-vessels or lym- phatics the primary lesion is usually in the tissues of the alveolar walls, in the capillary vessels, the epithelium of the air-cells, and in the connective-tissue * Lectures to Practitioners, Gairdner and Coats, 1888. TUBERCULOSIS. 229 framework of the septa. The process of cell division proceeds as already described in the general histology of tubercle. The irritation of the bacilli produces, within a few days, the small, gray miliary nodules, involv- ing several alveoli and consisting largely of round, cuboidal, uninuclear epithelioid cells. Depending upon the number of bacilli which reach the lung in this way, either a localized or a general tuberculosis is excited. The tubercles may be uniformly scattered through both lungs and form a part of a general miliary tuberculosis, or they may be confined to the lungs, or even in great part to one lung. The changes which the tuber- cles undergo have already been referred to. The further changes may be: (1) Arrest of the process of cell division, gradual sclerosis of the tubercle, and ultimately complete fibroid transformation. (2) Caseation of the centre of the tubercle, extension at the periphery by proliferation of the epithelioid and lymphoid cells, so that the individual tubercles or small groups become confluent and form diffuse areas which undergo caseation and softening. (3) Occasionally as a result of intense infection of a localized region through the blood-vessels the tubercles are thickly set. The intervening tissue becomes acutely inflamed, the air-cells are filled with the products of a desquamative pneumonia, and many lobules are involved. (b) When the bacilli reach the lung through the bronchi—inhalation or aspiration tuberculosis—the picture differs. The smaller bronchi and bronchioles are more extensively affected; the process is not confined to single groups of alveoli, but has a more lobular arrangement, and the tuberculous masses from the outset are larger, more diffuse, and may in some eases involve an entire lobe or the greater part of a lung. It is in this mode of infection that we see the characteristic peri-bronchial granu- lations and the areas of the so-called nodular broncho-pneumonia. These broncho-pneumonic areas, with on the one hand caseation, ulceration, and cavity formation, and on the other sclerosis and limitation, make up the essential elements in the anatomical picture of tuberculous phthisis. 1. Acute Pneumonic Phthisis. This form, known alsc by the name of galloping consumption, is met with both in children and adults. In the former many of the cases are mistaken for simple broncho-pneumonia. Two types may he recognized, the pneumonic and broncho-pneumonic, (a) In the pneumonic form one lobe may be involved, or in some in- stances an entire lung. The organ is heavy, the affected portion airless, the pleura usually covered with thin exudation, and on section the picture resembles closely that of ordinary hepatization. The following is an extract from the post-mortem report of a case in which death occurred twenty-nine days after the onset of the illness, having all the characters of an acute pneumonia ; “ Left lung weighs 1,500 grammes (double the weight of the 230 SPECIFIC INFECTIOUS DISEASES. other organ) and is heavy and airless, crepitant only at the anterior mar- gins Section shows a small cavity the size of a walnut at the apex, about which are scattered tubercles in a consolidated tissue. The greater part of the lung presents a grayish-white appearance due to the aggregation of tubercles which in some places have a continuous, uniform appearance, in others are surrounded by an injected and consolidated lung-tissue. Toward the margins of the lower lobe strands of this firm reddish tissue separate anaemic, dry areas. There are in the right lung three or four small groups of tubercles but no caseous masses. The bronchial glands are not tuberculous.” Here the intense local infection was due to the small focus at the apex of the lung, probably an aspiration process. Only the most careful inspection may reveal the presence of miliary tubercles, or the attention may be arrested by the detection of tubercles in the other lung or in the bronchial glands. The process may involve only one lobe. There may be older areas which are of a peculiarly yellowish- white color and distinctly caseous. The most remarkable picture is pre- sented by cases of this kind in which the disease lasts for some months. A lobe or an entire lung may be enlarged, firm, airless throughout, and converted into a dry, yellowish-white, cheesy substance. Cases are met with in which the entire lung from apex to base is in this condition, with perhaps only a small, narrow area of air-containing tissue on the margin. More commonly, if the case has lasted for two or three months, rapid softening has taken place at the apex with extensive cavity formation. In a recent study A. Fraenkel and Troje found tubercle bacilli alone in eleven of twelve cases. They suggest that in these cases of infection by aspiration the large areas of exudative inflammation, at some distance even from the seat of growth of the bacilli, are due to the presence of some diffusible poison produced by the germs. Symptoms.—The attack sets in abruptly with a chill, usually in an individual who has enjoyed good health, although in many cases the onset has been preceded by exposure to cold, or there have been debilitating cir- cumstances. The temperature rises rapidly after the chill, there are pain in the side, and cough, with at first mucoid, subsequently rusty-colored expectoration which may contain tubercle bacilli. The dyspnoea may be- come extreme and the patient may have suffocative attacks. The physical examination shows involvement of one lobe or of one lung, with signs of consolidation, dulness, increased fremitus, at first feeble or' suppressed vesicular murmur, and subsequently well-marked bronchial breathing. The upper or lower lobe may be involved, or in some cases the entire lung. At this time, as a rule, no suspicion enters the mind of the practitioner that the case is anything but one of frank lobar pneumonia. Occasionally there may be suspicious circumstances in the history of the patient or in his family; but, as a rule, no stress is laid upon them in comparison with the intense and characteristic mode of onset. Between the eighth and tenth day, instead of the expected crisis, the condition becomes aggra- TUBERCULOSIS. 231 vated, the temperature is irregular, and the pulse more rapid. There may he sweating, and the expectm-ation becomes muco-purulent and greenish in color—a point of special importance, to which Traube called attention. Even in the second or third week, with the persistence of these symptoms, the physician tries to console himself with the idea that the case is one of unresolved pneumonia, and that all will yet be well. Gradually, however, the severity of the symptoms, the presence of physical signs indicating softening, the existence of elastic tissue and tubercle bacilli in the sputa present the mournful proofs that the case is one of acute pneumonic phthisis. Death may occur before softening takes place, even in the second or third week. In other cases there is extensive destruction at the apex, with rapid formation of cavity, and the case may drag on for two or three months. Diagnosis.—It is by no means widely recognized in the profession that there is a form of acute phthisis which may closely simulate ordinary pneumonia. Waters, of Liverpool, gave an admirable description of these cases, and called attention to the difficulty in distinguishing them from ordinary pneumonia. Certainly the mode of onset affords no criterion whatever. A healthy, robust-looking young Irishman, a cab-driver, who had been kept waiting on a cold, blustering night until three in the morn- ing, was seized the next afternoon with a violent chill, and the following day was admitted to my wards at the University Hospital, Philadelphia. He was made the subject of a clinical lecture on the fifth day, when there tvas absent no single feature in history, symptoms, or physical signs of acute lobar pneumonia of the right upper lobe. It tvas not until ten days later, Avhen bacilli Avere found in his expectoration, that Ave were made aAvare of the true nature of the case. I knoAV of no criterion by Avhich cases of this kind can be distinguished in the early stage. The tubercle bacilli may not be present at first, but in one of Fraenkel and Troje’s cases they existed alone in the typical pneumonic sputum. A point to which Traube called attention, and Avhich is also referred to as important by Ilerard and Cornil, is the absence of breath-sounds in the consolidated region; but this, I am sure, does not hold good in all cases. The tubular breathing may be intense and marked as early as the fourth day; and again, Iioav common it is to have, as one of the earliest and most suggest- ive symptoms of lobar pneumonia, suppression or enfeeblement of the vesicular murmur! In many cases, however, there are suspicious circum- stances in the onset: the patient has been in bad health, or may have had pre\rious pulmonary trouble, or there are recurring chills. Careful exami- nation of the sputa and a study of the physical signs from day to day can alone determine the true nature of the case. A point of some moment is the character of the fever, which in true pneumonia is more continuous, particularly in sevTere cases, whereas in this form of tuberculosis remissions of 1*5° or 2° are not infrequent. (b) Acute tuberculous broncho-pneumonia is more common, particu- larly in children, and forms a majority of the cases oi phthisis Jlorida, or 232 SPECIFIC INFECTIOUS DISEASES. “galloping consumption.” It is an acute caseous broncho-pneumonia, starting in the smaller tubes, which become blocked with a cheesy sub- stance, while the air-cells of the lobule are filled with the products of a catarrhal pneumonia. In the early stages the areas have a grayish-red, later an opaque-white, caseous appearance. By the fusion of contiguous masses an entire lobe may be rendered nearly solid, but there can usually be seen between the groups areas of crepitant air tissue. This is not an uncom- mon picture in the acute phthisis of adults, but it is still more frequent in children. The following is an extract from the post-mortem of a case on a child aged four months, which died in the sixth week of illness: “ On section, the right upper lobe is occupied with caseous masses from five to twelve millimetres in diameter, separated from each other by an interven- ing tissue of a deep-red color. The bronchi are filled with cheesy substance. The middle and lower lobes are stuffed with tubercles, many of which are becoming caseous. Toward the diaphragmatic surface of the lower lobe there is a small cavity the size of a marble. The left lung is more crepitant and uniformly studded with tubercles of all sizes, some as large as peas. The bronchial glands are very large, and one contains a tuberculous abscess.” There is a form of tuberculous inspiration pneumonia, to which Baum- ler has called attention, developing as a sequence of haemoptysis, and due to the aspiration of blood and the contents of pulmonary cavities into the finer tubes. Following the haemoptysis, which may have occurred in an individual without suspected lesion, there are fever, dyspnoea, and signs of a diffuse broncho-pneumonia. Some of these cases run a very rapid course, and are examples of galloping consumption following haemoptysis. This accident may occur not alone early in the disease, but may follow haemor- rhage in a well-developed case of pulmonary tuberculosis. In children the enlarged bronchial glands usually surround the root of the lung, and even pass deeply into the substance, and the lobules are often involved by direct contact. In other cases the caseous broncho-pneumonia involves groups of alveoli or lobules in different portions of the lungs, more commonly at both apices, forming areas from one to three centimetres in diameter. The size of the mass depends largely upon that of the bronchus involved. There are cases which probably should come in this category, in which, with a history of an acute illness of from four to eight weeks, the lungs are extensively studded with large gray tubercles, ranging in size from five to ten millimetres. In some instances there are cheesy masses the size of a cherry. All of these are grayish-white in color, distinctly cheesy, and between the adjacent ones, particularly in the lower lobe, there may be recent pneumonia, or the condition of lung which has been termed splenization. In a case of this kind at the Philadelphia Hospital death took place about the eighth week from the abrupt onset of the illness with haemorrhage. There were no extensive areas of consolidation, but the cheesy nodules were uniformly scattered throughout both lungs. No soft- ening had taken place. TUBERCULOSIS. 233 Symptoms.—The symptoms of acute broncho-pneumonic phthisis are very variable. In adults the disease may attack persons in good health, but who are overworked or “ run down ” from any cause. Haemorrhage initiates the attack in a few cases. There may be repeated chills; the temperature is high, the pulse rapid, and the respirations are increased. The loss of flesh and strength is very striking. The physical signs may at first be uncertain and indefinite, but finally there are areas of impaired resonance, usually at the apices; the breath- sounds are harsh and tubular, with numerous rales. The sputa may early show elastic tissue and tubercle bacilli. In the acute cases, within three weeks, the patient may be in a marked typhoid state, with delirium, dry tongue, and high fever. Death may occur within three weeks. In other cases the onset is severe, with high fever, rapid loss of flesh and strength, and signs of extensive unilateral or bilateral disease. Softening takes place; there are sweats, chills, and progressive emaciation, and all the features of phthisis fioi'ida. Six or eight weeks or later the patient may begin to improve, the fever lessens, the general symptoms mitigate, and a case which looked as if it would certainly terminate fatally within a few weeks drags on and becomes chronic. In .children the disease most commonly follows the infectious diseases, particularly measles and whooping-cough.* The profession is gradually recognizing the fact that a majority of all such cases are tuberculous. At least three groups of these cases of tuberculous broncho-pneumonia may be recognized. In the first the child is taken ill suddenly while teething or during convalescence from fever; the temperature rises rapidly, the cough is severe, and there may be signs of consolidation at one or both apices with rales. Death may occur within a few days, and the lung shows areas of broncho-pneumonia, with perhaps here and there scattered opaque grayish-yellow nodules. Macroscopically the affection does not look tuber- culous, but histologically miliary granulations and bacilli may be found.f Tubercles are usually present in the bronchial glands, but the appearance of the broncho-pneumonia may be exceedingly deceptive, and it may re- quire careful microscopical examination to determine its tuberculous char- acter. The second group is represented by the case of the child previously quoted, which died at the sixth week with the ordinary symptoms of severe broncho-pneumonia. And the third group is that in which, during the convalescence from an infectious disease, the child is taken ill with fever, cough, and shortness of breath. The severity of the symptoms miti- gates within the first fortnight; but there is loss of flesh, the general condition is bad, and the physical examination shows the presence of scattered rales throughout the lungs, and here and there areas of de- fective resonance. The child has sweats, the fever becomes hectic in * “ Tussis eonvulsiva vestibulum tabis” (Willis). \ Cornil and Babes, Les Bacteries, tome ii, 1890. 234 SPECIFIC INFECTIOUS DISEASES. character, and in many cases the clinical picture gradually develops into that of chronic phthisis. 2. Chronic Ulcerative Phthisis. Under this heading may he grouped the great majority of cases of pul- monary tuberculosis, in which the lesions proceed to ulceration and soften- ing, and ultimately produce the well-known picture of chronic phthisis. At first a strictly tuberculous affection, it ultimately becomes, in a majority of cases, a mixed disease, many of the most prominent symptoms of which are due to septic infection from purulent foci and cavities. Morbid Anatomy.—Inspection of the lungs in a case of chronic phthisis shows a remarkable variety of lesions, comprising nodular tuber- cles, difi'use tuberculous infiltration, caseous masses, pneumonic areas, cavities of various size, Avitli changes in the pleura, bronchi, and bronchial glands. 1. The Distribution of the Lesions.—For years it has been recognized that the most advanced lesions are at the apices, and that the disease progresses downward, usually more rapidly in one of the lungs. This general statement, which has passed current in the text-books ever since the masterly description of Laennec, has recently been carefully elabo- rated by Kingston Fowler, who finds that the disease in its onward pro- gress through the lungs follows, in a majority of the cases, distinct routes. In the upper lobe the primary lesion is not, as a rule, at the extreme apex, but from an inch to an inch and a half below the summit of the lung, and nearer to the posterior and external borders. The lesion here tends to spread downward, probably from inhalation of the virus, and this accounts for the frequent circumstance that examination behind, in the supraspinous fossa, will give indications of disease before any evidences exist at the apex in front. Anteriorly this initial focus corresponds to a spot just below the centre of the clavicle, and the direction of extension in front is along the anterior aspect of the upper lobe, along a line run- ning about an inch and a half from the inner ends of the first, second, and third interspaces. A second less common site of the primary lesion in the apex “corresponds on the chest Avail with the first and second interspaces beloAv the outer third of the clavicle.” The extension is doAvn- Avard, so that the outer part of the upper lobe is chiefly imToWed. In the middle lobe of the right lung the affection usually follo\Ars the upper lobe on the same side. In the iiwolvement of the loAver lobe the first secondary infiltration is about an inch to an inch and a half below the posterior extremity of its apex, and corresponds on the chest Avail to a spot opposite the fifth dorsal spine. This involvement is of the greatest importance clinically, as “ in the great majority of cases, Avhen the physi- cal signs of the disease at the apex are sufficiently definite to allow of the diagnosis of phthisis being made, the lower lobe is already affected.” Ex- TUBERCULOSIS. 235 animation, therefore, should be made carefully of this posterior apex in all suspicious cases. In this situation the lesion spreads downward and laterally along the line of the interlobular septa, a line which is marked by the vertebral border of the scapula, when the hand is placed on the opposite scapula and the elbpw raised above the level of the shoulder. Once present in an apex, the disease usually extends in time to the oppo- site upper lobe; but not, as a rule, until the apex of the lower lobe of the lung first affected has been attacked. Of 427 cases above mentioned, the right apex was involved in 172, the left in 130, both in 111. Lesions of the base may be primary, though this is rare. Percy Kidd makes the proportion of basic to apicic phthisis one to five hundred, a smaller number than existed in my series. In very chronic cases there may be arrested lesions at the apex and more recent lesions at the base. 2. Summary of the Lesions in Chronic Ulcerative Phthisis.—(a) Mili- ary Tubercles.—These may not be evident on microscopical examination, or there may be a few colonies, “ the secondary crop ” of Laennec, about the caseous areas. In other instances, with old lesions at the apex, there are, throughout the lower lobes, scattered groups of miliary tubercles which have undergone fibroid and pigmentary changes. Sometimes, in cases with cavity formation at the apex, the greater part of the lower lobes present many groups of firm, sclerotic, miliary tubercles, which may in- deed form the distinguishing anatomical feature—a chronic miliary tuber- culosis. (b) Tuberculous Broncho-pneumonia.—In a large proportion of the cases of chronic phthisis the terminal bronchiole is the point of origin of the process, consequently we find the smaller bronchi and their alveolar territories blocked with the accumulated products of inflammation in all stages of caseation. At an early period a cross-section of an area of tuber- culous broncho-pneumonia gives the most characteristic appearance. The central bronchiole is seen as a small orifice, or it is plugged with cheesy con- tents, while surrounding it is a caseous nodule, the so-called peribronchial tubercle. The longitudinal section has a somewhat dendritic or foliaceous appearance. The condition of the picture depends much upon the slow- ness or rapidity .with which the process has advanced. The following changes may occur : Ulceration. — When the caseation takes place rapidly or ulceration occurs in the bronchial wall, the mass may break down and form a small cavity. Sclerosis.—In other instances the process is more chronic. Fibroid changes gradually produce a sclerosis of the affected area, a condition which is sometimes called cirrhosis nodosa tuberculosa. The sclerosis may be confined to the margin of the mass, forming a limiting capsule, within which is a uniform, firm, cheesy substance, in which lime salts are often deposited. This represents the healing of one of these areas of caseous 236 SPECIFIC INFECTIOUS DISEASES. bronchopneumonia. It is only, however, when complete fibroid trans- formation or calcification has occurred that we can really speak of healing. In many instances the colonies of miliary tubercles about these masses show that the virus is still active in them. Subsequently, in ulcerative processes, these calcareous bodies — lung-stones, as they are sometimes called—may be expectorated. (c) Pneumonia.—An important though secondary place is occupied by inflammation of the alveoli surrounding the tubercles, which become filled with epithelioid cells. The consolidation may extend for some dis- tance about the tuberculous foci and unite them into areas of uniform con- solidation. Although in some instances this inflammatory process may be simple, in others it is undoubtedly specific. It is excited by the tubercle bacilli and is a manifestation of their action. It may present a very varied appearance; in some instances resembling closely ordinary red hepatiza- tion, in others more homogeneous and infiltrated, the so-called infiltration tuberculeuse of Laennec. In other cases the contents of the alveoli un- dergo fatty degeneration, and appear on the cut surface as opaque white or yellowish-white bodies. In early phthisis much of the consolidation is due to this pneumonic infiltration, which may surround for some distance the smaller tuberculous foci. (d) Cavities.—A vomica is a cavity in the lung tissue, produced by necrosis and ulceration. It differs materially from the bronchiectatic form. The process usually begins in the wall of the bronchus in a tuber- culous area. Dilatation is produced by retained secretion, and necrosis and ulceration of the wall occur with gradual destruction of the contiguous tissues. By extension of the necrosis and ulceration the cavity increases, contiguous ones unite, and in an affected region there may be a series of small excavations communicating with a bronchus. In nearly all instances the process extends from the bronchi, though it is possible for necrosis and softening to take place in the centre of a caseous area without pri- mary involvement of the bronchial wall. Three forms of cavities may be recognized : The fresh ulcerative, seen in acute phthisis, in which there is no limiting membrane, but the walls are made up of softened, necrotic, and caseous masses. Small vomicae of this sort, situated just beneath the pleura, may rupture and cause pneumothorax. In cases of acute tuber- culo-pneumonic phthisis they may be large, occupying the greater portion of the upper lobe. In the chronic ulcerative phthisis, cavities of this sort are invariably present in those portions of the lung in which the disease is advancing. At the apex there may be a large old cavity with well-defined walls, while at the anterior margin of the upper lobes, or in the apices of the lower lobe, there are recent ulcerating cavities communicating with the bronchi. Cavities with well-defined walls.—A majority of the cavities in the chronic form of phthisis have a well-defined limiting membrane, the TUBERCULOSIS. inner surface of which constantly produces pus. The walls are crossed by trabeculae which represent remnants of bronchi and blood-vessels. Even the vomicae with the well-defined walls extend gradually by a slow necrosis and destruction of the contiguous lung tissue. The contents are usually purulent, similar in character to the grayish nummular sputa coughed up by phthisical patients. Not infrequently the membrane is vascular or it may be haemorrhagic. Occasionally, when gangrene has occurred in the wall, the contents are horribly foetid. These cavities may occupy the greater portion of the apex, forming an irregular series which communicate with each other and with the bronchi, or the entire upper lobe except the anterior margin may be excavated, forming a thin-walled cavity. In rare instances the process has proceeded to total excavation of the lung, not a remnant of which remains, except perhaps a narrow strip at the anterior margin. In a case of this kind, in a young girl, the cavity held forty fluid ounces. Quiescent Cavities.—When quite small and surrounded by dense cica- tricial tissue communicating with the bronchi they form the cicatrices jistuleuses of Laennec. Occasionally one apex may be represented by a series of these small cavities, surrounded by dense fibrous tissue. The lining membrane of these old cavities may be quite smooth, almost like a mucous membrane. Cavities of any size do not heal completely. Cases are often seen in which it has been supposed that a cavity has healed; but the signs of excavation are notoriously uncertain, and there may be pectoriloquy and cavernous sounds with gurgling, resonant rales in an area of consolidation close to a large bronchus. In the formation of vomicae the blood-vessels gradually become closed by an obliterating inflammation. They are the last structures to yield and may he completely exposed in a cavity, even when the circulation is still going on in them. Unfortunately, the erosion of a large vessel which has not yet been obliterated is by no means infrequent, and causes profuse and often fatal haemorrhage. Another common event is the development of aneurisms on the arteries running in the walls of cavities. These may be small, bunch-like dilatations, or they may form cavities the size of a walnut or even larger. Rasmussen, Douglas Powell and others have called attention to their importance in haemoptysis, under which section they are dealt with more fully. And finally, about cavities of all sorts, the connective tissue develops and tends to limit the extent. The thickening is particularly marked beneath the pleura, and in chronic cases an entire apex may be converted into a mass of fibrous tissue, enclosing a few small cavities. (e) Pleura.—Practically, in all cases of chronic phthisis the pleura is involved. Adhesions take place which may be thin and readily torn, or dense and firm, uniting layers of from two to five millimetres in thickness. This pleurisy may be simple, but in many cases it is tuberculous, and mili- ary tubercles or caseous masses are seen in the thickened pleural mem ■ 238 SPECIFIC INFECTIOUS DISEASES. brane. Pleural effusion is not at all infrequent, either serous, purulent, or haemorrhagic. Pneumothorax is a common accident. (f) Changes in the smaller bronchi control the situation in the early stages of tuberculous phthisis, and play an important role throughout the disease. The process very often begins in the walls of the smaller tubes and leads to caseation, distention with products of inflammation, and broncho-pneumonia of the lobules. In many cases the visible implication of the bronchus is an extension upward of a process which has begun in the smallest bronchiole. This involvement weakens the wall, leading to bronchiectasis, not an uncommon event in phthisis. The mucous mem- brane of the larger bronchi, which is usually involved in a chronic catarrh, is more or less swollen, and in some instances ulcerated. (g) The bronchial glands, in the more acute cases, are swollen and oedematous. Miliary tubercles and caseous foci are usually present. In cases of chronic phthisis the caseous areas are common, calcification may occur, and not infrequently purulent softening. (h) Changes in the other Organs.—Of these, tuberculosis is the most common. In my series of autopsies the brain presented tuberculous lesions in 31, the spleen in 33, the liver in 12, the kidneys in 32, the intes- tines in 65, and the pericardium in 7. Other groups of lymphatic glands besides the bronchial may be affected. Certain degenerations are common. Amyloid change is frequent in the liver, spleen, kidneys, and mucous membrane of the intestines. The liver is often the seat of extensive fatty infiltration, which may cause marked enlargement. The intestinal tuberculosis occurs in advanced cases and is responsible in great part for the troublesome diarrhoea. Endocarditis is not very uncommon, and was present in 12 of my post mortems and in 27 of Percy Kidd’s 500 cases. Tubercle bacilli have been found in the vegetations. The subject has been considered in an impor- tant monograph by Teissier (Paris, 1894). Tubercles may be present on the endocardium, particularly of the right ventricle. As pointed out by Norman Chevers, and confirmed by subsequent writers, the subjects of congenital stenosis of the pulmonary orifice very frequently have phthisis. The larynx is frequently involved, and ulceration of the vocal cords and destruction of the epiglottis are not at all uncommon. Modes of Onset.—We have already seen that tuberculosis of the lungs may occur as the chief part of a general infection, or may set in with symptoms which closely simulate acute pneumonia. In the ordinary type of pulmonary tuberculosis the invasion is gradual and less striking, but presents an extraordinarily diverse picture, so that the practitioner is often led into error. Among the most characteristic of these types of on- set are the following: (a) With dyspeptic and ancemic symptoms, forming a large and important group. The patients may naturally have had feeble digestion. They begin to show marked signs of dyspepsia and become pale, lose flesh, and look chlorotic before any pulmonary symptoms are TUBERCULOSIS. 239 manifest. (b) With chills and fever. This mode of onset is particularly important in malarial regions, as the diagnosis of ordinary intermittent fever is often made, and the nature of the disease entirely overlooked. In Philadelphia it was very common to have patients sent to hospital supposed to be suffering with malaria, who had well-developed signs of pulmonary tuberculosis, (c) Bronchitic onset. These are the instances which arise in what the patient calls a neglected cold. The patient has perhaps been subject to naso-pharyngeal catarrh, and has been liable to take cold readily; then a bronchial cough develops, which proves intrac- table. Sometimes the bronchitic symptoms are associated with wheezing, like mild asthma. The development in these instances may be extremely insidious and, without any special aggravation of the general symptoms or increase in the fever, the tuberculous nature of the trouble may be discovered accidentally by the examination of the sputum. (d) Onset ivitli haemoptysis. The relation of haemoptysis to pulmonary tuberculosis will be discussed elsewhere. The haemoptysis may come on in a con- dition of robust health, and it occasionally, though rarely, happens that the pulmonary symptoms follow rapidly. In other cases a long interval elapses. Undoubtedly these are cases in which there has been a small localized lesion in the lung which has not produced constitutional dis- turbance. {e) Pleuritic onset. This may be a dry pleurisy, developing at the apex or in a scapular region, or in some instances extending generally. It may be acute pleurisy with effusion, or the effusion may have come on insidiously without any acute manifestations. Phthisis developed in a third of ninety cases of pleurisy with effusion, the subsequent history of which was followed by Bowditch. (/) With laryngeal symptoms. In rare instances huskiness and loss of voice are the symptoms for which the pa- tient seeks advice, and the epiglottis or cords may be involved in a well- characterized tuberculosis before the physical signs in the lungs are at all clear. It is in these instances that the examination of the sputa is of the greatest value. These represent the usual modes of onset of the ordinary chronic phthisis. It occasionally happens that in an instance with an acute pneu- monic onset the severity of the symptoms subsides, and, instead of termi- nating as a majority of these cases do within ten or twelve weeks, the case drags on and becomes chronic. Symptoms.—In discussing the symptoms it is usual to divide the disease into three periods: the first embracing the time of the growth and development of the tubercles; the second, in which they soften ; and the third, in which there is a formation of cavities. Unfortunately, these ana- tomical stages can not be satisfactorily correlated with corresponding clini- cal periods, and we often find that a patient in the third stage with well- marked cavity is in a far better condition and has greater prospects of re- covery than a patient in the first stage with diffuse consolidation. It is therefore better perhaps to disregard them altogether. 240 • SPECIFIC INFECTIOUS DISEASES. 1. Local Symptoms.—Pain in the chest may be early and troublesome or absent throughout. It is usually associated with pleurisy, and may be sharp and stabbing in character, and either constant or felt only during coughing. Perhaps the commonest situation is in the lower thoracic zone, though in some instances it is beneath the scapula or referred to the apex. The attacks may recur at long intervals. Intercostal neuralgia occasionally develops in the course of ordinary phthisis. Cough is one of the earliest symptoms, and is present in the majority of cases from beginning to end. There is nothing peculiar or distinctive about it. At first dry and hacking, and perhaps scarcely exciting the attention of the patient, it subsequently becomes looser, more constant, and associated with a glairy, muco-purulent expectoration. In the early stages of the disease the cough is bronchial in its origin. When cavities have formed it becomes more paroxysmal, and is most marked in the morning or after a sleep. Cough is not a constant symptom, however, and a patient may present himself with well-marked excavation at one apex who will declare that he has had little or no cough. So, too, there may be well-marked physical signs, dulness and moist sounds, without either expectoration or cough. In well-established cases the nocturnal paroxysms are most distressing and prevent sleep. The cough may be of such persistence and severity as to cause vomiting, and the patient becomes rapidly emaciated from loss of food. Sputum.—This varies greatly in amount and character at the different stages of ordinary phthisis. There are cases with well-marked local signs at one apex, with slight cough and moderately high fever, without from day to day a trace of expectoration. So, also, there are instances with the most extensive consolidation (caseous pneumonia), with high fever, and, as in a recent instance under observation for several months, without enough expectoration to enable an examination for bacilli to be made. In the early stage of pulmonary tuberculosis the sputum is chiefly catarrhal and has a glairy, sago-like appearance, due to the presence of alveolar cells which have undergone the myelin degeneration. There is nothing dis- tinctive or peculiar in this form of expectoration, which may persist for months without indicating serious trouble. The earliest trace of charac- teristic sputum is seen in the presence of small grayish or greenish-gray purulent masses. These, when coughed up, are always suggestive and should be the portions picked out for microscopical examination. As softening comes on, the expectoration becomes more profuse and puru- lent, but may still contain a considerable quantity of alveolar epithelium. Finally, when cavities exist, the sputa assume the so-called nummular form; each mass is isolated, flattened, greenish-gray in color, quite airless, and sinks to the bottom when spat into water. By the microscopical examination of the sputum we determine whether the process is tuberculous, and whether softening has occurred. For tu- bercle bacilli the Ehrlich-Weigert method is the best. Eleven centimetres TUBERCULOSIS. 241 of a saturated solution of fuchsin in absolute alcohol is added to one hun- dred centimetres of the saturated solution of commercial aniline oil (made by shaking up the oil in water and then filtering). This should be made fresh every third or fourth day. A small bit of the sputum is picked out on a needle or platinum wire and spread thin on the top-cover so as to make a uniformly thin layer. The top-cover is slowly dried about a foot above a Bunsen burner. Sufficient of the staining fluid is then dropped upon the top-cover, which is held at a little distance above the flame un- til the fluid boils. The staining fluid is then washed off in distilled water or put under the tap, decolorized in thirty per cent nitric-acid fluid, again washed off in water, and mounted on the slide. In doubtful cases the long process is used, the cover-slips remaining twenty-four hours in the stain. The bacilli are seen as elongated, slightly curved, red rods, some- times presenting a beaded appearance. They are frequently in groups of three or four, but the number varies considerably. Only one or two may be found in a preparation, or, in some instances, they are so abundant that the entire field is occupied. The presence of these bacilli in the sputum is an infallible indication of the existence of tuberculosis. Sometimes they are found only after repeated examination. They may be abundant early in the disease and are usually numerous in the nummular sputum of the later stages. Elastic tissue may be derived from the bronchi, the alveoli, or from the arterial coats; and naturally the appearance of the tissue will vary with the locality from which it comes. In the examination for this-it is not necessary to boil the sputum with caustic potash. For years I have used a simple plan which was shown to me at the London Hospital by Sir Andrew Clark. This method depends upon the fact that in almost all instances if the sputum is spread in a sufficiently thin layer the frag- ments of elastic tissue can be seen with the naked eye. The thick, puru- lent portions are placed upon a glass plate fifteen by fifteen centimetres and flattened into a thin layer by a second glass plate ten by ten centi- metres. In this compressed grayish layer between the glass slips any fragments of elastic tissue show on a black background as grayish-yellow spots and can either be examined at once under a low power or the upper- most piece of glass is slid along until the fragment is exposed, when it is picked out and placed upon the ordinary microscopic slide. Fragments of bread and collections of milk-globules may also present an opaque white appearance, but with a little practice they can readily be recog- nized. Fragments of epithelium from the tongue, infiltrated with micro- cocci, are still more deceptive, but the microscope at once shows the dif- ference. The bronchial elastic tissue forms an elongated network, or two or three long, narrow fibres are found close together. From the blood-ves- sels a somewhat similar form may be seen and occasionally a distinct 242 SPECIFIC INFECTIOUS DISEASES. sheeting is found as if it had come from the intima of a good-sized ar- tery. The elastic tissue of the alveolar wall is quite distinctive; the fibres are branched and often show the outline of the arrangement of the air- cells. The elastic tissue from bronchus or alveoli indicates extensive erosion of a tube and softening of the lung-tissue. Another occasional constituent of the sputum is blood, which may be present as the chief constituent of the expectoration in haemoptysis or may simply tinge the sputum. In chronic cases with large cavities, in addition to bacteria, various forms of fungi may develop, of which the aspergillus is the most important. Sarcinae may also occur. The daily amount of expectoration varies. In rapidly advancing cases, with much cough, it may reach as high as five hundred cubic centi- metres in the day. In cases with large cavities the chief amount is brought up in the morning. The expectoration of tuberculous patients usually has a heavy, sweetish odor, and occasionally it is fetid, owing to decomposition in the cavities. Hemoptysis.— Haemoptysis is met with either early in the disease, be- fore there are physical signs, or during the course of the affection when there is softening or excavation. A majority of the haemorrhages believed to be precursory are really due to already existing disease of the lung, and there is no ground whatever for the opinion, so long held, that phthisis can originate directly from haemoptysis, the phthisis ah hcemoptoe of Rich- ard Morton. The blood may be either pure or mixed with sputum. A distinction should be made between these two forms. When the sputa are simply tinged or the blood is admixed, it comes, in all probability, from hyperaemic bronchial mucosa or locally congested areas of lung-tissue; but the brisk haemorrhage in which the blood comes up in mouthfuls is always due to erosion of vessels, small or large, in the process of softening, or, in the later stages of the disease, comes from the erosion of a branch of the pulmonary artery or from a ruptured aneurism of the pulmonary artery in a cavity. This latter is the most frequent cause of the fatal haemorrhage in consumption. Dyspnoea is not a common accompaniment of ordinary phthisis. The greater part of one lung may be diseased and local trouble exist at the other apex without any shortness of breath. Even in the paroxysms of very high fever the respirations may not be much increased. Rapid ad- vance of a broncho-pneumonia, or the development of miliary tubercles throughout the lung, causes great increase in the number of respirations. A degree of dyspnoea leading to cyanosis is almost unknown, apart from extensive invasion of the sound portions by miliary tubercles. In long standing cases, with contracted apices or great thickening of the pleura, the right heart is enlarged, and the dyspnoea may be cardiac. 2. General Symptoms.—Fever.—To get a correct idea of the tempera- ture range in pulmonary tuberculosis it is necessary, as Ringer pointed TUBERCULOSIS. 243 out, to make tolerably frequent observations. The usual 8 A. m. and 8 p. m. record is, in a majority of the cases, very deceptive, giving neither the minimum nor maximum. The former usually occurs between 2 and G A. m. and the latter between 2 and 6 p. m. A recognition of various forms of fever, viz., of tuberculization, of ulceration, and of absorption, emphasizes the anatomical stages of growth, softening and cavity formation; but practically such a division is of little use, as in a majority of cases these processes are going on together. Fever is the most important initial symptom and throughout the entire course the thermometer is the most trustworthy guide as to the progress of the affection. With pyrexia a patient loses in weight and strength, and the local disease usually progresses. The periods of apyrexia are those of gain in weight and strength and in limitation of the local lesion. It by no means necessarily follows that a patient with tuberculosis has pyrexia. There may be quite extensive disease without coexisting fever. At the moment of writing, I have eighteen instances of chronic phthisis under observation, of whom ten are practically free from fever ; but in the early stage, when tubercles are developing and caseous areas are in pro- cess of formation and when softening is in progress, fever is a constant symptom. It was present in one hundred consecutive cases at my dis- pensary service. Two types of fever are seen—the remittent and the intermittent. These may occur indifferently in the early or in the late stages of the disease or may alternate with each other, a variability which depends upon the fact that phthisis is a progressive disease and that all stages of lesions may be found in a single lung. Special stress should be laid upon the fact, particularly in malarial regions, that tuberculosis may set in with a fever typically intermittent in character—a daily chill, with subsequent fever and sweat. In Montreal, where malaria is practically unknown, this was always regarded as a suggestive symptom; but in Philadelphia and Baltimore, where ague prevails, it is no exaggeration to say that yearly scores of cases of early tuberculosis are treated for ague. These are often cases that pursue a rapid course. The fever of onset—tuberculization— may be almost continuous, with slight daily exacerbations; and at any time during the course of chronic phthisis, if there is rajoid extension, the remissions become less marked. A remittent fever, in which the temperature is constantly above normal but drops two or three degrees toward morning, is not uncommon in the middle and later stages and is usually associated with softening or extension of the disease. Here, too, a simple morning and evening register may give an entirely erroneous idea as to the range of the fever. With breaking down of the lung-tissue and formation of cavities, associ- ated as these processes always are with suppuration and with more or less systemic contamination, the fever assumes a characteristically intermittent or hectic type. For a large part of the day the patient is not only afebrile, SPECIFIC INFECTIOUS DISEASES. but the temperature is subnormal. In the annexed two-hourly chart, from a case of chronic tuberculosis of the lungs, it will be seen that from 10 p. m. to 8 or 12 A. M., the temperature continuously fell and reached as low as 95°. A slow rise then took place through the late morning and early afternoon hours and reached its maximum between 6 and 10 p. m. As shown in the chart there were in the three days about forty-three hours of pyrexia and twenty-nine hours of apyrexia. The rapid fall of No.: Admitted. ..Ward' Chart XII.—Three days. Chronic tuberculosis. the temperature in the early morning hours is usually associated with sweating. This hectic, as it is called, which is a typical fever of septic infection, is met with when the process of cavity formation and softening is advanced and extending. A continuous fever with remissions of not more than a degree, develop- ing in the course of pulmonary tuberculosis, is suggestive of acute pneu- monia. When a two-hourly chart is made, the remissions even in acute tuberculous pneumonia are usually well marked. A continued fever, such TUBERCULOSIS. 245 as is seen in the first week of typhoid, or in some cases of inflammation of the lung, is rare in tuberculosis. Sweating.—Drenching perspirations are common in phthisis and con- stitute one of the most distressing features of the disease. They occur usually at night, or at any time in the day when the patient sleeps. They may come on early in the disease, but are more persistent and frequent after cavities have formed. Some patients escape altogether. The pulse is increased in frequency, especially when the fever is high. It is often remarkably full, though soft and compressible. Pulsation may sometimes be seen in the capillaries and in the veins on the back of the hand. Emaciation is a pronounced feature. The loss of weight is gradual but, if the disease is extending, progressive. The scales give one of the best indications of the progress of the case. 3. Physical Signs.—(a) Inspection.—The shape of the chest is often suggestive, though it is to be remembered that pulmonary tuberculosis may be met with in chests of any build. Practically, however, in a con- siderable proportion of cases the thorax is long and narrow, with very wide intercostal spaces, the ribs more vertical in direction and the costal angle very narrow. The scapulae are “ winged,” a point noted by Hip- pocrates. Another type of chest which is very common is that which is flattened in the antero-posterior diameter. The costal cartilages may be prominent and the sternum depressed. Occasionally the lower sternum forms a deep concavity, the so-called funnel breast (Trichter-Brust). In- spection gives valuable information in all stages of the disease. Special examination should be made of the clavicular regions to see if one clavicle stands out more distinctly than the other, or if the spaces above or below it are more marked. Defective expansion at one apex is an early and im- portant sign. The condition of expansion of the lower zone of the thorax may be well estimated by inspection. The condition of the praecordia should also be noted, as a wide area of impulse, particularly in the second, third, and fourth interspaces, often results from disease of the left apex. From a point behind the patient, looking over the shoulders, one can often better estimate the relative expansion of the apices. (b) Palpation.—Deficiency in expansion at the apices or bases is per- haps best gauged by placing the hands in the subclavicular spaces and then in the lateral regions of the chest and asking the patient to draw slowly a full breath. Standing behind the patient and placing the thumbs in the supraclavicular and the fingers in the infraclavicular spaces one can judge accurately as to the relative mobility of the two sides. Disease at an apex, though early and before dulness is at all marked, may be indicated by deficient expansion. On asking the patient to count, the tactile fremitus is increased wherever there is local growth of tubercle or extensive caseation. In comparing the apices it is important to bear in mind that normally the fremitus is stronger at the right than SPECIFIC INFECTIOUS DISEASES. at the left. So too at the base, when there is consolidation of the lung, the fremitus is increased ; whereas, if there is pleural elfusion, it is diminished or absent. In the later stages, when cavities form, the tactile fremitus is usually much exaggerated over them. When the pleura is greatly thickened the fremitus may be somewhat diminished. (c) Percussion.—Tubercles, inflammatory products, fibroid changes, and cavities produce important changes in the pulmonary resonance. There may be localized disease, even of some extent, without inducing much alteration; as when the tubercles are scattered and have air-con- taining tissue between them. One of the earliest and most valuable signs is defective resonance upon and above a clavicle. In a considerable pro- portion of all cases of phthisis the dulness is first noted in these regions. The comparison between the two sides should be made also when the breath is held after a full inspiration, as the defective resonance may then be more clearly marked. In the early stages the percussion note is usually higher in pitch, and may require an experienced ear to detect the differ- ence. In recent consolidation from caseous pneumonia the percussion note often has a tubular or tympanitic quality. A wooden dulness is rarely heard except in old cases with extensive fibroid change at the apex or base. Over large, thin-walled cavities at the apex the so-called cracked- pot sound may be obtained. In thin subjects the percussion should be carefully practised in the supraspinous fossae and the interscapular space, as they correspond to very important areas early involved in the disease. In cases with numerous separated cavities at the apex, without much fibroid tissue or thickening of the pleura, the percussion note may show little change, and the contrast between the signs obtained on auscultation and percussion is most marked. (d) Auscultation.—Feeble breath-sounds are among the most charac- teristic early signs, since not as much air enters the tubes and vesicles of the affected area. It is well at first always to compare carefully the cor- responding points on the two sides of the chest without asking the patient either to draw a deep breath or to cough. With early apical disease the inspiration on quiet breathing may be scarcely audible. Expiration is usually prolonged. On the other hand there are cases in which the earliest sign is a harsh, rude, respiratory murmur. On deep breathing it is fre- quently to be noted that inspiration is jerking or wavy, the so-called “ cog- wheel ” rhythm ; which, however, is by no means confined to tuberculosis. With extension of the disease the inspiratory murmur is harsh, and, when consolidation occurs, whiffing and bronchial. With these changes in the character of the murmur there are rales, due to the accompanying bron- chitis. They may be heard only on deep inspiration or on coughing, and early in the disease are often crackling in character. When softening occurs they are louder and have a bubbling, sometimes a characteristic clicking quality. These “ moist sounds,” as they are called, when asso- ciated with change in the percussion resonance are extremely suggestive. TUBERCULOSIS. 247 When cavities form, the rales are louder, more gurgling, and resonant in quality. When there is consolidation of any extent the breath-sounds are tubular, and in the large excavations loud and cavernous, or have an am- phoric quality. In the unaffected portions of the lobe and in the opposite lung the breath-sounds may be harsh and even puerile. The vocal reso- nance is usually increased in all stages of the process, and bronchophony and pectoriloquy are met with in the regions of consolidation and over cavities. Pleuritic friction may be present at any stage and, as mentioned before, occurs very early. There are cases in which it is a marked feature throughout. When the lappet of lung over the heart is involved there may be a pleuro-pericardial friction, and when this area is consolidated there may be curious clicking rales synchronous with the heart-beat, due to the compression by the heart of, and the expulsion of air from, this portion. An interesting auscultatory sign, met most commonly in phthisis, is the so-called cardio-respiratory murmur, a whiffing systolic bruit due to the propulsion of air out of the tubes by the impulse of the heart. It is best heard during inspiration and in the antero-lateral regions of the chest. A systolic murmur is frequently heard in the subclavian artery on either side, the pulsation of which may be very visible. The murmur is in all probability due to pressure on the vessels by the thickened pleura. The signs of cavity may be here briefly enumerated. (a) When there is not much thickening of the pleura or condensation of the surrounding lung-tissue, the percussion sound may be full and clear, resembling the normal note. More commonly there is defective resonance or a tympanitic quality which may at times be purely amphoric. The pitch of the percussion note changes over a cavity when the mouth is opened or closed (Wintrich’s sign), or it may be brought out more clearly on change of position. The cracked-pot sound is only obtainable over tolerably large cavities with thin walls. It is best elicited by a firm, quick stroke, the patient at the time having the mouth open. In those rare instances of almost total excavation of one lung the percussion note may be amphoric in quality, (ft) On auscultation the so-called cavernous sounds are heard : (1) Various grades of modified breathing—blowing or tubular, cavernous or amphoric. There may be a curiously sharp hissing sound, as if the air was passing from a narrow opening into a wide space. In very large cavities both inspiration and expiration may be typically amphoric. (2) There are coarse bubbling rales which have a resonant quality, and on coughing may have a metallic or ringing character. On coughing they are often loud and gurgling. In very large thin-walled cavities, and more rarely in medium-sized cavities, surrounded by recent consolidation, the rales may have a distinctly amphoric echo, simulating those of pneumothorax. There are dry cavities in which no rales are heard. (3) The vocal resonance is greatly intensified and whispered pectoriloquy is clearly heard. In large apical cavities the heart-sounds are well heard, and occasionally there may be an intense systolic murmur, 248 SPECIFIC INFECTIOUS DISEASES. probably always transmitted to, and not produced, as has been supposed, in the cavity itself. Pseudo-cavernous signs may be caused by an area of consolidation near a large bronchus. The condition may be most deceptive—the high- pitched or tympanic percussion note, the tubular or cavernous breathing, and the resonant rales, simulate closely those of cavity. 4. Symptoms referable to other Organs.—(a) Cardio-vascular.—The retraction of the left upper lobe exposes a large area of the heart. In thin-chested subjects there may be pulsation in the second, third, and fourth interspaces close to the sternum. Sometimes with much retraction of the left upper lobe the heart is drawn up. A systolic murmur over the pulmonary area is common in all stages of phthisis. Apical murmurs are also not infrequent and may be extremely rough and harsh without neces- sarily indicating that endocarditis is present. The association of heart- disease with phthisis is not, however, very uncommon. As already men- tioned, there were twelve instances of endocarditis in 216 autopsies. The arterial tension is usually low in phthisis and the capillary resistance les- sened so that the pulse is often full and soft even in the later stages of the disease. The capillary pulse is not infrequently met with, and pulsa- tion of the veins in the back of the hand is occasionally to be seen. (b) Blood Glandular System. — The early ansemia has already been noted. It is often more apparent than real, a cliloro-angemia, and the blood-count rarely sinks below two million per cubic millimetre. The blood-plates are, as a rule, enormously increased and are seen in the withdrawn blood as the so-called Schultze’s granule masses. Without any significance, they are of interest chiefly from the fact that every few years some tyro announces their discovery as a new diagnostic sign of phthisis. The leucocytes are greatly increased, particularly in the later stages. (c) Gastro-intestinal System.—The tongue is usually furred, but may be clean and red. Small aphthous ulcers are sometimes distressing. A red line on the gums, a symptom to which at one time much attention was paid as a special feature of phthisis, occurs in other cachectic states. Ex- tensive tuberculous disease of the pharynx, associated with similar affec- tion of the larynx, may interfere seriously with deglutition and prove a very distressing and intractable symptom. Of late, special attention has been paid to the gastric symptoms of this affection. Tuberculous disease is rare. Ulceration may occur as an accidental complication and multiple catarrhal ulcers are not uncom- mon. Interstitial and parenchymatous changes in the mucosa are com- mon (possibly associated with the venous stasis) and lead to atrophy, but these cannot always be connoted with the symptoms, and they maybe found when not expected. On the other hand, when the gastric symp- toms have been most persistent the mucosa may show very little change. It is impossible always to refer the anorexia, nausea, and vomiting of con- sumption to local conditions. The hectic fever and the neurotic influ- TUBERCULOSIS. 249 ences, upon which Iramermann lays much stress, must be taken into ac- count, as they play an important role. The organ is often dilated, and to muscular insufficiency alone may be due some of the cases of dyspepsia. The condition of the gastric secretion is not constant, and the reports aro discordant. In the early stages there may be hyperacidity; later, a de- ficiency of acid. Anorexia is often a marked symptom at the onset; there may be positive loathing of food, and even small quantities cause nausea. Sometimes with- out any nausea or distress after eating the feeding of the patient is a daily battle. When practicable, Debove’s forced alimentation is of great benefit in such cases. Nausea and vomiting, though occasionally troublesome at an early period, are more marked in the later stages. The latter may be caused by the severe attacks of coughing. S. H. Haberslion refers to four different causes the vomiting in phthisis: (1) central, as from tuberculous meningitis; (2) pressure on the vagi by caseous glands; (3) stimulation from the peripheral branches of the vagus, either pulmonary, pharyngeal, or gastric; and (4) mechanical causes. Of the intestinal symptoms diarrhoea is the most serious. It may come on early, but is more usually a symptom of the later stages, and is associated with ulceration, particularly of the large bowel. Extensive ulceration of the ileum may exist without any diarrhoea. The associated catarrhal condition may account in part for it, and in some instances the amyloid degeneration of the mucous membrane. (d) Nervous System.—(1) Focal lesions due to the development of coarse tubercles and areas of tuberculous meningo-encephalitis. Aphasia, for instance, may result froin the growth of meningeal tubercles in the fissure of Sylvius, or even hemiplegia may develop. The solitary tuber- cles are more common in the chronic phthisis of children. (2) Basilar meningitis is an occasional complication. It may be confined to the brain, though more commonly it is a (3) cerebro-spinal meningitis, which may come on in persons without well-developed local signs in the chest. Twice have I known strong, robust men brought into hospital with signs of cerebro-spinal meningitis, in whom the existence of pulmonary disease was not discovered until the post-mortem. (4) Peripheral neuritis. This is not frequent, and has occurred but five times in the large number of consumptives who have come under my observation during the past seven years. It is nearly always an extensor paralysis of the arm or leg, more commonly the latter, causing foot-drop. It is usually a late manifes- tation. (5) Mental symptoms. It was noted, even by the older writers, that consumptives had a peculiarly hopeful temperament, and the spes phthisica forms a curious characteristic of the disease. Patients with ex- tensive cavities, high fever, and too weak to move will often make plans for the future and confidently expect to recover. Apart from tuberculosis of the brain, there is sometimes in chronic phthisis a form of insanity not unlike that which develops in the conva- 250 SPECIFIC INFECTIOUS DISEASES. lescence from acute affections. The whole question of the mutual relations of insanity and phthisis is dealt with at length in Mickle’s Gulstonian lectures. (e) A remarkable hypertrophy of the mammary gland may occur in pulmonary tuberculosis,* most commonly in males. It may only be on the affected side. Two cases came under my notice at the University Hospital, Philadelphia, both in young males. It is a chronic interstitial, non-tuber- culous mammitis (Allot). (/) Genito-urinary System.—The urine presents no special peculiari- ties in amount or constituents. Fever, however, has a marked influence upon it. Albumen is met with frequently and may be associated with the fever, or is the result of definite changes in the kidneys. In the latter case it is more abundant and more curd-like. Amyloid disease of the kidneys is not uncommon. Its presence is shown by albumen and tube- casts in the urine, and sometimes by a great increase in the amount of urine. In other instances there is dropsy, and the patients have all the characteristic features of chronic Bright’s disease. Pus in the urine may be due to disease of the bladder or of the pelves of the kidneys. In some instances the entire urinary tract is in- volved. In pulmonary phthisis, however, extensive tuberculous disease is rarely found in the urinary organs. Bacilli may occasionally be detected in the pus. Haematuria is not a very common symptom. It may occur occasionally as a result of congestion of the kidneys, which passes off and leaves the urine albuminous. In other instances it results from disease of the pelvis or of the bladder, and is associated either with early tubercu- losis of the mucous membranes or more commonly with ulceration. In any medical clinic the routine inspection of the testes for tubercle will save two or three mistakes a year. (g) Cutaneous System.—The skin is often dry and harsh. Local tubercles occasionally develop on the hands. There may be pigmentary staining, the chloasma plithisicorum, which is more common when the peritonaeum is involved. Upon the chest and back the brown stains of the pityriasis versicolor are very frequent. The hair of the head and beard may become dry and lanky. The terminal phalanges, in chronic cases, become clubbed and the nails incurvated—the Hippocratic fingers.f A remarkable and unusual complication is general emphysema, which may result from ulceration of an adherent lung or perforation of the larynx. Diagnosis.—When well advanced there is rarely any doubt as to the existence of tuberculous phthisis, for the sputum gives positive informa- tion, and the physical signs of local disease are well marked. The bacilli give an infallible indication of the existence of tuberculosis and may be * Allot, Pari? Thesis, 1887. f “ Morbo progrediente, corpus macrescit praeter crura; hajc autera tument et pedes, et ungues contorquentur ” (Hippocrates). TUBERCULOSIS. 251 found in the sputum before the physical signs are at all definite. On the other hand, it must be remembered that there are cases in which, even with tolerably well-defined physical signs, the sputum is extremely scanty and many examinations may be required to detect tubercle bacilli. So essential is the examination of the sputum in the early diagnosis of phthi- sis that I would earnestly insist upon the more frequent employment of this method. There is no excuse now for its omission, since, if the prac- titioner has not command of the necessary technique, there are labora- tories in many parts of the country at which the examination can be made. Early detection is of vital importance, as successful treatment depends upon the measures taken before the lungs are extensively involved. The presence of elastic fibres in the sputum is an indication of destruc- tion of the lung-tissue. In a large proportion of cases it is indicative, too, of tuberculous disease. It also may be found early, before the physical signs are well marked. Its detection is easy by the above-mentioned method, not requiring high powers of the microscope. In cases of early haemoptysis, before there is marked constitutional disturbance, or even local signs, it is very important to make a thorough examination of the sputum, from which mucoid and purulent portions may be picked out for examination. With localized and persistent signs in one lung, cough, fever, and loss of flesh, the diagnosis is rarely dubious. It is remarkable, however, to what an extent the local process may sometimes proceed with- out disturbance of health sufficient to excite the alarm of the physician or friends. There are puzzling cases with localized physical signs at one apex, chiefly moist rales, rarely any percussion changes, perhaps slight fever, and a glairy expectoration containing numerous alveolar cells. I have seen several cases of this kind which have been for a time very obscure, and in which repeated examinations failed to detect either bacilli or elastic tissue. They seem to be instances of local catarrhal trouble in the smaller tubes, some of which clear in a few weeks. In their monograph on Fibroid Diseases of the Lung (1894) Clark Hadley and Chaplin make the following classification : 1. Pure fibroid ; fibroid phthisis—a condition in which there is no tubercle. 2. Tuberculo- fibroid disease—a condition primarily tuberculous, but which has run a fibroid course. 3. Fibro-tuberculous disease—a condition primarily fibroid, but which has become tuberculous. The tuberculo-fibroid form may come on gradually as a sequence of a chronic tuberculous broncho- pneumonia, or follow a chronic tuberculous pleurisy. In other instances the process supervenes upon an ordinary ulcerative phthisis. The dis- ease becomes limited to one apex, the cavity is surrounded by layers of dense fibrous tissue, the pleura is thickened, and the lower lobe is gradu- ally invaded by the sclerotic change. Ultimately a picture is produced little if at all different from the condition known as cirrhosis of the 3. Fibroid Phthisis. 252 SPECIFIC INFECTIOUS DISEASES. lungs. It may even be difficult to say that the process is tuberculous, but in advanced cases the bacilli are usually present in the walls of the cavity at the apex, or old, encapsulated caseous areas exist in the lung, or there may be tubercles at the apex of the other lung and in the bronchial glands. Dilatation of the bronchi is present; the right ventricle, some- times the entire heart, is hypertrophied. The disease is chronic, lasting from ten to twenty or more years, dur- ing which time the patient may have fair health. The chief symptoms are cough, which is often paroxysmal in character and most marked in the morning. The expectoration is purulent, and in some instances, when the bronchiectasis is extensive, foetid. There is dyspnoea on exertion, hut little or no fever. The physical signs are very characteristic. The chest is sunken and the shoulder lower on the affected side; the heart is often drawn over and displaced. If the left lung is involved there may be an unusually large area of cardiac pulsation in the third, fourth, and fifth interspaces. Heart- murmurs are common. There is dulness over the affected side and defi- cient tactile fremitus. At the apex there may be well-marked cavernous sounds; at the base, distant bronchial breathing. The condition may persist indefinitely. In some cases the other lung becomes involved, or the patient has repeated attacks of haemoptysis, in one of which he dies. As a result of the chronic suppuration, amyloid degeneration of the liver, spleen, and intestines may take place; dropsy frequently supervenes from failure of the right heart. A more detailed account is found under Cirrhosis of the Lung, with which this form is clinically identical. Concurrent Infections in Pulmonary Tuberculosis. It has long been known that in pulmonary tuberculosis organisms other than the specific bacilli are present, particularly the micrococcus lanceolatus, the streptococcus pyogenes, and the staphylococcus aureus; less frequently the bacillus pyocyaneus. A majority of all cases of pulmonary tuberculosis are combined infec- tions ; streptococci and pneumococci may be found in the sputa, and the former have been isolated from the blood. The great importance of the secondary streptococcus infection is emphasized by the experiments of Prudden (New York Medical Journal, 1894, ii), who found that a large proportion of experimental animals, whose lungs had been the seat of con- current infection with the tubercle bacillus and the streptococcus, showed in addition to the lesions of a tuberculous broncho-pneumonia the most remarkable formation of cavities. It is possible that in man this ubiqui- tous streptococcus has a similar effect in promoting softening and cavity formation. The exudative pneumonia, which, as mentioned above in connection with the acute pneumonic tuberculosis, may be caused directly by the tubercle bacilli, is in many instances the result of secondary in- TUBERCULOSIS. 253 fection with other germs, particularly the streptococcus pyogenes and the micrococcus lanceolatus. Diseases associated with Pulmonary Tuberculosis. Lobar ‘pneumonia is a not uncommon cause of death. It is met with most frequently, indeed, as a terminal event in the chronic cases. It may, however, occur early, and be difficult to distinguish from an acute caseous pneumonia. The sputa in the latter are rarely rusty, while the fever in the former is more continuous and higher, but in many cases it is impossible to differentiate between the two conditions. Typhoid fever occasionally occurs in persons the subjects of pulmonary tuberculosis. In Case 8 of my series of post mortems in this disease, a girl, aged eighteen, had peritoneal adhesions, local disease at both apices, and perfectly characteristic lesions of enteric fever. In Case 34, a male aged twenty-five, with tuberculous cavities, had a very acute attack. The Peyer’s glands were greatly swollen with adherent sloughs. The spleen weighed 533 grammes. The characters of the ulceration are usually distinctive. Erysipelas not infrequently attacks old poitrinaires in hospital wards and almshouses. There are instances in which the attack seems to be beneficial, as the cough lessens and the symptoms ameliorate. It may, however, prove fatal. The eruptive fevers, particularly measles, frequently precede, but rarely develop in the course of pulmonary tuberculosis. In the revaccination of a tuberculous subject the vesicles run a normal course. Fistula in ano is associated with phthisis in an interesting manner. In a majority of such cases it is a tuberculous process. The general affec- tion may progress rapidly after an operation. The question is considered in tuberculosis of the alimentary canal. Heart Disease.—I have already referred (page 238) to the occurrence of endocarditis in tuberculosis. The antagonism between heart lesions and phthisis, upon which Rokitansky laid stress, is not pronounced. Stenosis of the pulmonary artery and aneurism of the aorta predispose to tubercu- losis pulmonum, probably by reducing the activity of the lesser circula- tion. In mitral stenosis pulmonary tuberculosis is not infrequent, in nine of fifty-four cases (Potain). A terminal acute tuberculosis of one or the other of the serous membranes is a very common event in all forms of cardio-vascular disease. In chronic and arrested phthisis arteriosclerosis is not uncommon. Ormerod noted thirty cases of chronic renal disease in one hundred post mortems. The association of tuberculosis with chronic arthritis, upon which certain writers lay stress, finds its explanation in the lowered resistance of these patients, and the greater liability to infection in the institutions in which so many of them live. 254 SPECIFIC INFECTIOUS DISEASES. (a) Old Age.—It is remarkable liow common tuberculosis is in the aged, particularly in institutions. McLaclilan noted a hundred and forty- five cases in which tuberculosis was the cause of death in old persons in Chelsea Hospital. All were over sixty years of age. The experience at Salpetriere is the same. Laennec met with a case in a person over ninety- nine years of age. At the Philadelphia Hospital, in the bodies of aged persons sent over from the almshouse it was extremely common to find either old or recent tuberculosis. A patien.t died under my care at the age of eighty-two with extensive peritoneal tuberculosis. Pulmonary tuberculosis in the aged is usually latent and runs a slow course. The physical signs are often masked by emphysema and by the coexisting chronic bronchitis. The diagnosis may depend entirely upon the discovery of the bacilli and elastic tissue. Contrary to the opinion which was held some years ago, tuberculosis is by no means uncommon with senile emphysema. Some of the cases of tuber- culosis in the aged are instances of quiescent disease which may have dated from an early period. (b) Infants.—The occurrence of acute tuberculosis in children has al- ready been mentioned, and also the fact that the disease is occasionally congenital. Recent studies, particularly of French writers, have shown that it is a frequent affection in children under two years of age. Leroux has analyzed the statistics of the late Prof. Parrot, embracing 219 cases in children under three years. Of these there were from one day to three months, 23; from three to six months, 35; from six to twelve months, 53 (a total of 111 under one year); and from one to three years, 108. Pul- monary cavities were present in 57 of the cases, and in only 50 was the pulmonary lesion the sole manifestation. At the St. Petersburg Found- ling Asylum, in the ten years ending 1884, there were 416 cases of tuber- culosis in 16,581 autopsies. The observations of Northrup, at the Hew York Foundling Hospital, are of special interest in connectien with the mode of infection. Of 125 cases of tuberculosis on the records of this in- stitution, in 34 the ravages were extensive, the seat of the primary affec- tion was not clear, and the bronchial glands were large and cheesy. In 20 cases of general tuberculosis there were cheesy masses in the bronchial glands and- in the lungs. In 42 cases of general tuberculosis the only cheesy masses were in the bronchial lymph-glands. In 9 cases the tuber- cles were limited to the bronchial nodes and the lungs; the latter contain- ing only discrete miliary bodies, while the bronchial glands were in ad- vanced caseation. In 13 cases there was tuberculosis of the bronchial nodes only. In most of these cases the patients died of infectious dis- eases. These figures are very suggestive, and point, as already noted, to infection through the bronchial passages as the most common method, even in children. Of 500 autopsies in children at the Munich Pathologi- Peculiarities of Pulmonary Tuberculosis at the Extremes of Life. TUBERCULOSIS. 255 cal Institute, in 150 (thirty per cent) tuberculosis was present and in over ninety-two per cent the lungs were involved (Muller). Modes of Death in Pulmonary Tuberculosis. (a) By asthenia, a gradual failure of the strength. The end is usu- ally peaceable and quiet,* occasionally disturbed by paroxysms of cough. Consciousness is often retained until near the close. (b) By asphyxia, as in some cases of acute miliary tuberculosis and in acute pneumonic phthisis. In chronic phthisis it is rarely seen, even when pneumothorax develops. (c) By syncope. This is not common. I have known it to happen once or twice in patients who insisted upon going about when in the ad- vanced stages of the disease. There may be, but not necessarily, fatty de- generation of the heart. A rapidly developing syncope may follow haemor- rhage or may be due to thrombosis or embolism of the pulmonary artery, or to pneumothorax. (d) From haemorrhage. The fatal bleeding in chronic phthisis is due to erosion of a large vessel or rupture of an aneurism in the pulmonary cavity, most commonly the latter. Of twenty-six analyzed by S. West, in eleven cases the fatal haemoptysis was due to aneurism, and of thirty-five cases collected by Percy Kidd, aneurism was present in thirty. In a case of Curtin’s, at the Philadelphia Hospital, the bleeding proved fatal before haemoptysis occurred, as the eroded vessel opened into a capacious cavity. (e) With cerebral symptoms. Coma may be due to meningitis, less often to uraemia. Death in convulsions is rare. The haemorrhagic pachy- meningitis which develops in some cases of phthisis occasionally causes loss of consciousness, but is rarely a direct cause of death. In one of my cases, death resulted from thrombosis of the cerebral sinuses with symp- toms of meningitis. V. Tuberculosis of the Serous Membranes. General Serous Membrane Tuberculosis.—The serous membranes may be chiefly involved, either simultaneously or consecutively, forming a dis- tinctive and readily recognizable clinical type of tuberculosis. There are three groups of cases. First, those in which an acute tuberculosis of the peritonaeum and pleurae develops rapidly, caused by local disease of the tubes in women, or of the mediastinal or bronchial lymph-glands. Sec- ondly, cases in which the disease is more chronic, with exudation in both peritonaeum and pleurae, the formation of cheesy masses, and the occur- rence of ulcerative and suppurative processes. Thirdly, there are cases in which the pleuro-peritoneal affection is still more chronic, the tubercles * As is so well described by Sir Thomas Browne, whose Letter to a Friend gives a unique account of the last illness of a consumptive. Hood’s Death-Bed is true of phthisis more frequently than of any other disease. 256 SPECIFIC INFECTIOUS DISEASES. hard and fibroid, the membranes much thickened, and with little or no exudate. In any one of these three forms the pericardium may be in- volved with the pleurae and peritonaeum. It is important to bear in mind that there may be in these cases no visceral tuberculosis. Tuberculosis of the Pleura.—1. Acute tuberculous pleurisy. It is difficult in the present state of our knowledge to estimate the proportion of instances of acute pleurisy due to tuberculosis. The cases are rarely fatal. In the study of the cases in the Johns Hopkins Hospital, which I made for the Shattuck Lecture in 1893, there were three groups of cases: (a) Acute tuberculous pleurisy with subsequent chronic course. (b) Sec- ondary and terminal forms of acute pleurisy (these are not uncommon in hospital practice). And (c) a form of acute tuberculous suppurative pleu- risy. A considerable number of the purulent pleurisies, designated as latent and chronic, are caused by tubercle bacilli, but the fact is not so widely recognized that there is an acute, ulcerative, and suppurative disease which may run a very rapid course. The disease sets in abruptly, with pain in the side, fever, cough, and sometimes with a chill. There may be nothing to suggest a tuberculous process, and the subject may have a fine physique and come of healthy stock. 2. The subacute and chronic tuber- culous pleurisies are more common. The largest group of cases comprises those with sero-fibrinous effusion. The onset is insidious, the true char- acter of the disease is frequently overlooked, and in almost every instance there are tuberculous foci in the lungs and in the bronchial glands. These are cases in which the termination is often in pulmonary tuber- culosis or general miliary tuberculosis. In not a few of these cases the exudate becomes purulent. And, lastly, there is a chronic adhesive pleurisy, a primary proliferative form which is of long standing, may lead to very great thickening of the membrane, and sometimes to invasion of the lung. Secondary tuberculous pleurisy is very common. The visceral layer is always involved in pulmonary tuberculosis. Adhesions usually form and a chronic pleurisy results, which may be simple, but usually tubercles are scattered through the adhesions. An acute tuberculous pleurisy may re- sult from direct extension. The fluid may be sero-fibrinous or haemor- rhagic, or may become purulent. And, lastly, a very common event in pulmonary tuberculosis is the perforation of a superficial spot of softening, and the production of pyo-pneumothorax. The general symptomatology of these forms will be considered under diseases of the pleura. Tuberculosis of the Pericardium.—Miliary tubercles may occur as a part of a- general infection, but the term is properly limited to those cases in which, either as a primary or secondary process, there is ex- tensive disease of the membrane. Tuberculosis is not so common in the pericardium as in the pleura and peritonaeum, but it is certainly more common than the literature would lead us to suppose. Seventeen TUBERCULOSIS. 257 cases had come under my observation to January, 1893 (American Journal of the Medical Sciences). It occurs in two forms: chronic and acute. (a) Chronic Tuberculous Pericarditis.—This may occur as a primary affection associated only with the caseation of the bronohial or particu- larly the anterior mediastinal lymph-glands. More commonly there is tuberculous disease elsewhere, either of the pleura or of the lungs, some- times of the peritonaeum. In a number of cases the pericarditis is only a part of a general infection of the serous membranes. The instances are very rare in which the process is confined to the pericardium. In one of my cases, a man aged seventy-two, who died of pneumonia in the Phila- delphia Hospital, the pericardium was thickened, both leaves were adher- ent and presented cheesy masses and gray nodules. The heart weighed 554 grammes; the bronchial glands were calcified ; there were no tuber- cles in the other organs. The disease occurs at all ages. My young- est case was in a child, aged five, in whom both layers of the pericardium were greatly thickened and cheesy. In nearly every instance the bron- chial or mediastinal glands are tuberculous. Occasionally it is due to extension from tuberculous disease of the sternum or of the spine; occa- sionally to extension from the lungs. In one case, a man, aged fifty, who died in the Philadelphia Hospital, the outer layer of the pericardium was alone involved and thickened, in connection with a tuberculous abscess in the anterior mediastinum. The condition is usually unsuspected. The physical signs are those of hypertrophy of the heart. In a recent case the organ weighed 600 grammes, and the clinical symptoms were those of hypertrophy and dilatation. The physical signs are somewhat uncertain, since they are those of ad- herent pericardium. The dulness may reach high along the left sternal margin, and in one case, in which it was as high as the middle of the manubrium, the thickened pericardial layers formed a solid cheesy mass which surrounded the aorta. (b) Acute Tuberculous Pericarditis.—This may occur as a secondary infection from tubercle in other parts, or it may arise by direct extension from the lungs, or more commonly by invasion from mediastinal lymph- glands. The exudation may be limited in amount and chiefly fibrinous, or it may be serous, and in many cases is haemorrhagic. Unless carefully sought for, the tubercles may be overlooked. Lastly, some of the cases of purulent pericarditis are tuberculous. The membranes may be much thickened and no trace of tubercles apparent. The nature of the case may, then, be gathered chiefly from the existence of tuberculous bronchial or mediastinal glands, or the existence of tuberculous foci in other re- gions. The effusion in these cases may be enormous, as in one reported by Musser, in which the sac contained sixty-four ounces of fluid. The symptoms and physical signs of this condition will be considered with those of ordinary pericarditis with effusion. 258 SPECIFIC INFECTIOUS DISEASES. (d) Tuberculosis of the Peritonaeum.—In connection with miliary and chronic pulmonary tuberculosis it is not uncommon to find the peritonaeum studded with small gray granulations. They are constantly present on the serous surface of tuberculous ulcers of the intestines. Apart from these conditions the membrane is often the seat of extensive tuberculous disease, which occurs in the following forms : (1) Acute miliary tuberculosis with sero-fibrinous or bloody exuda- tion. (2) Chronic tuberculosis, characterized by larger growths, which tend to caseate and ulcerate. It may lead to perforation of the intestinal coils. The exudate is purulent or sero-purulent, and is often sacculated. (3) Chronic fibroid tuberculosis, which may be subacute from the on- set, or which may represent the final stage of an acute miliary eruption. The tubercles are hard and pigmented. There is little or no exudation, and the serous surfaces are matted together by adhesions. The process may be primary and local, which was the case in five of my seventeen post-mortems. In children the infection appears to pass from the intestines, and in adults this is the source in the cases associated with chronic phthisis. In women the disease extends commonly from the Fallopian tubes. In at least 30 or 40 per cent of the instances of laparotomy in this alfection reported by gynaecologists the infection was from them. The prostate or the seminal vesicles may be the starting- point. In many cases the peritonaeum is involved with the pleura and pericardium, particularly with the former membrane. It is generally stated that males are attacked oftener than females. In my own series of 21 cases, 15 were males. The recent laparotomies, however, which have been performed in this disease have been chiefly in females; so that in the collected statistics I find the cases to be twice as numerous in females as in males; in the ratio, indeed, of 131 to 60. Tuberculous peritonitis occurs at all ages. It is common in children associated with intestinal and mesenteric disease. The incidence is most frequent between the ages of twenty and forty. It may occur in advanced life. In one of my cases the patient was eighty-two years of age. Of 357 cases collected from the literature,* there were under ten years, 27; between ten and twenty, 75; from twenty to thirty, 87; between thirty and forty, 71 ; from forty to fifty, 61; from fifty to sixty, 19 ; from sixty to seventy, 4; above seventy, 2. In America it is more common in the negro than in the white race. Symptoms.—In certain special features the tuberculous varies con- siderably from other forms of peritonitis. It presents a symptom-complex of extraordinary diversity. In the first place, the process may be latent and not cause a single symptom. Such are the cases met with accidentally in the operation for * Johns Hopkins Hospital Reports, vol. ii. TUBERCULOSIS. 259 liernia or for ovarian tumor. In direct contrast are the instances in which the onset is so sudden and violent that the diagnosis of enteritis or hernia is made. The operation for strangulated hernia has, indeed, been per- formed. Many cases set in acutely with fever, abdominal tenderness, and the symptoms of ordinary acute peritonitis. Cases with a slow onset, abdominal tenderness, tympanites, and low continuous fever resemble typhoid fever very closely, and may lead to error in diagnosis. Ascites is frequent, but the effusion is rarely large. It is sometimes haemorrhagic. It may simulate the effusion in cirrhosis of the liver, of which disease it is to be noted that tuberculous peritonitis is often a final complication. Tympanites may be present in the very acute cases, when it is due to loss of tone in the intestines, owing to inflammatory infiltra- tion ; or it may occur in the old, long-standing cases when universal adhesion has taken place between the parietal and visceral layers. Fever is a marked symptom in the acute cases, and the temperature may reach 103° or 104°. In many instances the fever is slight. In the more chronic cases subnormal temperatures are common, and for days the temperature may not rise above 97°, and the morning temperature may be as low as 95*5°. An occasional symptom is pigmentation of the skin, which in some cases has led to the diagnosis of Addison’s disease. A striking peculiarity of tuberculous peritonitis is the frequency with which either the condition simulates or is associated with tumor. These may be: («) Omental, due to puckering and rolling of this membrane until it forms an elongated firm mass, attached to the transverse colon and lying athwart the upper part of the abdomen. This cord-like structure is found also with cancerous peritonitis, but is much more common in tubercu- losis. Gairdner has called special attention to this form of tumor, and in children has seen it undergo gradual resolution. A resonant percussion note may sometimes be elicited above the mass. Though usually situated in the umbilical region, the omental mass may form a prominent tumor in the right iliac region. (b) Sacculated exudation, in which the effusion is limited and confined by adhesions between the coils, the parietal peritonaeum, the mesentery, and the abdominal or pelvic organs. This encysted exudate is most common in the middle zone, and has frequently been mistaken for ovarian tumor. It may occupy the entire anterior portion of the peritonaeum, or there may be a more limited saccular exudate on one side or the other. It may lie completely within the pelvis proper, associated with tuberculous disease of the Fallopian tubes. (c) In rare cases the tumor formations may be due to great retraction or thickening of the intestinal coils. The small intestine is found short- ened, the walls enormously thickened, and the entire coil may form a firm knot close against the spine, giving on examination the idea of a solid mass. Not the small intestine only, but the entire bowel from the duode- num to the rectum, has been found forming such a hard nodular tumor. 260 SPECIFIC INFECTIOUS DISEASES. (d) Mesenteric glands, which occasionally form very large, tumor-like masses, more commonly found in children than in adults. This condition may be confined to the abdominal glands. Ascites may coexist. The condition must be distinguished from that in children, in which, with as- cites or tympanites—sometimes both—there can be felt irregular nodular masses, due to large caseous formations between the intestinal coils. No doubt in a considerable number of cases of the so-called tabes mesenterica, particularly in those with enlargement and hardness of the abdomen— the condition which the French call carreau—there is involvement also of the peritonaeum. The diagnosis of these peritoneal tumors is sometimes very difficult. The omental tumor is a less frequent source of error than any other; but, as already mentioned, a similar condition may occur in cancer. The most important problem is the diagnosis of the saccular exudation from ovarian tumor. In fully one third of the recorded cases of laparotomy in tuber- culous peritonitis, the diagnosis of cystic ovarian disease had been made. The most suggestive points for consideration are the history of the patient and the evidence of old tuberculous lesions. The physical condition is not of much moment, as in many instances the patients have been robust and well nourished. Irregular febrile attacks, gastro-intestinal disturb- ance, and pains are more common in tuberculous disease. Unless in- flamed there is usually not much fever with ovarian cysts. The local signs are very deceptive, and in certain cases have conformed in every particular to those of cystic disease. The outlines in saccular exudation are rarely so well defined. The position and form may be variable, owing to alterations in the size of the coils of which in parts the walls are com- posed. Nodular cheesy masses may sometimes be felt at the periphery. Depression of the vaginal wall is mentioned as occurring in encysted peri- tonitis ; but it is also found in ovarian tumor. Lastly, the condition of the Fallopian tubes, of the lungs and of the pleurae, should be thoroughly examined. The association of salpingitis with an ill-defined anomalous' mass in the abdomen should arouse suspicion, as should also involvement of the pleura, the apex of one lung, or a testis in the male. VI. Tuberculosis of the Alimentary Canal. (a) Lips.—Tuberculosis of the lip is very rare. It occurs occasion- ally in the form of an ulcer, either alone or more commonly in association with laryngeal or pulmonary disease. Two cases are reported and the literature analyzed in Verneuil’s Etudes.* The ulcer is usually very sensi- tive and may be mistaken for a chancre or an epithelioma. The diagnosis may be made in cases of doubt by inoculation or the examination of a por- tion for tubercle bacilli. * Tome iii, Fas. I. TUBERCULOSIS. 261 (b) Tongue.—The disease begins by an aggregation of small grannlar bodies on the edge or dorsum. Ulceration proceeds, leaving an irregular sore with a distinct but uneven margin, and a rough, often caseous base. The disease extends slowly and may form an ulcer of considerable size. I have known it to be mistaken for epithelioma and the tongue to be excised. It is rarely met with except when other organs are involved. The glands of the angle of the jaw are not enlarged and the sore does not yield to iodide of potassium, which are points of distinction between the tuberculous and the syphilitic ulcer. In doubtful cases the inoculation test should be made, or a portion excised for microscopical examination. (c) Tubercles may develop on the hard or soft palate. In a recent case under the care of my colleague Halsted there was a rough, irregular patch on the roof of the mouth, grayish in spots, and fissured. (d) Tuberculosis of the tonsil has been recorded in a feAv cases, either in the form of the miliary granules or as' caseous foci. Ulceration may occur. In the acute cases the submaxillary glands may be enlarged. (e) Pharynx.—In extensive laryngeal tuberculosis an eruption of miliary granules on the posterior Avail of the pharynx is not very uncom- mon. In chronic phthisis an ulcerative pharyngitis, due to extension of the disease from the epiglottis and larynx, ds one of the most distressing of complications, rendering deglutition acutely painful. (/) A feAv instances occur in literature of tuberculosis of the oesopha- gus. The condition is a pathological curiosity, except in the slight exten- sion from the larynx, which is not infrequent; but in a case in my Avards the ulcer perforated and caused purulent pleurisy. (g) Stomach.—Many cases are reported Avhich are doubtful. Primary disease is unknown. Marfan * was able to collect only about a dozen authentic cases. Perforation of stomach occurred six times, thrice by a tuberculous gland. In Oppolzer’s case an ulcer of the colon perforated the organ. In Musser’s case there Avas a large tuberculous ulcer three by one and a half inches in extent. In a recent case in my Avard there Avere numerous ulcers of various sizes. (h) Intestines.—The tubercles may be (1) primary in the mucous membrane, or more commonly (2) secondary to disease of the lungs, or in rare cases the affection may (3) pass from the peritonaeum. (1) Primary intestinal tuberculosis occurs most frequently in children, in whom it may be associated Avith enlargement and caseation of the mesenteric glands, or Avith peritonitis. It may be difficult to say at the time of the autopsy whether the primary lesion has been intestinal or peritoneal. I have already referred to Woodhead’s statistics showing the remarkable frequency of infection through the bowel. In adults primary intestinal tuberculosis is rare, occurring in but one instance in one thousand autopsies upon tuberculous adults at the Munich Pathological Institute; * Paris Thesis, 1887. 262 SPECIFIC INFECTIOUS DISEASES. but now and then cases occur in which the disease sets in with irregular diarrhoea, moderate fever, and colicky pains. In a few cases haemorrhage has been the initial symptom. Regarded at first as a chronic catarrh, it is not until the emaciation becomes marked or the signs of disease appear in the lungs that the true nature is apparent. Still more deceptive are the cases in which the tuberculosis begins in the caecum and there are symp- toms of appendicitis—tenderness in the right iliac fossa, constipation, or an irregular diarrhoea and fever. These signs may gradually disappear, to recur again in a few weeks and still further complicate the diagnosis. Fatal haemorrhage has occurred in several of my cases. Perforation may occur with the formation of a pericaecal abscess, or perforation into the peritonaeum may take place, or in very rare instances there is partial heal- ing with great thickening of the walls and narrowing of the lumen. (2) Secondary involvement of the bowels is very common in chronic pulmonary tuberculosis, in 566 of the 1,000 Munich autopsies in tubercu- losis just referred to. In only three of these cases were the lungs not in- volved. The lesions are chiefly in the ileum, caecum, and colon. The affection begins in the solitary and agminated glands or on the surface of or within the mucosa. The caseation and necrosis lead to ulceration, which may be very extensive and involve the greater portion of the mucosa of the large and small bowels. In the ileum the Peyer’s patches are chiefly involved and the ulcer may be ovoid, but in the jejunum and colon the ulcers are usually round or transverse to the long axis. The tubercu- lous ulcer has the following characters: (a) It is irregular, rarely ovoid or in the long axis, more frequently girdling the bowel; (b) the edges and base are infiltrated, often caseous; (c) the submucosa and muscularis are usually involved; and (d) on the serosa may be seen colonies of young tubercles or a well-marked tuberculous lymphangitis. Perforation and peritonitis are not uncommon events in the secondary ulceration. Steno- sis of the bowel from cicatrization may occur; the strictures may be multiple. Tuberculosis of the rectum has a special interest in connection with fistula in ano, which, according to Spillman’s statistics, occurs in about 35 per cent of cases of pulmonary disease. In many instances the lesion has been shown to be tuberculous. It is very rarely primary, but if the tissue on removal contains bacilli and is infective the lungs are almost invariably found to be involved. It is a common opinion that the pulmonary symptoms may develop rapidly after the fistula is cut. This may have some basis if the operation consists in laying the tract open, and not in a free excision. (3) Extension from the peritonaeum may excite tuberculous disease in the bowels. The affection may be primary in the peritonaeum or extend from the tubes in women or the mesenteric glands in children. The coils of intestines become matted together, caseous and suppurating foci de- velop between the folds, and perforation may take place between the coils. TUBERCULOSIS. 263 VII. Tuberculosis of the Liver. This organ is very constantly involved in (a) general tuberculosis. The miliary granulation may be very small and in acute cases scarcely perceptible. The liver is pale and often fatty. (£) A remarkable condition of the organ is produced by the develop- ment of the tubercles in the finer bile-vessels. They may attain a con- siderable size and are almost always softened in the centre, resembling small abscesses. The contents are always bile-stained. The organ may be honeycombed with these tuberculous abscesses. (c) Large, coarse caseous masses are occasionally found, sometimes in association with perihepatitis or tuberculous peritonitis. They may attain the size of an orange or larger. (d) Tuberculous cirrhosis. With the eruption of miliary tubercles there may be slight increase in the connective tissue, which is over- shadowed by the fatty change. In all the chronic forms of tubercle in this organ there may be fibrous overgrowth. Hanot, who has described several varieties, states that the condition may be primary. Practically it is very rare, except in connection with chronic tuberculous peritonitis and perihepatitis, when the organ may be much deformed by a sclerosis in- volving the portal canals. In this last group there may be symptoms of ascites; as a rule, tuber- culosis of the liver has a purely anatomical interest VIII. Tuberculosis of the Braih and Cord. Tuberculosis of the brain occurs as («) an acute miliary infection caus- ing meningitis and acute hydrocephalus; (b) as a chronic meningo-en- cephalitis, usually localized, and containing small nodular tubercles; and (c) as the so-called solitary tubercle. Between the last two forms there are all gradations, and it is rare to see the meninges uninvolved. The acute variety has already been considered. I shall here consider the chronic form, which develops slowly and has the clinical characters of a tumor. It is most common in the young. Of 148 cases collected by Pribram 118 were under fifteen years of age. Other organs are usually involved, particularly the lungs, the bronchial glands, or the bones. In rare in- stances no tubercles are found elsewhere. They occur most frequently in the cerebellum ; next in the cerebrum and then in the pons. The growths are often multiple, in 100 out of 183 cases (Gowers). They range in size from a pea to a walnut; larger tumors occasionally occur, and sometimes an entire lobe of the cerebellum is affected. On section the tubercle pre- sents a grayish-yellow, caseous appearance, usually firm and hard, and en- circled by a translucent, softer tissue. The centre of the growth may be semi-diffluent. As in other localities the tubercle may calcify. The tu- 264 SPECIFIC INFECTIOUS DISEASES. mors are as a rule attached to the meninges, often to the pia at the bottom of a sulcus so that they look imbedded in the brain-substance. About the longitudinal fissure there may be an aggregation of the growths, with compression of the sinus, and the formation of a thrombus. The tuber- culous tumor not infrequently excites acute meningitis. In localized meningo-encephalitis the pia is thickened, tubercles are adherent to the under surface and grow about the arteries. It is often combined with cerebral softening from interference with the circulation. Several of the most characteristic instances which I have seen were on the meninges covering the insula. This form may develop in pulmonary tuberculosis, causing hemiplegia or aphasia which may persist for months. The symptoms of tuberculous growths in the brain are those of tumor, and will be considered in the section on the brain. In the spinal cord the same forms are found. The acute tuberculous meningitis has been considered and is almost ahvays cerebro-spinal. The solitary tubercle of the cord is rare. Ilerter has reported three cases and collected twenty-four instances from the literature. It was secondary in all save one case. The symptoms are those of spinal tumor or meningitis. IX. Tuberculosis of the Genito-urinary System. (a) Tuberculosis of the Kidneys (Phthisis renum).—In general tuber- culosis the kidneys frequently present scattered miliary tubercles. In pul- monary tuberculosis it is common to find a few nodules in the substance of the organ, or there may be pyelitis. Primary tuberculosis of the kid- neys is not very rare. In a majority of the cases the process involves the pelvis and the ureter as well, sometimes the bladder and prostate. In only one of eight cases was the prostate involved. It may be difficult to say in advanced cases whether the disease has started in the bladder, prostate, or vesicles, and crept up the ureters, or whether it started in the kidneys and proceeded downward. In a majority of cases it is, I believe, the latter, and the infection is through the blood. One kidney alone may be involved, and the disease creeps down the ureter and may only extend a few milli- metres on the vesical mucosa. In a recent instance a man with aortic in- sufficiency, who had no lesions in the lungs, presented a localized patch in the pelvis of the kidney, involving a pyramid, while the ureter, five centi- metres from the bladder and at its orifice, was thickened and tuberculous. The prostate showed an area of caseation. It is most common in the mid- dle period of life, but it may occur at the extremes of age. It is more fre- quent in men than in women. In the earliest stage, which may be met with accidentally, the disease is seen to begin in the pyramids and calyces. Necrosis and caseation proceed rapidly, and the colonies of tubercles start throughout the pyramids and extend upon the mucous membrane of the pelvis. As a rule, from the outset it is a tuberculous pyo-neplirosis. The disease may be confined to one kidney, or progress more extensively in TUBERCULOSIS. 265 one than in the other. At autopsy both organs are usually found enlarged. One organ may be completely destroyed and converted into a series of cysts containing cheesy substance; a form of kidney which the older writers called scrofulous. In the putty-like contents of these cysts lime salts may be deposited. In other instances the walls of the pelvis are thickened and cheesy, the pyramids eroded, and caseous nodules are scattered through the organ, even to the capsule, which may be thickened and adherent. The other organ is usually less affected, and shows only pyelitis or a super- ficial necrosis of one or two pyramids. The ureters are usually thickened and the mucous membrane ulcerated and caseous. Involvement of the bladder, vesiculee seminales, and testes is not uncommon in males. The symptoms are those of pyelitis. The urine may be purulent for years, and there may be little or no distress. When the bladder becomes involved micturition is frequent, and many instances are mistaken for cys- titis. The condition is for many years compatible with fair health. The curability is shown by the accidental discovery of the so-called scrofulous kidney, converted into cysts containing a putty-like substance. In cases in which the disease becomes advanced and both organs are affected, con- stitutional symptoms are more marked. There is irregular fever, with chills, and loss of weight and strength. General tuberculosis is common. In only one of my cases were the lungs uninvolved. In a case at the Montreal General Hospital a cyst perforated and caused fatal peritonitis. Physical examination may detect special tenderness on one side, or the kidney may be palpable in front on deep pressure; but tuberculous pyelo- nephritis seldom causes a large tumor. Occasionally the pelvis becomes enormously distended; but this is rare in comparison with calculous pyelitis. The urine presents changes similar to those of ordinary calcu- lous pyelitis — pus-cells, epithelium, and occasionally definite caseous masses. Albumen is, of course, present. Tubercle bacilli may be demon- strated by the ordinary methods. Tube-casts are not often seen. To distinguish the condition from calculous pyelitis is often difficult. Haemorrhage may be present in both, though not nearly so frequently in the tuberculous disease. Careful examination of the pus for tubercle bacilli gives most important information. The lungs or other organs may be tuberculous. The incidence of renal in uro-genital tuberculosis may be gathered from Orth’s Gottingen material, analyzed by Oppenheim. Of 60 cases there were 34 in which the kidneys were involved. (b) Tuberculosis of the Ureters and Bladder.—This rarely occurs as a primary affection, but is nearly always secondary to involvement of other parts, particularly the pelvis of the kidney. In the case of uro-genital tuberculosis, above mentioned, in a patient who died of heart disease, the ureter, just where it enters the bladder, showed a fresh patch of tuber- culosis. Protracted cystitis, which has come on without apparent cause, is 266 SPECIFIC INFECTIOUS DISEASES. always suggestive of tuberculosis. The renal regions, the testes, and the prostate should be examined with care. It may follow a pyelo-nephritis, or be associated with primary disease of the prostate or vesiculae seminales. Primary tuberculosis of the posterior wall of the bladder may simulate stone. (c) Tuberculosis of the Prostate and Vesiculae Seminales.—The pros- tate is frequently involved in tuberculosis of the uro-genital tract. In Krzyincki’s cases, of 15 males the prostate was involved in 14 and the ve- siculae seminales in 11. In Orth’s cases the prostate was involved in 18 of the 37 cases in males. These parts are much more frequently involved than ordinary post-mortem statistics indicate. Per rectum the prostatic lobes are felt to be occupied by hard nodules varying in size from a pea to a bean. There is great irritability of the bladder, and agonizing pain in catheterization. An extremely rare lesion is primary urethral tubercu- losis, which may simulate stricture. (d) Tuberculosis of the Testes.—This somewhat common affection may be primary, or, more frequently, is secondary to tuberculous disease elsewhere. Many cases occur before the second year, and it is stated to have been met with in the foetus. In infants it is serious and usually associated with tuberculous disease in other parts. In 9 cases recently reported by Hutinel and Deschamps,* in every one there was a general affection. In 20 cases reported by Jullien,f 6 were under one year, and 6 between one and two years old. In 5 of the cases both testicles were affected. Koplik holds that most of the cases of this kind are congenital, in Baumgarten’s sense. In the adult the tubercles begin within the sub- stance of the gland, but in children the tunica albuginea is first affected. The tubercle does not always undergo caseation, but it may present a number of embryonic cells, not unlike a sarcoma. Tubercle of the testes is most likely to be confounded with syphilis. In the latter the body of the organ is most often affected, there is less pain, and the outlines of the growth are more nodular and irregular. In obscure peritoneal disease the detection of tubercle in a testis has not infrequently led to a correct diagnosis. The association of the two con- ditions is not uncommon. The lesion in the testis may heal completely, or the disease may become generalized. General infection has followed operation. Too much stress cannot be laid on the importance of a routine examination of the testes in hospital patients. (e) Tuberculosis of the Fallopian Tubes, Ovaries, and Uterus.—The special attention which has been paid to local affections of these parts by gynaecologists has taught us that primary tuberculosis of the tubes is not at all uncommon. Within a year my colleague, Kelly, has operated upon five or six cases. The disease may be primary and produce a most char- acteristic form of salpingitis, in which the tubes are enlarged, the walls * Archives Generates deMedecine, 1891. f Ibid., 1890. TUBERCULOSIS. 267 thickened and infiltrated, and the contents cheesy. Adhesion takes place between the fimbriae and the ovaries, or the uterus may be invaded. The condition is usually bilateral. It may occur in young children. Although, as a rule, very evident to the naked eye, there are specimens resembling ordinary salpingitis, which show on microscopical examination numerous miliary tubercles (Welch and Williams). Tuberculous salpingitis may cause serious local disease with abscess formation, and it may be the start- ing-point of peritonitis. Tuberculosis of the uterus is very rare. Only three examples have come under my observation, all in connection with pulmonary phthisis. It may be primary. The mucosa of the fundus is thickened and caseous, and tubercles may be seen in the muscular tissue. Occasionally the pro- cess extends to the vagina. X. Tuberculosis of the Mammary Gland. Mandry (Bruns’s Beitriige, viii) has collected forty cases, one of which was in a male. The disease is most common between the fortieth and sixtieth years. The breast is frequently fistulous, unevenly indurated, and the nipple is retracted. The fistulas and ulcers present a characteristic tuberculous aspect. There is also a cold tuberculous abscess of the breast. The axillary glands are affected in about two thirds of the cases. The disease runs a chronic course of months or years. The diagnosis can be made by the general appearance of the fistulae and ulcers, and by the exist- ence of tubercle bacilli. The prognosis is not bad, if total eradication of the disease be possible. XI. Arteries. Primary tuberculosis of the larger blood-vessels is unknown. The dis- ease may, however, occur in a large artery and not result from external in- vasion. In a case of chronic tuberculosis Flexner found a fresh tubercu- lous growth in the aorta, which had no connection with cheesy masses outside the vessel. In the lungs and other organs attacked by tuberculosis the arteries are involved in an acute infiltration which usually leads to thrombosis, or tubercles may develop in the walls and proceed to caseation and softening frequently with the result of hasmorrhage. By extension into vessels, particularly veins, the bacilli are widely distributed. In meningitis tuber- culosis of the arteries plays an important role. XII. The Prognosis in Tuberculosis. Not all persons in whose bodies the bacilli gain a foothold present marked signs of tuberculosis. As will be stated in the next section, local SPECIFIC INFECTIOUS DISEASES. disease is found in a considerable number of all cadavers. Infection does not necessarily mean the establishment of a progressive and fatal disease. In my autopsies, excluding cases dead of pulmonary phthisis, 7*5 per cent presented tuberculous lesions of the lungs—a low percentage in compari- son with other records, as I carefully excluded the simple fibroid pucker- ing at the apex, and the solitary cheesy nodule, unless surrounded by colo- nies of tubercles. In many cases a natural or spontaneous cure is effected, for the condi- tions favorable to the development of the disease are not present—in other words, the tissue-soil is unsuitable. Apart from this group, a ma- jority of which probably do not show any sign of disease, there may be spontaneous arrest after the symptoms have become decided. Many years ago Flint called attention to the self-limitation and intrinsic tendency to recovery in well-marked pulmonary tuberculosis. Of his 670 cases, 44 re- covered, and in 31 the disease was arrested, spontaneously in 23 of the first group and in 15 of the second. This natural tendency to cure is still more strikingly shown in lymphatic and bone tuberculosis. The following may be considered favorable circumstances in the prog- nosis of pulmonary tuberculosis : A good family history, previous good health, a strong digestion, a suitable environment, and an insidious onset, without high fever, and without extensive pneumonic consolidation. Cases beginning with pleurisy seem to run a more protracted and more favorable course. Repeated attacks of haemoptysis are unfavorable. When well established the course of tuberculosis in any organ is marked by intervals of weeks or months in which the fever lessens, the symptoms subside, and there is improvement in the general health. In pulmonary cases the duration is extremely variable. Laennec placed the average duration at two years, and for the majority of cases this is perhaps a correct estimate. Pollock’s large statistics of over 3,500 cases shows a mean duration of the disease of over two years and a half. Will- iams’s analysis of 1,000 cases in private practice show's a much more pro- tracted course, as the average duration was over seven years. Under the subject of prognosis comes the question of the marriage of persons who have had tuberculosis, or in whose family the disease prevails. The following brief statements may be made with reference to it: {a) Subjects with healed lymphatic or bone tuberculosis marry with personal impunity and may beget healthy children. It is undeniable, how- ever, that in such families, scrofula, caries of the bone, arthritis, cerebral and pulmonary tuberculosis are more common. Which is it, “ heredite de graine ou heredite de terrain,” as the French have it, the seed or the soil, or both? We cannot yet say. The risks, however, are such as may properly be taken. (£) The question of marriage of a person who has arrested or cured lung tuberculosis is more difficult to decide. If a male, the personal risk is not so great; and when the health and strength are good, the external TUBERCULOSIS. 269 environment favorable, and the family history not extremely bad the experiment—for it is such—is often successful, and many healthy and happy families are begotten under these circumstances. In women the question is complicated with that of child-bearing, which increases the risks enormously. With a localized lesion, absence of hereditary taint, good physique, and favorable environment, marriage might be permitted. When tuberculosis has existed, however, in a girl whose family history is bad, whose chest expansion is slight, and whose physique is below the standard, the physician should, if possible, place his veto upon marriage. (c) With existing disease, fever, bacilli, etc., marriage should be abso- lutely prohibited. Pregnancy and parturition hasten the process in almost every case. There is much truth, indeed, in the remark of Dubois: “ If a woman threatened with phthisis marries, she may bear the first ac- couchement well; a second, with difficulty; a third, never.” XIII. Prophylaxis ih Tuberculosis. (a) General.—The sputa of phthisical patients should he carefully col- lected and destroyed. Patients should be urged not to spit about care- lessly, but always to use a spit-cup. Several forms of portable flasks have been devised and are now on sale. The destruction of the sputa of con- sumptives should be a routine measure in both hospital and private prac- tice. Thorough boiling or putting it into the fire is sufficient. It should be explained to the patient that the only risk, practically, is from this source. The chances of infection are greatest in young children. The nursing and care of consumptives involve very slight risks indeed if proper precautions are taken. The patient should occupy a single bed. A second important general prophylactic measure relates to the in- spection of dairies and slaughter-houses. The possibility of the transmis- sion of tuberculosis by infected milk has been fully demonstrated, and in the interest of public health the state should take measures to stamp out tuberculosis in cattle. Systematic veterinary inspection of dairies, par- ticularly in the large cities, .should be made, and full power granted to confiscate and kill suspected animals. The abattoirs should be under skilled veterinary control, and the carcasses of animals with advanced tuberculosis confiscated. There is, however, much less danger of infection through meat than through milk. The advisability of placing tuberculosis on the list of diseases of which notice must be given, has been much discussed. I am strongly in favor of it in all cases of pulmonary tuberculosis. The hardships entailed upon individuals would be trifling in comparison with the public good which would follow the adoption of systematic measures of inspection and dis- infection. (£) Individual.—A mother with pulmonary tuberculosis should not suckle her child. An infant born of tuberculous parents, or of a family 270 SPECIFIC INFECTIOUS DISEASES. in which consumption prevails, should be brought up with the greatest care and guarded most particularly against catarrhal affections of all kinds. Special attention should be given to the throat and nose, and on the first indication of mouth-breathing, or any obstruction of the naso- pharynx, a careful examination should be made for adenoid vegetations. The child should be clad in flannel and live in the open air as much as possible, avoiding close rooms. It is a good practice to sponge the throat and chest night and morning with cold wTater. Special attention should be paid to diet and to the mode of feeding. The meals should be at regu- lar hours and the food plain and substantial. From the outset the child should be encouraged to drink freely of milk. Unfortunately, in these cases there seems to be an uncontrollable aversion to fats of all kinds. As the child grows older, systematically regulated exercise or a course of pulmonary gymnastics may be taken. In the choice of an occupa- tion preference should be given to an out-of-door life. Families with a marked predisposition to tuberculosis should, if possible, reside in an equable climate. It would be best for a young man belonging to such a family to remove to Colorado or southern California, or to some other suitable climate, before trouble begins. The trifling ailments of children should be carefully watched. In the convalescence from the fevers, which so frequently prove dangerous, the greatest caution should be exercised to prevent catching cold. Cod-liver oil, the syrup of iodide of iron, and arsenic may be given. As mentioned, care of the throat in these children is very important. When the tonsils are chronically enlarged they should be removed. XIV. Treatment of Tuberculosis. I. The Natural or Spontaneous Cure.—The spontaneous healing of local tuberculosis is an every-day affair. Many cases of adenitis and dis- ease of the bone or of the joints terminate favorably without the aid of medicines. The healing of pulmonary tuberculosis is shown clinically by the recovery of patients in whose sputa elastic tissue and bacilli have been found; anatomically, by the presence of lesions in all stages of repair. In the granulation products and associated pneumonia a scar-tissue is formed, while the smaller caseous areas become impregnated with lime salts. To such conditions alone should the term healing be applied. When the fibroid change encapsulates but does not involve the entire tuberculous tissue, the tubercle may be termed involuted or quiescent, but is not de- stroyed. When cavities of any size have formed, healing, in the proper sense of the term, does not occur. I have yet to see a specimen which would indicate that a vomica had cicatrized. Cavities may be greatly reduced in size—indeed, an entire series of cavities may be so contracted by sclerosis of the tissue about them that an upper lobe, in which this TUBERCULOSIS. 271 process most frequently occurs, may be reduced to a third of its ordinary dimensions. Laennec understood thoroughly this natural process of cure in tuberculosis, and recognized the frequency with which old tuberculous lesions occurred in the lungs. He described cicatrices completes and cica- trices fistuleuses, the latter being the shrunken cavities communicating with the bronchi; and suggested that, as tubercles growing in the glands, which are called scrofula, often heal, why should not the same take place in the lungs? There is an old German axiom, “ Jedermann liat am Ende ein hischen Tuberculose,” a statement partly borne out by the statistics showing the proportion of cases in persons dying of all diseases in whom quiescent or tuberculous lesions are found in the lungs. We find at the apices the following conditions, which have been held to signify healed tuberculous processes: (1) Thickening of the pleura, usually at the posterior surface of the apex, with subadjacent induration for a distance of a few milli- metres. This has, perhaps, no greater significance than the milky patch on the pericardium. (2) Puckered cicatrices at the apex, depressing the pleura, and on section showing a large pigmented, fibrous scar. The bronchioles in the neighborhood may be dilated, but there are neither tubercles nor cheesy masses. This may sometimes, but not always, indi- cate a healed tuberculous lesion. (3) Puckered cicatrices with cheesy or cretaceous nodules, and with scattered tubercles in the vicinity. (4) The cicatrices fistuleuses of Laennec, in which the fibroid puckering has re- duced the size of one or more cavities which communicate directly with the bronchi. In 1,000 autopsies, excluding the 216 cases dead of phthisis, there were 59 cases (7‘5 per cent) which presented undoubted tuberculous lesions in the lungs. I excluded the simple fibroid puckering and the solitary cheesy nodules, unless, in the latter case, there were colonies of tubercles in the vicinity. These 59 cases died of various diseases and at various ages. A majority of them were between forty and sixty. My experience tallies closely with the larger analysis made by Heitler of the Vienna post-mortem records, in which, of 16,562 cases in which the death was not directly caused by phthisis, there were 780 instances of obsolete tubercle—a percentage of 4-7. He excluded, as I have done, the simple fibroid induration. Vari- ous observations have been made of late in which the percentage ranges from twenty-seven (Bollinger) to thirty-nine (Massini). In 200 autopsies, in which this point was specially examined, Harris found 38-8 per cent in which there were relics of former active tuberculosis. The statement is made by Bouchard that, of the post-mortems at the Paris morgue—gen- erally upon persons dying suddenly—the percentage found with some evidence of tuberculous lesion, active or obsolete, is as high as seventy-five. These figures show the extraordinary frequency of pulmonary infection and the encouraging fact that in so large a percentage the disease remains local and undergoes a process of arrest or healing. 272 SPECIFIC INFECTIOUS DISEASES. II. General Measures.—There are three indications—first, to place the patient in surroundings most favorable for the maintenance of a maximum degree of nutrition ; second, to take such measures as, in a local or general way, influence the tuberculous processes; third, to alleviate symptoms. The question of environment is of first importance in the treatment of tuberculosis. It is illustrated in an interesting and practical way by an experiment of Trudeau, showing that inoculated rabbits, confined in a dark, damp place, rapidly succumb, while others, allowed to run wild, either recover or show slight lesions. It is the same in human tubercu- losis. A patient confined to the house—particularly in the close, over- heated, stuffy dwellings of the poor, or treated in a hospital ward—is in a position analogous to the rabbit confined to a hutch in the cellar; whereas a patient living in the fresh air and sunshine for the greater part of the day has chances comparable to those of the rabbit running wild. In the majority of cases the treatment has to be carried out at home and often under adverse conditions. Still, much can be done if the patient is kept out of doors in the fresh air for the greater part of each day. In pulmonary tuberculosis neither the cough, the fever, the night-sweats, nor the hcemoptysis contra-indicates this rule. Only when the weather is blustering or rainy should the patient remain in the house. It is remark- able how quickly improvement in many instances follows this fresh-air treatment. In cities the patient can be wrapped up and placed on a sofa or in a reclining-chair on the balcony or even in the yard. The climatic treatment of tuberculosis is simply a modification of this plan. The requirements of a suitable climate are a pure atmosphere, an equable temperature not subject to rapid variations, and a maximum amount of sunshine. Given these three factors, and it makes little differ- ence where a patient goes so long as he lives an outdoor life. The purity of the atmosphere is the first consideration, and it is this requirement that is met so well in the mountains and forests. Altitude is a secondary consideration. The rarefaction of the air in high altitudes is of benefit in increasing the respiratory movements in pulmonary disease, but brings about in time a condition of dilatation of the air-vesicles and a permanent increase in the size of the chest which is a marked disadvan- tage when such persons attempt subsequently to reside at the sea-level. The temperature of the air is also a minor consideration, so long as it is tolerably equable and not subject to rapid variations. The winter cli- mates of the Adirondacks, of Colorado, or of Davos have the advantage of a steady cold combined with sunshine, just as the resorts of the Southern States and California, and of the south of France and Italy, have a tolerably uniform high temperature with the maximum amount of sunshine. The dryness of the air is certainly an important though not an essential factor. That it is not essential is seen in the good results obtained in the resorts at the sea-level, such as Florida, or even Torquay or Falmouth, on the south coast of England—one of the most humid atmospheres in the world. TUBERCULOSIS. 273 Other considerations which should influence the choice of a locality are good accommodations and good food. Very much is said concerning the choice of locality in the different stages of pulmonary tuberculosis, but when the disease is limited to an apex, in a man of fairly good personal and family history, the chances are that he may fight a winning battle if he lives out of doors in any climate, whether high, dry, and cold, or low, moist, and warm. With bilateral disease and cavity formation there is but little hope of permanent cure, and the mild or warm climates are pref- erable. Whether a patient should go from home or not is a grave question which the physician is called upon to decide. It is undoubtedly, in many instances, a positive hardship to send away a patient with tolerably advanced tuberculosis. With well-marked cavities, hectic fever, night- sweats, and emaciation he is better at home, and the physician should not be too much influenced by the importunities of the sick man or of his friends. Advanced cases and persons with feeble hearts should never be sent to high altitudes. Of American resorts I prefer the Adirondacks for early cases. The patient should go in October, so as to become gradually accustomed to the cold. It is accessible, the winter climate is admirable, and the camp-life delightful. As the reports of Saranac,Sanitarium show, recent tuberculosis does remarkably well. Personally I have seen better results from the Adirondacks than from any other place. Colorado and southern California have this advantage for early cases—they are progress- ive, prosperous countries, in which a man may find means of livelihood and live in comfort.* Under this section reference may be made to the question of the treat- ment of tuberculosis in sanitaria. The larger cities should build special institutions within easy access by railway, with pleasant surroundings, in which early cases of pulmonary tuberculosis among the poor could be systematically treated. Advanced cases should not be admitted, but should be cared for in separate wards of the city hospitals. Sanitaria for the care of recent pulmonary tuberculosis among the well-to-do classes are also urgently needed. The results obtained at Falkenstein near Frankfurt a. M. (which certainly has nothing special, as far as climate is concerned) and at the Saranac Sanitarium illustrate how much can be done by method and care. III. Measures which, by their Local or General Action, influence the Tuberculous Process.—Under this heading we may consider the specific, the dietetic, and the general medicinal treatment of tuberculosis. (a) Specific Treatment.—The use of Koch’s tuberculin has been in great part abandoned; modifications of it are under trial by several trustworthy investigators, whose results may justify its adoption in suitable cases. (b) Dietetic Treatment.—The outlook in tuberculosis depends much * On the question of climate, Yeo’s work may be consulted with advantage. 274 SPECIFIC INFECTIOUS DISEASES. upon the digestion. It is rare to see recovery in a case in which there is persistent gastric trouble, and the physician should ever bear in mind the fact that in this disease the primes vice control the position. The early nausea and loss of appetite in many cases of phthisis are serious obstacles. Many patients loathe food of all kinds. A change of air or a sea voyage may promptly restore the appetite. When either of these is impossible, and if, as is almost always the case, fever is present, the patient should be placed at rest, kept in the open air nearly all day, and fed at stated inter- vals with small quantities either of milk, buttermilk, or koumyss, alternat- ing if necessary with meat juice and egg albumin. Some cases which are disturbed by eggs and milk do well on koumyss. It may be necessary to resort to Debove’s method of over-alimentation or forced feeding. The stomach is first washed out with cold water, and then, through the tube, a mixture is given containing a litre of milk, an egg, and one hundred grammes of very finely powdered meat. This is given three times a day. Sometimes the patients will take this mixture without the unpleasant ne- cessity of the stomach-tube, in which case a smaller amount may be given. I can speak of the advantage of this plan in cases in which the gastric symptoms have been obstinate and distressing, and the general expression of opinion is, in such instances, very favorable to this plan of treatment. In many cases the digestion is not at all disturbed and the patient can take an ordinary diet. It is remarkable how rapidly the appetite and digestion improve on the fresh-air treatment, even in cases which have to remain in the city. Care should be taken that the medicines do not disturb the stomach. Not infrequently the sweet syrups used in the cough mixtures, cod-liver oil, creasote, and the hypophosphites produce irritation, and by interfering with digestion do more harm than good. On the other hand, the bitter tonics, with acids, and the various malt preparations are often in these cases most satisfactory. The indications for alcohol in tuberculosis are enfeebled digestion with fever, a weak heart, and rapid pulse. A routine administration is not advisable, and there is no evidence that its persistent use promotes fibroid processes in the tuberculous areas. In the advanced stages, particularly when the temperature is low between eight and ten in the morning, whisky and milk, or whisky, egg, and milk may be given with great advantage. The red wines are also beneficial in moderate quantities. (c) General Medical Treatment.—No medicinal agents have any special or peculiar action upon tuberculous processes. The influence which they exert is upon the general nutrition, increasing the physiological resist- ance, and rendering the tissues less susceptible to invasion. The fol- lowing are the most important remedies which seem to act in this manner : Creasote, which may be administered in capsules, in increasing doses, beginning with one minim three times a day and, if well borne, increas- ing the dose to eight or ten minims. It may also be given in solution TUBERCULOSIS. 275 with tincture of cardamom and alcohol. It is an old remedy, strongly recommended by Addison, and the reports of Jaccoud, Fraentzel, and many others show that it has a positive value in the disease. Guaiacol may be given as a substitute, either internally or hypodermically. In 101 cases in which it was used at my clinic, by Meredith Reese, the chief action was on the cough and expectoration, which were much lessened, but the remedy had no essential influence on the progress of the disease. Cod-liver Oil.—In glandular and bone tuberculosis, this remedy is undoubtedly beneficial in improving the nutrition. In pulmonary tuber- culosis its action is less certain, and it is scarcely worthy of the unbounded confidence which it enjoyed for so many years. It should be given in small doses, not more than a teaspoonful three times a day after meals. It seems to act better in children than in adults. When it is not well borne, a dessertspoonful of rich cream three times a day is an excellent substitute. The clotted or Devonshire cream is preferable. The Hypophosphites.—These in various forms are useful tonics, but it is doubtful if they have any other action. They certainly exercise no specific influence upon tubercle. They may be given in the form of the syrup of the hypophosphites of calcium, sodium, and potassium of the U. S. P. Arsenic.—There is no general tonic more satisfactory in cases of tuber- culosis of all kinds than Fowler’s solution. It may be given in five-minim doses three times a day and gradually increased; stopping its use when- ever unpleasant symptoms arise, and in any case intermitting it every third or fourth week. One or two special methods of dealing with pulmonary tuberculosis may here be mentioned. The local treatment, by direct injection into the lungs, has been practised since its strong advocacy by Pepper. It has, however, not gained the general support of the profession, and is occa- sionally followed by serious results. As a rule, it may be practised with impunity, and the injections may be made with a long hypodermic needle into any portion of the lung which is diseased. Iodine, carbolic acid, creasote (three per cent solution in almond oil), and iodoform have been used for the purpose. The remarkable results which surgeons have recently obtained in the treatment of joint tuberculosis by injections of iodoform point to this as a remedy which will probably prove of service when injected directly into the lungs. Treatment by compressed air is in many cases beneficial, and under its use the appetite improves, there is gain in weight, and reduction of the fever. The air may be saturated with creasote. IV. Treatment of Special Symptoms in Pulmonary Tuberculosis.—(a) The Fever.—There is no more difficult problem in practical therapeutics than the treatment of the pyrexia of tuberculosis. The patient should be at rest, and when practicable wheeled into the fresh air for as long a time as possible during the day. Fever does not contra-indicate an out-of-door SPECIFIC INFECTIOUS DISEASES. life, but it is well for patients with a temperature above 101° or 102° to be at rest. For the continuous pyrexia or the remittent type of the early stages, quinine, small doses of digitalis, and the salicylates may be tried; but they are uncertain and rarely reliable. Under no circumstances is that priceless remedy, quinine, so much abused as in the fever of tubercu- losis. In large doses it has a moderate antipyretic action, but it is just in these efficient doses that it is so apt to disturb the stomach. Antipyrin and antifebrin may be used cautiously; but it is better, when the fever rises above 103°, to rely upon cold sponging or the tepid bath, gradually cooled. When softening has taken place and the fever assumes the characteristic septic type, the problem becomes still more difficult. As shown by Chart XII (which is not by any means an ex- ceptional one), the pyrexia, at this stage, lasts only for twelve or fifteen hours. As a rule it is not more than from eight to ten hours in which the fever is high enough to demand antipyretic treatment. Sometimes antifebrin, given in two-grain doses every hour for three or four hours before the rise in temperature takes place, either prevents entirely or limits the paroxysm. If the temperature begins to rise between two and three in the afternoon, the antifebrin may be given at eleven, twelve, one, and, if necessary, at two. It answers better in this way than given in the single doses. Careful sponging of the extremities for from half an hour to an hour during the height of the fever is useful. Quinine is of little benefit in this type of fever; the salicylates still less. (b) Stveating.—Atropine, in doses of gr. T| a and the aromatic sulphuric acid in large doses, are the best remedies. When there are cough and nocturnal restlessness, an eighth of a grain of morphia may be given with the atropine. Muscarin (th, v of a one per cent solution), tincture of nux vomica (tt[ xxx), picrotoxin (gr. may be tried. The patient should use light flannel night-dresses, as the cotton night-shirts, when soaked with perspiration, have a very unpleasant cold, clammy feeling. (c) The cough is a troublesome, though necessary, feature in pulmo- nary tuberculosis. Unless very worrying and disturbing sleep at night, or so severe as to produce vomiting, it is not well to attempt to restrict it. When irritative and bronchial in character, inhalations are useful, particularly the tincture of benzoin or preparations of tar, creasote, or turpentine. The throat should be carefully examined, as some of the most irritable and distressing forms of cough in phthisis result from laryngeal erosions. The distressing nocturnal cough, which begins just as the patient gets into bed and is preparing to fall asleep, requires, as a rule, preparations of opium. Codeia, in quarter or half grain doses, or the syrupus codeiae (3 j) may be given. An excellent combination for the nocturnal cough of phthisis is morphia (gr. -J-£), dilute hydrocyanic acid (TTi ij-iij), and syrup of wild cherry (3 j). The spirits of chloroform, B. P., or the mistura chloroformi, U. S. P., or Hoffman’s anodyne, given LEPROSY". 277 in whisky before going to sleep, are efficacious. Mild counter-irritation, or the application of a hot poultice, will sometimes promptly relieve the cough. In the later stages of the disease, when cavities have formed, the accumulated secretion must be expectorated and the paroxysms of coughing are now most exhausting. The sedatives, such as morphia and hydrocyanic acid, should be given cautiously. The aromatic spirit of ammonia in full doses helps to allay the paroxysm. When the expectoration is profuse, creasote internally, or inhalations of turpentine and iodine, are useful. For the troublesome dysphagia a strong solution of cocaine (gr. x) with boric acid (gr. v) in glycerine and water ( f j) may be used locally. (cl) For the diarrhoea large doses of bismuth, combined with Dover powder, and small starch enemata, with or without opium, may be given. The acetate of lead and opium pill often acts promptly, and the acid diar- rhoea mixture, dilute acetic acid (m x-xv), morphia (gr. and acetate of lead (gr. j—ij), may be tried. (e) The treatment of the haemoptysis will be considered in the section on haemorrhage from the lungs. Dyspnoea is rarely a prominent symptom except in the advanced stages, when it may ba very troublesome and dis- tressing. Ammonia and morphia, cautiously administered, may be used. If the pleuritic pains are severe, the side may be strapped, or painted with tincture of iodine. The dyspeptic symptoms require careful treat- ment, as the outlook in individual cases depends much upon the condition of the stomach. Small doses of calomel and soda often allay the dis- tressing nausea of the early stage. XXVIII. LEPROSY. Definition.—A chronic infections disease caused by the bacillus leprce, characterized by the presence of tubercular nodules in the skin and mucous membranes (tubercular leprosy) or by changes in the nerves (anaesthetic leprosy). At first these forms may be separate, but ulti- mately both are combined, and in the characteristic tubercular form there are disturbances of sensation. Etiology.—The disease is very widely spread, and within the past few years renewed attention has been directed to it, owing to a belief that it is greatly on the increase. It is one of the oldest of known diseases. At present it prevails widely, particularly in hot countries. In India it is estimated that there are over 250,000 lepers. In Europe, where it pre- vailed in the middle ages, it has become almost unknown except in Norway and in the Orient. On this continent leprosy exists in the Gulf States and extensively in Mexico. At Key West Berger states that there are one hundred cases, and Blanc found forty lepers in New Orleans. A few isolated cases arrive from time to time in the cities of the Atlantic coast. In the Northwestern States a few cases exist among the Norwegian and Icelandic settlers. On the Pacific coast cases are seen not infrequently among the Chinese. An endemic focus is at Tracadie, 278 SPECIFIC INFECTIOUS DISEASES. New Brunswick. A few cases are also met with in Cape Breton, N. S. At Tracadie, which is on a bay of the Gulf of St. Lawrence, the disease is limited to two or three counties which are settled by French Canadians. The disease was imported from Normandy about the end of the last century. The cases are confined in a lazaretto, to which they are sent so soon as the disease is manifest. I made a visit to the settlement two years ago with the medical officer, A. C. Smith, of Chatham, at which time there were only eighteen patients in the hospital. It is interesting to note that the disease has gradually diminished by segregation; formerly there were over forty under surveillance. In the Sandwich Islands leprosy has developed to an enormous extent. Morrow states that in 1889 there were 1,100 lepers in the settlement at Molokai. In the West Indies the disease has been long endemic, and Beavan Rake, of Trinidad, has contributed some of the most interesting of recent clinical and pathological studies. The disease attacks all classes and persons of all ages. It is probably communicated by contagion. Inoculation was successfully performed by Arning in a Hawaiian convict. Graham, who some years ago carefully investigated the Tracadie settlement, came to the conclusion that the disease was there probably transmitted by contagion ; and A. C. Smith, the present medical officer, tells me that he knows of no facts which are opposed to that view. It is, however, only contagious in the same sense as syphilis, and just as accidental contamination with this virus is ex- tremely rare so it is with leprosy. The closest possible contact may take place for years, as between parent and child, wdthout transmission, and not one of the Sisters of Charity who have for more than forty years so faithfully nursed the lepers at Tracadie has contracted the disease. It is difficult to explain the rapid spread of the disease in the Sandwich Islands on any other view than contagion, and yet it is sti ange that there is no evidence of a primary lesion or external sore comparable to that of syphilis. Morrow states that “ in the immense majority of cases the disease is propagated by sexual congress.” The disappearance of the disease in the middle ages no doubt resulted directly from the isolation enforced at that time. The disease has possi- bly in some instances been transmitted by vaccination. Hereditary trans- mission cannot be excluded, and there is no good reason why the disease should not be communicated, as is syphilis, from parent to child. Jonathan Hutchinson believes that the disease is always associated with some special kind of food, particularly fish. Though he does not deny the specific nature of the disease or the possibility of contagion, he would make apparently the fish diet the tertium quid which renders the patient susceptible, or, if I gather aright from his recent communication, with which the poison may be taken. The facts which are manifest at the Tracadie settlement are very much opposed to this view. If a fish diet LEPROSY. 279 could alone in any way induce the disease, by this time leprosy would be wide-spread in the counties along the Gulf of St. Lawrence, as fish is the main article of diet winter and summer. There is not the slightest differ- ence in race, the mode of life, or in the surroundings of the inhabitants in the regions adjacent to Caraquet and Tracadie, and yet leprosy has been for nearly a century limited to two or three counties. The Bacillus Leprae.—Hansen, of Bergen, first discovered this organ- ism, which has many points of resemblance to the bacillus tuberculosis, but can be differentiated from it. It occurs in extraordinary numbers in the tuberculous tissue. It has been cultivated successfully (Babes), hut inoculation experiments on animals have been negative. Morbid Anatomy.—The leprosy tubercles consist of granuloma- tous tissue made up of cells of various sizes in a connective-tissue matrix. The bacilli in extraordinary numbers lie partly between and partly in the cells. The growth gradually involves the skin, producing tuberous out- growths with intervening areas of ulceration or cicatrization, which in the face may gradually produce the so-called facies leontina. The mucous membranes, particularly the conjunctiva, the cornea, the larynx, may be gradually involved. In many cases deep ulcers form which result in extensive loss of substance or loss of fingers or toes, the so-called lepra mutilans. In anaesthetic leprosy there is a peripheral neuritis due to the development of the bacilli in the nerve-fibres. Indeed, this involvement of the nerves plays a primary part in the etiology of many of the im- portant features, particularly the trophic changes in the skin and the disturbances of sensation. Clinical Forms.—(a) Tubercular Leprosy.—Prior to the appear- ance of the nodules there are areas of cutaneous erythema which may be sharply defined and often hypersesthetic. This is sometimes known as macular leprosy. The affected spots in time become pigmented. In some instances this superficial change continues without the development of nodules, the areas become anaesthetic, the pigment gradually disappears, and the skin gets perfectly white—the lepra alba. Among the patients at Tracadie it wTas particularly interesting to see three or four in this early stage presenting on the face and forearms a patchy erythema with slight swelling of the skin. The diagnosis of the condition is perfectly clear, though it may be a long time before any other than sensory changes develop. The eyelashes and eyebrows and the hairs on the face fall out. The mucous membranes finally become involved, particularly the mouth, throat, and larynx ; the voice becomes harsh and finally aphonic. Death results not infrequently from the laryngeal complications and aspiration pneumonia. The conjunctivae are frequently attacked, and the sight is lost by a leprous keratitis. (&) Anaesthetic Leprosy.—This remarkable form has, in characteristic cases, no external resemblance whatever to the other variety. It usually begins with pains in the limbs and areas of hyperaesthesia or of numbness. 280 SPECIFIC INFECTIOUS DISEASES. Very early there may be trophic changes, seen in the formation of small bullae (Hillis). Maculae apjeear upon the trunk and extremities, and after persisting for a variable time gradually disappear, leaving areas of anaes- thesia, but the loss of sensation may come on independently of the out- break of maculae. The nerve-trunks, where superficial, may be felt to be large and nodular. The trophic disturbances are usually marked. Pem- phigus-like bullae develop in the affected areas, which break and leave ulcers which may be very destructive. The fingers and toes are liable to contractures and to necrosis, so that in chronic cases the phalanges are lost. The course of anaesthetic leprosy is extraordinarily chronic and may persist for years without leading to much deformity. One of the most prominent clergymen on this continent has had anaesthetic leprosy for more than thirty years, which until recently has not seriously interfered with his usefulness, and not in the slightest with his career. Diagnosis.—Even in the early stage the dusky erythematous maculae with hyperaesthesia or areas of anaesthesia are very characteristic. In an advanced grade neither the tubercular nor anaesthetic forms could possi- bly be mistaken for any other affection. Treatment.—There are no specific remedies in the disease, and gen- eral tonics combined with local treatment meet the only available indica- tions. The gurjun and chaulmoogra oils have been recommended, the former in doses of from five to ten minims, the latter in two-drachm doses. The cases should be isolated, although the risk of catching the disease by direct contagion is extremely slight. XXIX. GLANDERS {Farcy). Definition.—An infectious disease of the horse, communicated occa- sionally to man. In the horse it is characterized by the formation of nodules, chiefly in the nares (glanders) and beneath the skin (farcy). Etiology.—The disease belongs to the infective granulomata. The local manifestations in the nostrils and the skin of the horse are due to one and the same cause. The specific germ bacillus mallei was discovered by Loeffler and Schiitz. It is a short, non-motile bacillus, not unlike that of tubercle. It grows readily on the ordinary culture media. For the full recognition of glanders in man we are indebted to the labors of Rayer, whose monograph remains one of the best descriptions ever given of the disease. Man becomes infected by contact with diseased animals, and usually by inoculation on an abraded surface of the skin. The contagion may also be received on the mucous membrane. In one of the Montreal cases a gentleman was probably infected by the material expelled from the nostril of his horse, which was not suspected to have the disease. Morbid Anatomy.—As in the horse, the disease may be localized in the nose (glanders) or beneath the skin (farcy). The essential lesion GLANDERS. 281 is the granulomatous tumor, characterized by the presence of numerous lymphoid and epithelioid cells, among and in which are seen the glanders bacilli. These nodular masses tend to break down rapidly, and on the mucous membrane form ulcers, while beneath the skin they form ab- scesses. The glanders nodules may also occur in the internal organs. Symptoms.—An acute and a chronic form of glanders may be recog- nized in man, and an acute and a chronic form of farcy. Acute Glanders.—The period of incubation is rarely more than three or four days. There are signs of general febrile disturbance. At the place of infection there are swelling, redness, and lymphangitis. Within two or three days there is involvement of the mucous membrane of the nose, the nodules break down rapidly to ulcers, and there is a muco- purulent discharge. An eruption of papules, which rapidly become pust- ules, breaks out over the face and about the joints. It has been mistaken for variola. This was carefully studied by Rayer and is figured in his monograph. In a Montreal case this copious eruption led the attending physician to suspect small-pox, and the patient was isolated. There is great swelling of the nose. The ulceration may go on to necrosis, in which case the discharge is very offensive. The lymph-glands of the neck are usually much enlarged. Subacute pneumonia is very apt to develop. This form runs its course in about eight or ten days, and is invariably fatal. Chronic glanders is rare and difficult to diagnose, as it is usually mistaken for a chronic coryza. There are ulcers in the nose, and often laryngeal symptoms. It may last for months, or even longer, and recovery sometimes takes place. The diagnosis may be extremely difficult. In such cases cultures should be made and portions of the pure culture inocu- lated in the guinea-pig. The animal dies within thirty hours, and the testicles are found to be enormously swollen and already in the condition of abscess. Acute farcy in man results usually from the inoculation of the virus into the skin. There is an intense local reaction with a phlegmonous in- flammation. The lymphatics are early affected, and along their course there are nodular subcutaneous enlargements, the so-called farcy buds, which may rapidly go on to suppuration. There are pains and swelling in the joints and abscesses may form in the muscles. The symptoms are those of an acute infection, almost like an acute septicaemia. The nose is not involved and the superficial skin eruption is not common. The disease is fatal in a large proportion of the cases, usually in from twelve to fifteen days. Chronic farcy is characterized by the presence of localized tumors, usu- ally in the extremities. These tumors break down into abscesses, and sometimes form deep ulcers, without much inflammatory reaction and without special involvement of the lymphatics. The disease may last for months or even years. Death may result from pyaemia, or occasionally 282 SPECIFIC INFECTIOUS DISEASES. acute glanders develops. The celebrated French veterinarian Bouley had it and recovered. The disease is transmissible also from man to man. Washer-women have been infected from the clothes of a patient. In the diagnosis of this affection the occupation is very important. Nowadays, in cases of doubt, the inoculation should be made in animals, as in this way the disease can be readily determined. Mallein, a product of the growth of the bacilli, is now used for the purpose of diagnosing glanders in animals. Treatment.—If seen early, the wound should be either cut out or thoroughly destroyed by caustics and an antiseptic dressing applied. The farcy buds should be early opened. In the acute cases there is very little hope. In the chronic cases recovery is possible, though often tedious. XXX. ACTINOMYCOSIS. Definition.—A chronic infective disorder produced by the acti- nomyces or ray-fungus. Etiology.—The disease is wide-spread among cattle, and occurs also in the pig. It was first described by Bollinger in the ox, in which it forms the affection known in this country as “ big-jaw.” Examples of the dis- ease were common in the cattle killed at the abattoir in Montreal. In man the disease was first described by James Israel, and subsequently Ponfick insisted upon the identity of the disease in man and cattle. In this country and in England the disease is rare. It is not uncom- mon in Germany and Russia. To the end of 1892 about 450 cases had been described (Leith, Edinburgh Hospital Reports, vol. ii). It is nearly three times as common in men as in women. The parasite belongs probably to the Cladotlirix group of bacteria. In both man and cattle it can be seen in the pus from the affected region as yellowish or opaque grannies from one half to two millimetres in diam- eter, which are made up of cocci and radiating threads, which present bulbous, club-like terminations. The relation of these three elements is still in dispute. The parasite has been successfully cultivated, and the disease has been inoculated both with the natural and artificially grown fungus. The Mode of Infection.—There is no evidence of direct infection with the flesh or milk of diseased animals. The fungus has not been detected outside the body. It seems highly probable that it is taken in with the food. The site of infection in a majority of cases in man and animals is in the mouth or neighboring passages. In the cow, possibly also in man, ears of barley or rye have been carriers of the fungus. Morbid Anatomy.—In the earliest stages of its growth the para- site gives rise to a small granulation tumor not unlike that produced by the bacillus tuberculosis, which contains, in addition to small round cells, ACTINOMYCOSIS. 283 epithelioid elements and giant cells. After it reaches a certain size there is great proliferation of the surrounding connective tissue, and the growth may, particularly in the jaw, look like, and was long mistaken for, osteo- sarcoma. Finally suppuration occurs, which, according to Israel, may be produced directly by the fungus itself. Clinical Forms.—(a) Alimentary Canal.—Israel is said to have found the fungus in the cavities of carious teeth. The jaw has been in- volved in a number of cases in man. The patient comes under observation with swelling of one side of the face, or with a chronic enlargement of the jawT which may simulate sarcoma. The tongue has been involved in several cases, forming small growths, which in one instance were primary, in the other secondary, to disease of the jaw. In the intestines the disease may occur either as a primary or sec- ondary affection. At the Charite, Berlin, in 1884,1 saw with Oscar Israel a remarkable instance in which there were actinomycotic ulcers in the small intestines. Cases have been reported of pericaecal abscess due to the fungus. An instance of primary actinomycosis of the large intestine with metastases has also been described. Ransom has found the actinomyces in the stools. The liver may be affected primarily, as in the case reported by Sharkey and Acland. The actinomycotic abscesses present a reticular or honeycomb-like arrangement (Leith). (5) Pulmonary Actinomycosis.—In September, 1878, James Israel de- scribed a remarkable mycotic disease of the lungs, which subsequent obser- vation showed to be the affection described the year before by Bollinger in cattle. Since that date thirty-four instances have been reported in which the lungs were affected. Hodenpyl has analyzed these and reports two cases from the Roosevelt Hospital. It is a chronic infectious disorder of the lungs, characterized by cough, fever, wasting, and a muco-purulent, sometimes foetid, expectoration. The lesions are unilateral in a majority of the cases. Hodenpyl classifies them in three groups : (1) Lesions of chronic bronchitis; in one case the diagnosis was made by the presence of the actinomyces in the sputum. (2) Miliary actinomycosis, closely resembling miliary tubercle, but the nodules are seen to be made up of groups of fungi, surrounded by granu- lation tissue. This form of pulmonary actinomycosis is not infrequent in oxen with advanced disease of the jaw or adjacent structures. (3) The cases in which there is more extensive destructive disease of the lungs, broncho-pneumonia, interstitial changes, and abscesses, the latter forming cavities large enough to be diagnosed during life. Actinomycotic lesions of other organs are often present in connection with the pulmonary disease; erosion of the vertebrse, necrosis of the ribs and sternum, subcutaneous abscesses, and occasionally metastases in all parts of the body. Symptoms.—The fever is of an irregular type and depends largely on the existence of suppuration. The cough is an important symptom, and the diagnosis in eighteen of the cases was made during life by the dis- 284 SPECIFIC INFECTIOUS DISEASES. eovery of the actinomyces. Death results usually with septic symptoms. Occasionally there is a condition simulating t}rphoid fever. The average duration of the disease was ten months. Of the thirty-four cases all died except two. Clinically the disease closely resembles certain forms of pul- monary tuberculosis and of foetid bronchitis. It is not to be forgotten in the examination of the sputum that, as Bizzozero mentions, certain degen- erated epithelial cells may resemble the fungus. The radiating leptothrix threads about the epithelium of the mouth sometimes present a striking resemblance. (c) Cutaneous Actinomycosis.—In several instances in connection with chronic ulcerative diseases of the skin the ray-fungus has been found. It is a very chronic affection resembling tuberculosis of the skin, associated with the development of tumors which suppurate and leave open sores, which may remain for years. (d) Cerebral Actinomycosis.—Bollinger has reported an instance of primary disease of the brain. The symptoms were those of tumor. A second remarkable case has been reported by Gamgee and Delepine. The patient was admitted to St. George’s Hospital with left-sided pleural effu- sion. At the post mortem three pints of purulent fluid were found in the left pleura; there was an actinomycotic abscess of the liver, and in the brain there were abscesses in the frontal, parietal, and temporo-sphe- noidal lobes which contained the mycelium, but no clubs. A third case, reported by 0. B. Keller, had empyema necessitatis, which was opened and actinomyces were found in the pus. Subsequently she had Jack- sonian epilepsy, for which she was trephined twice and abscesses opened, which contained actinomyces grains. Death occurred after the second ODeration. Diagnosis.—The disease is often mistaken for and is in reality a chronic pyaemia. The only test is the presence of the actinomyces in the pus. Metastases may occur as in pyaemia and in tumors. The tendency, however, is rather to produce a local purulent affection which erodes the bones and is very destructive. In cattle the disease may cause metastases without any suppuration; thus in a Montreal case the jaw and tongue were the seat of the most extensive disease with very slight suppuration, while the lungs presented numbers of secondary growths containing the fungus. Treatment.—This is largely surgical and is practically that of py- aemia. Incision of the abscess, removal of the dead bone, and thorough irrigation are appropriate measures. Thomassen has recommended iodide of potassium, which, in doses of from forty to sixty grains daily, has proved curative in a number of recent cases. INFECTIOUS DISEASES OF DOUBTFUL NATURE. 285 XXXI. INFECTIOUS DISEASES OF DOUBTFUL NATURE. (1) FEBRICULA—EPHEMERAL FEVER. Definition.—Fever of slight duration, probably depending upon a variety of causes. A febrile paroxysm lasting for twenty-four hours and disappearing com- pletely is spoken of as ephemeral fever. If it persists for three, four, or more days without local affection it is referred to as febricula. The cases may be divided into several groups : (a) Those which represent mild or abortive types of the infectious diseases. It is not very infrequent, during an epidemic of typhoid, scarlet fever, or measles, to see cases with some of the prodromal symptoms and slight fever which persist for two or three days without any distinctive features. I have already spoken of these in connection with the abortive type of typhoid fever. Possibly, as Kahler suggests, some of the cases of transient fever are due to the rheumatic poison. (b) In a larger and perhaps more important group of cases the symp- toms develop with dyspepsia. In children indigestion and gastrointes- tinal catarrh are often accompanied by fever. Possibly some instances of longer duration may be due to the absorption of certain toxic sub- stances. Slight fever has been known to follow the eating of decompos- ing substances or the drinking of stale beer; but the gastric juice has remarkable antiseptic properties, and the frequency with which persons take from choice articles which are “ high,” shows that poisoning is not likely to occur unless there is existing gastro-intestinal disturbance. (c) Cases which follow exposure to foul odors or sewer-gas. That a febrile paroxysm may follow a prolonged exposure to noxious odors has long been recognized. The cases which have been described under this heading are of two kinds: an acute severe form with nausea, vomiting, colic, and fever, followed perhaps by a condition of collapse or coma; secondly, a form of low fever with or without chills. A good deal of doubt still exists in the minds of the profession about these cases of so- called sewer-gas poisoning. It is a notorious fact that workers in sewers are remarkably free from disease, and in many of the cases which have been reported the illness may have been only a coincidence. There are instances in which persons have been taken ill with vomiting and slight fever after exposure to the odor of a very offensive post-mortem. Whether true or not, the idea is firmly implanted in the minds of the laity that very powerful odors from decomposing matters may produce sickness. (c?) Many cases doubtless depend upon slight unrecognized lesions, such as tonsillitis or occasionally an abortive or larval pneumonia. Chil- dren are much more frequently affected than adults. The symptoms set in, as a rule, abruptly, though in some instances there may have been preliminary malaise and indisposition. Headache, 286 SPECIFIC INFECTIOUS DISEASES. loss of appetite, and furred tongue are present. The urine is scanty and high-colored, the fever ranges from 101° to 103°, sometimes in children it rises higher. The cheeks may be flushed and the patient has the outward manifestations of fever. In children there may be bronchial catarrh with slight cough. Herpes on the lips is a common symptom. Occasionally in children the cerebral symptoms are marked at the outset, and there may be irritation, restlessness, and nocturnal delirium. The fever termi- nates abruptly by crisis from the second to the fourth day; in some in- stances it may continue for a week. The diagnosis generally rests upon the absence of local manifestations, particularly the characteristic skin rashes of the eruptive fevers, and most important of all the rapid disappearance of the pyrexia. The cases most readily recognized are those with acute gastro-intestinal disturbance. The treatment is that of mild pyrexia—rest in bed, a laxative, and a fever mixture containing nitrate of potash and sweet spirits of nitre. (2) WEIL’S DISEASE. Acute Febrile Icterus.—In 1886 Weil described an acute infectious disease, characterized by fever and jaundice. Much discussion has taken place concerning the true nature of this affection, but it has not been definitely determined whether it is a specific disease or only a jaundice which may be due to various causes. The majority of the cases have oc- curred during the summer months. The cases have occurred in groups in different cities. A few cases have been reported in this country (Lan- phear). Males are most frequently affected. Many of the cases have been in butchers. The age of the patients has been from twenty-five to forty. The disease sets in abruptly, usually without prodromes and often with a chill. There are headache, pains in the back, and sometimes in- tense pains in the legs and muscles. The fever is characterized by marked remissions. Jaundice appears early. The liver and spleen are usually swollen; the former may be tender. The jaundice may be light, but in many of the cases described it has been of the obstructive form, and the stools have been clay-colored. Gastro-intestinal symptoms are rarely pres- ent. The fever lasts from ten to fourteen days; sometimes there are slight recurrences, but a definite relapse is rare. Albumen is usually present in the urine; haematuria has occurred in some cases. Cerebral symptoms, delirium and coma, have been met. In the few post mortems which have been made nothing distinctive has been found. The investigations of Jaeger render it not impossible that this epidemic form of jaundice depends upon infection with a pro- teus—bacillus proteus Jluorescens. INFECTIOUS DISEASES OF DOUBTFUL CHARACTER. 287 (3) MILK-SICKNESS. This remarkable disease prevails in certain districts of the United States, west of the Alleghany Mountains, and is connected with the affec- tion in cattle known as the trembles. It prevailed extensively in the early i settlements in certain of the Western States and proved very fatal. The general opinion is that it is communicated to man only by eating the flesh or drinking the milk of diseased animals. The butter and cheese are also poisonous. In animals, cattle and the young of horses and sheep are most susceptible. It is stated that cows giving milk do not themselves show marked symptoms unless driven rapidly, and, according to Graff, the secre- tion may be infective when the disease is latent. When a cow is very ill, food is refused, the eyes are injected, the animal staggers, the entire mus- cular system trembles, and death occurs in convulsions, sometimes with great suddenness. Nothing definite is known as to the cause of the dis- ease. It is most frequent in new settlements. In man the symptoms are those of a more or less acute intoxication. After a few days of uneasiness and distress the patient is seized with pains in the stomach, nausea and vomiting, fever and intense thirst. There is usually obstinate constipation. The tongue is swollen and tremulous, the breath is extremely foul and, according to Graff, is as characteristic of the disease as the odor is of small-pox. Cerebral symptoms—restlessness, irritability, coma, and convulsions—are sometimes marked, and there may gradually be produced a typhoid state in which the patient dies. The duration of the disease is variable. In the most acute forms death occurs within two or three days. It may last for ten days, or even for three or four weeks. Graff states that insanity occurred in one case. The poisonous nature of the flesh and of the milk has been demonstrated ex- perimentally. An ounce of butter or cheese, or four ounces of the beef, raw or boiled, given three times a day, will kill a dog within six days. No definite pathological lesions are known. Fortunately, the disease has become rare, and the observation of Drake, Yandell, and others, that the disease gradually disappears with the clearing of the forests and improved tillage, has been amply substantiated. It still prevails in parts of North Carolina. (4) MALTA FEVER. This disease, also known as Mediterranean fever, Neapolitan fever, and rock fever, has been studied particularly by the naval and military medi- cal officers who have been stationed on the island of Malta. It prevails also in Naples and other districts of the Mediterranean. While endemic in the island of Malta, the disease in some years reaches epidemic propor- tions. Young persons are, as a rule, affected. The incubation may be from six to ten days. The symptoms are thus briefly and clearly described in an editorial in 288 SPECIFIC INFECTIOUS DISEASES. the British Medical Journal: * “ The disease declares itself gradually, with headache, sleeplessness, loss of appetite, and thirst, often without shiver- ing or diarrhoea, and without spots. Symptoms of this kind, with more or less severity, last for three or four weeks; apparent but deceptive con- valescence then usually sets in, to be followed in a few days by a relapse, with rigors, intense headache and fever, with, frequently, diarrhoea. In this state the patient may continue for five or six weeks, with more or less delirium. Improvement again sets in, to be followed, it may be, by an- other relapse in about ten days or a fortnight, with shivering, headache, sleeplessness, great debility, with night-sweats, pains in the hips, knees, ankles, and elbows, and often in one or both testicles. Again, the patient enters on a state of convalescence, which may last for a month or six weeks. The old symptoms may again appear, with extreme debility, a thickly coated tongue, with thirst, a temperature ranging from 105° Fahr. in the evening to nearly normal in the morning, with night-sweats bring- ing no relief to the general distress. The rheumatic symptoms are the most constant and the most distressing; all the joints, large and small, may suffer. Dr. Veale described cases in which the intervertebral joints, especially those of the lumbar region and the sacro-iliac synchondroses, were so severely affected that the patient “dreads every movement”; he will lie for days in one position, risking the formation of bed-sores, and resisting the desire to evacuate his bowels rather than encounter the suf- fering that a movement will entail. Oftentimes the tendo Achillis and the fibrous structures around the ankle-joint are involved; but perhaps the lumbar aponeuroses and the sheaths of the nerves issuing from the sacral plexus are still more commonly affected.” The affection is distinct from either typhoid fever or malaria. The mortality is about two per cent. According to Bruce, no characteristic typhoid lesions are found in fatal cases. This author has described the presence of a micrococcus in the spleen. The researches of Hughes con- firm the observations of Bruce, and the micrococcus melitensis, as it is called, has been obtained in pure cultures, and in six cases the disease has been reproduced in monkeys. Fortunately, the mortality is not great. With reference to the treat- ment, Bruce concludes that it should be directed principally to keeping the patient’s strength up by fluid, easily digested food, by stimulants when required, and by attention to ordinary hygienic principles. The removal of the patient from the infected area does not cut short the fever. (5) MOUNTAIN FEVER—MOUNTAIN SICKNESS. Residence for a time at a high altitude is in some instances followed by a group of symptoms to which the term mountain sickness or mountain * Vol. i, 1889. INFECTIOUS DISEASES OF DOUBTFUL CHARACTER. 289 fever has been given. Several distinct diseases have undoubtedly been described. It is by no means certain that there is a special affection to which the term may be applied. An important group, the mountain ancemia, is associated with the anchylostoma, which has not yet been met with in this country. A second group of cases belongs unquestionably to typhoid fever, and undoubted instances of this disease occurring in mount- ainous regions in the West are referred to as mountain fever. In the very full and clear report which Hoff * gives of five cases, the clinical picture is that of typhoid fever, and one of the patients died of perforation of the ileum with well-defined typhoid-lesion. Even from the clinical reports, unless biased by notions of a rigidly characteristic picture of the disease, one might have said that all of Surgeon Iloff’s cases were typhoid fever, and the post-mortem record leaves no question as to the nature of the malady. Woodward, commenting upon this communication, states that there is in the United States Army Medical Museum a second specimen from the case of so-called mountain fever contributed by Sur- geon Girard. Smart, who reviewed the entire question a few years ago, regarded the disease as a typho-malarial fever; but there is nothing in his account opposed to the opinion that it is a typhoid fever. The term mountain sickness should properly be applied to the remark- able phenomena which develop in very high altitudes. The condition has been very accurately described by Mr. Whymper. In the ascent of Chimborazo they were first affected at a height of 16,664 feet. The symp- toms were severe headache, gasping for breath, evidently urgent besoin de respirer. The throat was parched, and there was intense thirst, loss of appetite, and general malaise. Mr. Whymper’s temperature was 100-4°. The symptoms in his case lasted for nearly three days. In a less aggra- vated form such symptoms may present themselves at much lower levels, and in the ascent of the railroad at Pike’s Peak many persons suffer from distress in breathing. The original cases described by General Eremont were of this nature. (6) MILIARY FEVER—SWEATING SICKNESS. The disease is characterized by fever, profuse sweats, and an eruption of miliary vesicles. The disease prevailed and was very fatal in England in the fifteenth and sixteenth centuries, but of late years it has been con- fined entirely to certain districts in France (Picardy) and Italy. An epidemic of some extent occurred iu France in 1887. Ilirsch gives a chronological account of 194 epidemics between 1718 and 1879, many of which were limited to a single village or to a few localities. Occasion- ally the disease has become widely spread. Slight epidemics have oc- * American Journal of the Medical Sciences, January, 1880. 290 SPECIFIC INFECTIOUS DISEASES. curred in Germany and Switzerland. They are usually of short duration, lasting only for three or four weeks—sometimes not more than seven or eight days. As in influenza, a very large number of persons are attacked in rapid succession. In the mild cases there is only slight fever, with loss of appetite, an erythematous eruption, profuse perspiration, and an outbreak of miliary vesicles. The severe cases present the symptoms of intense infection—delirium, high fever, profound prostration, and haemorrhage. The death-rate at the outset of the disease is usually high, and, as is so graphically described in the account of some of the epidemics of the mid- dle ages, death may follow in a few hours. (7) FOOT AND MOUTH DISEASE—EPIDEMIC STOMATITIS- APHTHOUS FEVER. Foot and month disease is an acute infectious disorder met with chiefly in cattle, sheep, and pigs, but attacking other domestic animals. It is of extraordinary activity, and spreads with “ lightning rapidity ” over vast territories, causing very serious losses. In cattle, after a period of incuba- tion of three or five days, the animal gets feverish, the mucous membrane of the mouth swells, and little grayish vesicles the size of a hemp seed begin to develop on the edges and lower portion of the tongue, on the gums, and on the mucous membrane of the lips. They contain at first a clear fluid, which becomes turbid, and then they enlarge and gradually become converted into superficial ulcers. There is ptyalism, and the animals lose flesh rapidly. In the cow the disease is also frequently seen about the udder and teats, and the milk becomes yellowish-white in color and of a mucoid consistency. The transmission to man is by no means uncommon, and of late sev- eral important epidemics have been studied in the neighborhood of Berlin. Dr. Salmon informs me that in the United States foot and mouth disease has very rarely occurred, but in 1870, as well as in 1841, the disease was communicated in a few instances to man. In Zuill’s translation of Fried- berger and Frohner’s Pathology and Therapeutics of Domestic Animals (Philadelphia, 1895) the disease is thus described: “ Transmission of aphthous fever to man is not rare. The veterinarian has oftener occasion to observe it than the physician. The use of milk from aphthous cows contaminates children quite frequently and is fatal to them. This may also happen through ingestion of butter or cheese made of milk coming from aphthous animals, or also directly through wounds of the arms, hands, or by intermediary agents. In man the symptoms are: fever, digestive troubles, and vesicular eruption upon the lips, the buccal and pha- ryngeal mucous membranes (angina). The disease does not seem to be transmissible through the meat of diseased animals. Perhaps the serious affections of the skin which were observed to develop in children after INFECTIOUS DISEASES OF DOUBTFUL CHARACTER. 291 vaccination (especially in 1883-’84) may have been determined by mis- taking the mammary eruption of aphthous fever for cow-pox.” In wide-spread epidemics there has been sometimes a marked tendency to haemorrhages. The disease runs, as a rule, a favorable course, but in Siegel’s report of a recent epidemic the mortality was 8 per cent. Several forms of micro-organisms have been described in connection with it. When epidemics are prevailing in cattle the milk should be boiled, and the proper prophylactic measures taken to isolate both the cattle and the individuals who come in contact with them. SECTION II. CONSTITUTIONAL DISEASES. I. RHEUMATIC FEVER. Definition.—An acute, non-contagious, febrile affection, depending upon an unknown infective agent, and characterized by multiple arthritis and a special tendency to involve the heart. Etiology.—Acute rheumatism prevails in temperate and in humid climates. It is rare in the tropics. Newsholme (Milroy Lectures, 1895) concludes that the disease occurs in epidemics without regular periodicity, but which recur at intervals of three, four, or six years; that they vary much in intensity ; a severe epidemic is apt to be followed by two or three light outbreaks. It prevails most extensively during the spring months. In Bell’s statistics, of 456 cases treated at the Montreal General Hospital during ten years, the largest number of cases were admitted in February, March', and April. The same proportion seems true in Europe and in the cities of the Atlantic coast. Age.—Young adults are most frequently affected, but the disease is by no means uncommon in children between the ages of ten and fifteen years. Sucklings are rarely affected, and probably many of the cases which have been described belong to a totally different affection, the arthritis of in- fants. In exceptional cases, however, time rheumatism does occur. The following age table is based upon 456 cases admitted to the Montreal Gen- eral Hospital: Under 15 years, 4-38 per cent; from 15 to 25 years, 48,68' per cent; from 25 to 35 years, 25-87 per cent; from 35 to 45 years, 13'6 per cent; above 45 years, 7*4 per cent. Of the 655 cases analyzed by Whipham for the Collective Investigation Committee of the British Medi- cal Association, only 32 cases occurred under the tenth year and 80 per cent between the twentieth and fortieth year. These figures scarcely give the ratio of cases in children. Sex.—If all ages are taken, males are affected oftener than females. In the Collective Investigation Report there were 375 males and 279 females. Up to the age of twenty, however, females predominate. Be- tween the ages of ten and fifteen girls are more prone to the disease. RHEUMATIC FEVER. 293 Occupations which necessitate exposure to cold and to great changes in temperature predispose strongly to rheumatism. We meet the disease oftenest in drivers, servants, bakers, sailors, and laborers. Heredity seems in some cases to have a special influence, and the disease is more common in certain families. Of all etiological factors, cold is believed to be the most potent: Many cases follow a sudden wetting or chilling of the skin. The essential cause of rheumatism is still unknown. There are three chief theories: (a) Metabolic: that it depends upon a morbid material produced within the system in defective processes of assimilation. It has been sug- gested that this material is lactic acid (Prout) or certain combinations with lactic acid (Latham). Our knowledge of the chemical relations of the various products produced in the regressive nutritive changes is too limited to base much reliance upon these views. Richardson claims to have produced rheumatism by injecting lactic acid and by its internal ad- ministration. (£) The nervous theory advanced by J. K. Mitchell has many advo- cates. According to this view, either the nerve-centres are primarily affected by cold and the local lesions are really trophic in character, or the primary nervous disturbance leads to errors in metabolism and the accumulation of lactic acid in the system. The advocates of this view regard as analogous the arthropathies of myelitis, locomotor ataxia, and chorea. (c) Germ theory: that the arthritis is due to a specific microbe. In favor of this view may be mentioned the close analogy which exists be- tween rheumatism and certain of the infectious diseases. The analogy is marked with gonorrhoea, scarlet fever, and septic processes, which are fre- quently associated with arthritis and endocarditis. The investigations hitherto made have not, however, shown the constancy of any micro- organism in the disease. Sahli has found an organism resembling the staphylococcus citreus, but of low virulence; and Leyden a diplococcus differing from that of pneumonia. Morbid Anatomy.—There are no changes characteristic of the disease. The affected joints show hyperamia and swelling of the synovial membranes and of the ligamentous tissues. There may be slight erosion of the cartilage. The fluid in the joint is turbid, albuminous in charac- ter, and contains leucocytes and a few fibrin flakes. Pus is very rare in uncomplicated cases. Rheumatism rarely proves fatal, except when there are serious complications, such as pericarditis, endocarditis, myocarditis, pleurisy, or pneumonia. The conditions found have nothing peculiar, nothing to distinguish them from other forms of inflammation. In death from hyperpyrexia no special changes occur. The blood usually contains an excessive amount of fibrin. In the secondary rheumatic inflammations, as pleurisy and pericarditis, various pus organisms have been found, possi- bly the result of a mixed infection. 294 CONSTITUTIONAL DISEASES. Symptoms.—As a rule, the disease sets in abruptly, but it may be preceded by irregular pains in the joints, slight malaise, sore throat, and particularly by tonsillitis. A definite rigor is uncommon; more often there is slight chilliness. The fever rises quickly, and with it one or more of the joints become painful. Within twenty-four hours from the onset, the disease is fully developed. The temperature range is from 102° to 104°. The pulse is frequent, soft, and usually above 100. The tongue is moist, and rapidly becomes covered with a white fur. There are the ordi- nary symptoms associated with an acute fever, such as loss of appetite, thirst, constipation, and a scanty, highly acid, highly colored urine. In a majority of the cases there are profuse, very acid sweats, of a peculiar sour odor. Sudaminal and miliary vesicles are abundant. The mind is clear, except in the cases with hyperpyrexia. The affected joints are painful to move, and soon become swollen and hot, and present a reddish flush. The knees, ankles, elbows, and wrists are the joints usually attacked, not together, but successively. For example, if the knee is first affected, the redness may disappear from it as the wrists become painful and hot. The disease is seldom limited to a single articulation. The amount of swelling is variable. Extensive effusion into a joint is rare, and much of the enlargement is due to the infiltration of the periarticular tissues with serum. The swelling may be limited to the joint proper, but in the wrists and ankles it sometimes involves the sheaths of the tendons and produces great enlargement of the hands and feet. Corresponding joints are often affected. In attacks of great severity every one of the larger joints may be involved. The vertebral, sterno-clavicular, and phalangeal articula- tions are less often inflamed in acute than in gonorrhoeal rheumatism. Perhaps no disease is more painful than acute polyarthritis. The in- ability to change the posture without agonizing pain, the drenching sweats, the prostration and utter helplessness, combine to make it one of the most distressing of febrile affections. A special feature of the disease is the tendency of the inflammation to subside in one joint while develop- ing with great intensity in another. The temperature range in an ordinary attack is between 102° and 104°. It is peculiarly irregular, with marked remissions and exacerba- tions, depending very much upon the intensity and extent of the articular inflammation. Defervescence is usually gradual. The profuse sweats materially influence the temperature curve. If a two-hourly chart is made and observations upon the sweats are noted, the remissions will usually be found coincident with the sweats. The perspiration is sour-smelling and acid at first; but, when persistent, becomes neutral or even alkaline. The blood is profoundly and rapidly altered in acute rheumatism. There is, indeed, no acute febrile disease in which the ansemia develops with greater rapidity. There is a well-marked leucocytosis. With the high fever a murmur may often be heard at the apex re- gion. Endocarditis is also a common cause of an apex bruit. The heart RHEUMATIC FEVER. 295 should be carefully examined at the first visit and subsequently each day. The urine is, as a rule, reduced in amount, of high density and high col- or. It is very acid, and, on cooling, deposits urates. The chlorides may be greatly diminished or even absent. Febrile albuminuria is not uncommon. The saliva may become acid in reaction and is said to contain an excess of sulphocyanides. Subacute Rheumatism. This represents a milder form of the disease, in which all the symp- toms are less pronounced. The fever rarely rises above 101°; fewer joints are involved; and the arthritis is less intense. The cases may drag on for weeks or months, and the disease may finally become chronic. It should not be forgotten that in children this mild or subacute form may be asso- ciated with endocarditis or pericarditis. Complications.—These are important and serious. (1) Hyperpyrexia.—The temperature may rise rapidly a few days after the onset, and be associated with delirium; but not necessarily, for the temperature may rise to 108° or, as in one of Da Costa’s cases, 110°, without cerebral symptoms. The delirium may precede or follow the onset of the hyperpyrexia. As a rule, with the high fever, the pulse is feeble and fre- quent, the prostration is extreme, and finally stupor supervenes. (2) Cardiac Affections.—(«) Endocarditis, the most frequent and seri- ous complication, occurs in a considerable percentage of all cases. The statistics upon this point are not of much value, as the diagnosis has been based, as a rule, upon the development of a. systolic murmur at apex or base. This is quite untrustworthy; since it may depend upon causes other than endocarditis. The mitral segments are most frequently in- volved and the affection is usually of the simple, verrucose variety. Ulcer- ative endocarditis in the course of acute rheumatism is very rare. Of 209 cases of this disease which I analyzed, in only 24 did the symptoms of a severe endocarditis arise during the progress of acute or subacute rheuma- tism. This complication, in itself, is rarely dangerous. It produces few symptoms and is usually overlooked. Unhappily, though the valve at the time may not be seriously damaged, the inflammation starts changes which lead to sclerosis and retraction of the segments, and so to chronic valvular disease. (b) Pericarditis may occur independently of or together with endo- carditis. It may be simple fibrinous, sero-fibrinous, or in children puru- lent. Clinically we meet it more frequently in connection with rheuma- tism than all other affections combined. The physical signs are very characteristic. The condition will be fully described under its appropriate section. A peculiar form of delirium may develop during the progress of rheumatic pericarditis. CONSTITUTIONAL DISEASES. (c) Myocarditis is most frequent in connection with endo-pericardial changes. The anatomical condition is a granular or fatty degeneration of the heart-muscle, which leads to weakening of the walls and to dilata- tion. It is not, I think, nearly so common as the other cardiac affections. S. West has reported instances of acute dilatation of the heart in rheu- matic fever, in one of which marked fatty changes were found in the heart-fibres. (3) Pulmonary Affections.—Pneumonia and pleurisy are not uncom- mon, and frequently accompany the cases of endo-pericarditis. According to Howard’s analysis of a large number of cases, there were pulmonary complications in only 10‘5 per cent of cases of rheumatic endocarditis; in 58 per cent of cases of pericarditis; and in 71 per cent of cases of endo- pericarditis. Congestion of the lung is occasionally found, and in several cases has proved rapidly fatal. (4) Cerebral Complications.—These are due, in part, to the hyper- pyrexia and in part to the special action upon the brain of the toxic agent of the disease. They may be grouped as follows : (a) Delirium. This is usually associated with the hyperpyrexia, but may be independent of it. It may be active and noisy in character; more rarely a low muttering delirium, passing into stupor and coma. Special mention must be made of the delirium which occurs in connection with rheumatic pericarditis. Delirium, too, may be excited by the salicylate of soda, either shortly after its administration, or more commonly a week or ten days later. (b) Coma, which is more serious, may develop without preliminary delirium or con- vulsions, and may prove rapidly fatal. Certain of these cases are asso- ciated with hyperpyrexia; but Southey has reported the case of a girl who, without previous delirium or high fever, became comatose, and died in less than an hour. A certain number of such cases, as those reported by Da Costa, have been associated with marked renal changes and were evidently uraemic. The coma may develop during the attack, or after convalescence has set in. (c) Convulsions are less common, though they may precede the coma. Of 127 observations cited by Besnier, there were 37 of delirium, only 7 of convulsions, 17 of coma and convulsions, 54 of delirium, coma, and convulsions, and 3 of other varieties (Howard). (d) Chorea. The relations of this disease and rheumatism will be subsequently discussed. It is sufficient here to say that in only 88 out of 554 cases which I have analyzed from the Infirmary for Diseases of the Nervous System, Phila- delphia, were chorea and rheumatism associated. It is most apt to develop in the slighter attacks in childhood, (e) Meningitis is extremely rare, though undoubtedly it does occur. It must not be forgotten that in ulcerative endocarditis, which is occasionally associated with acute rheu- matism, meningitis is frequent. (5) Cutaneous Affections.—Sweat-vesicles have already been mentioned as extremely common. A red miliary rash may also develop. Scarlatini- form eruptions are occasionally seen. Purpura, with or without urticaria, RHEUMATIC FEVER. may occur, and various forms of erythema. It is doubtful whether the cases of extensive purpura with urticaria and arthritis—peliosis rheumatica —belong truly to acute rheumatism. (6) Rheumatic Nodules.—These curious structures, in the form of small subcutaneous nodules attached to the tendons and fasciae, have been known for some years; but special attention has been paid to them of late, since their careful study by Barlow and Warner. They vary in size from a small shot to a large pea, and are most numerous on the fingers, hands, and wrists. They also occur about the elbows, knees, the spines of the vertebrae, and the scapulae. They are not often tender. They do not necessarily come on during the fever, but may be found on its decline, or even independently altogether of an acute attack. They may develop with great rapidity and usually last for weeks or months. They are more common in children than in adults, and their presence may be regarded as a positive indication of rheumatism. They have been noted particularly in association with severe and chronic rheumatic endocarditis. They may occur in large numbers in adults, as in a case reported from my clinic in Philadelphia, by J. K. Mitchell. Histologically they are made up of round and spindle-shaped cells. The course of acute rheumatism is extremely variable. It is, as Austin Flint first showed, a self-limited disease, and it is not probable that medi- cines have any special influence upon its duration or course. Gull and Sutton who likewise studied a series of sixty-two cases without special treatment arrived at the same conclusion. Diagnosis.—Practically, the recognition of acute rheumatism is very easy; but there are several affections which, in some particulars, closely resemble it. (1) Multiple Secondary Arthritis.—Under this term may be embraced the various forms of arthritis which come on or follow in the course of the infective diseases, such as gonorrhoea, scarlet fever, dysentery, and cerebro-spinal meningitis. Of these the gonorrhoeal form will receive special consideration and is the type of the entire group. (2) Septic Arthritis, which develops in the course of pyaemia from any cause, and particularly in puerperal fever. No hard and fast line can be drawn between these and the cases in the first group; but the inflammation rapidly passes on to suppuration and there is more or less destruction of the joints. The conditions under which the arthritis de- velops give a clew at once to the nature of the case. Under this section may also be mentioned : (a) Acute necrosis or acute osteo-myelitis, occurring in the lower end of the femur, or in the tibia, and which may be mistaken for acute rheu- matism. Sometimes, too, it is multiple. The greater intensity of the local symptoms, the involvement of the epiphyses rather than the joints, and the more serious constitutional disturbances are points to be considered. The condition is unfortunately often mistaken for acute arthritis, and, as 298 CONSTITUTIONAL DISEASES. the treatment is essentially surgical, the error is one which may cost the life of the patient. (b) The acute arthritis of infants must be distinguished from rheu- matism. It is a disease which is usually confined to one joint (the hip or knee), the effusion in which rapidly becomes purulent. The affection is most common in sucklings and is undoubtedly pygemic in character.* It may also develop in the gonorrhoeal ophthalmia or vaginitis of the new- born, as pointed out by Clement Lucas. (3) It is only in rare instances that gout and acute rheumatism are confounded. The localization in a single, usually a small, joint, the age, the history, the mode of onset—are features which enable us to recognize the cases readily. Treatment.—The bed should have a smooth, soft, yet elastic mattress. The patient should wear a flannel night-gown, which may be opened all the way down the front and slit along the outer margin of the sleeves. Three or four of these should be made, so as to facilitate the frequent changes required after the sweats. He may wear also a light flannel cape about the shoulders. He should sleep in blankets, not in sheets, so as to reduce the liability to catch cold and obviate the unpleasant clamminess consequent upon heavy sweating. Chambers insisted that the liability to endocar- ditis and pericarditis was much reduced when the patients were in blankets. Milk is the most suitable diet. It may be diluted with alkaline min- eral waters. Lemonade and oatmeal or barley water should be freely given. The thirst is usually great and may be fully satisfied. There is no objection to broths and soups if the milk is not well borne. The food should be given at short and stated intervals. As convalescence is estab- lished a fuller diet may be allowed, but meat should be used sparingly. The local treatment is of the greatest importance. It often suffices to wrap the affected joints in cotton. If the pain is severe, hot cloths may be applied, saturated with Fuller’s lotion (carbonate of soda, 6 drachms; laudanum, 1 o'z.; glycerine, 2 oz.; and water, 9 oz.). Tincture of aconite or chloral may be employed in an alkaline solution. Chloroform liniment is also a good application. Fixation of the joints is of great service in allaying the pain. I have seen, in a German hospital, the joints enclosed in plaster of Paris, apparently with great relief. Splints, padded and bandaged with moderate firmness, will often be found to relieve pain. Friction is rarely well borne in an acutely inflamed joint. Cold com- presses are much used in Germany. The application of blisters above and below the joint, often relieves the pain. This method, which was used so much a few years ago, is not to be compared with the light appli- cation of the Paquelin thermo-cautery. Medicines have little or no control over the duration or course of the * Townsend, Acute Arthritis of Infants, American Journal of the Medical Sciences, January, 1890. RHEUMATIC FEVER. disease, which, like other self-limited affections, practically takes its own time to disappear. Salicyl compounds, which were regarded so long as specific in the disease, are now known to act chiefly by relieving pain. E. P. Howard’s elaborate analysis shows that they do not influence the duration of the disease. Nor do they prevent the occurrence of cardiac complications, while under their use relapses are considerably more fre- quent than in any other method of treatment. In acute cases with severe pain the salicyl compounds give prompt relief and rarely disappoint us in their action. Sodium salicylate, in fifteen-grain doses for eight or ten doses, may be given. The bicarbonate of potassium in twenty-grain doses may be used with it. Many prefer salicin (gr. 20) in wafers; others the salicylic acid (gr. 20) or salol. I have for the past five or six years used the oil of wintergreen, recommended by Kinnicutt, and have found it quite as efficacious. Twenty minims may be given every two hours in milk. The salicyl compounds are best given in full doses at the outset of the disease, to relieve the pain. Then the dose should be reduced in fre- quency, or, if the symptoms have abated, stopped altogether, as relapses are certainly more frequent under their use. Alkalies may be combined with the salicylates, or may be used alone. The potassium bicarbonate in lialf-drachm doses may be given every three or four hours until the urine is rendered alkaline. Fuller, who so warmly supported this method of treatment, was in the habit of ordering a drachm and a half of the sodium bicarbonate with half a drachm of potassium acetate in three ounces of water, rendered effervescent at the time of ad- ministration by half a drachm of citric acid or an ounce of lemon-juice. This is given every three or four hours, and usually by the end of twenty- four hours the urine is alkaline in reaction. The alkali is then reduced, and the amount subsequently regulated by the degree of acidity of the urine, only enough being given to keep the secretion alkaline. Opinion is almost unanimous that, under the alkaline treatment, cardiac complica- tions are less common. The combination of the salicylates with the alkali is probably the most satisfactory. Care must be taken to watch the heart during the administration of these remedies. In the only fatal case of rheumatism which has come in my experience the patient had, owing to an error, taken the full first day’s dose of Fuller’s alkaline treatment for five successive days, instead of having the salt gradually reduced. She died suddenly on the fifth day after sitting up in bed. Salicylates also, if given largely, are very depressing to the circulation. To allay the pain opium may be given in the form of Dover’s powder, or morphia hypodermically. Antipyrin, antifebrin, and phenacetin are useful sometimes for the purpose. During convalescence iron is indicated in full doses, and quinine is a useful tonic. Of the complications, hyper- pyrexia should be treated by the cold bath or the cold-pack. The treat- ment of endocarditis and pericarditis and the pulmonary complications will be considered under their respective sections. 300 CONSTITUTIONAL DISEASES. II. CHRONIC RHEUMATISM. Etiology.—This affection may follow an acute or subacute attack, but more commonly comes on insidiously in persons who have passed the middle period of life. In my experience it is extremely rare as a sequence of acute rheumatism. It is most common among the poor, particularly washer-women, day laborers, and those whose occupation exposes them to cold and damp. Morbid Anatomy.—The synovial membranes are injected, but there is usually not much effusion. The capsule and ligaments of the joints are thickened, and the sheaths of the tendons in the neighborhood undergo similar alterations, so that the free play of the joint is greatly impaired. In long-standing cases the cartilages also undergo changes, and may show erosions. Even in cases with the severest symptoms, the joint may be very slightly altered in appearance. Important changes take place in the muscles and nerves adjacent to chronically inflamed joints, particularly in the mono-articular lesions of the shoulder or hip. Muscular atrophy supervenes partly from disuse, partly through nervous influences, either centric or reflex (Vulpian), or as a result of peripheral neuritis. In some cases when the joint is much distended the wasting may be due to press- ure, either on the muscles themselves or on the vessels supplying them. Symptoms.—Stiffness and pain are the chief features of chronic rheumatism. The latter is very liable to exacerbations, especially dur- ing changes in the weather. The joints may be tender to the touch and a little swollen, but seldom reddened. As a rule, many joints are affected ; but there are instances in which the disease is confined to one shoulder, knee, or hip. The stiffness and pain are more marked after rest, and as the day advances the joints may, with exertion, become much more supple. The general health may not be seriously impaired. The disease is not immediately dangerous. Anchylosis may occur, and ultimately the joints may become very distorted. In many instances, particularly those in which the pain is severe, the general health may be seriously involved and the subjects become anaemic and very apt to suffer with neuralgia and dyspepsia. Valvular lesions, due to slow sclerotic changes, are not un- common. They are associated with, not dependent upon, the articular disease. The prognosis is not favorable, as a majority of the cases resist all methods of treatment. It is, however, a disease which persists indefin- itely, and does not necessarily shorten life. Treatment.—Internal remedies are of little service. It is important to maintain the digestive functions and to keep the general health at a high standard. Iodide of potassium, sarsaparilla, and guaiacum are some- times beneficial. The salicylates are useless. Local treatment is very beneficial. “ Firing ” with the Paquelin cautery relieves the pain, and it is perhaps the best form of counter- PSEUDO-RHEUMATIC AFFECTIONS. 301 irritation. Massage, with passive motion, helps to reduce swelling, and prevents anchylosis. It is particularly useful in cases which are asso- ciated with atrophy of the muscles. Electricity is not of much benefit. Climatic treatment is very advantageous. Many cases are greatly helped by prolonged residence in southern Europe or southern California. Rich patients should always winter in the South, and in this way avoid the cold, damp weather. Hydrotherapeutic measures are specially beneficial in chronic rheu- matism. Great relief is afforded by wrapping the affected joints in cold cloths, covered with a thin layer of blanket, and protected with oiled silk. The Turkish bath is useful, but the full benefit of this treatment is rarely seen except at bathing establishments. The hot alkaline waters are par- ticularly useful, and a residence at the Hot Springs of Virginia or Ar- kansas, or at Banff, in the Rocky Mountains, on the Canadian Pacific Rail- way, will sometimes cure even obstinate cases. III. PSEUDO-RHEUMATIC AFFECTIONS. These are numerous, and occur as complications or sequelae of many infectious diseases with which they have been considered. The one which is of most importance, and which, though a surgical affection, is usually treated of in works on medicine, is— Gonorrhoeal Arthritis.—Though custom has sanctioned the term, the affection has nothing whatever to do with rheumatism, but is an arthritis or synovitis of a septic nature, due to infection from the urethral dis- charge. It occurs either during an acute attack of gonorrhoea, or, more commonly, as the attack subsides, or when it has become chronic. It is far more frequent in men than in women. An attack may occur in a newly married woman infected by an old gleet of the husband. It is liable to recur, and is an affection of extraordinary obstinacy. Many joints may be affected, the knees and ankles at times most commonly. It is peculiar in attacking certain joints which are rarely involved in acute rheumatism—as the sterno-clavicular, the intervertebral, the temporo- maxillary, and the sacro-iliac. The anatomical changes are variable. The inflammation is often peri- articular, and extends along the sheaths of the tendons. When effusion occurs in the joints it rarely becomes purulent. It has more commonly the characters of a synovitis. About the wrist and hand suppuration sometimes occurs in the sheaths, and in a recent case in Dr. Ilalsted’s wards the gonococci were obtained in pure culture. In the bacteriological examination the gonococci have been found in the exudate, but not often. They may be present in the tissues, however, and cause an effusion which may be sterile. It has been suggested that the simple arthritis or synovi- tis follows absorption of ptomaines from the urethral discharge, while the more severe suppurating forms are due to infection with pus organisms. 302 CONSTITUTIONAL DISEASES. The symptoms of this disease are very variable. The following clinical forms may be recognized : {a) Arthralgic, in which there are wandering pains about the joints, without redness or swelling. These persist for a long time. (h) Poly arthritic, in which several joints become affected, just as in subacute articular rheumatism. The fever is slight; the local inflamma- tion may fix itself in one joint, but more commonly several become swollen and tender. In this form cerebral and cardiac complications may occur. (ic) Acute gonorrhoeal arthritis, in which a single articulation becomes suddenly involved. The pain is severe, the swelling extensive, and due chiefly to peri-articular oedema. The general fever is not at all propor- tionate to the intensity of the local signs. The affection usually resolves, though suppuration occasionally supervenes. (d) Chronic Hydrarthrosis.—This is usually mono-articular, and is particularly apt to involve the knee. It comes on often without pain, redness, or swelling. Formation of pus is rare. It occurred only twice in ninety-six cases tabulated by Nolen. (e) Bursal and Synovial Form.—This attacks chiefly the tendons and their sheaths and the bursae and the periosteum. The articulations may not be affected. The bursae of the patella, the olecranon, and the tendo Achillis are most apt to be involved. (/) Septiccemic.—Occasionally with an acute arthritis the gonococci invade the blood, and the picture is that of an intense septico-pyaemia, usually with endocarditis. It. L. MacDonnell recently analyzed twenty-seven cases of gonorrhoeal rheumatism at the Montreal General Hospital, of which four presented signs of recent cardiac disease. Gluzinski has collected thirty-one cases from the literature. The endocarditis is usually simple, but occasionally there is an intense infection and ulcerative endocarditis with symptoms resembling typhoid fever. From the blood of a patient, a woman, recently in my wards, with ma- lignant endocarditis, the gonococci were cultivated and the diagnosis made during life. Acute gonorrhoeal myocarditis may also occur (Councilman). The disease is much more intractable than ordinary rheumatism, and relapses are extremely common. It may become chronic and last for years. Complications.—Iritis is not infrequent and may recur with suc- cessive attacks. The visceral complications are rare. Pericarditis and pleurisy may occur. Treatment.—The salicylates are of very little service, nor do they often relieve the pains in this affection. Iodide of potassium has also proved useless in my hands, even given in large doses. A general tonic treatment seems much more suitable—quinine, iron, and, in the chronic cases, arsenic. The local treatment of the joints is very important. The thermo- cautery may be used to allay the pain and reduce the swelling. In acute MUSCULAR RHEUMATISM. 303 cases, fixation of the joints is very beneficial, and in the chronic forms, massage and passive motion. The surgical treatment of this affection, as carried out nowadays, is more satisfactory, and I have seen strikingly good results follow incision and irrigation. IV. MUSCULAR RHEUMATISM {Myalgia). Definition.—A painful affection of the voluntary muscles and of the fasciae and periosteum to which they are attached. The affection has re- ceived various names, according to its seat, as torticollis, lumbago, pleuro- dynia, etc. Etiology.—The attacks follow cold and exposure, the usual condi- tions favorable to the development of rheumatism. It is by no means cer- tain that the muscular tissues are the seat of the disease. Many writers claim, perhaps correctly, that it is a neuralgia of the sensory nerves of the muscles. Until our knowledge is more accurate, however, it may he con- sidered under the rheumatic affections. It is most commonly met with in men, particularly those exposed to cold and whose occupations are laborious. It is apt to follow exposure to a draught of air, as from an open window in a railway carriage. A sud- den chilling after heavy exertion may also bring on an attack of lumbago. Persons of a rheumatic or gouty habit are certainly more prone to this affection. One attack renders an individual more liable to another. It is usually acute, but may become subacute or even chronic. Symptoms.—The affection is entirely local. The constitutional dis- turbance is slight, and, even in severe cases, there may be no fever. Pain is a prominent symptom. It may be constant, or may occur only when the muscles are drawn into certain positions. It may be a dull ache or a bruised pain, or sharp, severe, and cramp-like. It is often sufficiently in- tense to cause the patient to cry out. Pressure on the affected part usu- ally gives relief. As a rule, myalgia is a transient affection, lasting from a few hours to a few days. Occasionally it is prolonged for several weeks. It is very apt to recur. The following are the principal varieties : (1) Lumbago, one of the most common and painful forms, affects the muscles of the loins and their tendinous attachments. It occurs chiefly in workingmen. It comes on suddenly, and in very severe cases completely incapacitates the patient, who may be unable to turn in bed or to rise from the sitting posture. (2) Stiff neck or torticollis affects the muscles of the antero-lateral region of the neck. It is very common, and occurs most frequently in the young. The person holds the head in a peculiar manner, and rotates the whole body in attempting to turn it. Usually it is confined to one side. The muscles at the back of the neck may also be affected. 304 CONSTITUTIONAL DISEASES. (3) Pleurodynia involves the intercostal muscles on one side, and in some instances the pectorals and serratus magnus. This is, perhaps, the most painful form of the disease, as the chest cannot be at rest. It is more common on the left than on the right side. A deep breath, or coughing, causes very intense pain, and the respiratory movements are restricted on the affected side. There may be pain on pressure, sometimes over a very limited area. It may be difficult to distinguish from intercostal neuralgia, in which affection, however, the pain is usually more circumscribed and paroxysmal, and there are tender points along the course of the nerves. It is sometimes mistaken for pleurisy, but careful physical examination readily distinguishes between the two affections. (4) Among other forms which may be mentioned are cephalodynia, affecting the muscles of the head; scapulodynia, omodynia, and dorsodynia, affecting the muscles about the shoulder and upper part of the back. My- algia may also occur in the abdominal muscles and in the muscles of the extremities. Treatment.—Rest of the affected muscles is of the first importance. Strapping the side will sometimes completely relieve pleurodynia. No belief is more wide-spread among the public than the efficacy of porous plasters for muscular pains of all sorts, particularly those about the trunk. If the pain is severe and agonizing, a hypodermic of morphia gives im- mediate relief. For lumbago acupuncture is, in acute cases, the most effi- cient treatment. Needles of from three to four inches in length (ordinary bonnet-needles, sterilized, will do) are thrust into the lumbar muscles at the seat of the pain, and withdrawn after five or ten minutes. In many Instances the relief is immediate, and I can corroborate fully the state- ments of Ringer, who taught me this practice, as to its extraordinary and prompt efficacy in many instances. The constant current is sometimes very beneficial. In many forms of myalgia the thermo-cautery gives great relief. In obstinate cases blisters may be tried. Hot fomentations are soothing, and at the outset a Turkish bath may cut short the attack. In chronic cases iodide of potassium may be used, and both guaiacum and sulphur have been strongly recommended. Persons subject to this affec- tion should be warmly clothed, and avoid, if possible, exposure to cold and damp. In gouty persons the diet should be restricted and the alka- line mineral waters taken freely. Large doses of nux vomica are some- times beneficial. ARTIIRITIS DEFORMANS. 305 V. ARTHRITIS DEFORMANS (Rheumatoid arthritis). Definition.—A chronic disease of the joints, characterized by changes in the cartilages and synovial membranes, with periarticular formation of bone and great deformity. Etiology.—Long believed to be intimately associated both with gout and rheumatism (whence the names rheumatic gout and rheumatoid ar- thritis), this close relationship seems now very doubtful, since in a ma- jority of the cases no history of either affection can be determined. It is difficult to separate some cases from ordinary chronic rheumatism, but the multiple form has, in all probability, a nervous origin, as suggested by J. K. Mitchell. This view is based upon such facts as the association of the disease with shock, worry, and grief; the similarity of the arthritis to the arthropathies due to disease of the cord, as in locomotor ataxia; the sym- metrical distribution of the lesions ; the remarkable trophic changes which lead to alterations in the skin and nails, and occasionally to muscular wasting out of proportion to the joint mischief. Ord regards the disease as analogous to progressive muscular atrophy, and due either to a primary lesion in the cord or to changes the result of peripheral irritation, trau- matic, uterine, urethral, etc. The true nature of the disease is still ob- scure, but the neuro-trophic theory meets very many of the facts. Females are more liable to the disease than males. In Archibald E. Garrod’s table of 500 cases there were 411 females and 89 males. It most commonly sets in between the ages of twenty and thirty, but it may begin as late as fifty. It occurs also in children; within the past five years there have been at my clinics four cases in children under twelve. The degree of deformity may be extreme even at this early age. Hereditary influences are not uncommon. In Garrod’s cases there were in 216 instances a family history of joint disease. Seguin has reported the occurrence of three cases in children of the same family. It is stated that the disease is more common in families with phthisical history. It seems to be more frequent in women who have had ovarian and uterine trouble, or who are sterile. In this country acute rheumatism or gout in the forebears is rare. Mental worry, grief, and anxiety seem frequent antecedents. It is an affection quite as common in the rich as in the poorer classes, though in England and the Continent the latter seem more prone to the disease. Though often attrib- uted to cold or damp, and occasionally to injury, there is no evidence that these are efficient causes. Morbid Anatomy.—The changes in the joints differ essentially from those of gout in the absence of deposits of urate of soda, and from chronic rheumatism by the existence of extensive structural alterations, particularly in the cartilages. We are largely indebted to the magnificent work of Adams for our knowledge of the anatomy of this disease. The changes begin in the cartilages and synovial membranes, the cells of 306 CONSTITUTIONAL DISEASES. which proliferate. The cartilage covering the joint undergoes a peculiar fibrillation, becomes soft, and is either absorbed or gradually thinned by attrition, thus laying bare the ends of the bone, which become smooth, polished, and eburnated. At the margins, where the pressure is less, the proliferating elements may develop into irregular nodules, which ossify and enlarge the heads of the bones, forming osteophytes which completely lock the joint. The periosteum may also form new bone. There is usu- ally great thickening of the ligaments, and finally complete anchylosis results. This is rarely, however, a true anchylosis, but is caused by the osteophytes and. thickened ligaments. There are often hyperostosis and increase in the articular ends of the bone in length and thickness. In long-standing cases and in old persons there may, on the other hand, be great atrophy of the heads of the affected bones. The spongy substance becomes friable, and in the hip-joint the wasting may reach such an extreme grade that the articulating surface lies between the trochanters. This is sometimes called morbus coxes senilis. The anatomical changes may lead to great deformity. The metacarpal joints are enlarged and thickened, and the fingers are deflected toward the ulnar side. The toes often show a similar deflection. The nodosities at the joints are known as Haygarth’s nodosities. The muscles become atrophied, and in some cases the wasting reaches a high grade. Neuritis has been demonstrated in the nerves about the joints. Symptoms.—Charcot makes a convenient division of the cases into Ileberden’s nodosities, the general progressive form, and the partial or mono-articular form. Heberden’s Nodes.—In this form the fingers are affected, and “ little hard knobs ” develop gradually at the sides of the distal phalanges. They are much more common in women than in men. They begin usually between the thirtieth and fortieth year. The subjects may have had digestive troubles or gout. Ileberden, however, says “ they have no con- nection with gout, being found in persons who never had it.” In the early stage the joints may be swollen, tender, and slightly red, particularly when knocked. The attacks of pain and swelling may come on in the joints at long intervals or follow indiscretion in diet. The little tubercles at the sides of the dorsal surface of the second phalanx increase in size, and give the characteristic appearance to the affection. The cartilages also become soft, and the ends of the bones eburnated. Urate of soda is never deposited (Charcot). The condition is not curable; but there is this hopeful feature—the subjects of these nodosities rarely have involve- ment of the larger joints. They have been regarded, too, as an indication of longevity. Charcot states that in women with these nodes cancer seems more frequent. General Progressive Form.—This occurs in two varieties, acute and chronic. The acute form may resemble, at its outset, ordinary articular ARTHRITIS DEFORMANS. 307 rheumatism. There are involvement of many joints; swelling, particularly of the synovial sheaths and bursae; not often redness; but there is mod- erate fever. Howard describes this condition as most frequent in young women from twenty to thirty years of age, often in connection with recent delivery, lactation, or rapid child-bearing. Acute cases may develop at the menopause. It may also come on in children. “ These patients suffer in their general health, become weak, pale, depressed in spirits, and lose flesh. In several cases of this form marked intervals of improvement have occurred; the local disease has ceased to progress, and tolerable comfort has been experienced perhaps until pregnancy,, delivery, or lactation again determine a fresh outbreak of the disease.” The chronic form is by far the most common. The joints are usually involved symmetrically. The first symptoms are pain on movement and slight swelling, which may be in the joint itself or in the peri-articular sheaths. In some cases the effusion is marked, in others slight. The local conditions vary greatly, and periods of improvement alternate with attacks of swelling, redness, and pain. At first only one or two joints are affected; usually the joints of the hands, then the knees and feet; gradu- ally other articulations are involved, and in extreme cases every articula- tion in the body is affected. Pain is an extremely variable symptom. Some cases proceed to the most extreme deformity without pain; in others the suffering is very great, particularly at night and during the exacerbations of the disease. There are cases in which pain of an agoniz- ing character is an almost constant symptom, requiring for years the use of morphia. Gradually the shape of the joints is greatly altered, partly by the pres- ence of osteophytes, partly by the great thickening of the capsular liga- ments, and still more by the retraction of the muscles. In moving the affected joint crepitation can be felt, due to the eburnation of the articular surfaces. Ultimately the joints become completely locked, not by a true bony anchylosis, but by the osteophytes which form around the articular surfaces, like ring-bone in horses. There is also a spurious anchylosis, caused by the thickening of the capsular ligaments and fibrous adhesions. The muscles about the joints undergo important changes. Atrophy from disuse gradually supervenes, and contractures tend to flex the thigh upon the abdomen and the leg upon the thigh. There are cases with rapid muscular wasting, symmetrical involvement of the joints, and trophic changes, which strongly suggest a central origin. Numbness, tingling, pigmentation or glossiness of the skin, and onychia may be present. In extreme cases the patient is completely helpless, and lies on one side with the legs drawn up, the arms fixed, and all the articulations of the extremi- ties locked. Fortunately, it often happens in these severe general cases that the joints of the hand are not so much affected, and the patient may be able to knit or to write, though unable to walk or to use the arms. It is surprising indeed how much certain patients with advanced arthritis 308 CONSTITUTIONAL DISEASES. deformans can accomplish. No one who had seen the beautiful models and microscopic preparations of the late H. D. Schmidt, of New Orleans, could imagine that he had been afflicted for years with a most extreme grade of this terrible disease. In many cases, after involving two or three joints, the disease becomes arrested, and no further development occurs. It may be limited to the wrists, or to the knees and wrists, or to the knees and ankles. A majority of the patients finally reach a quiescent stage, in which they are free from pain and enjoy excellent health, suffering only from the inconvenience and crippling necessarily associated with the disease. Coincident affections are not uncommon. In the active stage the pa- tients are often anaemic and suffer from dyspepsia, which may recur at intervals. There is no tendency to involvement of the heart. The partial or mono-articular form affects chiefly old persons, and is seen particularly in the hip, the knee, the spinal column, or shoulder. It is, in its anatomical features, identical with the general disease. In the hip and shoulder the muscles early show wasting, and in the hip the con- dition ultimately becomes that already described as morbus coxce senilis. These cases seem not infrequently to follow an injury. They differ from the polyarticular form in occurring chiefly in men and at a later period of life. One of the most interesting forms affects the vertebras, completely locking the articulations, and producing the condition known as spondy- litis deformans. When the cervical spine is involved the head cannot be moved up and down, but is carried stiffly. Usually rotation can be effected. The dorsal and lumbar spines may also be involved, and the body cannot be flexed in the slightest degree. No other joints may be affected. Diagnosis.—Arthritis deformans can rarely be mistaken for either rheumatism or gout. It is important to distinguish from the mono-articu- lar form the local arthritis of the shoulder-joint which is characterized by pain, thickening of the capsule and of the ligaments, wasting of the shoulder-girdle muscles, and sometimes by neuritis. This is an affection which is quite distinct from arthritis deformans, and is, moreover, in a majority of cases curable. Treatment.—Arthritis deformans is an incurable disease. In many cases, after involvement of two or three joints, the progress is arrested. Too often it invades successively all the articulations, and in ten, fifteen, or twenty years the crippling becomes general and permanent. The best that can be hoped for is a gradual arrest. It is useless to saturate the patients with iodide of potassium, salicylates, or quinine. Arsenic seems to do good as a general tonic. The improvement may be marked if large doses of it are given. Iron should be used freely, if there is anaemia. An old recipe, called the “ Chelsea Pensioner,” contain- ing sulphur 1 j, cream of tartar | j, rhubarb 3 iv, gum guaiacum 3 j, honey § xvj (Sig.: § j night and morning), in warm wine, was formerly GOUT. 309 much used. Careful attention to the digestion, plenty of good food, and fresh air are important measures. Hydrotherapy, with carefully per- formed massage, is best for the alleviation of the pain, and may possibly restrain the progress of the affertion. In early cases local improvement and often great gain in the general strength follow a prolonged treat- ment at the hot mineral baths; but the practitioner should exercise care in recommending this mode of treatment, which is of very doubtful value when the disease is well established. I have repeatedly known cases to be rendered much worse by residence at these institutions. When good results, it is largely from change of scene and climate, and the careful regulation of the diet. The local treatment is of benefit in arresting the progress. When there are much heat and pain the limb should be at rest, cold compresses applied at night, the joints wrapped in oiled silk, and in the morning thoroughly massaged. It is surprising how much can be done by carefully applied friction to reduce the thickening, to promote absorption of effusion, and to restore mobility. Massage is also of special benefit in maintaining the nutrition of the muscles, which early tend to atrophy. In the case of the knees this mode of treatment will sometimes prevent the retraction of the muscles and the gradual flexion of the legs on the thighs. No benefit can be expected from electricity. VI. GOUT {Podagra). Definition.—A nutritional disorder, one factor of which is an excess- ive formation of uric acid, characterized clinically by attacks of acute arthritis, by the gradual deposition of urate of soda in and about the joints, and by the occurrence of irregular constitutional symptoms. Etiology.—The precise nature of the disturbance in metabolism is not known. There is probably defective oxidation of the foodstuffs, com- bined with imperfect elimination of the waste products of the body. Among important etiological factors in gout are the following: {a) Hereditary Hifluences.—Statistics show that in from fifty to sixty per cent of all cases the disease existed in the parents or grandparents. The transmission is supposed to be more marked from the male side. Cases with a strong hereditary taint have been known to develop before puberty. The disease has been seen even in infants at the breast. Males are more subject to the disease than females. It rarely develops before the thirtieth year, and in a large majority of the cases the first manifes- tations appear before the age of fifty. (b) Alcohol is the most potent factor in the etiology of the disease. Fermented liquors favor its develop- ment much more than distilled spirits, and it prevails most extensively in countries like England and Germany, which consume the most beer and ale. The lighter beers used in this country are much less liable to produce gout than the heavier English and Scotch ales. (c) Food plays a role equal in importance to that of alcohol. Overeating without active bodily exer- 310 CONSTITUTIONAL DISEASES. cise is regarded as a very special predisposing cause. A form of gouty dyspepsia has been described. A robust and active digestion is, however, often met in gouty persons. Gout is by no means confined to the rich. In England the combination of poor food, defective hygiene, and an excess- ive consumption of malt liquors makes the “ poor man’s gout ” a common affection. (d) Lead. Garrod has shown that workers in lead are specially prone to gout. In thirty per cent of the hospital cases the patients had been painters or workers in lead. The association is probably to be sought in the production by this poison of arterio-sclerosis and chronic nephritis. Something in addition is necessary, or certainly in this country we should more frequently see cases of the kind so common in London hospitals. Chronic lead-poisoning is here frequently associated with arterio-sclerosis and contracted kidneys, but acute arthritis is rare. Gouty deposits are, however, to be found in the big-toe joint and in the kidneys in these cases. The nature of gout is unknown. That there is faulty metabolism, as- sociated in some very special way with the chemistry of uric acid, we know, but nothing more. The remainder is theory, awaiting refutation or confirmation. The conditions of life favorable to the development of gout are thus well drawn by a careful student of the disease (G. W. Bal- four). After speaking of the increasing disposition to “ venosity ” of the blood as years advance with consequent diminished oxidation, he says: “ Add to this that in a state of civilization man is always supplied with a superfluity of foods and drinks, which the habits of society and the anxiety of his friends tempt him, if they do not actually compel him, to partake of four or even five times a day. “ Moreover, as the bubbling energy of youth fails, the mere pleasure of it no longer incites us to violent exertions; the needs of civilization do not require such exertions from us, and the many luxurious appliances of civilized life aid and abet the natural indolence that grows upon man as age advances, and largely preclude the need for any but the most trifling bodily exertion. “ Hence this less highly oxygenated blood is flooded with a redundancy of nutritive material far in excess of the requirements of the frame, which can neither be used up in any of its ordinary appropriations, nor fully oxidated in any other way, and so excreted. The general metabolism is thus impaired, every function of the body impeded, every secretion de- teriorated ; all the organs suffer. “ Thus we have the gouty diathesis fully developed ; a diathesis—habit of body—present in each one of us after middle life, and which modifies the organic metabolism of each one of us, both in health and in disease. The gouty diathesis is only a comprehensive term for all those changes in the character and composition of the blood induced by the evils of civiliza- tion—deficient exercise and excess of nutriment. . . . Gout, on the other hand, is the name given to all those modifications of our metabolism GOUT. 311 caused by the gouty diathesis, as well as to all the symptoms to which those modifications give rise.” The views regarding uric acid and its relation to gout are very numerous. Garrod holds that with lessened alkalinity of the blood there is an in- crease in the uric acid, due chiefly to diminished elimination. He attrib- utes the deposition of the urate of soda to the diminished alkalinity of the plasma, which is unable to hold it in solution. In an acute paroxysm there is an accumulation of the urates in the blood, and the inflammation is caused by their sudden deposit in crystalline form about the joint. Haig thinks that there is no increased formation of uric acid in gout, but that the blood is less alkaline than normal, and less able to hold the uric acid or its salts in solution. Roberts (Sir William), in the Croonian Lectures, 1892, has advanced a new view with reference to the chemistry of gout. The chalk-like deposits are formed of the crystalline biurate of sodium, and “ the arthritic inci- dents of gout may be said, not improperly, to be simply incidents pertain- ing to the precipitation of these crystals in the structures of the joints.” The factor of capital importance in the pathology of the disease relates to the chemical properties of this insoluble biurate. In the metabolism of the healthy body uric acid and the neutral and acid urates play a very minor part. They are in the form, in reality, of a quadriurate, which, unlike the biurate, is easily soluble in the blood-serum, and it is in this form that the uric acid circulates in the blood and is ex- creted by the kidneys. “ In perfect health the elimination of the quadri- urate proceeds with sufficient speed and completeness to prevent any undue detention or any accumulation of it in the blood; but in the gouty state this tranquil process is interrupted, either from deficient action of the kidneys or from excessive introduction of urates into the circulation, or from some other cause, and the quadriurate lingers unduly in the blood and accumulates therein. The detained quadriurate, circulating in a medium which is rich in sodium carbonate, gradually takes up an addi- tional atom of base, and is thereby transformed into biurate. This trans- formation alters the physiological problem. The uric acid, or, rather, a portion of it, circulates no longer as the more soluble and presumably easily secreted quadriurate, but as biurate, which is less soluble, and proba- bly also—either for that reason or because it is a compound foreign to the normal economy—less easy of removal by the kidneys. The biurate thus produced exists at first in the gelatinous modifications, but with the lapse of time and increasing accumulation it passes on into the almost insoluble crystalline condition, and then precipitation becomes imminent, or actu- ally takes place.” The precipitation is particularly apt to occur in certain parts of the body where circulation is feeble and the temperature low, and in regions where the lymph contains a relatively high percentage of sodium chloride, as in the synovial sheaths. 312 CONSTITUTIONAL DISEASES. Levison (Die Harnsaurediathese, Berlin, 1893) accepts the quadriurate theory of Roberts, adopting at the same time Horbaczewski’s views that the uric acid is related especially to the nucleins of the body, and is derived in great part from the destruction of the white blood-corpuscles, the excre- tion increasing pari passu with the intensity of the leucocytosis. While this is true in many diseases, as in pneumonia, Richter, in a recent careful study, has shown that there are important exceptions. Ebstein thinks that the first change is a nutritive-tissue disturbance, which leads to necrosis, and in the necrotic areas the urates are deposited —a view which has been modified by von Noorden, who holds that a spe- cial ferment leads to the tissue change, to which the deposit of the urates is secondary. Cullen held that gout was primarily an affection of the nervous system. On this nervous theory of gout there is a basic, arthritic stock—a diathetic habit, of which gout and rheumatism are two distinct branches. The gouty diathesis is expressed in (a) a neurosis of the nerve-centres, which may be inherited or acquired ; and (b) “ a peculiar incapacity for normal elaboration within the whole body, not merely in the liver or in one or two organs, of food, whereby uric acid is formed at times in excess, or is in- capable of being duly transformed into more soluble and less noxious products ” (Duckworth). The explosive neuroses and the influence of de- pressing circumstances, physical or mental, point strongly to the part played by the nervous system in the disease. Morbid Anatomy.—The blood shows an excess of uric acid, as proved originally by Garrod. The uric acid may be obtained from the blood-serum by the method known as uric-acid thread experiment, or from the serum obtained from a blister. To 3 ij of serum add Ttyv-vj of acetic acid in a watch-glass. A thread immersed in this will show in a few hours an incrustation of uric acid. This is not, however, peculiar to gout, but occurs in leukmmia and chlorosis. The important changes are in the articular tissues. The first joint of the great toe is most frequently in- volved ; then the ankles, knees, and the small joints of the hands and wrists. The deposits may be in all the joints of the lower limbs and absent from those of the upper limbs (Norman Moore). If death takes place during an acute paroxysm, there are signs of inflammation, hyperas- mia, swelling of the ligamentous tissues, and of effusion into the joint. The primary change, according to Ebstein, is a local necrosis, due to the presence of an excess of urates in the blood. This is seen in the cartilage and other articular tissues in which the nutritional currents are slow. In these areas of coagulation necrosis the reaction is always acid and the neutral urates are deposited in crystalline form, as insoluble acid urates. The articular cartilages are first involved. The gouty deposit may be uni- form, or in small areas. Though it looks superficial, the deposit is in- variably interstitial and covered by a thin lamina of cartilage. The de- posit is thickest at the part most distant from the circulation. The liga- GOUT. 313 ments and fibro-cartilage ultimately become involved and are infiltrated with chalky deposits, the so-called chalk-stones, or tophi. These are usu- ally covered by skin; but in some cases, particularly in the metacarpo- phalangeal articulations, this ulcerates and the chalk-stones appear ex- ternally. The synovial fluid may also contain crystals. In very long- standing cases, owing to an excessive deposit, the joint becomes immobile. The marginal outgrowths in gouty arthritis are true exostoses (Wynne). The cartilage of the ear may contain tophi, which are seen as whitish nodules at the margin of the helix. The cartilages of the nose, eyelids, and larynx are less frequently affected. Of changes in the internal organs, those in the renal and vascular sys- tems are the most important. The kidney changes believed to be charac- teristic of gout are: (a) A deposit of urates chiefly in the region of the papillae. This is a less common change, however, than is usually sup- posed. Norman Moore found it in only twelve out of eighty cases. The apices of the pyramids show lines of whitish deposit. On microscopical examination the material is seen to be largely in the intertubular tissue. In some instances, however, the deposit seems to be both in the tissue and in the tubules. Ebstein, in his monograph, has described and figured areas of necrosis in both cortex and medulla, in the interior of which were crystalline deposits of urate of soda. The presence of these uratic con- cretions at the apices of the pyramids is not a positive indication of gout. They are not infrequent in this country, in which gout is rare, (b) An interstitial nephritis, either the ordinary “ contracted kidney ” or the arterio-sclerotic form, neither of which are in any way distinctive. It is not possible to say in a given case that the condition has been due to gout unless marked evidences of the disease coexist. The metatarso-phalangeal joint of the big toe should be carefully ex- amined, as it may show typical lesions of gout without any outward token of arthritis. Arterio-sclerosis is a very constant lesion. With it the heart, particu- larly the left ventricle, is found hypertrophied. According to some au- thors, concretions of urate of soda may occur on the valves. Changes in the respiratory system are rare. Deposits have been found in the vocal cords, and uric-acid crystals have been met in the sputa of a gouty patient (J. W. Moore). Emphysema is a very constant condition in old cases. Symptoms.—Gout is usually divided into acute, chronic, and irregu- lar forms. Acute Gout.—Premonitory symptoms are common—twinges of pain in the small joints of the hands or feet, nocturnal restlessness, irrita- bility of temper, and dyspepsia. The urine is acid, scanty, and high- colored. It deposits urates on cooling, and there may be, according to Garrod, transient albuminuria. There may be traces of sugar (gouty gly- cosuria). Before an attack the output of uric acid is low and is also di- 314 CONSTITUTIONAL DISEASES. minished in the early part of the paroxysm. In some instances the throat is sore, and there may be asthmatic attacks. The attack sets in usually in the early morning hours. The patient is aroused by a severe pain in the metatarso-phalangeal articulation of the big toe, and more commonly on the right than on the left side. The pain is agonizing, the joint swells rapidly, and becomes hot, tense, and shiny. The sensitiveness is extreme, and the patient describes the pain as if the joint were being pressed in a vise. There is fever, and the temperature may rise to 102° or 103°. Toward morning the severity of the symptoms subsides, and, although the joint remains swollen, the day may be passed in comparative comfort. The symptoms recur the next night, and the fit, as it is called, usually lasts for from five to eight days, the severity of the symptoms gradually abating. Occasionally other joints are involved, particularly the big toe of the op- posite foot. The inflammation, however intense, never goes on to suppu- ration. With the subsidence of the swelling the skin desquamates. After the attack the general health may be much improved. Recurrences are frequent. Some patients have three or four attacks in a year; others at longer intervals. Lecorche has shown that the amount of uric acid is reduced prior to an attack, diminishes during the first two days, then in- creases very much and falls toward the close. The term retrocedent or suppressed gout is applied to serious internal symptoms, coincident with a rapid. disappearance or improvement of the local signs. Very remarkable manifestations may occur under these cir- cumstances. The patient may have severe gastro-intestinal symptoms— pain, vomiting, diarrhoea, and great depression—and death may occur during such an attack. Or there may be cardiac manifestations—dyspnoea, pain, and irregular action of the heart. In some instances in which the gout is said to attack the heart, an acute pericarditis develops and proves fatal. So, too, there may be marked cerebral manifestations—delirium and coma, and even apoplexy—but in a majority of these instances the symptoms are, in all probability, uraemic. Acute gout is a rare disease in America, particularly in hospital prac- tice. Among the well-to-do, and even among club-men—a class particu- larly liable—it is infrequent, in comparison with the prevalence in the corresponding classes in England. Men in large family practice may pass a year or more without seeing a case. It has become more common, however, during the past twenty-five years. Chronic Gout.—With increased frequency in the attacks, the articular symptoms persist for a longer time, and gradually many joints become affected. Deposits of urates take place, at first in the articular cartilages and then in the ligaments and capsular tissues; so that in the course of years the joints become swollen, irregular, and deformed. The feet are usually first affected, then the hands. In severe cases there may be exten- sive concretions about the elbows and knees and along the tendons and in the bursas. The tophi appear in the ears. Finally, a unique clinical pic- GOUT. 315 ture is produced which cannot be mistaken for any other affection. The skin over the tophi may rupture or ulcerate, and about the knuckles the chalk-stones may be freely exposed. Patients with chronic gout are usu- ally dyspeptic, often of a sallow complexion, and show signs of arterio- sclerosis. The pulse tension is increased, the vessels are stiff, and the left ventricle is hypertrophied. The urine is increased in amount, is of low specific gravity, and usually contains a slight amount of albumin, with a few hyaline casts. Intercurrent attacks of acute polyarthritis may develop, in which the joints become inflamed, and the temperature ranges from 101° to 103° ; but even with slight fever the condition is apt to be dan- gerous, as ursemia, pleurisy, pericarditis or, in some instances, meningitis may supervene. Patients with chronic gout may show remarkable mental and even bodily vigor. Certain of the most distinguished members of our profession have been terrible sufferers from this disease, notably the elder Scaliger, Jerome Cardan, and Sydenham, whose statement that “ more wise men than fools are victims of the affection ” still holds good. Irregular Gout.—This is a motley, ill-defined group of symptoms, manifestations of a condition of disordered nutrition, to which the terms gouty diathesis or lithcemic state have been given. Cases are seen in mem- bers of gouty families, who may never themselves have suffered from the acute disease, and in persons who have lived not wisely but too well, who have eaten and drunk largely, lived sedentary lives, and yet have been for- tunate enough to escape an acute attack. It is interesting to note the various manifestations of the disease in a family with marked hereditary disposition. The daughters often escape, while one son may have gouty attacks of great severity, even though he lives a temperate life and tries in every way to avoid the conditions favoring the disorder. Another son has, perhaps, only the irregular manifestations and never the acute articu- lar affection. While the irregular features are perhaps more often met with in the hereditary affection, they are by no means infrequent in per- sons who appear to have acquired the disease. The tendency in some families is to call every affection gouty. Even infantile complaints, such as scald-head, naso-pharyngeal vegetations, and enuresis, are often re- garded, without sufficient grounds, I believe, as evidences of the family ailment. Among the commonest manifestations of irregular gout are the following : (a) Cutaneous Eruptions.—Garrod and others have called special at- tention to the frequent association of eczema with the gouty habit. The French in particular insist upon the special liability of gouty persons to skin affections, the arthritides, as they call them. (b) Gastro-intestinal Disorders.—Attacks of what is termed bilious- ness, in which the tongue is furred, the breath foul, the bowels consti- pated, and the action of the liver torpid, are not uncommon in gouty persons. A gouty parotitis is described. (c) Cardio-vascular Symptoms.—With the lithaemia, arterio-sclerosis 316 CONSTITUTIONAL DISEASES. is frequently associated. The blood tension is persistently high, the vessel walls become stiff, and cardiac and renal changes gradually develop. In this condition the manifestations may be renal, as when the albuminuria becomes more marked, or dropsical symptoms supervene. The manifesta- tions may be cardiac, when the hypertrophy of the left ventricle fails and there are palpitation, irregular action, and ultimately a condition of asys- tole. Or, finally, the manifestations may be vascular, and thrombosis of the coronary arteries may cause sudden death. Aneurism may develop and prove fatal, or, as most frequently happens, a blood-vessel gives way in the brain, and the patient dies of apoplexy. It makes but little differ- ence whether we regard this condition as primarily an arterio-sclerosis, or as a gouty nephritis; the point to be remembered is that the nutritional dis- order with which an excess of uric acid is associated induces in time in- creased tension, arterio-sclerosis, chronic interstitial nephritis, and changes in the myocardium. Pericarditis is not infrequent in connection with the granular kidney met with in gout. (d) Nervous Manifestations.—Headache is frequent. Ilaig has called special attention to the association of this symptom with retention of uric acid in the system. Neuralgias are not uncommon ; sciatica and paraes- thesias may develop. A common gouty manifestation, upon which Duck- worth has laid stress, is the occurrence of hot or itching feet at night. I notice in Plutarch that Strabo called this symptom “ the lisping of the gout.” Cramps in the legs may also be very troublesome. Hutchinson has called attention to hot and itching eyeballs as a frequent sign of masked gout. More serious cerebral manifestations result from a condi- tion of arterio-sclerosis. Apoplexy is a common termination of gout. Meningitis may develop, usually basilar. (e) Urinary Disorders.—The urine is highly acid and high-colored, and may deposit on standing crystals of lithie acid. Transient and tem- porary increase in this ingredient cannot be regarded as serious. In many cases of chronic gout the amount may be diminished, and only increased at certain periods, forming the so-called uric-acid showers. E. Pfeiffer’s investigations on the urine in gout are of interest, and are believed to have some diagnostic significance : “ On passing 100 c. c. of the day’s urine through a filter charged with from 02 to 0-5 grains of pure uric acid, there is less uric acid (precipitable by hydrochloric acid) in the fil- trate than in the unfiltered urine. The difference is represented by what he calls ‘ easily separable ’ or ‘ free ’ uric acid. Applying this test to gouty urine, he found (1) that during and just after an acute attack there is none, or almost none, of this ‘easily separable’ uric acid present; and (2) that in the intervals between the attacks and in chronic gout nearly all of the uric acid of the urine (precipitable by HC1) is of this‘easily separable’ variety. It is to be noted that healthy urine loses by filtration through 02 grains of uric acid rarely more than 35 per cent of the amount which can be precipitated by hydrochloric acid.” Sugar is found inter- GOUT. 317 mittently in the urine of gouty persons—gouty glycosuria. It may pass into true diabetes, but is usually very amenable to treatment. Oxaluria may also be present. Gouty persons are specially prone to calculi, Jerome Cardan to the contrary, who reckoned freedom from stone among the chief of the dona podagra. Minute quantities of albumin are very common in persons of gouty dyscrasia, and, when the renal changes are well estab- lished, tube casts. Urethritis, accompanied with a well-marked purulent discharge, may develop, so it is stated, usually at the end of an attack. It may occur spontaneously, or follow a pure connection. (f) Pulmonary Disorders.—There are no characteristic changes, but, as Greenhow has pointed out, chronic bronchitis occurs with great fre- quency in persons of a gouty habit. (g) Of eye affections, iritis, glaucoma, haemorrhagic retinitis, and sup- purative panopthalmitis have been described. Treatment.—Hygienic.—Individuals who have inherited a tendency to gout, or who have shown any manifestations of it, should live temper- ately, abstain from alcohol, and eat moderately. An open-air life, with plenty of exercise and regular hours, does much to counteract an inborn tendency to the disease. The skin should be kept active : if the patient is robust, by the morning cold bath with friction after it; but if he is weak or debilitated the evening warm bath should be substituted. An occa- sional Turkish bath with active shampooing is very advantageous. The patient should dress warmly, avoid rapid alterations in temperature, and be careful not to have the skin suddenly chilled. Dietetic.—With few exceptions, persons over forty eat too much, and the first injunction to a gouty person is to keep his appetite within reason- able bounds, to eat at stated hours, and to take plenty of time at his meals. In the matter of food, quantity is a factor of more importance than qual- ity with many gouty persons. As Sir William Roberts well says, “ Nowhere perhaps is it more necessary than in gout to consider the man as well as the ailment, and very often more the man than the ailment.” Very remarkable differences of opinion exist as to the most suitable diet in this disease, some urging warmly a vegetable diet, others allowing a very liberal amount of meat. On the one hand, the author just quoted says: “ The most trustworthy experiments indicate that fat, starch, and sugar have not the least direct influence on the production of uric acid; but as the free consumption of these articles naturally operates to restrict the intake of the nitrogenous food, their use has indirectly the effect of diminishing the average production of uric acid.” On the other hand, W. H. Draper says: “ The conversion of azotized food is more complete with a minimum of carbohydrates than it is with an excess of them; in other words, one of the best means of avoiding the accumulation of lithic acid in the blood is to diminish the carbohydrates rather than the azotized foods.” The weight of opinion leans to the use of a modified nitrogenous diet, without excess in starchy and saccharine articles of food. Fresh vege- 318 CONSTITUTIONAL DISEASES. tables and fruits may be used freely, but among the latter strawberries and bananas should be avoided. Ebstein urges strongly the use of fat in the form of good fresh butter, from to 3£ ounces in the day. He says that stout gouty subjects not only do not increase in weight with plenty of fat in the food, but that they actually become thin and the general condition improves very much. Hot bread of all sorts and the various articles of food prepared from Indian corn should, as a rule, be avoided. Roberts advises gouty patients to re- strict as far as practicable the use of common salt with their meals, since the sodium biurate very readily crystallizes out in tissues with a high per- centage of sodium salts. In this matter of diet each individual case must receive separate con- sideration. There are very few conditions in the gouty in which stimulants of any sort are required. Whenever indicated, whisky will be found per- haps the most serviceable. While all are injurious to these patients, some are much more so than others, particularly malted liquors, champagne, port, and a very large proportion of all the light wines. Mineral Waters.—All forms may be said to be beneficial in gout, as the main element is the water, and the ingredients are usually indiffer- ent. Much of the humbuggery in the profession still lingers about min- eral waters, more particularly about the so-called lithia waters. There is not the slightest evidence that the carbonate of lithium has any influence whatever in promoting the solubility of uric acid. Fortunately, they all contain the essential ingredient, and one perhaps cannot overlook, even in the gouty, the influence of suggestion. The water should be drunk when the stomach is empty. Three, four, or five glasses a day suffice, and in the early morning it may be taken hot. The question of the utility of alkalies in the treatment of gout is closely connected with this subject of mineral waters. This deep-rooted belief in the profession was rudely shaken a few years ago by Sir William Roberts, who claims to have shown conclusively that alkalescence as such has no influence whatever on the sodium biurate. The sodium salts are believed by this author to be particularly harmful. In Yeo’s Manual of Clinical Treatment the efficacy of the alkalies is maintained; and as he well says, in spite of all the theoretical denunciation of the use of the sodium salts in gout, the gouty from all parts of the world flock to those very Continental springs in which these salts are most predominant. Of the mineral springs best suited for the gouty may be mentioned, in this country, those of Saratoga, Bedford, and the White Sulphur; Buxton and Bath, in England; in France, Aix-les-Bains and Contrex6- ville; and in Germany, Carlsbad, Wildbad, and Homburg. The efficacy in reality is in the waters, in the way they are taken, on an empty stomach and in large quantities; and, as every one knows, the important accessories in the modified diet, proper hours, regular GOUT. 319 exercise, with baths, douches, etc., play a very important role in the “ cure.” Medicinal Treatment.—In an acute attack the limb should be elevated and the affected joint wrapped in cotton-wool. Warm fomentations, or Fuller’s lotion, may be used. Steaming the joint is sometimes beneficial. A brisk mercurial purge is always advantageous at the outset. The wine or tincture of colchicum, in doses of twenty to thirty minims, may be given every four hours in combination with the citrate of potash or the citrate of lithium. The action of the colchicum should be carefully watched. It has, in a majority of the cases, a powerful influence over the symptoms—relieving the pain, and reducing, sometimes with great rapidity, the swelling and redness. It should be promptly stopped so soon as it has relieved the pain. In cases in which the pain and sleep- lessness are distressing and do not yield to colchicum, morphia is neces- sary. The patient should be placed on a diet chiefly of milk and barley- water, but if there is any debility, strong broths may be given, or eggs. It is occasionally necessary to give small quantities of stimulants. During convalescence meats and fish and game may be taken, and gradually the patient may resume the diet previously laid down. In some of the subacute intercurrent attacks of arthritis in old, de- formed joints the sodium salicylate is occasionally useful, but its adminis- tration must be watched in cases of cardiac and renal insufficiency. It is also much advocated by Haig in the uric-acid habit. The chronic and irregular forms of gout are best treated by the dietetic and hygienic measures already referred to. Iodide of potassium is some- times useful, and preparations of guaiacum, quinine, and the bitter tonics combined with alkalies are undoubtedly of benefit. Piperazin has been much lauded as an efficient aid in the solution of uric acid. The clinical results, however, are very discordant. It may be employed in doses of from fifteen to thirty grains in the day, and is conveniently given in aerated water containing five grains to the tum- blerful. 320 CONSTITUTIONAL DISEASES. VII. DIABETES MELLITUS. Definition.—A disorder of nutrition, in which sugar accumulates in the blood and is excreted in the urine, the daily amount of which is greatly increased. Etiology.—Hereditary influences play an important role, and cases are on record of its occurrence in many members of the same family. There are instances of the coexistence of the disease in husband and wife. Men are more frequently affected than women. It is a disease of adult life; a majority of the cases occur from the third to the sixtli decade. It is rare in childhood, but cases are on record in children under one year of age. Persons of a neurotic temperament are often affected. It is a disease of the higher classes. Hebrews seem especially prone to it; one fourth of Frerichs’ patients were of the Semitic race. In a considerable proportion of the cases of diabetes the subjects have been excessively fat at the beginning of, or prior to, the onset of the disease. A slight trace of sugar is not very uncommon in obese persons. This so-called lipogenic glycosuria is not of grave significance, and is only occasionally followed by true diabetes. On the other hand, as von Noorden has shown, there may be a “ diabetogenous obesity,” in which diabetes and obesity develop in early life, and these cases are very unfavorable. There are instances on record in which obesity with diabetes has occurred in three genera- tions. Diabetes is more common in cities than in country districts. Gout, syphilis, and malaria have been regarded as predisposing causes. Mental shock, severe nervous strain, and worry precede many cases. The combi- nation of intense application to business, over-indulgence in food and drink, with a sedentary l'fe, seem particularly prone to induce the disease. It may set in during pregnancy, and in rare instances may only occur at this period. Injury to or disease of the spinal cord or brain has been followed by diabetes. In the carefully analyzed cases of Frerichs there were thirty instances of organic disease of these parts. The medulla is not always involved. In only four of his cases, which showed organic dis- ease, was there sclerosis or other anomaly of this part. An irritative lesion of Bernard’s diabetic centre in the medulla is an occasional cause. I saw with Riess, at the Friedrichshain, Berlin, a woman who had anomalous cerebral symptoms and diabetes, and in whom there was found post mor- tem a cysticercus in the fourth ventricle. The disease has occasionally followed the infectious fevers. A few cases have followed injury without involvement of the brain or cord. In comparison with European countries diabetes is a rare disease in America. The last census gave only 2S per one hundred thousand of DIABETES MELL1TUS. 321 population, against a ratio of from five to nine in the former. In this region the incidence of the disease may be gathered from the fact that among thirty-five thousand patients under treatment at the Johns Hop- kins Hospital and Dispensary there were only ten cases. We are ignorant of the nature of the disease. Normally the carbo- hydrates taken with the food are stored in the liver and in the muscles as glycogen, and then utilized as needed by the system. Glycogen can also be formed from the proteids of the food, and under certain circumstances sugar may be directly formed from the body proteids. Whenever the sugar in the systemic blood exceeds a definite amount (about 02 per cent) it is discharged by the kidneys, producing glycosuria. Theoretically dia- betes may be supposed to be induced by: (a) The ingestion of a larger quantity of carbohydrates and peptones than can be warehoused, so to speak, in the liver as glycogen, so that part has to pass over into the hepatic blood. Some of the instances of lipogenic or dietetic glycosuria are of this nature. (b) Disturbances of the liver function : (1) Changes in the circula- tion under nervous influences. Puncture of the medulla, lesions of the cord, and central irritation of various kinds are followed by glycosuria, which is attributed to a vaso-motor paralysis (more rapid blood-flow) in- duced by these causes. On this view the disease is a neurosis. (2) In- stability of the glycogen, owing either to imperfect formation or to con- ditions of the cells which render it less stable. Phloridzin and other substances which cause diabetes very probably act in this way, though phloridzin is said to act primarily in the renal epithelium, destroying its power of keeping back the sugar. (c) Defective assimilation of the glucose in the system. How and under what normal circumstances the sugar is utilized we do not yet know. Theoretically faulty metabolism would explain the condition. Interesting observations have of late made it probable that the pancreas may in some cases be the seat of the trouble. Lesions of this organ are met with in about 50 per cent of the cases (Ilansemann). Yon Mering and Minkowski have shown that extirpation of the gland in dogs is fol- lowed by glycosuria, but, if a small portion remains, sugar does not appear in the urine, facts which have been confirmed by Lepine and others. The pancreas, on this view, has, like the liver, a double secretion—an external, which is poured into the intestines, and an internal, which passes into the blood. This latter is supposed to be of the nature of a ferment, in the presence of which alone the normal assimilative processes can take place with the glycogen. Disease of the pancreas causes diabetes by preventing the formation of the glycolytic ferment. Even when, as in a majority of instances of diabetes, the organ is apparently normal, a func- tional trouble may disturb the formation of this ferment. The fact that if a small portion of the gland is left, in the experiments upon dogs, dia- betes does not occur, is analogous to the remarkable circumstance that a 322 CONSTITUTIONAL DISEASES. small fragment of the thyroid is sufficient to prevent the development of artificial myxcedema. Morbid Anatomy.—Saundby* has recently analyzed the changes which occur in this disease. The nervous system shows no constant lesions. In a few instances there have been tumors or sclerosis in the medulla, or, as in the case above mentioned, a cysticercus has pressed on the floor. Cysts have been met with in the white matter of the cerebrum and perivascular changes have been described. Glycogen has been found in the spinal cord. In the peripheral nervous system there are instances in which tumors have been found pressing on the vagus. A secondary multiple neuritis is not rare, and to it the so-called diabetic tabes is probably due. It. T. Williamson has found changes in the posterior columns of the cord similar to those which occur in pernicious anaemia. In the sympathetic system the ganglia have been enlarged and in some instances sclerosed, but there is nothing peculiar in these changes. The blood may contain as high as 0-4 per cent of sugar instead of 0T5 per cent. The plasma is usually loaded with fat, the molecules of which may be seen as fine particles. When drawn, a white creamy layer coats the coagulum, and there may be lipaemic clots in the small vessels. There are no special changes in the red or white corpuscles. Gabritschewsky has shown that the polynuclear leucocytes in diabetes contain glycogen. Glycogen can occur in normal blood, but it is here extra-cellular. It has been also found in the polynuclear leucocytes in leukaemia. The heart is hyper- trophied in some cases. Endocarditis is very rare. Arterio-sclerosis is common. The lungs show important changes. Acute broncho-pneu- monia or croupous pneumonia (either of which may terminate in gan- grene) and tuberculosis are common. The so-called diabetic phthisis is always tuberculous and results from a caseating broncho-pneumonia. In rare cases there is a chronic interstitial pneumonia, non-tuberculous. Fat embolism of the pulmonary vessels has been described in connection with diabetic coma. The liver is usually enlarged, fatty degeneration is common, and French writers have described a form of cirrhosis. Letulle, who has de- scribed remarkable examples of this so-called diabetic cirrhosis—the cir- rhose pigmentaire—thinks the change is due to abnormal destruction of the blood-cells. It may be associated with bronzing of the skin. The pancreas, as pointed out by Lancereaux, shows important changes. IIansemann,f in forty cases of pancreatic disease with diabetes, found sim- ple atrophy in thirty-six ; and he gives a table of seventy-two cases from the literature. * Bradshaw Lecture, Royal College of Physicians of London, 1890; and Lectures on Diabetes, E. B. Treat, New York, 1891. f Zeitschrift f. klin. Med., Bd. 26. DIABETES MELLITUS. 323 A patient of W. T. Bull died of diabetes after extirpation of the pan- creas. In some instances there is a pigmentary cirrhosis analogous to that which occurs in the liver, and this induration seems to be an important change. Cancer and calculi have been met with; and Longstreth found, in one instance, cystic disease of the organ. Fat necrosis of the pancreas has also been found. Dilatation of the stomach is common. The kidneys show- usually a diffuse nephritis with fatty degeneration. A hyaline change occurs in the tubal epithelium, particularly of the de- scending limb of the loop of Henle, and also in the capillary vessels of the tufts. Symptoms.—Acute and chronic forms are recognized, but there is no essential difference between them, except that in the former the pa- tients are younger, the course more rapid, and the emaciation more marked. It is also possible to divide the cases into (1) lipogenic or dietetic, which includes the transient glycosuria of stout persons; (2) neurotic, due to injuries or functional disorders of the nervous system; and (3) pancreatic, in which there is a lesion of the pancreas. It is, however, by no means easy to discriminate in all cases between these forms. Of late attempts have been made to separate a clinical variety analogous to experimental pancreatic diabetes. Hirschfeld, from Guttmann’s clinic, has described cases running a rapid and severe course usually in young and middle-aged persons. The polyuria is less common or even absent, and there is a strik- ing defect in the assimilation of the albuminoids and fats, as shown by the examination of the fasces and urine. In four of seven cases autopsies were made and the pancreas was found atrophic in two, cancerous in one, and in the fourth exceedingly soft. The onset of the disease is gradual and either frequent micturition or inordinate thirst first attracts attention. Very rarely it sets in rapidly, after a sudden emotion, an injury, or after a severe chill. When fully established the disease is characterized by great thirst, the passage of large quantities of saccharine urine, a voracious appetite, and, as a rule, pro- gressive emaciation. The Urine.—The amount varies from six or eight pints in mild cases to thirty or forty pints in very severe cases. In rare instances the quan- tity of urine is not much increased. Under strict diet the amount is much lessened, and in intercurrent febrile affections it may be reduced to normal. The specific gravity is high, ranging from 1-025 to 1-045; but in exceptional cases it may be low, 1-013 to 1-020. The urine is pale in color, almost like water, and has a sweetish odor and a distinctly sweetish taste. The reaction is acid. Sugar is present in varying amounts. In mild cases it does not exceed one and a half or two per cent, but it may reach from five to ten per cent. The total amount excreted in the twenty- four hours may range from ten to twenty ounces, and in exceptional cases from one to two pounds. The following are the most satisfactory tests : 324 CONSTITUTIONAL DISEASES. Fehling's Test.—The solution consists of sulphate of copper (grs. 90£), neutral tartrate of potash (grs. 364), solution of caustic soda (fl. ozs. 4), and distilled water to make up six ounces. Put a drachm of this in a test- tube and boil (to test the reagent); add an equal quantity of urine and boil again, when, if sugar is present, the yellow suboxide of copper is thrown down. The solution must be freshly prepared, as it is apt to decompose. Trommer's Test.—To a drachm of urine in a test-tube add a few drops of a dilute sulphate-of-copper solution and then as much liquor potassce as urine. On boiling, the copper is reduced if sugar be present, forming the yellow or orange-red suboxide. There are certain fallacies in the cop- per tests. Thus, a substance called glycuronic acid is met with in the urine after the use of certain drugs—chloral, phenacetin, morphia, chloro- form, etc.—which reduces copper. Glycosuric acid or alcapton may also prove a source of error (see page 777). Fermentation Test.—This is free from all doubt. Place a small frag- ment of yeast in a test-tube full of urine, which is then inverted over a glass vessel containing the same fluid. If sugar is present, fermentation goes on with the formation of carbon dioxide, which accumulates in the upper part of the tube and gradually expels the urine. In doubtful cases a control test should always be used. Of other ingredients in the urine, the urea is increased, the uric acid does not show special changes, and the phosphates may be greatly in ex- cess. Ralfe has described a great increase in the phosphates, and in some of these cases, with an excessive excretion, the symptoms may be very similar to those of diabetes, though the sugar may not be constantly pres- ent. The term phosphatic diabetes has sometimes been applied to them. Acetone and acetone-forming substances are not infrequently present. Le Nobel’s test for acetone is as follows: “ Pour an ounce of urine into a urine glass; add a drachm or two of nitro-prusside of sodium (five grains to one ounce) and a few drops of strong liquor ammonias. After standing a few minutes a rose-violet color is developed, which, if much acetone is present, may require diluting with water in order to bring out the bril- liancy of its color ” (Saundby). Glycogen has also been described as present in the urine. Albumin is not infrequent. It occurred in nearly thirty-seven per cent of the examinations made by Lippman at Carlsbad. Pneumaturia, the formation of gas in the urine, due to fermentative processes in the bladder, is occasionally met with. Fat may be passed in the urine in the form of a fine emulsion (lipuria). Among the general symptoms of the disease thirst is one of the most distressing. A very large amount of water is required to keep the sugar in solution and for its excretion in the urine. The amount of water con- sumed will be found to bear a definite ratio to the quantity excreted. In- stances, however, are not uncommon of pronounced diabetes in which the DIABETES MELLITUS. 325 thirst is not excessive; but in such cases the amount of urine passed is never large. The thirst is most intense an hour or two after meals. As a rule, the digestion is good and the appetite inordinate. A story is told of a man with diabetes who was paid to stay away from a certain restau- rant at which dinners were given at fixed prices. It is sometimes impos- sible to satiate the ravenous appetite of a diabetic patient. The condition is sometimes termed bulimia or polyphagia. The tongue is usually dry, red, and glazed, and the saliva scanty. The gums may become swollen, and in the later stages aphthous stomatitis is common. Constipation is the rule. In spite of the enormous amount of food consumed a patient may be- come rapidly emaciated. This loss of flesh bears some ratio to the poly- uria, and when, under suitable diet, the sugar is reduced, the patient may quickly gain in flesh. The skin is dry and harsh, and perspirations rarely occur, except when phthisis coexists. Drenching sweats have been known to alternate with excessive polyuria. The temperature is often subnor- mal ; the pulse is usually frequent, and the tension increased. Many dia- betics, however, do not show marked emaciation. Patients past the mid- dle period of life may have the disease for years without much disturbance of the health, and may remain well nourished. These are the cases of the diabete gras in contradistinction to diabete maigre. Diabetes in Children.—Recently Stern has analyzed 117 cases in chil- dren. They usually occur among the better classes. Six were under one year of age. Hereditary influences were marked. The course of the dis- ease is, as a rule, much more rapid than in adults. The shortest duration was two days. In seven cases it did not last a month. One case is men- tioned of a child apparently born with the glycosuria, who recovered in eight months. Complications.—(a) Cutaneous.—Boils and carbuncles are extreme- ly common. Eczema is also met with and at times an intolerable itching. In women the irritation of the urine may cause the most intense pruritus pudendi, and in men a balanitis. Rarer affections are xanthoma and pur- pura. Gangrene is not uncommon. William Hunt has analyzed 64 cases. In 50 the localities were as follows : Feet and legs, 37; thigh and buttock, 2; nucha, 2 ; external genitals, 1; lungs, 3 ; fingers, 3 ; back, 1; eyes, 1. Perforating ulcer of the foot may occur. (b) Pulmonary.—The patients are not infrequently carried off by acute pneumonia, which may be lobar or lobular. Gangrene is very apt to supervene, but the breath does not necessarily have the foul odor of ordi- nary gangrene. Tuberculous bronclio-pneumonia is very common. It was formerly thought, from its rapid course and the limitation of the disease to the lung, that this was not a true tuberculous affection; but in the cases which have come under my notice bacilli have been present, and the condition is now generally regarded as tuberculous. 326 CONSTITUTIONAL DISEASES. (c) Renal.—Albuminuria is a tolerably frequent complication. The amount varies greatly, and, when slight, does not seem to be of much mo- ment. It is sometimes associated with arterio-sclerosis. It occasionally precedes the development of the diabetic coma. Occasionally cystitis develops. (d) Nervous System.—(1) Diabetic coma, first studied by Kussmaul, is the most serious complication of the disease, and carries off a considerable proportion of all cases, particularly in the young. It may occur when diabetes is unsuspected, as in two cases recently reported by Francis Minot. Frerichs recognized three groups of cases: (a) Those in which after exertion the patients were suddenly attacked with weakness, syncope, somnolence, and gradually deepening unconsciousness ; death occurring in a few hours. (/3) Cases with preliminary gastric disturbance, such as nausea and vomiting, or some local affection, as pharyngitis, phlegmon, or a pulmonary complication. In such cases the attack begins with head- ache, delirium, great distress, and dyspnoea, affecting both inspiration and expiration, a condition called by Kussmaul air-hunger. Cyanosis may or may not be present. If it is, the pulse becomes rapid and weak and the patient gradually sinks into coma; the attack lasting from one to five days. There may be a very heavy, sweetish odor of the breath, due to the presence of acetone, (y) Cases in which, without any previous dyspnoea or distress, the patient is attacked with headache and a feeling of intoxi- cation, and rapidly falls into a deep and fatal coma. There has been much dispute as to the nature of these symptoms, but our knowledge of the disease is not yet sufficiently advanced to give a rational explanation. The character of the attack and the similarity, in many instances, to uraemia would indicate that it depended upon some toxic agent in the blood. The theory most commonly held, that this material is acetone, is supported by the presence of the acetone reaction in the urine and its odor in the breath. Stadelmann believes that the con- dition is not acetonsemia, but that the poisonous agent is an intermediate product between the sugar and acetone, an oxy-butyric acid. Saunders and Hamilton have described cases in which the lung capil- laries were blocked with fat. They attributed the symptoms to fat embo- lism, but there are many cases on record in which this condition was not found, though lipremia is by no means infrequent in diabetes. The symptoms have been attributed to uraemia, and albuminuria fre- quently precedes or accompanies the attack. (2) Peripheral Neuritis.—The neuralgias, numbness, and tingling, which are not uncommon symptoms in diabetes, are probably minor neu- ritic manifestations. Diabetic Tabes (so called).—This is a peripheral neuritis, characterized by lightning pains in the legs, loss of knee-jerk—which may occur with- out the other symptoms—and a loss of power in the extensors of the feet. The gait is the characteristic steppage, as in arsenical, alcoholic, and other DIABETES MELLITUS. 327 forms of neuritic paralysis. Charcot states that there may be atrophy of the optic nerves. Changes in the posterior columns of the cord have been found. Diabetic Paraplegia.—This is also in all probability due to neuritis. There are cases in which power has been lost in both arms and legs. (3) Mental Symptoms.—The patients are often morose, and there is a strong tendency to become hypochondriacal. General paralysis has been known to develop. Some patients display an extraordinary degree of rest- lessness and anxiety. (4) Special Senses.—Cataract is liable to occur, and may develop with rapidity in young persons. Diabetic retinitis closely resembles the albu- minuric form. Haemorrhages are common. Sudden amaurosis, similar to that which occurs in uraemia, may occur. Paralysis of the muscles of accommodation may be present; and lastly atrophy of the optic nerves. Aural symptoms may come on with great rapidity, either an otitis media, or in some instances inflammation of the mastoid cells. (5) Sexual Function.—Impotence is common, and may be an early symptom. Course.—In children the disease is rapidly progressive, and may prove fatal in a few days. It may be stated, as a general rule, that the older the patient at the time of onset the slower the course. Cases without hered- itary influences are the most favorable. In stout, elderly men diabetes is a much more hopeful disease than it is in thin persons. Middle-aged patients may live for many years, and persons are met with who have had the disease for ten, twelve, or even fifteen years. Diagnosis.—Glycosuria, which to all intents and purposes is a mild form of the disease, is to be distinguished only by its transient character. There is no other disease with which true diabetes can be confounded. There are cases in which the diabetes presents a remarkable intermittency, and sugar may be absent for weeks or months at a time. It must not be forgotten that hysterical women sometimes put sugar in the urine for the purposes of deception. Prognosis.—In true diabetes instances of cure are rare. On the other hand, the transient or intermittent glycosuria, met with in stout overfeeders, or in persons who have undergone a severe mental strain, is very amenable to treatment. Not a few of the cases of reputed cures be- long to this division. Practically, in cases under forty years of age the outlook is bad; in older persons the disease is less serious and much more amenable to treatment. It is a good plan at the outset to determine whether the urine of a patient contains sugar or not on a diet absolutely free from carbohydrates. In mild cases the sugar disappears; in the severer cases it continues to be formed from the proteids. Treatment.—In families with a marked predisposition to the disease the use of starchy and saccharine articles of diet should be restricted. The personal hygiene of a diabetic patient is of the first importance. 328 CONSTITUTIONAL DISEASES. Sources of worry should he avoided, and he should lead an even, quiet life, if possible in an equable climate. Flannel or silk should be worn next to the skin, and the greatest care should be taken to promote its action. A lukewarm, or if tolerably robust, a cold bath, should be taken every day. An occasional Turkish bath is useful. Systematic, moderate exercise should be taken. When this is not feasible, massage should be given. Diet.—Our injunctions to-day are those of Sydenham: “ Let the j>atient eat food of easy digestion, such as veal, mutton, and the like, and abstain from all sorts of fruit and garden stuff.” The carbohydrates in the food should be reduced to a minimum. Under a strict hydrocarbonaceous and nitrogenous regimen all cases are benefited and some are cured. The most minute and specific instructions should be given in each case, and the dietary arranged with scrupulous care. It is of the first importance to give the patient variety in the food, otherwise the loathing of certain essential articles becomes intolerable, and too often the patient gives up in disgust or despair. It is well, perhaps, not to attempt the absolute exclusion of the carbohydrates, but to allow a small proportion of ordinary bread, or, better still, as containing less starch, potatoes. It is best gradually to enforce a rigid system, cutting off one article after another. The following is a list of articles which diabetic patients may take: Liquids: Soups — ox-tail, turtle, bouillon, and other clear soups. Lemonade, coffee, tea, chocolate, and cocoa; these to be taken without sugar, but they may be sweetened with saccharin. Potash or soda water, and Apollinaris, or the Saratoga-Vichy, and milk in moderation, may be used. Of animal food: Fish of all sorts, including crabs, lobsters, and oys- ters ; salt and fresh butcher’s meat (with the exception of liver), poultry, and game. Eggs, butter, buttermilk, curds, and cream cheese. Of bread : Gluten and bran bread, and almond and cocoanut biscuits. Of vegetables: Lettuce, tomatoes, spinach, chicory, sorrel, radishes, asparagus, water-cress, mustard and cress, cucumbers, celery, and endives. Pickles of various sorts. Fruits : Lemons and oranges. Currants, plums, cherries, pears, apples (tart), melons, raspberries and strawberries may be taken in moderation. Nuts are, as a rule, allowable. Among prohibited articles are the following : Thick soups and liver. Ordinary bread of all sorts (in quantity): rye, wheaten, brown, or white. All farinaceous preparations, such as hominy, rice, tapioca, semo- lina, arrowroot, sago, and vermicelli. Of vegetables: Potatoes, turnips, parsnips, squashes, vegetable marrow of all kinds, beets, corn, artichokes. Of liquids: Beer, sparkling wine of all sorts, and the sweet aerated drinks. DIABETES MELLITUS. 329 The chief difficulty in arranging the daily menu of a diabetic patient is the bread, and for it various substitutes have been advised—bran bread, gluten bread, and almond biscuits. Most of these are unpalatable, and' many are frauds. A friend, a distinguished physician, who has, unfortu- nately, had to make trial of a great many of them, writes : “ That made from almond flour is usually so heavy and indigestible that it can only be used to a limited extent. Gluten flour obtained in Paris or London con- tains about 15 per cent of the ordinary amount of starch and can be well used. The gluten flour obtained in this country has from 35 to 45 per cent of starch, and can be used successfully in mild but not in severe forms of diabetes.” Unless a satisfactory and palatable gluten bread can be obtained, it is better to allow the patient a few ounces of ordinary bread daily. The “ Soya ” bread is not any better than that made from the best gluten flour. As a substitute for sugar, saccharin is very useful, and is perfectly harm- less. Glycerin may also be used for this purpose. Levulose, fruit sugar, is readily assimilated, and seems to be not only harmless in diabetes, but very beneficent. It may be used for sweetening purposes in moderate amounts (Hale White). It is well to begin the treatment by cutting off article after article until the sugar disappears from the urine. Within a month or two the patient may gradually be allowed a more liberal regimen. An exclusively milk diet, either skimmed milk, buttermilk, or koumyss, has been recom- mended by Donkin and others. Certain cases seem to improve on it, but it is not, on the whole, to be recommended. Medicinal Treatment.—This is most unsatisfactory, and no one drug appears to have a directly curative influence. Opium alone stands the test of experience as a remedy capable of limiting the progress of the dis- ease. Diabetic patients seem to have a special tolerance for this drug. Codeia is preferred by Pavy, and has the advantage of being less consti- pating than morphia. A patient may begin with half a grain three times a day, which may be gradually increased to six or eight grains in the twenty-four hours. Not much effect is noticed unless the patient is on a rigid diet. When the sugar is reduced to a minimum, or is absent, the opium should be gradually withdrawn. The patients not only bear well these large doses of morphia, but they stand its gradual reduction. Po- tassium bromide is often a useful adjunct. The arsenite of bromine, a solution of arsenious acid with bromine in glycerin (dose, three to five min- ims after meals), has been very highly recommended, but it is by no means so certain as opium. Arsenic alone may be used. Antipyrin may be given in doses of ten grains three times a day, and in cases with a marked neu- rotic constitution is sometimes satisfactory. The salicylates, iodoform, nitroglycerin, jambul, lithium salts, strychnine, creasote, and lactic acid have been employed. Preparations of the pancreas (glycerin extract, dried and fresh gland) 330 CONSTITUTIONAL DISEASES. have been used in the hope that they would supply the internal secretion necessary to normal sugar metabolism. The success has not, however, been in any way comparable with the use of the thyroid extract in myx- cedema. Lepine has isolated a glycolytic ferment from the pancreas and also from malt diastase, and has used it with some success in four cases. Of the complications, the pruritus and eczema are best treated by cool- ing lotions of boric acid or hyposulphite of soda (1 ounce; water, 1 quart), or the use of ichthyol and lanolin ointment. The coma is an almost hopeless complication. Inhalations of oxy- gen have been recommended, and the intravenous injections of a saline solution, as practised by Hilton Fagge. The three per cent solution of the sodium bicarbonate has generally been employed. The treatment has not, however, been satisfactory. Of seventeen cases, collected by Chadbourne, in only one was it successful; in seven there was temporary improvement; and the best that can be said for it is that it may give the patient a few hours of complete consciousness. Injections should be made as soon as possible after the appearance of the coma. VIII. DIABETES INSIPIDUS. Definition.—A chronic affection characterized by the passage of large quantities of normal urine of low specific gravity. The condition is to be distinguished from diuresis or polyuria, which is a frequent symptom in hysteria, in Bright’s disease, and occasionally in cerebral or other affections. Willis, in 1674, first recognized the dis- tinction between a saccharine and non-saccharine form of diabetes. Etiology.—The disease is most common in young persons. Of the 85 cases collected by Strauss, 9 were under five years; 12 between five and ten years; 36 between ten and twenty-five years. Males are more fre- quently attacked than females. The affection may be congenital. A hereditary tendency has been noted in many cases, the most extraordinary of which has been reported by Weil. Of 91 members in four generations, 23 had persistent polyuria without any deterioration in health. Injury to the nervous system has been present in certain instances, and the disease has followed sunstroke, or a violent emotion, such as fright. Traumatism has occasionally been the exciting cause. The injury may have been to the head, but in other cases the lesion has been to the trunk or to the limbs. The disease has followed rapidly the copious drinking of cold water, or a drinking-bout; or has set in during the convalescence from an acute disease. Tumors of the brain and lesions of the medulla have been met with in a few instances. Cases of polyuria have been accompanied by paralysis of the sixth nerve. Maguire has seen an instance after menin- gitis in which paralysis of the sixth pair occurred with it. Bernard, it will be remembered, discovered a spot in the floor of the fourth ventricle DIABETES INSIPIDUS. 331 of animals which, when punctured, produced polyuria. Lesions of the organs of the abdomen may be associated with an excessive flow of urine, which, however, should not be regarded as true diabetes insipidus. Dick- enson mentions its occurrence in abdominal tumors; Ralfe, in abdominal aneurism. I have noted it in several cases of tuberculous peritonitis. The nature of the disease is unknown. It is, doubtless, of nervous origin. The most reasonable view is that it results from a vaso-motor dis- turbance of the renal vessels, due either to local irritation, as in a case of abdominal tumor, or to central disturbance in cases of brain-lesion, or to functional irritation of the centre in the medulla, giving rise to continu- ous renal congestion. Morbid Anatomy.—There are no constant anatomical lesions. The kidneys have been found enlarged and congested. The bladder has been found hypertrophied. Dilatation of the ureters and of the pelves of the kidneys has been present. Death has not infrequently resulted from chronic pulmonary disease. Very varied lesions have been met with in the nervous system. Symptoms.—The disease may come on rapidly, as after a fright or an injury. More commonly it develops slowly. A copious secretion of urine, with increased thirst, are the prominent features of the disease. The amount of urine in the twenty-four hours may range from, twenty to forty pints, or even more. The specific gravity is low, 1-001 to 1-005 ; the color is extremely pale and watery. The total solid constituents may not be reduced. The amount of urea has sometimes been found in excess. Abnormal ingredients are rare. Muscle sugar, inosite, has been occasionally found. Albumin is rare. Traces of sugar have been met with. Naturally, with the passage of such enormous quantities of urine, there is a propor- tionate thirst, and the only inconvenience of the disease is th6 necessity for frequent micturition and frequent drinking. The appetite is usually good, rarely excessive as in diabetes mellitus. The patients may be well nourished and healthy-looking. The disease in many instances does not appear to interfere in any way with the general health. The perspiration is naturally slight and the skin is harsh. The amount of saliva is small and the mouth usually dry. Cases have been described in which the toler- ance of alcohol has been remarkable, and patients have been known to take a couple of pints of brandy, or a dozen or more bottles of wine, in the day. The course of the disease depends entirely upon the nature of the pri- mary trouble. Sometimes, with organic disease, either cerebral or abdomi- nal, the general health is much impaired; the patient becomes thin, and rapidly loses strength. In the essential or idiopathic cases, good health may be maintained for an indefinite period, and the affection has been known to persist for fifty years. Death usually results from some inter- current affection. Spontaneous cure may take place. Diagnosis.—A low specific gravity and the absence of sugar in the 332 CONSTITUTIONAL DISEASES. urine distinguish tlie disease from diabetes mellitus. Hysterical polyuria may sometimes simulate it very closely. The amount of urine excreted may be enormous, and only the development of other hysterical manifes- tations may enable the diagnosis to be made. This condition is, however, always transitory. In certain cases of chronic Bright’s disease a very large amount of urine of low specific gravity may be passed, but the presence of albumin and of hyaline casts, and the existence of heightened arterial tension, stiff vessels, and hypertrophied left ventricle make the diagnosis easy. Treatment.—The treatment is not satisfactory. No attempt should be made to reduce the amount of liquid. Opium is highly recommended, but is of doubtful service. The preparations of valerian may be tried; either the powdered root, beginning with five grains three times a day, and increasing until two drachms are taken in the day, or the valerianate of zinc, in fifteen-grain doses, gradually increased to thirty grains, three times a day. Ergot, ergotin, antipyrin, the salicylates, arsenic, strychnine, tur- pentine, and the bromides have been recommended. Electricity may be used. IX. RICKETS. Definition.—A disease of infants, characterized by impaired nutrition and alterations in the growing bones. Glisson, the anatomist of the liver, described the disease accurately in the seventeenth century. Etiology.—The disease exists in all parts of the world, but is par- ticularly marked among the poor of the larger cities, who are badly housed and ill fed. It is much more common in Europe than in America. In Vienna and Loudon from 50 to 80 per cent of all the children at the clinics present signs of rickets. It is a comparatively rare disease in Canada. In the cities of • this continent it is very prevalent, particularly among the children of the negro and of the Italian races. Want of sunlight and impure air are important factors. A starchy diet, too much cow’s milk, and the indiscriminate feeding so common in the children of the poor, are important agents; but something is required beyond these, for children of healthy parents, who have an ample quantity of the proper food, may become rickety. It seems probable, however, that the combi- nation of defective food and bad air plays the most important role. Pro- longed lactation or suckling a child during pregnancy are accessory etio- logical factors. There is no evidence that the disease is hereditary, but there is prob- ably a form of foetal rickets. It is doubtful, however, whether the changes met with in this are identical with the post-natal disease. In these babies, which are generally still-born, the limbs are short, the curves of the bones are exaggerated, and at the junction of the epiphyses there is no prolifer- ating zone of cartilage. This condition is called by Parrot achondroplasy, RICKETS. 333 and chondrodystrophia foetalis by Kaufmann, who has written a mono- graph on the subject (1892). In the children which survive, the growth, particularly of the limbs, is stunted, and they form an important group (micromelia) of the dwarfs. Bickets affects male and female children equally. It is a disease of the first and second years of life, rarely beginning before the sixth month. Jenner has described a late rickets, in which form the disease may not ap- pear until the ninth or even until the twelfth year. It has been held that rickets is only a manifestation of congenital syphilis (Parrot), but this is certainly not correct. Syphilitic bones rarely, if ever, present the spongy tissue peculiar to rickets, and rachitic bones never show the multiple oste- ophytes of syphilis. Morbid Anatomy.—The bones show the most important changes, particularly the ends of the long bones and the ribs. Between the shaft and epiphyses a slight bulging is apparent, and on section the zone of pro- liferation, which normally is represented by two narrow bands, is greatly thickened, bluish in color, more irregular in outline, and very much softer. The width of this cushion of cartilage varies from five to fifteen millimetres. The line of ossification is also irregular and more spongy and vascular than normal. The periosteum strips off very readily from the shaft, and beneath it there may be a spongioid tissue not unlike de- calcified bone. The practical outcome of these changes is a delay in, and imperfect performance of, the ossification, so that the bone has neither the natural rate of growth nor the normal firmness. In the cranium there may be large areas, particularly in the parieto-occipital region, in which the ossification is delayed, producing the so-called cranio-tabes, so that the bone yields readily to pressure with the finger. There are local- ized depressed spots of atrophy, which, on pressure, give the so-called “ parchment crackling.” Flat hyperostoses develop from the outer table, particularly on the frontal and parietal bones, and produce the character- istic broad forehead with prominent frontal eminences, a condition some- times mistaken for hydrocephalus. The chemical analysis of rickety bones shows a marked diminution in the calcareous salts, which may be as low as from 25 to 35 per cent. The liver and spleen are usually enlarged, and sometimes the mesen- teric glands. As Gee suggests, these conditions probably result from the general state of the health associated with rickets. It is interesting to note that Beneke describes a relative increase in the size of the arteries in rickets. Kassowitz, the leading authority on the anatomy of rickets, regards the hyperaemia of the periosteum, the marrow, the cartilage, and of the bone itself as the primary lesion, out of which all the others develop. This disturbs the normal development of the growing bone and ex- cites changes in the bone already formed. The cartilage cells in conse- quence proliferate, the matrix is softer, and as a result the bone which is 334 CONSTITUTIONAL DISEASES. formed from this unhealthy cartilage is lacking in firmness and solidity. In the bone already formed this excessive vascularity favors the normal processes of absorption, so that the relation between removal and deposi- tion is disturbed, absorption taking place more rapidly. The new material is poor in lime salts. Kassowitz seems to have proved experimentally that hyperasmia of bone results in defective deposition of lime salts. Bar- low and Bury * have given an elaborate analysis of the changes described by this author. It is interesting to note that Glisson attributed rickets to disturbed nutrition by arterial blood, and believed the changes in the long bones to be due to excessive vascularity. Symptoms.—The disease comes on insidiously about the period of dentition, before the child begins to walk. In many cases digestive dis- turbances precede the appearance of the characteristic lesions, and the nutrition of the child is markedly impaired. There is usually slight fever, the child is irritable and restless, and sleeps badly. If the child has already walked, it shows a marked disinclination to do so, and seems feeble and unsteady in its gait. Sir William Jenner has called attention to three general symptoms which are present in many cases of rickets. There is first a diffuse soreness of the body, so that the child cries when an attempt is made to move it, and prefers to keep perfectly still. This tenderness is often a marked and suggestive symptom. Associated with this are slight fever and a tendency at night to throw off the bedclothes. This may be partly due to the fact that the general sensitiveness is such that even their Aveight may be distressing. And, third, there is such profuse sweating, particularly about the head and neck, that in the morn- ing the pillow is found soaked with perspiration. The tissues become soft and flabby ; the skin is pale; and from a healthy, plump condition, the child becomes puny and feeble. It is in this stage of the disease that we sometimes find such a degree of disability in the muscles, particularly of the legs, that paralysis may be suspected. This so-called pseudo-paresis of rickets results in part from the flabby, Aveak condition of the legs and in part from the pain associated with the movements. Such cases are by no means uncommon, but they are readily distinguished from infantile paralysis. Coincident with, or following closely upon, the general symptoms the characteristic skeletal lesions are observed. Among the first of these to appear are the changes in the ribs, at the junction of the bone with the cartilage, forming the so-called rickety rosary. When the child is thin these nodules may be distinctly seen, and in any case can be easily made out by touch. They very rarely appear before the third month. They may increase in size up to the sec- ond year, and are rarely seen after the fifth year. The thorax undergoes important changes. Just outside the junction of the cartilages with the ribs there is an oblique, shallow depression extending downA\Tard and out- * Cyclopedia of the Diseases of Children, vol. ii. RICKETS. 335 ward. A transverse curve, sometimes called Harrison’s groove, passes out- ward from the level of the ensiform cartilage toward the axilla and may be deepened at each inspiration. It is rendered more prominent by the eversion and prominence of the costal border. The sternum projects, particularly in its lower half, forming the so-called pigeon or chicken breast. These changes in the thorax are not peculiar, however, to rickets, aud are much more commonly associated with hypertrophy of the tonsils, or any trouble which interferes with the free entrance of air into the lungs. Posteriorly the spine is usually curved, the processes are promi- nent, and lateral curvature may he produced. The head of a rickety child usually looks large, and the fontanelles remain open for a long time. There are areas, particularly in the parieto- occipital regions, in which ossification is imperfect; and the bone may yield to the pressure of the finger, a condition to which the term cranio- tabes has been given. The relation of this condition to rickets is still somewhat doubtful, as it is very often associated with syphilis—in 47 of 100 cases recently studied by George Carpenter. Coincidently with this, hyperplasia proceeds in the frontal and parietal eminences, so that these portions of the skull increase in thickness, and may form irregular bosses. In one type the skull may be large and elongated, with the top considera- bly flattened. In another, and perhaps more common case, the shape of the skull, when seen from above, is rectangular—the caput quadratum. The skull looks large in proportion to the face. The forehead is broad and square, and the frontal eminences marked. The anterior fontanelle is late in closing and may remain open until the third or fourth year. The skin is thin, the veins are perceptible, and the hair is often rubbed from the back of the skull. In contradistinction to the cranio-tabes is the condition of cranio-sclerosis, which has also been ascribed to rickets. On placing the ear over the anterior fontanelle, or in the temporal region, a systolic murmur may frequently be heard. This condition, first described by Fisher, of Boston, was believed by him to be peculiar to rickets. While unquestionably heard with the greatest frequency in this disease, its presence and persistence in perfectly healthy infants have been amply demonstrated.* The murmur is rarely heard after the fifth year. A knowledge of the existence of this systolic brain murmur may prevent errors. A case in which it was 'well marked was reported as an instance of supposed gummy tumor of the brain, in which the murmur was thought to be due to pressure on the vessels at the base. Changes occur in the bones of the face, chiefly in the maxillae, which are reduced in size. The normal process of dentition is much disturbed; indeed, late teething is one of the marked features in rickets. The teeth which appear may he small and badly formed. * Osier, On the Systolic Brain Murmur of Children, Boston Medical and Surgical Journal, 1880. 336 CONSTITUTIONAL DISEASES. In the upper limbs changes in the scapulae are not common. The clavicle may be thickened at the sternal end, and there may be thickening near the attachment of the sterno-cleido muscle. The most noticeable changes are at the lower ends of the radius and ulna. The enlargement is at the junction-area of the shaft and epiphysis. Less evident enlarge- ments may occur at the lower end of the humerus. In severe cases the natural shape of the bones of the arm may be much altered, having to support the weight of the child in crawling on the floor. The changes in the pelvis are of special importance, particularly in female children, as in extreme cases they lead to great deformity and narrowing of the outlet. In the legs, the lower end of the tibia first becomes enlarged; and in slight cases it may alone be affected. In the severe forms the upper end of the bone, the corresponding parts of the fibula, and the lower end of the femur become greatly thickened. If the child walks, slight bowing of the tibiae inevitably results. In more advanced cases the tibiae and even the femora may be arched forward. In other cases the condition of knock-knee occurs. Unquestionably the chief cause of these deformi- ties is the weight of the body in walking, but muscular action takes part in it. The green-stick fracture is not uncommon in the soft bones of rickets. These changes in the skeleton proceed slowly, and the general symp- toms vary a good deal with their progress. The child becomes more or less emaciated, though “ fat rickets ” is by no means uncommon. Fever is not constant, but in actively progressing changes in the bone there is usually a slight pyrexia. The abdomen is large, due partly to flatulent distention, partly to enlargement of the liver, and in severe cases to diminution of the volume of the thorax. The spleen is often enlarged and readily palpable. The urine is stated to contain an excess of lime salts, but Jacobi and Barlow say this has not been proved. No special or peculiar changes, indeed, have as yet been described. Many rickety chil- dren show marked nervous symptoms; irritability, peevishness, and sleep- lessness are constantly present. Jenner called attention to the close rela- tionship which existed between rickets and infantile convulsions, par- ticularly to the fits which occur after the sixth month. Tetany is by no means uncommon. It involves most frequently the arms and hands; oc- casionally the legs as well. Laryngismus stridulus is a common complica- tion, and though not, as some state, invariably associated with this disease, yet it is certainly much more frequent in rickety than in other children. Severe rickets interfere seriously with the growth of a child. Extreme examples of rickety dwarfs are not uncommon. The disease known as acute rickets is in reality a manifestation of scurvy and will be described with that disease. Prognosis.—The disease is never in itself fatal, but the condition of the child is such that it is readily carried off by intercurrent affections, particularly those of the respiratory organs. Spasm of the larynx and SCURVY. 337 convulsions occasionally cause death. In females the deformity of the pelvis is serious, as it may lead to difficulties in parturition. Treatment.—The better the condition of the mother during preg- nancy the less likelihood is there of the development of rickets in the child. Rapidly repeated pregnancies and suckling a child during preg- nancy seem important factors in the production of the disease. Of the general treatment, attention to the feeding of the child is the first con- sideration. If the mother is unhealthy, or cannot from any cause nurse the child, a suitable wet-nurse should be provided, or the child must be artificially fed. Cows’ milk, diluted according to the age of the child, should constitute the chief food. Care should be taken to examine the condition of the stools, and if curds are present the child is taking too much, or it is not sufficiently diluted. Barley-water or carefully strained and well-boiled oatmeal gruel form excellent additions to the milk. The child should be warmly clad and should be in the fresh air and sunshine the greater part of the day. It is a “ vulgar error ” to suppose that delicate children cannot stand, when carefully wrapped up, an even low tem- perature. The child should be bathed daily in warm water. Careful friction with sweet oil is very advantageous, and, if properly performed, allays rather than aggravates the sensitiveness. Special care should be taken to pre- vent deformity. The child should not be allowed to walk, and for this purpose splints applied so as to extend beyond the feet are very effective. Of medicines, phosphorus has been warmly recommended by Kassowitz, and its use is also advised by Jacobi. The child may be given gr. two or three times a day, dissolved in olive oil. Cod-liver oil, in doses of from a half to one teaspoonful, is very advantageous. The syrup of the iodide of iron may be given with the oil. The digestive disturbances, together with the respiratory and nervous complications, should receive appropriate treatment. X. SCURVY (Scorbutus). Definition.—A constitutional disease characterized by great debility, with ansemia, a spongy condition of the gums, and a tendency to haemor- rhages. Etiology.—The disease has been known from the earliest times, and has prevailed particularly in armies in the field and among sailors on long voyages. From the early part of this century, owing largely to the efforts of Lind and to a knowledge of the conditions upon which the disease de- pends, scurvy has gradually disappeared from the naval service. In the mercantile marine, cases still occasionally occur, owing to neglect of proper and suitable food. The disease develops whenever individuals have subsisted for pro- 338 CONSTITUTIONAL DISEASES. longed periods upon a diet in which fresh vegetables or their substitutes are lacking. An insufficient diet appears to be an essential element in the disease, and all observers are now unanimous that it is the absence of those ingredients in the food which are supplied by fresh vegetables. What these constituents are has not yet been definitely determined. Gar- rod holds that the defect is in the absence of the potassic salts. Others believe that the essential factor is the absence of the organic salts present in fruits and vegetables. Ralfe, who has made a very careful study of the subject, believes that the absence from the food of the malates, citrates, and lactates reduces the alkalinity of the blood, which depends upon the carbonate directly derived from these salts. This diminished alkalinity, gradually produced in the scurvy patients, is, he believes, identical with the effect which can be artificially produced in animals by feeding them with an excess of acid salts; the nutrition is impaired, there are ecchymoses, and profound alterations in the characters of the blood. The acidity of the urine is greatly reduced and the alkaline phosphates are diminished in amount. In opposition to this chemical view it has been urged that the disease really depends upon a specific (as yet unknown) micro-organism. In comparison with former times it is now a rare disease. In seaport towns sailors suffering with the disease are now and then admitted to hospitals. In large almshouses, during the winter, cases are sometimes seen. On several occasions in Philadelphia characteristic examples were admitted to my wards from the almshouse. Some years ago it was not very uncommon among the lumbermen in the winter camps in the Ottawa Valley. Among the Hungarian, Bohemian, and Italian miners in Penn- sylvania the disease is not infrequent. This so-called land scurvy differs in no particular from the disease in sailors. The only case of scurvy admitted to the Johns Hopkins Hospital in six years was a well-to-do woman with chronic dyspepsia, who had lived for many months on tea and bread. In parts of Russia scurvy is endemic, at certain seasons reaching epi- demic proportions; and the leading authorities upon the disorder, now in that country, are almost unanimous, according to Hoffmann,* in regard- ing it as infectious. Other factors play an important part in the disease, particularly phys- ical and moral influences—overcrowding, dwelling in cold, damp quarters, and prolonged fatigue under depressing influences, as during the retreat of an army. Among prisoners, mental depression plays an important role. It is stated that epidemics of the disease have broken out in the French convict-ships en route to New Caledonia even when the diet was amply sufficient. Nostalgia is sometimes an important element. It is an * Lehrbuch der Constitutionskrankheiten, F. A. Hoffmann (1893), a work to which the student is referred for the best modern exposition of this group of disorders. SCURVY. 339 interesting fact that prolonged starvation in itself does not necessarily cause scurvy. Not one of the professional fasters of late years has dis- played any scorbutic symptom. The disease attacks all ages, hut the old are more susceptible to it. Sex has no special influence, but during the siege of Paris it was noted that the males attacked were greatly in excess of the females. Infantile scurvy will be considered in a special note. Morbid Anatomy.—The anatomical changes are marked, though by no means specific, and are chiefly those associated with haemorrhage. The blood is dark and fluid. The microscopical alterations are those of a severe anaemia, without leucocytosis. The bacteriological examination has not yielded anything very positive. Practically there are no changes in the blood, either anatomical or chemical, which can be regarded as pecul- iar to the disease. The skin shows the ecchymoses evident during life. There are haemorrhages into the muscles, and occasionally about or even into the joints. Haemorrhages occur in the internal organs, particularly on the serous membranes and in the kidneys and bladder. The gums are swollen and sometimes ulcerated, so that in advanced cases the teeth are loose and have even fallen out. Ulcers are occasionally met with in the ileum and colon. Haemorrhages are extremely common into the mucous membranes. The spleen is enlarged and soft. Parenchymatous changes are constant in the liver, kidneys, and heart. Symptoms.—The disease is insidious in its onset. Early symptoms are loss in weight, progressively developing weakness, and pallor. Very soon the gums are noticed to be swollen and spongy, to bleed easily, and in extreme cases to present a fungous appearance. These changes, re- garded as characteristic, are sometimes absent. The teeth may become loose and even fall out. Actual necrosis of the jaw is not common. The breath is excessively foul. The tongue is swollen, but may be red and not much furred. The salivary glands are occasionally enlarged. Haem- orrhages beneath the mucous membranes of the mouth are common. The skin becomes dry and rough, and ecchymoses soon appear, first on the legs and then on the arms and trunk, and particularly into and about the hair-follicles. They are petechial, but may become larger, and when subcutaneous may cause distinct swellings. In severe cases, particularly in the legs, there may be effusion between the periosteum and the bone, forming irregular nodes, which, in the case of a sailor from a whaling vessel who came under my observation, had broken down and formed foul-looking sores. The slightest bruise or injury causes haemorrhage into the injured part. (Edema about the ankles is common. The “ scurvy sclerosis,” seen oftenest in the legs, is a remarkable infiltration of the sub- cutaneous tissues and muscles, forming a brawny induration, the skin over which may be blood-stained. Haemorrhages from the mucous membranes are less constant symptoms; epistaxis is, however, frequent. Haemop- tysis and haematemesis are uncommon. Haematuria and bleeding from the bowels may be present in very severe cases. 340 CONSTITUTIONAL DISEASES. ' Palpitation of the heart and feebleness and irregularity of the impulse are prominent symptoms. A haemic murmur can usually be heard at the base. Haemorrhagic infarction of the lungs and spleen has been described. Respiratory symptoms are not common. The appetite is impaired, and owing to the soreness of the gums the patient is unable to chew the food. Constipation is more frequent than diarrhoea. The urine is often albu- minous. The changes in the composition of the urine are not constant; the specific gravity is high ; the color is deeper; and the phosphates are increased. The statements with reference to the inorganic constituents are contradictory. Some say the phosphates and potash are deficient; others that they are increased. There are mental depression, indifference, in some cases headache, and in the later stages delirium. Cases of convulsions, of hemiplegia, and of meningeal haemorrhage have been described. Remarkable ocular symp- toms are occasionally met with, such as night-blindness or day-blind- ness. In advanced cases necrosis of the bones may occur, and in young per- sons even separation of the epiphyses. There are instances in which the cartilages have separated from the sternum. The callus of a recently repaired fracture has been known to undergo destruction. Fever is not present, except in the later stages, or when secondary inflammations in the internal organs appear. The temperature may, indeed, be sometimes below normal. Acute arthritis is an occasional complication. Diagnosis.—No difficulty is met in the recognition of scurvy when a number of persons are affected together. In isolated cases, however, the disease is distinguished with difficulty from certain forms of purpura. The association with manifest insufficiency in diet, and the rapid amel- ioration with suitable food, are points by which the diagnosis can be read- ily settled. Prognosis.—The outlook is good, unless the disease is far advanced and the conditions persist which lead to its development. The mortality now is rarely great. During the civil war the death-rate was 16 per cent. Death results from gradual heart-failure, occasionally from sudden syncope. Meningeal haemorrhage, extravasation into the serous cavities, entero-coli- tis, and other intercurrent affections may prove fatal. Prophylaxis.—The regulations of the Board of Trade require that a sufficient su-pply of antiscorbutic articles of diet be taken on each ship; so that now, except as the result of accident, the occurrence of scurvy is rare in sailors. Treatment.—The juice of two or three lemons daily and a varied diet, with plenty of fresh vegetables, suffice to cure all cases of scurvy, unless far advanced. When the stomach is much disordered, small quantities of scraped meat and milk should be given at short intervals, and the lemon- juice in gradually increasing quantities. A bitter tonic, or a steel and bark mixture, may be given. As the patient gains in strength, the diet may be SCURVY. 341 more liberal, and he may eat freely of potatoes, cabbage, water-cresses, and lettuce. The stomatitis is the symptom which causes the greatest distress. The permanganate of potash or dilute carbolic acid forms the best mouth- wash. Pencilling the swollen gums with a tolerably strong solution of nitrate of silver is very useful. The solution is better than the solid stick, as it reaches to the crevices between the granulations. The constipation which is so common is best treated with large enemata. For other con- ditions, such as haemorrhages and ulcerations, suitable measures must be employed. INFANTILE SCURVY (Barlow's Disease). As in adults, scurvy may occur in children in consequence of imperfect food supply. A few years ago I saw a well-marked case in a child of four, whose diet had been chiefly “ grits ” and potatoes. The complexion was muddy, the gums spongy, and there was a purpuric rash on the legs. W. B. Cheadle and Gee, in London, have described in very young children a cachexia associated with haemorrhage. Cheadle regarded the cases as scurvy ingrafted on a rickety stock. Gee called his cases periosteal cachexia. Cases had previously been regarded as acute rickets. A few years later Barlow made an exhaustive study of the condition with careful anatomical observations. The affection is now recognized as infantile scurvy, and in Germany is called Barlow’s Disease. The affection is very much more frequent in this country than has been supposed.* The children attacked are almost invariably those which have been fed upon condensed milk, and the proprietary and preserved foods for chil- dren ; some instances, too, have followed the use of sterilized milk. The cases are met with at any period after the age of four months, but they are most common in the second period of infancy, from the ninth to the eighteenth months. The child may look well nourished, but is pallid and has a muddy complexion. There are very often signs of rickets. If the teeth have appeared, the gums may be spongy or there may be haemor- rhages on the mucous membranes. The following is a general clinical summary, taken from Barlow’s Brad- shaw Lecture, 1894: “ So long as it is left alone the child is tolerably quiet; the lower limbs are kept drawn up and still; but when placed in its bath or other- wise moved there is continuous crying, and it soon becomes clear that the pain is connected with the lower limbs. At this period the upper limbs may be touched with impunity, but any attempt to move the legs or thighs gives rise to screams. Next, some obseure swelling may be detected, first on one lower limb, then on the other, though it is not absolutely symmet- rical. . . . The swelling is ill-defined, but is suggestive of thickening round the shafts of the bones, beginning above the epiphyseal junctions. * Northrop and Crandall, New York Medical Journal, 1894, i. 342 CONSTITUTIONAL DISEASES. Gradually the bulk of the limbs affected becomes visibly increased. . . . The position of the limbs becomes somewhat different from what it was at the outset. Instead of being flexed they lie everted and immobile, in a state of pseudo-paralysis. . . . About this time, if not before, great weak- ness of the back becomes manifest. A little swelling of one or both scap- ulae may appear, and the upper limbs may show changes. These are rarely so considerable as the alterations in the lower limbs. There may be swell- ing above the wrists, extending for a short distance up the forearm, and some swelling in the neighborhood of the epiphyses of the humerus. There is symmetry of lesions, but it is not absolute; and the limb affec- tion is generally consecutive, though the involvement of one limb follows very close upon another. The joints are free. In severe cases another symp- tom may now be found—namely, crepitus in the regions adjacent to the junctions of the shafts with the epiphyses. The upper and lower extremi- ties of the femur, and the upper extremity of the tibia, are the common sites of such fractures; but the upper end of the humerus may also be so affected. ... A very startling appearance may be observed at this period in the front of the chest. The sternum, with the adjacent costal carti- lages and a small portion of the contiguous ribs, seems to have sunk bod- ily back, en bloc, as though it had been subjected to some violence which had fractured several ribs in the front and driven them back. Occasion- ally thickenings of varying extent may be found on the exterior of the vault of the skull, or even on some of the bones of the face. . . . Here also must be mentioned a remarkable eye phenomenon. There develops a rather sudden proptosis of one eyeball, with puffiness and very slight staining of the upper lid. Within a day or two the other eye presents similar appearances, though they may be of less severity. The ocular con- junctiva may show a little eechymosis, or may be quite free. With respect to the constitutional symptoms accompanying the above series of events the most important feature is the profound anaemia which is devel- oped. . . . The anaemia is proportional to the amount of limb involve- ment. As the case proceeds, there is a certain earthy-colored or sallow tint, which is noteworthy in severe cases, and when once this is estab- lished bruise-like ecchymoses may appear, and more rarely small purpura. Emaciation is not a marked feature, but asthenia is extreme and sug- gestive of muscular failure. The temperature is very erratic; it is often raised for a day or two, when successive limbs are involved, especially during the tense stage, but is rarely above 101° or 102°. At other times it may be normal or subnormal.” The essential lesion is a subperiosteal blood extravasation, which causes the thickening and tenderness in the shafts of the bones. In some instances there is haemorrhage in the intramuscular tissue. The prophylaxis is most important. The various proprietary forms of condensed milk and preserved foods for infants should not be used. The fresh cow’s milk should be substituted, and a teaspoonful of meat-juice PURPURA. 343 or gravy may be given with a little sieved potato. A little orange-juice or lemon-juice may also be given in water. Recovery is usually prompt and satisfactory. XI. PURPURA. Strictly speaking, purpura is a symptom, not a disease; but under this term are conveniently arranged a number of affections characterized by extravasations of the blood into the skin. In the present state of our knowledge a satisfactory classification cannot be made. Excluding symp- tomatic purpura, W. Koch groups all forms, including haemophilia, under the designation haemorrhagic diathesis, believing that intermediate forms link the mild purpura simplex and the most intense purpura hem- orrhagica ; while F. A. Hoffmann considers them all (except hemophilia) under the heading morbus maculosus. The purpuric spots vary from one to three or four millimetres in diameter. When small and pin-point-like they are called petechie ; when large, they are known as ecchymoses. At first bright red in color, they become darker, and gradually fade to brown- ish stains. They do not disappear on pressure. The following is a provisional grouping of the cases: Symptomatic Purpura.—(«) Infectious.—In pyaemia, septicaemia, malignant endocarditis (particularly in the latter affection), ecchymoses may be very abundant. In typhus fever the rash is always purpuric. Measles, scarlet fever, and more particularly small-pox, have each a variety characterized by an extensive purpuric rash. (b) Toxic.—The virus of snakes produces with great rapidity extrava- sation of blood—a condition which has been very carefully studied by Weir Mitchell. Certain medicines, particularly copaiba, quinine, bella- donna, mercury, ergot, and the iodides occasionally, are followed by a petechial rash. Purpura may follow the use of comparatively small doses of iodide of potassium. It is not a very common occurrence, considering the great frequency with which the drug is employed. A fatal event may be caused by a small amount, as in a case reported by Stephen Mackenzie of a child which died after a dose of two and a half grains. An erythema may precede the haemorrhage. It is not always a simple purpura, but may be an acute febrile eruption of great intensity. In September, 1894, a man aged forty-eight was admitted under my care with arterio-sclerosis and dropsy. The latter yielded rapidly to digitalis and diuretin. When convalescent he was ordered iodide of potassium in ten-grain doses three times a day, and took in fourteen days 420 grains. He had high fever, coryza, swelling of the throat, and the most extensive purpura over the whole body. Under this division, too, comes the purpura so often asso- ciated with jaundice. (c) Cachectic.—Under this heading are best described the instances of purpura which develop in the constitutional disturbance of cancer, tuber- culosis, Hodgkin’s disease, Bright’s disease, scurvy, and in the debility of CONSTITUTIONAL DISEASES. old age. In these cases the spots are usually confined to the extremities. They may be very abundant in the lower limbs and about the wrists and hands. This constitutes, probably, the commonest variety of the disease, and many examples of it can be seen in the wards of any large hospital. (d) Neurotic.—One variety is met with in cases of organic disease. It is the so-called myelopathic purpura, which is seen occasionally in locomotor ataxia, particularly following attacks of the lightning pains and, as a rule, involving the area of the skin in which the pains have been most intense. Cases have been met with also in acute myelitis and in transverse myelitis, and occasionally in severe neuralgia. Another form is the remarkable hysterical condition in which stigmata, or bleeding points, appear upon the skin. (e) Mechanical.—This variety is most frequently seen in venous stasis of any form, as in the paroxysms of whooping-cough and in epilepsy. Arthritic.—This form is characterized by involvement of the joints. It is usually known, therefore, as rheumatic, though in reality the evi- dence upon which this view is based is not conclusive. For the present it seems more satisfactory to use the designation arthritic. Three groups of cases may be recognized : (a) A mild form, often known as Purpura simplex, seen most com- monly in children, in whom, -with or without articular pain, a crop of purpuric spots appears upon the legs, less commonly upon the trunk and arms. As pointed out by Graves, this form is not infrequently associated with diarrhoea. The disease is seldom severe. There may be loss of ap- petite, and slight ansemia. Fever is not, as a rule, present, and the pa- tients get well in a week or ten days. These cases are usually regarded as rheumatic, and are certainly associated, in some instances, with un- doubted rheumatic manifestations; yet in a majority of the patients which I have seen the arthritis was slighter than in the ordinary rheumatism of children, and no other manifestations were present. (b) Peliosis rheumatica (Schonlein's Disease).—This remarkable affec- tion is characterized by multiple arthritis, and an eruption which varies greatly in character, sometimes purpuric, more commonly associated with urticaria or with erythema exudativum. The disease is most common in males between the ages of twenty and thirty. It not infrequently sets in with sore throat, a fever from 101° to 103°, and articular pains. The rash, which makes its appearance first on the legs or about the affected joints, may be a simple purpura or ordinary urticarial wheals. In other instances there are nodular infiltrations, not to be distinguished from erythema nodosum. The combination of wheals and purpura, the pur- pura urticans, is very distinctive. Much more rarely vesication is met with, the so-called pemphigoid purpura. The amount of oedema is vari- able ; occasionally it is excessive. In one case, which I saw in Montreal with Molson, the chin and lower lip were enormously swollen, tense, glazed, and deeply ecchymotic. The eyelids were swollen and purpuric, PURPURA. 345 while scattered over the cheeks and about the joints were numerous spots of purpura urticans. These are the cases which have been described as febrile purpuric oedema. The temperature range, in mild cases, is not high, but may reach 102° or 103°. The urine is sometimes reduced in amount and may be albuminous. The joint affections are usually slight, though associated with much pain, particularly as the rash comes out. Kelapses may occur and the disease may return at the same time for several years in succession. The diagnosis of Schonlein’s disease offers no difficulty. The associa- tion of multiple arthritis with purpura and urticaria is very characteristic. In a case which I saw with Musser there was endo-pericarditis, and the question at first arose whether the patient had malignant endocarditis with extensive cutaneous infarcts. Schonlein’s peliosis is thought by most writers to be of rheumatic origin, and certainly many of the cases have the characters of ordinary rheumatic fever, plus purpura. By many, however, it is regarded as a special affection, of which the arthritis is a manifestation analogous to that which occurs in hemophilia and in scurvy. The frequency with which sore throat precedes the attack, and the occasional occurrence of en- docarditis or pericarditis, are certainly very suggestive of true rheumatism. The cases usually do well, and a fatal event is extremely rare. The throat symptoms may persist and give trouble. In two instances I have seen necrosis and sloughing of a portion of the uvula. (c) Henoch’s Purpura.—This variety, seen chiefly in children, is char- acterized by (1) relapses or recurrences, often extending over several years; (2) cutaneous lesions, which are those of erythema multiforme rather than of simple purpura; (3) gastro-intestinal crises—pain, vomiting, and diar- rhoea; (4) joint pains or swelling, often trifling; (5) haemorrhages from the mucous membranes. When from the kidney, an intense haemorrhagic nephritis may supervene, which proved fatal, with the symptoms of acute Bright’s disease, in one of my cases, and became chronic in a base of D. W. Prentiss. Any one or two of the above symptoms may be absent; the intestinal crises with enlargement of the spleen may be present and recur for months before the true nature of the trouble becomes manifest. This form has an interesting connection with the angio-neurotic oedema, which is also characterized by severe gastro-intestinal crises. The prog- nosis is good; but one of the nine cases which have come under my care died. A series of cases has been collected by von Deusch and Hoche,* but this form is very much more common than their study of it would indicate. Purpura Hsemorrliagica.—Under this heading may be consid- ered the cases of very severe purpura with hemorrhages from the mucous membranes. The affection, known as the morbus macnlosus of Werlhof, * Festschrift Herrn Edouard Henoch, Berlin, 1890. 346 CONSTITUTIONAL DISEASES. is most commonly met with in young and delicate individuals, particu- larly in girls; but cases are described in which the disease has attacked MEAN NORM. NUMBER OF WHITE CORPUSCLE8 Chart XIII.—Illustrates the rapidity with which anaemia is produced in purpura BLACKjRED CORPUSCLES, RED, HAEMAGLOBIN. BLUE, COLORLESS CORPUSCLES. haemorrhagica and the gradual recovery. adults in full vigor. After a few days of weakness and debility, purpuric spots appear on the skin and rapidly increase in numbers and size. Bleed- ing from the mucous surfaces sets in, and the epistaxis, haematuria, and .haemoptysis may cause profound anaemia. Chart XIII illustrates the rapid- ity with which anaemia is produced and the gradual recovery. Death may take place from loss of blood, or from haemorrhage into the brain. Slight fever usually accompanies the disease. In favorable cases the affection terminates in from ten days to two weeks. There are instances of purpura haemorrhagica of great malignancy, which may prove fatal within twenty- four hours—purpura fulminans. This form is most commonly met with in children, and is characterized by cutaneous haemorrhages, which develop with great rapidity. Death may occur before any bleeding takes place from the mucous membranes. In the diagnosis of purpura haemorrhagica it is important to exclude scurvy, which may be done by the consideration of the previous health, PURPURA. 347 the circumstances under which the disease develops, and by the absence of swelling of the gums. The malignant forms of the fevers, particularly small-pox and measles, are distingished by the prodromes and the higher temperature. Treatment.—In symptomatic purpura attention should be paid to the conditions under which it develops, and measures should be employed to increase the strength and to restore a normal blood condition. Tonics, good food, and fresh air meet these indications. In the simple purpura of children, or that associated with slight articular trouble, arsenic in full doses should be given. No good is obtained from the small doses, but the Fowler’s solution should be pushed freely until physiological effects are obtained. In peliosis rheumatica the sodium salicylates may be given, but with discretion. I confess not to have seen any special control of the hasm- orrhages by this remedy. We are still without a trustworthy medicine which can always be relied upon to control purpura. Aromatic sulphuric acid, ergot, turpentine, acetate of lead, or tannic and gallic acids, may be used, and in some instances they seem to check the bleeding. In other cases the whole series of hasmostatics may be tried in succession without any benefit. HAEMORRHAGIC DISEASES OF THE NEW-BORN. 1. Syphilis Haemorrhagica Neonatorum.—The child may be bom healthy, or there may be signs of haemorrhage at birth. Then in a few days there are extensive cutaneous extravasations and bleeding from the mucous surfaces and from the navel. The child may become deeply jaundiced. The post-mortem shows numerous extravasations in the inter- nal organs and extensive syphilitic changes in the liver and other organs. 2. Epidemic Hemoglobinuria (WincheVs Disease).—Hfemoglobinuria in the new-born, which occasionally develops in epidemic form in lying-in institutions, is a very fatal affection, which sets in usually about the fourth day of life. The child becomes jaundiced, and there are marked gastro- intestinal symptoms, with fever, jaundice, rapid respiration, and sometimes cyanosis. The urine contains albumin and blood-coloring matter— methaemoglobin. The disease has to be distinguished from the simple icterus neonatorum, with which there may sometimes be blood or blood- coloring matter in the urine. The post-mortem shows an absence of any septic condition of the umbilical vessels, but the spleen is swollen, and there are punctiform haemorrhages in different parts. Some cases have shown in a marked degree acute fatty degeneration of the internal organs —the so-called Buhl’s disease. 3. Morbus Maculosus Neonatorum.—Apart from the common visceral haemorrhages, the result of injuries at birth (see p. 961), bleeding from one or more of the surfaces is a not uncommon event in the new-born, particularly in hospital practice. Forty-five cases occurred in 6,700 deliv- 348 CONSTITUTIONAL DISEASES. eries (C. W. Townsend). The bleeding may be from the navel alone, but more commonly it is general. Of Townsend’s 50 cases, in 20 the blood came from the bowels {melcena neonatorum), in 14 from the stomach, in 14 from the mouth, in 12 from the nose, in 18 from the navel, in 3 from the navel alone. The bleeding begins within the first week, but in rare instances is delayed to the second or third. Thirty-one of the cases died and 19 recovered. The disease is usually of brief duration, death occur- ring in from one to seven days. The temperature is often elevated. The nature of the disease is unknown. As a rule, nothing abnormal is found post mortem. The general and not local nature of the affec- tion, its self-limited character, the presence of fever, and the greater prevalence of the disease in hospitals, suggest an infectious origin (Town- send). The bleeding may be associated with intense haematogenous jaun- dice. Not every case of bleeding from stomach or bowels belongs in this category. Ulcers of the oesophagus, stomach, and duodenum have been found in the new-born dead of melcena neonatorum. The child may draw the blood from the breast and subsequently vomit it. In the treatment the external warmth must be maintained, and in feeble infants the cou- veuse may be used. Camphor is recommended and ergotin hypodermic- ally. XII. HEMOPHILIA. Definition.—An hereditary, constitutional fault, characterized by a tendency to uncontrollable bleeding, either spontaneous or from slight wounds. It is sometimes associated with a form of arthritis. Early in the century several physicians of this country called attention to the occurrence of profuse haemorrhage from slight causes. The fact that fatal haemorrhage might occur from slight, trifling wounds had been known for centuries. The recognition of the family nature of the disease is due to the writings of Buel, Otto, Hay, Coates, and others in this coun- try. The disease has been elaborately treated in the monographs of Legg and Grandidier. Etiology.—In a majority of cases the disposition is hereditary. The fault may be acquired, however, but nothing is known of the conditions under which the disease may thus arise in healthy stock. The hereditary transmission in this disease is remarkable. In the Appleton-Swain family, of Reading, Mass., there have been cases for nearly two centuries; and F. F. Brown, of that town, tells me that in- stances have already occurred in the seventh generation. The usual mode of transmission is through the mother, who is not herself a bleeder, but the daughter of one. Atavism through the female alone is almost the rule, and the daughters of a bleeder, though healthy and free from any tendency, are almost certain to transmit the disposition to the male off- spring. The affection is much more common in males than in females, HEMOPHILIA. 349 the proportion being estimated at eleven to one, or even thirteen to one. The tendency usually appears within the first two years of life. It is rare for manifestations to be delayed until the tenth or twelfth year. Families in all conditions of life are affected. The bleeder families are usually large. The members are healthy-looking, and have fine, soft skins. Morbid Anatomy.—No special peculiarities have been described. In some instances changes have been found in the smaller vessels; but in others careful studies have been negative. An unusual thinness of the vessels has been noted. Haemorrhages have been found in and about the capsules of the joints, and in a few instances inflammation of the synovial surfaces. The nature of the disease is undetermined, and we do not yet know whether it depends upon a peculiar frailty of the blood-vessels or some peculiarity in the constitution of the blood, which prevents the nor- mal thrombus formation in a wound. Symptoms.—Usually haemophilia is not noted in the child until a trifling cut is followed by serious or uncontrollable haemorrhage, or spon- taneous bleeding occurs and presents insuperable difficulties in its arrest. The symptoms may be grouped under three divisions : external bleedings, spontaneous and traumatic; interstitial bleedings, petechiae and ecchy- moses; and the joint affections. The external bleedings may be spon- taneous, but more commonly they follow cuts and wounds. In 334 cases (Grandidier) the chief bleedings were epistaxis, 1G9; from the mouth, 43 ; stomach, 15; bowels, 36; urethra, 16; lungs, 17; and in a few instances bleeding from the skin of the head, the tongue, finger-tips, tear-papilla, eyelids, external ear, vulva, navel, and scrotum. Traumatic bleeding may result from blows, cuts, scratches, etc., and the blood may be diffused into the tissues or discharged externally. Trivial operations have proved fatal, such as the extraction of teeth, circumcision, or venesection. It is possible that there may be local defects which make bleeding from certain parts of the body more dangerous. D. Hayes Agnew mentioned to me the case of a bleeder who had always bled from cuts and bruises above the neck, never from those below. The bleeding is a capil- lary oozing. It may last for hours, or even many days. Epistaxis may prove fatal in twenty-four hours. In the slow bleeding from the mucous surfaces large blood tumors may form and project from the nose or mouth, forming remarkable-looking structures, and showing that the blood has the power of coagulation. The interstitial haemorrhages may be spontaneous, or may result from injury. Petechiae or large extravasa- tions—hasmatomata—may occur, the latter usually following blows. The joint affections of haemophilia are remarkable. There may simply be pain, or attacks which come on suddenly with fever, and closely resem- ble acute rheumatism. The larger joints are usually affected. Arthritis may usher in an attack of haemorrhage. So far as the examination of the blood goes, no changes of special moment have been noted. When the bleeding has been severe it is thin 350 CONSTITUTIONAL DISEASES. and watery, but at the beginning of the bleeding the blood is rich in corpuscles and coagulates firmly. Diagnosis.—In the diagnosis of the condition the family tendency is important. A single uncontrollable haemorrhage in child or adult is not to be ranked as haemophilia; but it is only when a person shows a marked tendency to multiple haemorrhages, spontaneous or traumatic, which tendency is not transitory but persists, particularly if there have been joint affections, that we may consider the condition haemophilia. Peliosis rheumatica is an affection which touches haemophilia very closely, particularly in the relation of the joint swelling. It may also show itself in several members of a family. The diagnosis from the various forms of purpura is usually easy. Prognosis. — The patients rarely die in the first bleeding. The younger the individual the worse is the outlook, though it is rarely fatal in the first year. Grandidier states that of 152 boy subjects, 81 died before the termination of the seventh year. The longer the bleeder survives the greater the chance of his outliving the tendency; but it may persist to old age, as shown in the case of Oliver Appleton, the first reported Ameri- can bleeder, who died at an advanced age of haemorrhage from a bed-sore and from the urethra. The prognosis is graver in a boy than in a girl. In the latter menstruation is sometimes early and excessive, but fortunate- ly, in the female members of haemopliilic families, neither this function nor the act of parturition brings with it special dangers. Treatment.—Members of a bleeder’s family, particularly the boys, should be guarded from injury, and operations of all sorts should be avoided. The daughters should not marry, as it is through them that the tendency is propagated. When an injury or wound has occurred, absolute rest and compression should first be tried, and if these fail the styptics may be used. In epis- taxis ice,tannin, and gallic acid maybe tried before resorting to plugging. Internally ergot seems to have done good in several cases. Legg advises the perchloride of iron in half-drachm doses every two hours with a purge of sulphate of soda. Venesection has been tried in several cases. Transfusion has been employed, but without success. During convales- cence, iron and arsenic should be freely used. SECTION III. DISEASES OF THE DIGESTIVE SYSTEM. I. DISEASES OF THE MOUTH. STOMATITIS. (1) Acute Stomatitis.—Simple or erythematous stomatitis, the com- monest form of inflammation of the mouth, results from the action of irritants of various sorts. It is frequent at all ages. In children it is often associated with dentition and with gastro-intestinal disturbance, particularly in ill-nourished, unhealthy subjects. In adults it follows the overuse of tobacco and the use of too hot or too highly seasoned food. It is a frequent concomitant of indigestion, and is met with in the acute spe- cific fevers. The affection may be limited to the gums and lips or may extend over the whole surface of the mouth and include the tongue. There is at first superficial redness and dryness of the membrane, followed by increased secretion and swelling of the tongue, which is furred, and indented by the teeth. There is rarely any constitutional disturbance, but in children there may be slight elevation of temperature. The condition is sufficient to cause considerable discomfort, sometimes amounting to actual distress and pain, particularly in mastication. In infants the mouth should be carefully sponged after each feeding. A mouth-wash of borax or the glycerine of borax may be used, and in se- vere cases, which tend to become chronic, a dilute solution of nitrate of silver (three or four grains to the ounce) may be applied. (2) Aphthous Stomatitis.—This form, also known as follicular or ve- sicular stomatitis, is characterized by the presence of small, slightly raised spots, from two to four millimetres in diameter, surrounded by reddened areolas. The spots appear first as vesicles, which rupture, leaving small ulcers with grayish bases and bright-red margins. They are seen most frequently on the inner surfaces of the lips, the edges of the tongue, and the cheeks. They are seldom present on the mucous membrane of the pharynx. This form is met with most often in children under three years. It may occur either as an independent affection or in association with any 352 DISEASES OF THE DIGESTIVE SYSTEM. one of the febrile diseases of childhood or with an attack of indigestion. The crop of vesicles conies out with great rapidity and the little ulcers may be fully formed within twenty-four hours. The child complains of soreness of the mouth and takes food with reluctance. The buccal secre- tions are increased, and the breath is heavy, but not foul. The constitu- tional symptoms are usually those of the disease with which the aphthae are associated. The disease must not be confounded with thrush. No special parasite has been found in connection with it. It is not a serious condition, and heals rapidly with the improvement of the constitutional state. In severe cases it may extend to the pillars of the fauces and to the pharynx, and produce ulcers which are irritating and difficult to heal. Each ulcer should be touched with nitrate of silver and the mouth should be thoroughly cleansed after taking food. A wash of chlorate of potash, or of borax and glycerine, may be used. The constitutional symp- toms should receive careful attention. Here may be mentioned a curious affection which has been observed chiefly in southern Italy, and which is characterized by a pearly-colored membrane with induration, immediately beneath the tongue on the frgenum (Riga’s disease). There may be much induration and ultimately ulceration. It occurs in both healthy and cachetic children, usually about the time of the eruption of the first teeth. It is sometimes epidemic. (3) Ulcerative Stomatitis.—This form, which is also known by the names of fetid stomatitis, or putrid sore mouth, occurs particularly in children after the first dentition. It may prevail as a wide-spread epi- demic in institutions in which the sanitary conditions are defective. It has been met with in jails and camps. Insufficient and unwholesome food, improper ventilation, and prolonged damp, cold weather seem to be special predisposing causes. Lack of cleanliness of the mouth, the presence of carious teeth, and the collection of tartar around them favor the development of the disease. The affection spreads like a specific dis- ease, but the microbe has not yet been isolated. It has been held that the disease is the same as the foot-and-mouth disease of cattle, and that it is conveyed by the milk, but there is no positive evidence on these points. Payne suggests that the virus is identical with that of conta- gious impetigo. The morbid process begins at the margin of the gums, which become swollen and red, and bleed readily. TJlcers form, the bases of which are covered with a grayish-white, firmly adherent membrane. In severe cases the teeth may become loosened and necrosis of the alveolar process may occur. The ulcers extend along the gum-line of the upper and lower jaws; the tongue, lips, and mucosa of the cheeks are usually swollen, but rarely ulcerated. There is salivation, the breath is foul, and mastication is painful. The submaxillary lymph glands are enlarged. An exanthem often develops and may be mistaken for measles. The constitutional STOMATITIS. 353 symptoms are often severe, and in institutions death sometimes results in the case of debilitated children. In the treatment of this form of stomatitis chlorate of potash has been found to be almost specific. It should be given in doses of ten grains, three times a day, to a child, and to an adult double that amount. Locally it may be used as a mouth-wash, or the powdered salt may be ap- plied directly to the ulcerated surfaces. When there is much fetor a per- manganate-of-potash wash may be used, and an application of nitrate of silver may be made to the ulcers. There are several other varieties of ulcerative sore mouth, which differ entirely from this form. Ulcers of the mouth are common in nursing women, and are usually seen on the mucous membrane of the lips and cheeks. They develop from the mucous follicles, and are from three to five millimetres in diameter. They may cause little or no inconvenience; but in some instances they are very painful and interfere seriously with the taking of food and its mastication. As a rule they heal readily after the application of nitrate of silver, and the condition is an indication for tonics, fresh air, and a better diet. Recurring outbreaks of an herpetic, even pemphigoid, eruption are seen in neurotic individuals (stomatitis neurotica chronica, Jacobi). In some cases it is associated with an erythema multiforme. Parrot describes the occasional appearance in the new-born of small ulcers symmetrically placed on the hard palate on either side of the middle line. They are met with in very debilitated children. The' ulcers rarely heal; usually they tend to increase in size, and may involve the bone. Bednar’s aphthae consist of small patches and ulcers on the hard palate, caused as a rule in young infants by the artificial nipple or the nurse’s finger. (4) Parasitic Stomatitis (Thrush; Soor; Muguet).—This affection, most commonly seen in children, is dependent upon a fungus, the sac- charomyces albicans, called by Robin the oidiuni albicans. It belongs to the order of yeast fungi, and consists of branching filaments, from the ends of which ovoid torula cells develop. The disease does not arise appar- ently in a normal mucosa. The use of an improper diet, uncleanliness of the mouth, the acid fermentation of remnants of food, or the development, from any cause, of catarrhal stomatitis predispose to the growth of the fungus. In institutions it is frequently transmitted by unclean feeding- bottles, spoons, etc. It is not confined to children, but is met with in adults in the final stages of fever, in chronic tuberculosis, diabetes, and in cachectic states. The parasite develops in the upper layers of the mucosa, and the filaments form a dense felt-work among the epithelial cells. The disease begins on the tongue and is seen in the form of slightly raised, pearly-white spots, which increase in size and gradually coalesce. The membrane thus formed can be readily scraped off, leaving an intact mu- cosa, or, if the process extends deeply, a bleeding, slightly ulcerated sur- 354 DISEASES OF THE DIGESTIVE SYSTEM. face. The disease spreads to the cheeks, lips, and hard palate, and may involve the tonsils and pharynx. In very severe cases the entire buccal mucosa is covered by the grayish-white membrane. It may even extend into the oesophagus and, according to Parrot, to the stomach and caecum. It is occasionally met with on the vocal cords. Robust, well-nourished children are sometimes affected, but it is usually met with in enfeebled, emaciated infants with digestive or intestinal troubles. In such cases the disease may persist for months. The affection is readily recognized, and must not be confounded with aphthous stomatitis, in which the ulcers, preceded by the formation of vesicles, are perfectly distinctive. In thrush the microscopical examina- tion shows the presence of the characteristic fungus throughout the mem- brane. In this condition, too, the mouth is usually dry—a striking contrast to the salivation accompanying aphthae. Thrush is more readily prevented than removed. The child’s mouth should be kept scrupulously clean, and, if artificially fed, the bottles should be thoroughly sterilized. Lime-water or any other alkaline fluid, such as the bicarbonate of soda (a drachm to a tumbler of water), may be employed. When the patches are present these alkaline mouth-washes may be continued after each feeding. A spray of borax or of sulphite of soda (a drachm to the ounce) or the black wash with glycerine may be employed. The permanganate of potassium is also useful. The con- stitutional treatment is of equal importance, and it will often be found that the thrush persists, in spite of all local measures, until the general health of the infant is improved by change of air or the relief of the diar- rhoea, or, in obstinate cases, the substitution of a natural for the artificial diet. (5) Gangrenous Stomatitis (Cancrum Oris; Noma).—An affection characterized by a rapidly progressing gangrene, starting on the gums or cheeks, and leading to extensive sloughing and destruction. This terrible but fortunately rare disease is seen only in children under very insanitary conditions or during convalescence from the acute fevers. It is more common in girls than in boys. It is met with between the ages of two and five years. In at least one half of the cases the disease has developed during convalescence from measles. Cases have been seen also after scar- let fever and typhoid. The mucous membrane is first affected, usually of the gums or of one cheek. It begins insidiously, and when first seen there is a sloughing ulcer of the mucous membrane, which spreads rapidly and leads to brawny induration of the skin and adjacent parts. The sloughing extends, and in severe cases the cheek is perforated. The disease may spread to the tongue and chin; it may invade the bones of the jaws and even in- volve the eyelids and ears. In mild cases an ulcer forms on the inner surface of the cheek, which heals or may perforate and leave a fistulous opening. Naturally in such a severe affection the constitutional disturb- ance is very great, the pulse is rapid, the prostration extreme, and death STOMATITIS. 355 usually takes place within a week or ten days. The temperature may reach 103° or 104°. Diarrhoea is usually present, and aspiration pneumonia often develops. II. E. Wharton has described a case in Avhich there was extensive colitis. Lingard has found in cases of noma a thread-like bacillus, but its precise relation to the disease is doubtful. The highly refractile bodies described by Sansom in the blood were probably blood- plates. The treatment of the disease is unsatisfactory. In many cases the onset is so insidious that there is an extensive sloughing sore when the case first comes under observation. Destruction of the sore by the cautery, either the Paquelin or fuming nitric acid, is the most effectual. Antisep- tic applications should be made to destroy the fetor. The child should be carefully nourished and stimulants given freely. (6) Mercurial Stomatitis (Ptyalism).—An inflammation of the mouth and salivary glands caused by mercury, which occurs chiefly in persons who have a special susceptibility, and rarely now as a result of the excessive use of the drug. It is met with also in persons whose occupation neces- sitates the constant handling of mercury. It often follows the adminis- tration of repeated small doses. Thus, a patient with heart disease who was ordered an eighth of a grain of calomel every three hours for diu- retic purposes had, after taking eight or ten doses, a severe stomatitis, which persisted for several weeks. I have known it to follow also the admin- istration of small doses of gray powder. The patient complains first of a metallic taste in the mouth, the gums become swollen, red, and sore, mas- tication is difficult, and soon there is a great increase in the secretion of the saliva, which flows freely from the mouth. The tongue is swollen, the breath has a foul odor, and, if the affection progresses, there may be ulceration of the mucosa, and, in rare instances, necrosis of the jaw. Al- though troublesome and distressing, the disease is rarely serious, and re- covery usually takes place in a couple of weeks. Instances in which the teeth become loosened or detached or in which the inflammation extends to the pharynx and Eustachian tubes are rarely seen now. The administration of mercury should be suspended so soon as the gums are “touched.” Mild cases of the affection subside within a.few days and require only a simple mouth-wash. In severer cases the chlorate of potash may be given internally and used to rinse the mouth. The bowels should be freely opened; the patient should take a hot bath every evening and should drink plentifully of alkaline mineral waters. Atropine is sometimes serviceable, and may be given in doses of one one hundredth of a grain twice a day. Iodine is also recommended. When the salivation is severe and protracted the patient becomes much debilitated, anaemia de- velops, and a supporting treatment is indicated. The diet is necessarily liquid, for the patient finds the chief difficulty in taking food. If the pain is severe a Dover powder may be given at night. Here may be appropriately mentioned the influence of stomatitis, par- 356 DISEASES OF THE DIGESTIVE SYSTExM. ticularly the mercurial form, upon the developing teeth of children. The condition known as erosion, in which the teeth are honeycombed or pitted owing to defective formation of enamel, is indicative as a rule of infantile stomatitis. Such teeth must be distinguished carefully from those of congenital syphilis, which may of course coexist, but the two conditions are distinct. The honeycombing is frequently seen on the incisors; but, according to Jonathan Hutchinson, the test teeth of infan- tile stomatitis are the first permanent molars, then the incisors, “ which are almost as constantly pitted, eroded, and of bad color, often showing the transverse furrow which crosses all the teeth at the same level.” Magitot regards these transverse furrows as the result of infantile convulsions or of severe illness during early life. He thinks they are analogous to the furrows on the nails which so often follow a serious disease. (7) Eczema of the Tongue (Geographical Tongue).—A remarkable desquamation of the superficial epithelium of the tongue in circinate patches, which spread while the central portions heal. Fusion of patches leads to areas with sinuous outlines. When extensive the tongue may be covered with these areas, like a geographical map. The affection causes a good deal of itching and heat, and may be a source of much mental worry to the patients, who often dread lest it may be a commencing cancer. The etiology of the disease is unknown. It occurs in infants and children, and it is not very infrequent in adults. It has been regarded as a gouty manifestation, and transient attacks may accompany indigestion. It is very liable to relapse. In adults it may prove very obstinate, and I know of one instance in which the disease persisted in spite of all treat- ment for more than two years. Solutions of nitrate of silver give the most satisfactory results in relieving the intense burning. (8) Leukoplakia buccalis.—Samuel Plumbe described the condition as icthyosis lingualee. It has also been called buccal psoriasis and keratosis mucosae oris. There are unsymmetrical patches of various shapes, whitish or often pearly white in color, smooth, and without any tendency to ulcerate. They have been called lingual corns. The intensity of the opaque white color depends upon the thickness of the epidermis. The patches may extend and become slightly papillomatous. There are in- stances in which genuine epithelioma has developed from them. The condition is met with most commonly in heavy smokers, and is sometimes known as the smoker’s tongue. An interesting question is the relation to syphilis. While somewhat similar patches develop in infected persons, the true syphilitic glossitis rarely presents the same opaque white, smooth appearance. It is more commonly at the edge and the point of the tongue than on the dorsum, and yields promptly to specific treatment. Leukoplakia is a very obstinate affection and resists as a rule all forms of treatment. All irritants, such as smoke and very hot food, should be avoided. Local treatment with one-half-per-cent corrosive sublimate or a one-per-cent chromic-acid solution has been recommended. The propriety DISEASES OF THE PHARYNX. 357 of active local treatment is doubtful. The appearance of anything like papillomatous outgrowths should be regarded as an indication for surgical intervention. II. DISEASES OF THE SALIVARY GLANDS. 1. Hypersecretion (Ptyalism).—The normal amount of saliva varies from two to three pints in the twenty-four hours. The secretion is in- creased during the taking of food and in the physiological processes of dentition. A great increase, to which the term ptyalism is applied, is met with under many circumstances. It occurs occasionally in mental and nervous affections and in rabies. Occasionally it is seen in the acute fevers, particularly in small-pox. It has been met with during gestation, usually early, though it may persist throughout the entire course. It has been known to occur at each menstrual period; and, lastly, it is a com- mon effect of certain drugs. Mercury, gold, copper, the iodine com- pounds, and (among vegetable remedies) jaborandi, muscarin, and tobacco excite the salivary secretion. Of these we most frequently see the effect of mercury in producing ptyalism. The salivation may be present with- out any inflammation of the mouth. 2. Xerostomia (Arrest of the Salivary and Buccal Secretions; Dry Mouth).—In this condition, first described by Jonathan Hutchinson, the secretions of the mouth and salivary glands are suppressed. The tongue is red, sometimes cracked, and quite dry; the mucous membrane of the cheeks and of the palate is smooth, shining, and dry; and mastication, deglutition, and articulation are very difficult. The condition is not com- mon. A majority of the cases are in women, and in several instances have been associated with nervous phenomena. The general health, as a rule, is unimpaired. Hadden suggests that it is due to involvement of some centre which controls the secretion of the salivary and buccal glands. A well-marked case came under my observation in a man aged thirty-two, who was sent to me by Donald Baynes on account of a peculiar growth along the gums. This proved to be the remnants of food which, owing to the absence of any salivary or buccal secretions, collected along the gums, became hardened, and adhered to them. The condition lasted for three weeks, and was cured by the galvanic current.* 3. Inflammation of the Salivary Glands. (a) Specific Parotitis. (See Mumps.) (b) Symptomatic parotitis or parotid bubo occurs: (1) In the course of the infectious fevers—typhus, typhoid, pneumo- nia, pyaemia, etc. In ordinary practice it occurs oftenest, perhaps, in typhoid fever. It is the result either of septic infection through the blood, or the in- * Canada Medical and Surgical Journal, vol. v, p. 439, 1877. 358 DISEASES OF THE DIGESTIVE SYSTEM. flammation, in many cases, passes up the salivary duct, and so reaches the gland. The process is usually very intense and leads rapidly to suppura- tion. It is, as a rule, an unfavorable indication in the course of a fever. I have seen recently parotitis in secondary syphilis. (2) In connection with injury or disease of the abdomen or pelvis, a condition to which Stephen Paget has called special attention. Of 101 cases of this kind, “ 10 followed injury or disease of the urinary tract, 18 were due to injury or disease of the alimentary canal, and 23 were due to injury or disease of the abdominal wall, the peritonaeum, or the pelvic cellular tissue. The remaining 50 were due to injury, disease, or tempo- rary derangement of the genital organs.” By temporary derangement is meant slight injuries or natural processes—a slight blow on the testis, the introduction of a pessary, menstruation, or pregnancy. The etiology of this form of parotitis is obscure. Many of the cases are undoubtedly septic. (3) In association with facial paralysis, as in a case of fatal peripheral neuritis described by Gowers. In the treatment of parotid bubo the application of half a dozen leeches will sometimes reduce the inflammation and promote resolution. When suppuration seems inevitable hot fomentations should be applied. A free incision should be made early. (c) Chronic parotitis, a condition in which the glands are enlarged, sometimes painful, has been described, following in one case inflammation of the throat, in another mumps. Salivation may be present. It may be due to lead or mercury. It is met with occasionally in chronic Bright’s disease. I have under my care at present a young girl, aged thirteen, with hereditary syphilis, who has had for nearly a year enlargement of all the salivary glands, the lachrymal glands, the buccal mucous glands, and the spleen. III. DISEASES OF THE PIIARYXX. (1) Circulatory Disturbances.—(a) Hypermmia is a common condition in acute and chronic affections of the throat, and is frequently seen as a result of the irritation of tobacco smoke. Venous stasis is seen in valvular disease of the heart, and in mechanical obstruction of the superior vena cava by tumor or aneurism. In aortic insufficiency the capillary pulse may sometimes be seen and the intense throbbing of the internal carotid may be mistaken for aneurism. {!)) Hcemorrhage is found in association with bleeding from other mucous surfaces, or it is due to local causes in the pharynx itself. In the latter case it may be mistaken for haemorrhage from the lungs or stomach. The bleeding may come from granulations or vegetations in the naso-pharynx. Sometimes the patient finds the pillow stained in the morning with bloody secretion. The condition is rarely serious, and only DISEASES OF THE PHARYNX. 359 requires suitable local treatment of the pharynx. Occasionally a haemor- rhage takes place into the mucosa, producing a pharyngeal haematoma. I have thrice seen a condition of the uvula resembling haemorrhagic infarc- tion. One was in a patient with acute rheumatism, to whom large doses of salicylic acid had been given; the other two were instances of peliosis rheumatica, in both of which partial sloughing of the uvula took place. (c) (Edema.—An infiltrated cedematous condition of the uvula and adjacent parts is not very uncommon in conditions of debility, in pro- found anaemia, and in Bright’s disease. The uvula is sometimes from this cause enormously enlarged, and may lead to difficulty in swallowing or in breathing. (2) Acute Pharyngitis (Sore Throat; Angina Simplex).—The entire pharyngeal structures, often with the tonsils, are involved. The condi- tion may follow cold or exposure. In other instances it is associated with constitutional states, such as rheumatism or gout, or with digestive dis- orders. The patient complains of uneasiness and soreness in swallowing, of a feeling of tickling and dryness in the throat, together with a con- stant desire to hawk and cough. Frequently the inflammation extends into the larynx and produces hoarseness. Not uncommonly it is only part of a general naso-pharyngeal catarrh. The process may pass into the Eustachian tubes and cause slight • deafness. There is stiffness of the neck, the lymph glands of which may be enlarged and painful. The constitutional symptoms are rarely severe. The disease sets in with a chilly feeling and slight fever, and the pulse is increased in frequency. Occasionally the febrile symptoms are more severe, particularly if the tonsils are specially involved. The examination of the throat shows gen- eral congestion of the mucous membrane, which is dry and glistening, and in places covered with sticky secretion. The uvula may be much swollen. Acute pharyngitis lasts only a few days and requires mild measures. If the tonsils are involved and the fever is high, aconite or sodium salicylate may be given. G-uaiacum also is beneficial; but in a majority of the cases a calomel purge or a saline aperient and inhalations with steam meet the indications. (3) Chronic Pharyngitis.—This may follow repeated acute attacks. It is very common in persons who smoke or drink to excess, and in those who use the voice very much, such as clergymen, hucksters, and others. It is frequently met with in chronic nasal catarrh. The naso-pharynx and the posterior wall are the parts most frequently affected. The mucous membrane is relaxed, the venules are dilated, and roundish bodies, from two to four millimetres in diameter, reddish in color, pro- ject to a variable distance beyond the mucous membrane. These repre- sent the proliferations of lymph tissue about the mucous glands. They may be very abundant, forming elongated rows in the lateral walls of the pharynx. With this there may be a dry glistening state of the 360 DISEASES OF THE DIGESTIVE SYSTEM. pharyngeal mncosa, sometimes known as phary7igitis sicca. The pillars of the fauces, and the uvula are often much relaxed. The secretion forms at the hack of the pharynx and the patient may feel it drop down from the vault, or it is tenacious and adherent, and is only removed by re- peated efforts at hawking. In the treatment, special attention must be paid to the general health. If possible, the cause should be ascertained. The condition is almost constant in smokers, and cannot be cured without stopping the use of tobacco. The use of food either too hot or too much spiced should he for- bidden. When it depends upon excessive exercise of the voice, rest should be enjoined. In many of these cases change of air and tonics help very much. In the local treatment of the throat gargles, washes, and pastilles of various sorts give temporary relief, but when the hypertrophic condi- tion is marked the spots should be thoroughly destroyed by the galvano- cautery. In many instances this affords great and permanent relief, but in others the condition persists, and as it is not unbearable, the patient gives up all hope of permanent relief. (4) Ulceration of the Pharynx.—(a) Follicular. The ulcers are usu- ally small, superficial, and generally associated with chronic catarrh. (b) Syphilitic ulcers are usually painless, and most frequently situated on the posterior wall of the pharynx. They occur in the secondary stage as small, shallow excavations with the mucous patches. In the tertiary stage the ulcers are due to erosion of gummata, and in healing they leave whitish cicatrices. (c) Tuberculous ulceration is not very uncommon in advanced cases of phthisis, and, if extensive, is one of the most distressing features of the later stages of the disease. The ulcers are irregular, with ill-defined edges and grayish-yelloAV bases. The posterior wall of the pharynx may have an eroded, worm-eaten appearance. These ulcers are, as a rule, intensely painful. (cl) Ulcers occur in connection with pseudo-membranous inflamma- tion, particularly the diphtheritic. In cancer and in lupus ulcers are also present. (e) Ulcers are met with in certain of the fevers, particularly in typhoid. In many instances the diagnosis of the nature of pharyngeal ulcers is very difficult. The tuberculous and cancerous varieties are readily recog- nized, but it happens not infrequently that a doubt arises as to the syphilitic character of an ulcer. In many instances the local condi- tions may be uncertain. Then other evidences of syphilis should be sought for, and the patient should be placed on mercury and iodide of potassium, under which remedies syphilitic ulcers usually heal with great rapidity. (5) Acute Infectious Phlegmon of the Pharynx.—Under this term Senator has described cases in which, along with difficulty in swallowing, soreness of the throat, and sometimes hoarseness, the neck enlarges, the ACUTE TONSILLITIS. 361 pharyngeal mucosa becomes swollen and injected, the fever is high, the constitutional symptoms are severe, and the inflammation passes on rap- idly to suppuration. The symptoms are very intense. The swelling of the pharyngeal tissues early reaches such a grade as to impede respiration. Very similar symptoms may be produced by foreign bodies in the pharynx. (6) Retro-pharyngeal abscess occurs : (1) In healthy children between six months and two years. The child becomes restless, the voice changes and is nasal or metallic in t©ne, and there are pain and difficulty in swallowing. Inspection of the pharynx reveals a projecting tumor in the middle line, or it may not be visible, but is readily felt on palpation pro- jecting from the posterior wall. This form has been carefully described by Koplik. (2) As a not infrequent sequel of the fevers, particularly of scarlet fever and diphtheria. (3) In caries of the bodies of the cervical vertebrae. The diagnosis is readily made, as the projecting tumor can be seen, and felt with the finger on the posterior wall of the pharynx. (7) Angina Ludovici (Ludwig's Angina; Cellulitis of the Neck).—In medical practice this is seen as a secondary inflammation in the specific fevers, particularly diphtheria and scarlet fever. It may, however, occur idiopathically or result from trauma. It is probably always a streptococcus infection which spreads rapidly from the glands. The swelling at first is most marked in the submaxillary region of one side. The symptoms are, as a rule, intense, and, unless early and thorough surgical measures are em- ployed, there is great risk of systemic infection. Felix Semon holds that the various acute septic inflammations of the throat—acute oedema of the larynx, phlegmon of the pharynx and larynx, and angina Ludovici— “ represent degrees varying in virulence of one and the same process.” IY. DISEASES OF THE TONSILS. ACUTE TONSILLITIS. (1) Follicular or Lacunar Tonsillitis.—For practical purposes, under this name may be described the various forms which have been called ca- tarrhal, erythematous, ulcero-membranous, and herpetic. Etiology.—The disease is met with most frequently in young per- sons, but in children under ten it is less common than the chronic form. It is rare in infants. Sex has no special influence. Exposure to wet and cold, and bad hygienic surroundings appear to have a direct etiological connection with the disease. In so many instances defective drainage has been found associated with outbreaks of follicular tonsillitis that sewer-gas is regarded as a common exciting cause. One attack renders a patient more liable to subsequent infection. Special stress is laid by some writers upon the coexistence of tonsillitis with rheumatism. Cheadle describes it as one of the phases of rheumatism in childhood with which articular at- tacks may alternate. I cannot say that, in my experience, the connection 362 DISEASES OF THE DIGESTIVE SYSTEM. between the two affections has been very striking, except in one point, viz., that an attack of acute rheumatism is not infrequently preceded by in- flammation of the tonsils. The existence of pains in the limbs is no evi- dence of the connection of the affection with rheumatism. A disease so common and wide-spread as acute tonsillitis necessarily attacks many per- sons in whose families rheumatism prevails or who may themselves have had acute attacks. Mackenzie gives a table showing that in four successive years more cases occurred in September than in any other month; in October nearly as many, with July, August, and November next. In this country it seems more prevalent in the spring. So many cases develop within a short time that the disease may be almost epidemic. It spreads through a family in such a way that it must be regarded as contagious. An old notion prevails that there is a definite relation between the tonsils and the testes and ovaries. F. J. Shepherd has called attention to the circumstance that acute tonsillitis is a very common affection in newly married persons. That view is probably correct which regards tonsillitis as a local disease with severe constitutional manifestations, although the fever is often high in proportion to the local symptoms. The commonest organism found in tonsillitis is a streptococcus. Staphylococci also occur. In some cases the bacillus diphtheria of Loeffler have been found, but they do not always possess the full virulence (see Atypical Forms of Diph- theria). Morbid Anatomy.—The lacunae of the tonsils become filled with exudation products, which form cheesy-looking masses, projecting from the orifices of the crypts. Not infrequently the exudations of contiguous lacunae coalesce. The intervening mucosa is usually swollen, deep-red in color, and may present herpetic vesicles or, in some instances, even mem- branous exudation, in which case it may be difficult to distinguish the condition from diphtheria. The creamy contents of the crypt are made up of micrococci and epithelial debris. Symptoms.—Chilly feelings, or even a definite chill, and aching pains in the back and limbs may precede the onset. The fever rises rap- idly, and in the case of a young child may reach 105° on the evening of the first day. The patient complains of soreness of the throat and diffi- culty in swallowing. On examination, the tonsils are seen to be swollen and the crypts present the characteristic creamy exudate. The tongue is furred, the breath is heavy and foul, and the urine is highly colored and loaded with urates. In children the respirations are usually very hurried, and the pulse is greatly increased in rapidity. Swallowing is painful, and the voice often becomes nasal. Slight swelling of the cervical glands is present. In severe cases the symptoms increase and the tonsils become still more swollen. The inflammation gradually subsides, and, as a rule, within a week the fever departs and the local symptoms greatly improve. The tonsils, however, remain somewhat swollen. The prostration and ACUTE TONSILLITIS. 363 constitutional disturbance are often out of proportion to the intensity of the local disease. There are complications which occasionally excite uneasiness. Febrile albuminuria is not uncommon, as Haig-Brown has pointed out. Cases of endocarditis or pericarditis have been found. It is to be borne in mind that in children an apex systolic murmur is by no means uncommon at the height of any fever. The disease may extend to the middle ear. The development of paralytic symptoms, local or general, after an attack which has been regarded as follicular tonsillitis indicates an error in diag- nosis. A diffuse erythema may develop, simulating scarlet fever. Diagnosis.—It may be difficult to distinguish follicular tonsillitis from diphtheria. It would seem, indeed, as if there were intermediate forms between the mildest lacunar and the severer pseudo-membranous tonsillitis. In the follicular form the individual yellowish-gray masses, separated by the reddish tonsillar tissue, are very characteristic; whereas in diphtheria the membrane is of ashy gray, and uniform,, not patchy. A point of the greatest importance in diphtheria is that the membrane is not limited to the tonsils, but creeps up the pillars of the fauces or appears on the uvula. The diphtheritic membrane when removed leaves a bleeding, eroded surface; whereas the exudation of lacunar tonsillitis is easily sepa- rated, and there is no erosion beneath it. In all doubtful cases cultures should, if possible, be made to determine the presence of Loeffler’s bacillus. (2) Suppurative Tonsillitis. Etiology.—This arises under conditions very similar to those men- tioned in the lacunar form. It may follow exposure to cold or wet, and is particularly liable to recur. It is most common in adolescence. The in- flammation is here more deeply seated. It involves the stroma, and tends to go on to suppuration. Symptoms.—The constitutional disturbance is very great. The temperature rises to 104° or 105°, and the pulse ranges from 110 to 130. Nocturnal delirium is not uncommon. The prostration may be extreme. There is no local disease of similar extent which so rapidly exhausts the strength of a patient. Soreness and dryness of the throat, with pain in swallowing, are the symptoms of which the patient first complains. One or both tonsils may be involved. They are enlarged, firm to the touch, dusky red and cedematous, and the contiguous parts are also much swol- len. The swelling of the glands may be so great that they meet in the middle line, or one tonsil may even push the uvula aside and almost touch the other gland. The salivary and buccal secretions are increased. The glands of the neck enlarge, the lower jaw is fixed, and the patient is un- able to open his mouth. In from two to four days the enlarged gland becomes softer, and fluctuation can be distinctly felt by placing one finger on the tonsil and the other at the angle of the jaw. The abscess usually points toward the mouth, but it may point toward the pharynx. It may burst spontaneously, affording instant and great relief. Suffocation has 364 DISEASES OF THE DIGESTIVE SYSTEM. followed the rupture of a large abscess and the entrance of the pus into the larynx. When the suppuration is peritonsillar and extensive, the internal carotid artery may be opened; but these are, fortunately, very rare accidents. Treatment.—In the follicular form aconite may be given in full doses. It acts very beneficially in children. The salicylates, given freely at the outset, are regarded by some as specific, but I have seen no evidence of such prompt and decisive action. At night, a full dose of Dover’s pow- der may be given. The use of guaiacum, in the form of two-grain loz- enges, is warmly recommended. Iron and quinine should be reserved until the fever has subsided. A pad of spongio-piline or thick flannel dipped in ice-cold water may be applied around the neck and covered with oiled silk. More convenient still is a small ice-bag. Locally the tonsils may be treated with the dry sodium bicarbonate. The moistened finger-tip is dipped into the soda, which is then rubbed gently on the gland and repeated every hour. Astringent preparations, such as iron and glycerine, alum, zinc, and nitrate of silver, may be tried. To cleanse and disinfect the throat, solutions of borax or thymol in glycerine and water may be used. In suppurative tonsillitis hot applications in the form of poultices and fomentations are more comfortable and better than the ice-bag. The gland should be felt—it cannot always be seen—from time to time, and should be opened when fluctuation is distinct. The progress of the dis- ease may be shortened and the patient spared several days of great suffer- ing if the gland is scarified early. The curved bistoury, guarded nearly to the point with plaster or cotton, is the most satisfactory instrument. The incision should be made from above downward, parallel with the an- terior pillar. There are cases in which, before suppuration takes place, the parenchymatous swelling is so great that the patient is threatened with suffocation. In such instances the tonsil must either be excised or tracheotomy or, possibly, intubation performed. Delavan refers to two cases in which he states that tracheotomy would, under these circum- stances, have saved life. Patients with this affection require a nourishing liquid diet, and during convalescence iron in full doses. CHRONIC TONSILLITIS. (Chronic Naso-pharyngeal Obstruction; Mouth-Breathing; Aprosexia.) Under this heading will be considered also hypertrophy of the adenoid tissue in the vault of the pharynx, sometimes known as the pharyngeal tonsil, as the affection usually involves both the tonsils proper and this tissue, and the symptoms are not to be differentiated. Chronic enlargement of the tonsillar tissues is an affection of great im- portance, and may influence in an extraordinary way the mental and bodily development of children. CHRONIC TONSILLITIS. 365 Etiology.—Hypertrophy of the tonsillar structures is occasionally congenital. Cases are perhaps most frequent in children, during the third hemi-decade. The condition also occurs in young adults, more rarely in the middle-aged. The enlargement may follow diphtheria or the eruptive fevers. The frequency of the occurrence of adenoid growths in the naso- pharynx has been variously stated. Meyer, to whom the profession is in- debted for calling attention to the subject, found them in about one per cent of the children in Copenhagen, while Chappell found sixty cases in the examination of two thousand children in Hew York. These figures give a very moderate estimate of the prevalence of the trouble. It occurs equally in boys and girls, according to some writers with greater preva- lence in the former. Morbid Anatomy.—The tonsils proper present a condition of chronic hypertrophy, due to multiplication of all the constituents of the glands. The lymphoid elements may be chiefly involved without much development of the stroma. In other instances the fibrous matrix is in- creased, and the organ is then harder, smaller, firmer, and is cut with much greater difficulty. The adenoid growths, which spring from the vault of the pharynx, form masses varying in size from a small pea to an almond. They may be sessile, with broad bases, or pedunculated. They are reddish in color, of moderate firmness, and contain numerous blood-vessels. “ Abundant, as a rule, over the vault, on a line with the fossa of the Eustachian tube, the growths may lie posterior to the fossa—namely, in the depression known as the fossa of Kosenmuller, or upon the parts which are parallel to the posterior wall of the pharynx. The growths appear to spring in the main from the mucous membrane covering the localities where the connective tissue fills in the inequalities of the base of the skull ” (Har- rison Allen). The growths are most frequently papillomatous with a lymphoid parenchyma. Hypertrophy of the pharyngeal adenoid tissue may be present without great enlargement of the tonsils proper. Chronic catarrh of the nose usually coexists. Symptoms.—The direct effect of chronic tonsillar hypertrophy is the establishment of month-breathing. The indirect effects are deforma- tion of the thorax, changes in the facial expression, sometimes marked alteration in the mental condition, and in certain cases stunting of the growth. Woods Hutchinson has suggested that the embryological rela- tion of these structures with the pituitary body may account for the in- terference with development. The establishment of mouth-breathing is the symptom which first attracts the attention. It is not so noticeable by day, although the child may present the vacant expression characteristic of this condition. At night the child’s sleep is greatly disturbed ; the respirations are loud and snorting, and there are sometimes prolonged pauses, followed by deep, noisy inspirations. The pulse may vary strangely during these attacks, and in the prolonged intervals may be slow, to in- 366 DISEASES OF THE DIGESTIVE SYSTEM. crease greatly with the forced inspirations. The ala? nasi should be ob- served during the sleep of the child, as they are sometimes much retracted during inspiration, due to a laxity of the walls, a condition readily reme- died by the use of a soft wire dilator. Night terrors are common. The child may wake up in a paroxysm of shortness of breath. Some of these nocturnal attacks may be due to reflex spasm of the glottis. During the day there may be choking fits when eating. When the mouth-breathing has persisted for a long time definite changes are brought about in the face, mouth, and chest. The facies is so peculiar and distinctive that the condition may be evident at a glance. The expression is dull, heavy, and apathetic, due in part to the fact that the mouth is habitually left open. In long-standing cases the child is very stupid-looking, responds slowly to questions, and may be sullen and cross. The lips are thick, the nasal orifices small and pinched-in looking, and the superior dental arch is narrowed and the roof of the mouth con- siderably raised. The remarkable alterations in the shape of the chest in connection with enlarged tonsils were first carefully studied by Dupuytren (1828), who evidently fully appreciated the great importance of the condition. He noted “ a lateral depression of the parietes of the chest consisting of a depression, more or less great, of the ribs on each side, and a proportionate protrusion of the sternum in front.” J. Mason Warren (Medical Exam- iner, 1839) gave an admirable description of the constitutional symptoms and the thoracic deformities induced by enlarged tonsils. These, with the memoir of Lambron (1861), constitute the most important contribu- tions to our knowledge on the subject. Three types of deformity may be recognized: {a) The Pigeon or Chicken Breast, by far the most common form, in which the sternum is prominent and there is a circular depression in the lateral zone (Harrison’s groove), corresponding to the attachment of the diaphragm. The ribs are prominent anteriorly and the sternum is angu- lated forward at the manubrio-gladiolar junction. As a mouth-breather is watched during sleep, one can see the lower and lateral thoracic regions retracted during inspiration by the action of the diaphragm. (b) Barrel Chest.—Some children, the subject of chronic naso-pharyn- geal obstruction, have recurring attacks of asthma, and the chest may be gradually deformed, becoming rounded and barrel-shaped, the neck short, and the shoulders and back bowed. A child of ten or eleven may have the thoracic conformation of an old man with emphysema. (c) The Funnel Breast (Trichter-brust).—This remarkable deformity, in which there is a deep depression at the lower sternum, has excited much controversy as to its mode of origin. I believe that in some in- stances, at least, it is due to the obstructed breathing in connection with adenoid vegetations. Within the past three years I have seen two cases in children, in which the condition was in process of development. During CHRONIC TONSILLITIS. 367 inspiration the lower sternum was forcibly retracted, so much so that at the height the depression corresponded to a well-marked “ trichter-brust.” While in repose the lower sternal region was distinctly excavated. The voice is altered and acquires a nasal quality. The pronunciation of certain letters is changed, and there is inability to pronounce the nasal consonants n and m. Bloch, in his monograph,* lays great stress upon the association of mouth-breathing with stuttering. The hearing is impaired, usually owing to the extension of inflamma- tion along the Eustachian tubes and the obstruction with mucus or the narrowing of their orifices by pressure of the adenoid vegetations. In some instances it may be due to retraction of the drums, as the upper pharynx is insufficiently supplied with air. Naturally the senses of taste and smell are much impaired. With these symptoms there may be little or no nasal catarrh or discharge, but the pharyngeal secretion of mucus is always in- creased. Children, however, do not notice this, as the mucus is usually swallowed, but older persons expectorate it with difficulty. Among other symptoms may be mentioned headache, which is by no means uncommon, general listlessness, and an indisposition for physical or mental exertion. Habit-spasm of the face has been described in con- nection with it. I have known several instances in which permanent relief has been afforded by the removal of the adenoid vegetations. Enu- resis is occasionally an associated symptom. The influence upon the men- tal development is striking. Mouth-breathers are usually dull, stupid, and backward. It is impossible for them to fix the attention for long at a time, and to this impairment of the mental function Guye, of Amsterdam, has given the name aprosexia. Headaches, forgetfulness, inability to study without discomfort, are frequent symptoms of this condition in stu- dents. There is more than a grain of truth in the aphorism shut your mouth and save your life, which is found on the title-page of Captain Catlin’s celebrated pamphlet on mouth-breathing. A symptom specially associated with enlarged tonsils is fetor of the breath. In the tonsillar crypts the inspissated secretion undergoes de- composition and an odor not unlike that of Rochefort or Limburger cheese is produced. The little cheesy masses may sometimes be squeezed from the crypts of the tonsils. Though the odor may not apparently be very strong, yet if the mass be squeezed between the fingers its intensity will at once be appreciated. In some cases of chronic enlargement the cheesy masses may be deep in the tonsillar crypts ; and if they remain for a prolonged period lime salts are deposited and a tonsillar calculus in this way produced. Children with enlarged tonsils are especially prone to take cold and to recurring attacks of follicular disease. They are also more liable to diph- theria, and in them the anginal features in scarlet fever are always more * Die Pathologie und Therapie der Mundathmung. Wiesbaden, 1889. 368 DISEASES OF THE DIGESTIVE SYSTEM. serious. The ultimate results of untreated adenoid hypertrophy are im- portant. In some cases the vegetations disappear, leaving an atrophic condition of the vault of the pharynx. Neglect may also lead to the so- called Thornwaldt’s disease, in which there is a cystic condition of the pharyngeal tonsil and constant secretion of muco-pus. Diagnosis.—The facial aspect is usually distinctive. Enlarged ton- sils are readily seen on inspection of the pharynx. There may be no great enlargement of the tonsils and nothing apparent at the back of the throat even when the naso-pliarynx is completely blocked with adenoid vege- tations. In children the rhinoscopic examination is rarely practicable. Digital examination is the most satisfactory. The growths can then be felt either as small, flat bodies or, if extensive, as velvety, grape-like papillomata. Treatment.—If the tonsils are large and the general state is evi- dently influenced by them they should be at once removed. Applications of iodine and iron, or pencilling the crypts with nitrate of silver, are of service in the milder grades, but it is waste of time to apply them in very enlarged glands. There is a condition in which the tonsils are not much enlarged, but the crypts are constantly filled with cheesy secretions and cause a very bad odor in the breath. In such instances the removal of the secretion and thorough pencilling of the crypts with chromic acid may be practised. The galvano-cautery is of great service in many cases of enlarged tonsils when there is any objection to the more radical surgi- cal procedure. The treatment of the adenoid growths in the pharynx is of the great- est importance, and should be thoroughly carried out. Parents should be frankly told that the affection is serious, one which impairs the men- tal not less than the bodily development of the child. In spite of the thorough ventilation of this subject by specialists, practitioners do not appear to have grasped as yet the full importance of this disease. They are far too apt to temporize and unnecessarily to postpone radical meas- ures. The child must be etherized, when the growths can be removed either with the finger-nail, which in most instances is sufficient, or with a suitable curette. Considerable haemorrhage may follow, but it is usually checked quickly. The good effects of the operation are often apparent within a few days, and the child begins to breathe through the nose. In some instances the habit of mouth-breathing persists. As soon as the child goes to sleep the lower jaw drops and the air is drawn into the mouth. In these cases a chin strap can be readily adjusted, which the child may wear at night. In severe cases it may take months of careful training before the child can speak properly. Throughout the entire treatment attention should be paid to hygiene and diet, and cod-liver oil and the iodide of iron may be administered with benefit. ACUTE (ESOPHAGITIS. 369 Y. DISEASES OF THE (ESOPHAGUS. I. ACUTE CESOPHAGIT1S. Etiology.—Acute inflammation occurs (ff) in the catarrhal processes of the specific fevers; more rarely as an extension from catarrh of the pharynx, (b) As a result of intense mechanical or chemical irritation, produced by foreign bodies, by very hot liquids, or by strong corrosives. (c) In the form of pseudo-membranous inflammation in diphtheria, and occasionally in pneumonia, typhoid fever, and pyaemia, (cl) As a pustular inflammation in small-pox, and, according to Laennec, as a result of a pro- longed administration of tartar emetic, (e) In connection with local dis- ease, particularly cancer either of the tube itself or extension to it from without. And, lastly, acute oesophagitis, occasionally with ulceration, may occur spontaneously in sucklings. Morbid Anatomy.—It is extremely rare to see redness of the mucosa, except when chemical irritants have been swallowed. More com- monly the epithelium is thickened and has desquamated, so that the sur- face is covered with a fine granular substance. The mucous follicles are swollen and occasionally there may be seen small erosions. In the pseudo- membranous inflammation there is a grayish croupous exudate, usually limited in extent, at the upper portion of the gullet. This must not be confounded with the grayish-white deposit of thrush in children. The pustular disease is very rare in small-pox. In the phlegmonous inflamma- tion the mucous membrane is greatly swollen, and there is purulent infil- tration in the submucosa. This may be limited as about a foreign body, or extremely diffuse. It may even extend throughout a large part of the gullet. Gangrene occasionally supervenes. Birch-IIirschfeld describes a remarkable case in an hysterical woman, who vomited a long membranous tube which proved, on examination, to be the detached epithelial lining of the oesophagus. Practically, in post-mortem work, there is no portion of the alimentary canal which more rarely shows signs of disease. Symptoms.—Pain in deglutition is always present in severe inflam- mation of the oesophagus, and in the form which follows the swallowing of strong irritants may prevent the taking of food. A dull pain beneath the sternum is also present. In the milder forms of catarrhal inflamma- tion there are usually no symptoms. The presence of a foreign body is indicated by dysphagia and spasm with the regurgitation of portions of the food. Later, blood and pus may be ejected. It is surprising how ex- tensive the disease may be in the oesophagus without producing much pain or great discomfort, except in swallowing. The intense inflammation which follows the swallowing of corrosives, when not fatal, gradually sub- sides, and often leads to cicatricial contraction and stricture. The treatment of acute inflammation of the oesophagus is extremely 370 DISEASES OF THE DIGESTIVE SYSTEM. unsatisfactory, particularly in the severer forms. The slight catarrhal cases require no special treatment. When the dysphagia is intense it is best not to give food by the mouth, but to feed entirely by enemata. Frag- ments of ice may be given, and as the pain and distress subside, demulcent drinks. External applications of cold often give relief. A chronic form of oesophagitis is described, but it results usually from the prolonged action of the causes which produce the acute form. Associated with chronic heart disease and more frequently with the senile and the cirrhotic liver, the oesophageal veins may be enormously distended and varicose, particularly toward the stomach. In these cases the mucous membrane is in a state of chronic catarrh, and the patient has frequent eructations Qf mucus. Rupture of these oesophageal veins may cause fatal haemorrhage. Two cases of the kind have occurred in my ex- perience. II. SPASM OF THE CESOPHAGUS (CEsophagismus). This so-called spasmodic stricture of the gullet is met with in hysteri- cal patients and hypochondriacs, also in chorea, epilepsy, and especially hydrophobia. It is sometimes associated also with the lodgment of foreign bodies. The idiopathic form is found in females of a marked neurotic habit, but may also occur in elderly men. It may be pres- ent only during pregnancy. Of three cases which have come under my observation, two were in men, one a hypochondriac over sixty years of age who for many months had taken only liquid food, and with great difficulty, owing to a spasm which accompanied every attempt to swallow. The readiness with which the bougie passed and the subsequent history showed the true nature of the case. The patient complains of inability to swallow solid food, and in extreme instances even liquids are rejected. The attack may come on abruptly, and be associated with emotional dis- turbances and with substernal pain. The bougie, when passed, may be arrested temporarily at the seat of the spasm, which gradually yields, or it may slip through without the slightest effort. The condition is rarely seri- ous. Death has however followed. The diagnosis is not difficult, particularly in young persons with marked nervous manifestations. In elderly persons cesophagismus is almost always connected with hypochondriasis, but great care must be taken to exclude cancer. In some cases a cure is at once effected by the passage of a bougie. The general neurotic condition also requires special attention. Paralysis of the oesophagus scarcely demands separate consideration. It is a very rare condition, due most often to central disease, particularly bulbar paralysis. It may be peripheral in origin as in diphtheritic paralysis. Occasionally it occurs also in hysteria. The essential symptom is dysphagia. STRICTURE OF THE (ESOPHAGUS. 371 III. STRICTURE OF THE CESOPHAGUS. This results from : (a) Congenital narrowing. (£) The cicatricial con- traction of healed ulcers, usually due to corrosive poisons, occasionally to syphilis, (e) The growth of tumors in the walls, as in the so-called cancerous stricture. Occasionally polypoid tumors projecting from the mucosa produce great narrowing. (d) External pressure by aneurism, en- larged lymph glands, enlarged thyroid, other tumors, and sometimes by pericardial elfusion. The cicatricial stricture may occur anywhere in the gullet, and in ex- treme cases may, indeed, involve the whole tube, but in a majority of in- stances it is found either high up near the pharynx or low down toward the stomach. The narrowing may be extreme, so that only small quanti- ties of food can trickle through, or the obstruction may be quite slight. There is usually no difficulty in making a diagnosis of the cicatricial strict- ure, as the history of mechanical injury or the swallowing of a corrosive fluid makes clear the nature of the case. When the stricture is low down the oesophagus is dilated and the walls are usually much hypertrophied. When it is high in the gullet the food is usually rejected at once, whereas if low it may be retained and a considerable quantity collects before it is regurgitated. Any .doubt as to its having reached the stomach is removed by the alkalinity of the materials ejected and the absence of the character- istic gastric odor. Auscultation of the oesophagus may be practised and is sometimes of service. The patient takes a mouthful of water and the auscultator listens along the left of the spine. During deglutition at the seat of the stricture, in place of the normal oesophageal bruit, there will be heard a loud splashing, gurgling sound, and the secondary murmur, heard as the fluid enters the stomach, may be absent. The passage of the oeso- phageal bougie will determine more accurately the locality. Conical bougies attached to a flexible whalebone stem are the most satisfactory, but the gum-elastic stomach tube may be used; a large one should be tried first. The patient should be placed on a low chair with the head well thrown back. The index finger of the left hand is passed far into the pharynx, and in some instances this procedure alone may determine the presence of a new growth. The bougie is passed beside the finger until it touches the posterior wall of the pharynx, then along it, more to one side than in the middle line, and so gradually pushed into the gullet. It is to be borne in mind that in passing the cricoid cartilage there is often a slight ob- struction. Great gentleness should be used, as it has happened more than once that the bougie has been passed through a cancerous ulcer into the mediastinum or through a diverticulum. I have known this accident to happen twice—once in the case of a distinguished surgeon, who performed cesophagotomy and passed the tube, as he thought, into the stomach. The post-mortem on the next day showed that the tube had entered a diverticu- lum and through it the left pleura, in which the milk injected through 372 DISEASES OF THE DIGESTIVE SYSTEM, the tube was found. In the other instance the tube passed through a cancerous ulcer into the lung, which was adherent and inflamed. For- tunately theSe accidents, sometimes unavoidable, are extremely rare. It is well always, as a precautionary measure before passing the bougie, to examine carefully for aneurism, which may produce all the symptoms of organic stricture. In cases in which the stricture is extreme there is al- ways emaciation. For treatment, surgical works must be consulted. IV. CANCER OF THE CESOPHAGUS. This is usually epithelioma. It is not an uncommon disease, and oc- curs more frequently in males than in females. The common situation is in the upper third of the tube. At first confined to the mucous mem- brane, the cancer gradually increases and soon ulcerates. The lumen of the tube is narrowed, but when ulceration is extensive in the later stages the stricture may be less marked. Dilatation of the tube and hypertrophy of the walls usually take place above the cancer. The cancerous ulcer may perforate the trachea or a bronchus, the lung, the mediastinum, the aorta or one of its larger branches, the pericardium, or it may erode the vertebral column. In my experience perforation of the lung has been the most frequent, producing, as a rule, local gangrene. Symptoms.—The earliest symptom is dysphagia, which is progress- ive and may become extreme, so that the patient emaciates rapidly. Re- gurgitation may take place at once; or, if the cancer is situated near the stomach, it may be deferred for ten or fifteen minutes, or even longer if the tube is much dilated. The rejected materials may be mixed with blood and may contain cancerous fragments. In persons over fifty years of age persistent difficulty in swallowing accompanied by rapid emaciation usually indicates oesophageal cancer. The cervical lymph-glands are fre- quently enlarged and may give early indication of the nature of the trouble. Pain may be persistent or is present only when food is taken. In certain instances the pain is very great. I saw an autopsy on a case of cancer of the oesophagus in which the patient gradually became emaciated, but had no special symptoms to call attention to the disease. These latent cases are, however, very rare. The prognosis is hopeless, and the patients usually become progressive- ly emaciated, and die either of asthenia or sudden perforation of the ulcer. In the diagnosis of the condition it is important, in the first place, to exclude pressure from without, as by aneurism or other tumor. The history enables us to exclude cicatricial stricture and foreign bodies. The sound may be passed and the presence of the stricture determined. As mentioned above, great care should be exercised. Fragments of carcinom- atous tissue may in some instances be removed with the tube. On aus- cultation along the left side of the spine the primary oesophageal murmur may be much altered in quality. DILATATIONS AND DIVERTICULA. 373 Treatment.—In most cases milk and liquids can be swallowed, but supplementary nourishment should be given by the rectum. It may be advisable in some instances to pass a tube into the stomach and attempt to feed in this way. If the patient is willing to take the risk, cesopha- gotomy or gastrotomy may be performed in order to prolong life. V. RUPTURE OF THE CESOPHAGUS. This may occur in a healthy organ as a result of prolonged vomiting. Boerliaave described the first case in Baron Wassennar, who “broke asun- der the tube of the oesophagus near the diaphragm, so that, after the most excruciating pain, the elements which he swallowed passed, together with the air, into the cavity of the thorax, and he expired in twenty-four hours.” Fitz has reported a case and has analyzed the literature on the subject up to 1877. The accident has usually occurred during vomiting after a full meal or when intoxicated. It is, of course, invariably fatal. Much more common is the post-mortem digestion of the oesophagus, which was first described by King, of Guy’s Hospital. It is not very infrequent. In one instance I found the contents of the stomach in the left pleura. The erosion is in the posterior wall, and may be of consider- able extent. VI. DILATATIONS AND DIVERTICULA. Stenosis of the gullet is followed by secondary dilatation of the tube above the constriction and great hypertrophy of the walls. Primary dila- tation is extremely rare. The tube may attain extraordinary dimensions— 30 cm. in circumference in Luschka’s case. Regurgitation of food is the most common symptom. There may also be difficulty in breathing from pressure. Diverticula are of two forms : (a) Pressure diverticula, which are most common at the junction of the pharynx and gullet, on the posterior wall. Owing to weakness of the muscles at this spot, local bulging occurs, which is gradually increased by the pressure of food, and finally forms a saccular pouch, (b) The traction diverticula situated on the anterior wall near the bifurcation of the trachea, result, as a rule, from the extension of inflammation from the lymph glands with adhesion and subsequent cica- tricial contraction, by which the wall of the gullet is drawn out. Diver- ticula have been successfully extirpated by von Bergmann and by Mixter. A rare and remarkable condition, of which a case has been recorded by MacLachlan, and of which a second is in attendance at my clinic, is the cesophago-pleuro-cutaneous fistula. In my patient fluids are discharged at intervals through a fistula in the right infra-clavicular region, which appears to communicate with a cavity in the upper part of the pleura or lung. The condition has persisted for more than twenty years. VI. DISEASES OF THE STOMACH. {Simple Gastritis; Acute Gastric Catarrh; Acute Dyspepsia). 1. ACUTE GASTRITIS Etiology.—Acute gastric catarrh, one of the most common of com- plaints, occurs at all ages, and is usually traceable to errors in diet. It may follow the ingestion of more food than the stomach can digest, or it may result from taking unsuitable articles, which either themselves irritate the mucosa or, remaining undigested, decompose, and so excite an acute dyspepsia. A frequent cause is the taking of food which has begun to decompose, particularly in hot weather. In children these fermentative processes are very apt to excite acute catarrh of the bowels as well. An- other very common cause is the abuse of alcohol, and the acute gastritis which follows a drinking-bout is one of the most typical forms of the dis- ease. The tendency to acute indigestion varies very much in different individuals, and indeed in families. We recognize this in using the ex- pressions a “ delicate stomach ” and a “ strong stomach.” Gouty persons are generally thought to be more disposed to acute dyspepsia than others. Acute catarrh of the stomach occurs at the outset of many of the infec- tious fevers. Lebert described a special infectious form of gastric catarrh, occurring in epidemic form, and only to be distinguished from mild typhoid fever by the absence of rose spots and swelling of the spleen. Many practitioners still adhere to the belief that there is a form of gastric fever, but the evi- dence of its existence is by no means satisfactory, and certainly a great majority of all cases in this country are examples of mild typhoid. Morbid Anatomy.—Beaumont’s study of St. Martin’s stomach showed that in acute catarrh the mucous membrane is reddened and swollen, less gastric juice is secreted, and mucus covers the surface. Slight hsemorrhages may occur or even small erosions. The submucosa may be somewhat cedematous. Microscopically the changes are chiefly noticeable in the mucous and peptic cells, which are swollen and more granular, and there is an infiltration of the intertubular tissue with leuco- cytes. Symptoms.—In mild cases the symptoms are those of slight “ in- digestion ”—uncomfortable feeling in the abdomen, headache, depression, ACUTE GASTRITIS. 375 nausea, eructations, and vomiting, which usually gives relief. The tongue is heavily coated and the saliva is increased. In children there are intes- tinal symptoms—diarrhoea and colicky pains. There is usually no fever. The duration is rarely more than twenty-four hours. In the severer forms the attack may set in with a chill and febrile reaction, in which the tem- perature rises to 102° or 103°. The tongue is furred, the breath heavy, and vomiting is frequent. The ejected substances, at first mixed with food, subsequently contain much mucus and bile-stained fluids. There may be constipation, but very often there is diarrhoea. The urine presents the usual febrile characteristics, and there is a heavy deposit of urates. The abdomen may be somewhat distended and slightly tender in the epigastric region. Herpes may appear on the lips. The attack may last from one to three days, and occasionally longer. The examination of the vomitus shows, as a rule, absence of the hydrochloric acid, presence of lactic and fatty acids, and marked increase in the mucus. Diagnosis.—The ordinary afebrile gastric catarrh is readily recog- nized. The acute febrile form is so similar to the initial symptoms of many of the infectious diseases that it is impossible for a day or two to make a definite diagnosis, particularly in the cases which have come on, so to speak, spontaneously and independently of an error in diet. Some of these resemble closely an acute infection; the symptoms may be very intense, and if, as sometimes happens, the attack sets in with severe head- ache and delirium the case may be mistaken for meningitis. When the abdominal pains are intense the attack may be confounded with gallstone colic. In discriminating between acute febrile gastritis and the abortive forms of typhoid fever it is to be borne in mind that in the former the temperature rises abruptly, the remissions are slighter and the drop is more sudden. The initial bronchitis, the well-marked sjflenic enlargei ment, and the rose spots are not present. It is a very common error to class under gastric fever the mild forms of the various infectious disorders. The gastric crises in locomotor ataxia have in many instances been con- founded with a simple acute gastritis, and it is always wise in adults to test the knee-jerks and pupillary reactions. Treatment.—Mild cases recover spontaneously in twenty-four hours, and require no treatment other than a dose of castor oil in children or of blue mass in adults. In the severer forms, if there is much distress in the region of the stomach, the vomiting should be promoted by warm water or the simple emetics. A full dose of calomel, eight to ten grains, should be given, and followed the next morning by a dose of Hunyadi-Janos or Carlsbad water. If there is eructation of acid fluid, bicarbonate of soda and bismuth may be given. The stomach should have, if possible, abso- lute rest, and it is a good plan in the case of strong persons, particularly in those addicted to alcohol, to cut off all food for a day or two. The pa- tient may be allowed soda water and ice freely. It is well not to attempt to check the vomiting unless it is excessive and protracted. Recovery is 376 DISEASES OF THE DIGESTIVE SYSTEM. usually complete, though repeated attacks may lead to subacute gastritis or to the establishment of chronic dyspepsia. Phlegmonous Gastritis; Acute Suppurative Gastritis.—This is an ex- cessively rare disease, characterized by the occurrence of suppurative pro- cesses in the submucosa. The affection is more common in men than in women. The cause is seldom obvious. It has been met with as an idio- pathic affection, but it has occurred also in puerperal fever and other sep- tic processes, and has occasionally followed trauma. Anatomically there appear to be two forms, a diffuse purulent infiltration and a localized ab- scess formation, in which case the tumor may reach the size of an egg, and may burst into the stomach or into the peritoneal cavity. The symptoms are variable. There are usually pain in the abdomen, fever, dry tongue, and symptoms of a severe infective process, delirium and coma preceding death. Jaundice has been met with in some in- stances. Occasionally, when the abscess tumor is large, it has been felt externally, in one case forming a mass as large as two fists. There are in- stances which run a more chronic course, with pains in the abdomen, fever, and chills. The diagnosis is rarely possible, even when with abscess rupture oc- curs, and the pus is vomited, as it is not possible to differentiate this con- dition from an abscess perforating into the stomach from without. It is stated, however, that Chvostek made the diagnosis in one of liis cases. Toxic Gastritis.—This most intense form of inflammation of the stom- ach is excited by the swallowing of concentrated mineral acids or strong alkalies, or by such poisons as phosphorus, corrosive sublimate, ammonia, arsenic, etc. In the non-corrosive poisons, such as phosphorus, arsenic, and antimony, the process consists of an acute degeneration of the gland- ular elements, and haemorrhage. In the powerful concentrated poisons the mucous membrane is extensively destroyed, and may he converted into a brownish-black eschar. In the less severe grades there may be areas of necrosis surrounded by inflammatory reaction, while the submucosa is haemorrhagic and infiltrated. The process is of course more intense at the fundus, but the active peristalsis may drive the poison through the pylorus into the intestine. The symptoms are intense pain in the mouth, throat, and stomach, salivation, great difficulty in swallowing, and constant vomiting, the vom- ited materials being bloody and sometimes containing portions of the mucous membrane. The abdomen is tender, distended, and painful on pressure. In the most acute cases symptoms of collapse supervene; the pulse is weak, the skin pale and covered with sweat; there is restlessness, and sometimes convulsions. There may he albumen or blood in the urine, and petechias may develop on the skin. When the poison is less intense, the sloughs may separate, leaving ulcers, which too often lead, in the oesophagus, to stricture, and in the stomach to chronic atrophy, and finally to death from exhaustion. CHRONIC GASTRITIS. 377 The diagnosis of toxic gastritis is usually easy, as inspection of the mouth and pharynx shows, in many instances, corrosive effects, while the examination of the vomit may indicate the nature of the poison. In poisoning by acids, magnesia should be administered in milk or with egg albumen. When strong alkalies have been taken, the dilute acids should be administered. For the severe inflammation which follows the swallowing of the stronger poisons palliative treatment is alone available, and morphia may be freely employed to allay the pain. Diphtheritic or Membranous Gastritis.—This condition is met with occasionally in diphtheria, but more commonly as a secondary process in typhus or typhoid fever, pneumonia, pyaemia, small-pox, and occasionally in debilitated children. An instance of it came under my notice in pneu- monia. The exudation may be extensive and uniform or in patches. The condition is not recognizable during life, unless, as in a case of John Thomson’s, the membranes are vomited. Mycotic and Parasitic Gastritis.—It occasionally happens that fungi develop in the stomach and excite inflammation. One of the most re- markable cases of the kind is that reported by Kundrat, in which the favus fungus developed in the stomach and intestine. In cancer and in dilatation of the stomach the sarcinae and yeast fungi probably aid in maintaining the chronic gastritis. As a rule, the gastric juice is capable of killing the ordinary bacteria. Orth states that the anthrax bacilli, in certain cases, produce swelling of the mucosa and ulcer- ation. Klebs has described a bacillus gastricus which develops in the tubules and produces numerous spores, and Eug. Fraenkel has reported a case of acute emphysematous gastritis probably of mycotic origin. The larvae of certain insects may excite gastritis, as in the cases reported by Gerhardt, Meschede, and others. In rare instances tuberculosis and syphi- lis attack the gastric mucosa. II. CHRONIC GASTRITIS {Chronic Catarrh of the Stomach ; Chronic Dyspepsia). Definition.—A condition of disturbed digestion associated with in- creased mucus formation, qualitative or quantitative changes in the gastric- juice, enfeeblement of the muscular coats, so that the food is retained for an abnormal time in the stomach; and, finally, with alterations in the structure of the mucosa. Etiology.—The causes of chronic gastritis may be classified as fol- lows : (1) Dietetic. The use of unsuitable or improperly prepared food. The persistent use of certain articles of diet, such as very fat substances or foods containing too much of the carbohydrates. The use in excess of tea or coffee, and, above all, alcohol in its various forms. Under this head- ing, too, may be mentioned the habits of eating at irregular hours or too rapidly and imperfectly chewing the food. A common cause of chronic 378 DISEASES OF THE DIGESTIVE SYSTEM. catarrh is drinking too freely of ice-water during meals, a practice which plays no small part in the prevalence of dyspepsia in America. Another frequent cause is the abuse of tobacco. (2) Constitutional causes. Anaemia, chlorosis, chronic tuberculosis, gout, diabetes, and Bright’s disease are often associated with chronic gastric catarrh. (3) Local conditions: (a) of the stomach, as in cancer, ulcer and dilatation, which are invariably ac- companied by catarrh; (b) conditions of the portal circulation, causing chronic engorgement of the mucous membrane, as in cirrhosis, chronic heart disease, and certain chronic lung affections. Morbid Anatomy.—Anatomically two forms of chronic gastritis may be recognized, the simple and the sclerotic. (a) Simple Chronic Gastritis.—The organ is usually enlarged, the mucous membrane pale gray in color, and covered with closely adherent, tenacious mucus. The veins are large, patches of eccliymosis are not in- frequently seen, and in the chronic catarrh of portal obstruction and of chronic heart disease small haemorrhagic erosions. Toward the pylorus the mucosa is not infrequently irregularly pigmented, and presents a rough, wrinkled, mammillated surface, the etat mammelone of the French, a condition which may sometimes be so prominent that writers have de- scribed it as gastritis polyposa. The membrane may be thinner than normal, and much firmer, tearing less readily with the finger-nail. Ewald thus describes the histological changes: The minute anatomy shows the picture of a parenchymatous and an interstitial inflammation. The gland cells are in part eroded or show cloudy granular swelling or atrophy. The distinction between the principal and marginal cells cannot be recog- nized, and in many places, particularly in the pyloric region, the tubes have lost their regular form and show in many places an atypical branch- ing, like the fingers of a glove. Individual glands are cut off toward the fundus, but appear at the border of the submucosa as cysts, partly empty, with a smooth membrane, partly filled with remnants of hyaline and re- tractile epithelium. An abundant small-celled infiltration presses apart the tubules and is particularly marked toward the surface of the mucosa, and from the submucosa extensions of the connective tissue may be seen passing between the glands. The mucoid transformation of the cells of the tubules is a striking feature in the process and may extend to the very fundus of the glands. (/;) Sclerotic Gastritis.—As a final result of the parenchymatous and interstitial changes the mucous membrane may undergo complete atrophy, so that but few traces of secreting substance remain. There appear to he two forms of this sclerotic atrophy—one with thinning of the coats of the stomach, phthisis ventriculi, and a retention or even increase of the size of the organ; the other with enormous thickening of the coats and great reduction in the volume of the organ, the condition which is usually described as cirrhosis ventriculi. Extreme atrophy of the mu- cous membrane of the stomach has been carefully studied by Fenwick, CHRONIC GASTRITIS. 379 Ewald, and others, and we now recognize the fact that there may be such destruction and degeneration of the glandular elements by a progressive development of interstitial tissue that ultimately scarcely a trace of secret- ing tissue remains. In a characteristic case, studied by Henry and myself, the greater portion of the lining membrane of the stomach was converted into a perfectly smooth, cuticular structure, showing no trace whatever of glandular elements, with enormous hypertrophy of the muscularis mucosae, and here and there formation of cysts. In the other form, with identical atrophy and cyst formation, there is enormous increase in the connective tissue, and the stomach may be so contracted that it does not hold more than a couple of ounces. The walls may measure from two to three centimetres; the greatest increase in thickness is in the submucosa, but the hypertrophy also extends to the muscular layers. A similar affec- tion may coexist in the cascum and colon. The condition may be difficult to distinguish from diffuse carcinoma. There may be also proliferative peritonitis, with perihepatitis, perisplenitis, and ascites. While one is not justified in saying that all cases of cirrhosis of the stomach represent a final stage in the history of a chronic catarrh, it is true that in most cases the process is associated with atrophy of the gastric mucosa, while the history indicates the existence of chronic dyspepsia. Symptoms.—The affection persists for an indefinite period, and, as is the case with most chronic diseases, changes from time to time. The appetite is variable, sometimes greatly impaired, at others very good. Among early symptoms are feelings of distress or oppression after eating, which may become aggravated and amount to actual pain. When the stomach is empty there may also be a painful feeling. The pain differs in different cases, and may be trifling or of extreme severity. When local- ized and felt beneath the sternum or in the praecordial region it is known as heart-burn or sometimes cardialgia. There is pain on pressure over the stomach, usually diffuse and not severe. The tongue is coated, and the patient complains of a bad taste in the mouth. The tip and margin of the tongue are very often red. Associated with this catarrhal stomati- tis there may be an increase in the salivary and pharyngeal secretions. Nausea is an early symptom, and is particularly apt to occur in the morn- ing hours. It is not, however, nearly so constant a symptom in chronic gastritis as in cancer of the stomach, and in mild grades of the affec- tion it may not occur at all. Eructation of gas, which may continue for some hours after taking food, is a very prominent feature in cases of so- called flatulent dyspepsia, and there may be marked distension of the intestines. With the gas, bitter fluids may be brought up: The vomit- ing does not often occur when the stomach is empty, but either imme- diately after eating or an hour or two later. The vomitus consists of food in various stages of digestion and slimy mucus, and the chemical examina- tion shows the presence of abnormal acids, such as butyric, or even acetic, in addition to lactic acid, while the hydrochloric acid, if indeed it is present, 380 DISEASES OF THE DIGESTIVE SYSTEM. is much reduced in quantity. The digestion may be much delayed, and on washing out the stomach as late as seven hours after eating, portions of food are still present. The prolonged retention favors decomposition, the stomach becomes distended with gas, and this, with the chronic catarrh, may induce gradually an atony of the muscular walls. The ab- sorption is slow, and iodide of potassium, given in capsules, which should normally reach the saliva within fifteen minutes, may not be evident for more than half an hour. Constipation is usually present, but in some instances there is diarrhoea, and undigested food passes rapidly through the bowels. The urine is often scanty, high-colored, and deposits a heavy sediment of urates. Of other symptoms headache is common, and the patient feels con- stantly out of sorts, indisposed for exertion, and low-spirited. In aggra- vated cases melancholia may develop. Trousseau called attention to the occurrence of vertigo, a marked feature in certain cases. The pulse is small, sometimes slow, and there may be palpitation of the heart. Fever does not occur. Cough is sometimes present, but the so-called stomach cough of chronic dyspeptics is in all probability dependent upon pharyn- geal irritation. The symptoms of atrophy of the mucous membrane of the stomach, with or without contraction of the organ, are very complex, and cannot be said to present a uniform picture. The majority of the cases present the symptoms of an aggravated chronic dyspepsia, often of such severity that cancer is suspected. In one of the cases which I examined the persistent distress after eating, the vomiting, and the gradual loss of flesh and strength, very naturally led to this diagnosis, but the duration of the disease far exceeded that of ordinary carcinoma. In the cirrhotic form the tumor mass may sometimes be felt. In atrophy of the stomach, whether associated with cirrhosis or not, the clinical picture may be that of pernicious ansemia. As early as 18G0, Flint called attention to this connection between atrophy of the gastric tubules and anaemia, an obser- vation which Fenwick and others have amply confirmed. Diagnosis.—The use of the stomach-tube and the chemical examina- tion of the contents of the stomach obtained in this way have given us special information with reference to the various forms of gastritis and the modes of differentiating them. The soft-rubber stomacli-tube, provided with a funnel-shaped dilatation, is the most satisfactory to use, as it is very readily passed, and if used by the patient is not likely to cause damage. It should be open at the end and possess one or two lateral openings. Ewald distinguishes three forms of chronic gastritis: (1) Simple gas- tritis; (2) mucous (schleimige) gastritis; (3) atrophy. In (1) the fasting stomach contains only a small quantity of a slimy fluid, while after the test breakfast the IIC1 is diminished in quantity or may be absent. Lactic acid and the fat acids may be present. After Boas’s more rigid test meal the organic acids are rarely found. CHRONIC GASTRITIS. 381 In (2) the acidity is always slight and the condition is distinguished from (1) chiefly by the large amount of mucus present. In (3) the fasting stomach is generally empty, while after the test breakfast IICl, pepsin, and the curdling ferment are wholly wanting. Treatment.—When possible the cause in each case should be ascer- tained and an attempt made to determine the special form of indi- gestion. Usually there is no difficulty in differentiating the ordinary catarrhal and the nervous varieties. A careful study of the phenomena of digestion in the way already laid down, though not essential in every instance, should certainly be carried out in the more obstinate and obscure forms. Two important questions should be asked of every dys- peptic—first, as to the time taken at his meals; and, second, as to the quantity he eats. Practically a large majority of all cases of disturbed digestion come from hasty and imperfect mastication of the food and from overeating. Especial stress should be laid upon the former point. In some instances it will alone suffice to cure dyspepsia if the patient will count a certain number before swallowing each mouthful. The second point is of even greater importance. People habitually eat too much, and it is probably true that a greater number of maladies arise from excess in eating than from excess in drinking. Particularly is this the case in America, where the average man is abstemious in the matter of alcohol, but imprudent to a degree in all matters relating to food. Moreover, peo- ple have not had time to learn the art of cooking, and much of the indi- gestion, particularly in the country districts, may be charged to the bar- barous methods of preparing the food. The treatment may be consid- ered under the headings of dietetic and medicinal. (a) General and Dietetic.—A careful and systematically arranged di- etary is the first, sometimes the only essential in the treatment of a case of chronic dyspepsia. It is impossible to lay down rules applicable to all cases. Individuals differ extraordinarily in their capability of digesting different articles of food, and there is much truth in the old adage, “ One man’s food is another man’s poison.” The individual preferences for dif- ferent articles of food should be permitted in the milder forms. Physi- cians have probably been too arbitrary in this direction, and have not yielded sufficiently to the intimations given by the appetite and desires of the patient. A rigid milk diet may be tried in obstinate cases. Much depends upon whether the patient is able to take and digest milk properly. In the forms associated with Bright’s disease and chronic portal congestion, as well as in many instances in which the dyspepsia is part of a neurasthenic or hysterical trouble, this plan in conjunction with rest is most efficacious. If milk is not digested well it may be diluted one third with soda water or Yichy, or five to ten grains of carbonate of soda, or a pinch of salt may be added to each tumblerful. In many cases the milk from which the cream has been taken is better borne. Buttermilk is particularly 382 DISEASES OF THE DIGESTIVE SYSTEM. suitable, but can rarely be taken for as long a time alone, as patients tire of it much more readily than they do of ordinary milk. Not only can the general nutrition be maintained on this diet, but patients some- times increase in weight, and the unpleasant gastric symptoms disappear entirely. It should be given at fixed hours and in definite quantities. A patient may take six or eight ounces every three hours. The amount necessary varies a good deal, but at least three to five pints should be given in the twenty-four hours. This form of diet is not, as a rule, well borne when there is a tendency to dilatation of the stomach. The milk may be previously peptonized, but it is impossible to feed a chronic dys- peptic in this way. The stools should be carefully watched, and if more milk is taken than can be digested it is well to supplement the diet with eggs and dry toast or biscuits. In a large proportion of the cases of chronic indigestion it is not necessary to annoy the patient with such strict dietaries. It may be quite sufficient to cut off certain articles of food. Thus, if there are acid eruc- tations or flatulency, the farinaceous foods should be restricted, particularly potatoes and the coarser vegetables. A fruitful source of indigestion is the hot bread which, in different forms, is regarded as an essential part of an American breakfast. This, as well as the various forms of pan- cakes, pies and tarts, with heavy pastry, and fried articles of all sorts, should be strictly forbidden. As a rule, white bread, toasted, is more readily digested than bread made from the whole meal. Persons, how- ever, differ very much in this respect, and the Graham or brown bread is for many people most digestible. Sugar and very sweet articles of food should be taken in great moderation or avoided altogether by persons with chronic dyspepsia. Many instances of aggravated indigestion have come to my notice due to the prevalent practice of eating largely of ice- cream. One of the most powerful enemies of the American stomach in the present day is the soda-water fountain, which has usurped so impor- tant a place in the apothecary shop. Fats, with the exception of a moderate amount of good butter, very fat meats, and thick, greasy soups should be avoided. Ripe fruit in moderation is often advantageous, particularly when cooked. Bananas are not, as a rule, well borne. Strawberries are to many persons a cause of an annual attack of indigestion and sore throat in the spring months. As stated, in the matter of special articles of food it is impossible to lay down rigid rules, and it is the common experience that one patient with indigestion will take with impunity the very articles which cause the greatest distress to another. Another detail of importance which may be mentioned in this con- nection is the general hygienic management of dyspeptics. These pa- tients are often introspective, dwelling in a morbid manner on their symptoms, and much inclined to take a despondent view of their con- dition. Very little progress can be made unless the physician gains CHRONIC GASTRITIS. 383 their confidence from the outset. Their fears and whims should not be made too light of or ridiculed. Systematic exercise, carefully regulated, particularly when, as at watering places, it is combined with a restricted diet, is of special service. Change of air and occupation, a prolonged sea voyage, or a summer in the mountains will sometimes cure the most obstinate dyspepsia. (1) Medicinal.—The special therapeutic measures may be divided into those which attempt to replace in the digestive juices important elements which are lacking and those which stimulate the weakened action of the organ. In the first group come the hydrochloric acid and ferments, which are so freely employed in dyspepsia. The former is the most im- portant. It is the ingredient in the gastric juice most commonly deficient. It is not only necessary for its own important actions, but its presence is intimately associated with that of the pepsin, as it is only in the presence of a sufficient quantity that the pepsinogen is converted into the active digestive ferment. It is best given as the dilute acid taken in somewhat larger quantities than are usually advised. Ewald recommends large doses—of from 90 to 100 drops—at intervals of fifteen minutes after the meals. Leube and Eiegel advise smaller doses. Probably from 15 to 20 drops is sufficient. The prolonged use of it does not appear to be in any way hurtful. The use, however, should be restricted to cases of neurosis and atrophy of the mucous membrane. In actual gastritis its value is doubtful. The digestive ferments: These are extensively employed to strengthen the weakened gastric and intestinal secretions. The use of pepsin, ac- cording to Ewald, may be limited to the cases of advanced mucous catarrh and the instances of atrophy of the stomach, in which it should be given, in doses of from 10 to 15 grains, with dilute hydrochloric acid a quarter of an hour after meals. It may be used in various different forms, either as a powder or in solution or given with the acid. The powder is much more certain. Pepsin wine is generally inert, as there is little of the ferment taken up by alcohol. It is important to use a reliable article. Much that is in the market is valueless. Pancreatin is of equal or even greater value than the pepsin. Pains should be taken to use a good article, such as that prepared by Merck. It should be given in doses of from 15 to 20 grains, in combination with bicarbonate of soda. It is conveniently administered in tablets, each of which contains 5 grains of the pancreatin and the soda, and of these two or three may be taken fifteen or twenty minutes after each meal. Ptyalin and diastase are particularly indicated when the acid is excessive. The action of the former continues in the stomach during normal diges- tion. The malt diastase is often very serviceable given with alkalies. Of measures which stimulate the glandular activity in chronic dys- pepsia lavage is by far the most important, particularly in the forms characterized by the secretion of a large quantity of mucus. Luke-warm 384 DISEASES OP THE DIGESTIVE SYSTEM. water should be used, or, if there is much mucus, a one per cent salt solu- tion, or a three to five per cent solution of bicarbonate of soda. If there is much fermentation the three per cent solution of boric acid may be used, or a dilute solution of carbolic acid. It is best employed in the morning on an empty stomach, or in the evening some hours after the last meal. It is perhaps preferable in the morning, except in those cases in which there is much nocturnal distress and flatulency. Once a day is, as a rule, sufficient, or, in the case of delicate persons, every second day. The irrigation may be continued until the water which comes away is quite clear. It is not necessary to remove all the fluid after the irrigation. While perhaps in some hands this measure has been carried to ex- tremes, it is one of such extraordinary value in certain cases that it should be more widely employed by practitioners. When there is an insuperable objection to lavage a substitute may be used in the form of warm alkaline drinks, taken slowly in the early morning or the last thing at night. Of medicines which stimulate the gastric secretion the most important are the bitter tonics, such as quassia, gentian, columbo, cundurango, ipecacu- anha, strychnia, and cardamoms. These are probably of more value in chronic gastritis than the hydrochloric acid. Of these strychnia is the most powerful, though none of them have probably any very great stimulating action on the secretion, and influence rather the appetite than the digestion. Of stomachics which are believed to favorably influence digestion the most important are alcohol and common salt. The former would appear to act in moderate quantities by increasing the acid in the gastric juice, and with it probably the pepsin formation. Others hold that it is not so much the secretory as the motor function of the stomach which the alcohol stimu- lates. In moderate quantities it has certainly no directly injurious influ- ence on the digestive processes. Special care should be taken, however, in ordering alcohol to dyspeptics. If a patient has been in the habit of tak- ing beer or light wines or stimulants with his meals, the practice may be continued if moderate quantities are taken. Beer, as a rule, is not well borne. A dry sherry or a glass of claret is preferable. In the case of women with any form of dyspepsia stimulants should be employed with the greatest caution, and the practitioner should know his patient well before ordering alcohol. The importance of salt in gastric digestion rests upon the facjt that its presence is essential in the formation of the hydrochloric acid. An in- crease in its use may be advised in all cases of chronic dyspepsia in wdiicli the acid is defective. Treatment of Special Conditions.—Fermentation and flatu- lency. When the digestion is slow or imperfect, fermentation goes on in the contents, with the formation of gas and the production of lactic, bu- tyric, and acetic acids. For the treatment of this condition careful diet- ing may suffice, particularly forbidding such articles as tea, pastry, and the coarser vegetables. It is usually combined with pyrosis, in which the NEUROSES OF THE STOMACH. 385 acid fluids are brought into the mouth. Bismuth and carbonate of soda sometimes suffice to relieve the condition. Thymol, creosote, and carbolic acid may be employed. For acid dyspepsia Sir William Boberts recom- mends the bismuth lozenge of the British Pharmacopoeia, the antacid properties of which depend on chalk and bicarbonate of soda. It should be taken an hour or two after meals, and only when the pain and un- easiness are present. Glycerine in from twenty to sixty minim doses, the essential oils, animal charcoal alone or in combination with compound cinnamon powder, may be tried. If there is much pain, chloroform in twenty-minim doses or a teaspoonful of Hoffman’s anodyne may be used. If obstinate, lavage is indicated and is sometimes striking in its effects. Alkaline solutions may be used. Vomiting is not a feature which often calls for treatment in chronic dyspepsia; sometimes in children it is a persistent symptom. Creosote and carbolic acid in drop doses, a few drops of chloroform or of dilute hy- drocyanic acid, cocaine, bismuth, and oxalate of cerium may be used. If obstinate, the stomach should be washed out daily. Constipation is a frequent and troublesome feature of most forms of indigestion. Occasionally small doses of mercury, podophyllin, the laxa- tive mineral waters, sulphur, and cascara may be employed. Glycerine sup- positories or the injection of from half a teaspoonful to a teaspoonful of glycerine is very efficacious. Many cases of chronic dyspepsia are greatly benefited by the use of mineral waters, particularly a residence at the springs with a careful super- vision of the diet and systematic exercise. The strict regime of certain German Spas is particularly advantageous in the cases in which the chronic dyspepsia has resulted from excess in eating and in drinking. Kissingen, Carlsbad, Ems, and Wiesbaden are to be specially recom- mended. III. NEUROSES OF THE STOMACH. (1) Gastralgia; Gastrodynia.—Severe pains in the epigastrium, parox- ysmal in character, occur (a) as a manifestation of a functional neurosis, independent of organic disease, and usually associated with other nervous symptoms (it is this form which will here be described); (b) in chronic disease of the nervous system, forming the so-called gastric crises; and (c) in organic disease of the stomach, such as ulcer or cancer.' The functional neurosis occurs chiefly in women, very commonly in connection with disturbed menstrual function or with pronounced hys- terical symptoms. The affection may set in as early as puberty, but it is more common at the menopause. Anaemic, constipated women who have worries and anxieties at home are most prone to the affection. It is more frequent in brunettes than in blondes. Attacks of it sometimes occur in robust, healthy men. More often it is only one feature in a condition of general neurasthenia or a manifestation of that form of nervous dyspepsia 386 DISEASES OF THE DIGESTIVE SYSTEM. in which the gastric juice or hydrochloric acid is secreted in excess. I am very skeptical as to the existence of a gastralgia of purely malarial origin. The symptoms are very characteristic; the patient is suddenly seized with agonizing pains in the epigastrium, which pass toward the back and around the lower ribs. The attack is usually independent of the taking of food, and may recur at definite intervals, a periodicity which has given rise to the supposition in some cases that the affection is due to malaria. The most marked periodicity, however, may be in the gastralgic attacks of ulcer. They frequently come on at night. Vomiting is rare; more com- monly the taking of food relieves the pain. To this, however, there are striking exceptions. Pressure upon the epigastrium commonly gives re- lief, but deep pressure may be painful. It seems scarcely necessary to separate the forms, as some have done, into irritative and depressive, as the cases insensibly merge into each other. Stress has been laid upon the occurrence of painful points, but they are so common in neurasthenia that very little importance can be attributed to them. The diagnosis offers many difficulties. Organic disease either of the stomach or of the nervous system, particularly the gastric crises of loco- motor ataxia, must be excluded. In the case of ulcer or cancer this is not always easy. I well remember the case of a poor fellow who was discharged from the Montreal General Hospital as a malingerer. A week subsequent to his discharge he was readmitted with peritonitis from perforation. The fact that the pain is most marked when the stomach is empty and is re- lieved by the taking of food is sometimes regarded as pathognomonic of simple gastralgia, but to this there are many excejDtions, and in cancer the pains may be relieved on eating. The prolonged intervals between the attacks and their independence of diet are important features in simple gastralgia; but in many instances it is less the local than the general symptoms of the case which enable us to make the diagnosis. It is to be remembered that in gall-stone colic jaundice is frequently absent, and in any long-standing case of gastralgia, in which the attacks recur at intervals for years, the question of cholelithiasis should be considered. (2) Nervous Dyspepsia.—According to Leube, who first separated it from the ordinary gastric catarrh, nervous dyspepsia is characterized by sensations of distress and uneasiness during digestion, and yet the act is accomplished within the physiological time limit. The studies of Ewald, Oser, Rosenbach, and others have greatly extended our knowledge of the condition. The cases are met with most frequently in those who have either inherited a neurotic constitution or have gradually, through indis- cretions, brought about a condition of nervous prostration. All grades oc- cur, from the emaciated, skeleton-like subject of anorexia nervosa to the well-nourished, healthy-looking, fresh-complexioned patient whose con- stant complaint is distress and uneasiness after eating. If in a case of dyspepsia the stomach is found empty seven hours after the test dinner, the supposition is that the trouble is nervous (Leube). The separation of NEUROSES OF THE STOMACH. 387 the different forms can only be made accurately by the chemical examina- tion of the juices. Clinical Forms.—Leu be recognizes three chief types, (a) Nervous dyspepsia with normal secretion. There is no dilatation of the stomach, no pain on pressure, and no change in the condition of the acid. The test meal is digested within the normal time. Yet, despite the fact that the motor and chemical functions of the organ are perfectly performed, there are distress and uneasiness during the act of digestion. The patient complains of pressure and distention of the stomach; eructations occur. (b) The condition of subacidity or inacidity. Lack of the normal amount of acid is found in chronic catarrh, and particularly in cancer. According to Leube, reduction in the normal amount of acid may exist with the most pronounced symptoms of nervous dyspepsia, and yet the stomach will be free from food within the regular time. A condition in which the gastric juice is entirely without acid may occur in cancer, in ex- treme sclerosis of the mucous membrane, and as a nervous manifestation of hysteria, and occasionally of tabes. The most aggravated cases are those associated with hysteria and neurasthenia. In addition to the gen- eral symptoms, there are loss of appetite, sleeplessness, and gastric distress, and when the stomach is empty there are uneasy local sensations and gen- eral feelings of malaise, headache, and dizziness. (c) Nervous dyspepsia with hyperacidity of the gastric juices. This is a form of dyspepsia which has long been recognized, but of late has been specially studied by Reichmann and others. The percentage of acid may be doubled. This increase in the acid may be an intermittent condi- tion or continuous. The periodic form is really a neurosis of secretion— gastroxynsis of Eosenbach—which may be quite independent of the time of digestion. Such cases are rare and are associated either with profound neurasthenia or with locomotor ataxia. The attack may last for several days. It usually sets in with a gnawing, unpleasant sensation of the stomach, severe headache, and shortly after the patient vomits a clear, watery secretion of such acidity that the throat is irritated and made raw and sore. As mentioned, the attacks may be quite independent of food. The chronic condition of hyperacidity is more common. Digestion is usually retarded, particularly for the starches, and there are eructations of acid fluid and gastric distress. There are instances also in which when the stomach contains no food there is a secretion of a highly acid juice. In these cases burning acid eructations, or even vomiting, occurring during the night or early in the morning, are quite characteristic. The relation of hyperacidity to gastric ulcer will be considered later. (3) Nervous Vomiting; Peristaltic Unrest; Rumination.—(a) Nerv- ous Vomiting — a condition which is not associated with anatomical changes in the stomach or with any state of the contents, but is due to nervous influences acting either directly or indirectly upon the centres presiding over the act of vomiting. The patients are, as a rule, women— 388 DISEASES OF THE DIGESTIVE SYSTEM. usually brunettes—and the subject of more or less marked hysterical mani- festations. A special feature of this form is the absence of the prelimi- nary nausea and of the straining efforts of the ordinary act of vomiting. It is rather a regurgitation, and without visible effort and without gag- ging the mouth is filled with the contents of the stomach, which are then spat out. It comes on, as a rule, after eating, but may occur at irregular intervals. In some cases the nutrition is not impaired, a feature which may give a clew to the true nature of the disease, as there may be no other hysterical manifestation present. As noted by Tuckwell, it may occur in children. Nervous vomiting is rarely serious. Death may, however, fol- low, as in the case reported by Garland,* in which a young woman, aged twenty, had had from the age of two attacks of vomiting which lasted for twenty-four hours, and which were very apt to occur when the child was extra well and vivacious. She had St. Vitus’s dance at eleven. At about the age of twenty, she had excessive muscular twitchings, clonic in char- acter and uncontrollable, and amounting to violent motion of the muscles. When twenty-two she had severe headache, gradually lost flesh, and be- came low-spirited. In January, 1884, she had headache, twitchings, and constant vomiting, and died on the 13th. There was slight atrophy of the mucous membrane of the stomach and slight increase in the firmness of the kidneys. A type of vomiting is that associated with certain diseases of the nerv- ous system—particularly locomotor ataxia—forming part of the gastric crises. Leyden has reported cases of primary periodic vomiting, which he regards as a neurosis. (b) Peristaltic Unrest.—This condition, as described by Kussmaul, is an extremely common and distressing symptom in neurasthenia. Shortly after eating the peristaltic movements of the stomach are increased, and borborygmi and gurgling may be heard, even at a distance. The sub- jective sensations are most annoying, and it would appear as if in the hyperaesthetic condition of the nervous system the patient felt normal peristalsis, just as in these states the usual beating of the heart may be perceptible to him. A further analogy is afforded by the fact that emotion increases this peristalsis. It may extend to the intestines, par- ticularly to the duodenum, and on palpation over this region the gur- gling is most marked. The movement may be anti-peristalsis, in which the wave passes from left to right, a condition which may also extend to the intestines. There are cases on record in which colored enemata or even scybala have been discharged from the mouth. (c) Rumination; Merycismus.—In this remarkable and rare condi- tion the patients regurgitate and cheAV the cud like ruminants. It occurs in neurasthenic or hysterical persons, epileptics, and idiots. In some in- stances it is hereditary. There is an instance in which a governess taught * Transactions of the Association of American Physicians, yoI. iv. NEUROSES OF THE STOMACH. 389 it to two children. The habit may persist for years, and does not neces- sarily impair the health. Here may be mentioned the condition known as pica, met with chiefly in insanity, hysteria, and chlorosis, in which the appetite is inordinate and perverted, and in which all sorts of non-nutritive articles are eaten. Geophagism, earth or clay eating, prevails as a habit in parts of the South- ern States. Treatment of Neuroses of the Stomach.—The gastralgia, if very severe, requires morphia, which is best administered subcutaneously in combination with atropia. In the milder attacks the combination of morphia (gr. with cocaine and belladonna is recommended by Ewald. The greatest caution should, however, be exercised in these cases in the use of the hypodermic syringe. It is preferable, if opium is necessary, to give it by the mouth, and not to let the patient know the character of the drug. Chloroform, in from ten to twenty drop doses, or Hoffman’s ano- dyne will sometimes allay the severe pains. The general condition should receive careful attention, and in many cases the attacks recur until the health is restored by change of air with the prolonged use of arsenic. If there is anaemia iron may be given freely. Nitrate of silver in doses of gr. £ to £ in a large claret-glass of water taken on an empty stomach is useful in some cases. Many cases of nervous dyspepsia with marked neurasthenic or hysteri- cal symptoms do well on the Weir-Mitchell treatment, and in obstinate forms it should be given a thorough trial. The most striking results are perhaps seen in the cases of anorexia nervosa, which will be referred to subsequently. It is also of value in the nervous vomiting. In the dis- tressing cases of hyperacidity, in addition to the treatment of the general neurotic condition, alkalies must be employed, either in the form of mag- nesia or bicarbonate of soda. The burning acid eructations are usually relieved in this way. Limiting the patient to a strictly meat diet is a valuable procedure in many cases of dyspepsia associated with hyperacidity. The meat should be taken either raw or, if an insuperable objection exists to this, very slightly cooked. It is best given finely minced or grated on stale bread. An ample dietary is ounces (100 grammes) of meat, two medium slices of stale bread, and an ounce (30 grammes) of butter. This may be taken three times a day with a glass of Apollinaris water, soda water, or, what is just as satisfactory, spring water. The fluid should not be taken too cold. Special care should be had in the examination of the meat to guard against tape-worm infection, but suitable instructions on this point can be given. This is sufficient for an adult man, and many obstinate cases yield satisfactorily to a month or six weeks of this treat- ment, after which time the less readily digested articles of food may be gradually added to the dietary. In other instances the use of the stom- ach-tube is most effectual. 390 DISEASES OF THE DIGESTIVE SYSTEM. There are forms of nervous dyspepsia occurring in women who are often well nourished and with a good color, yet who suffer—particularly at night—with flatulency and abdominal distress. The sleep may be quiet and undisturbed for two or three hours, when they are aroused with pain- ful sensations in the abdomen and eructations. The appetite and diges- tion may appear to be normal. Constipation is, however, usually present. In many of these patients the condition seems rather intestinal dyspepsia, and the distress is due to the accumulation of gases, the result of excess- ive putrefaction. The fats, starches, and sugars should be restricted. A diastase ferment is sometimes useful. The flatulency may be treated by the methods above mentioned. Naphthalin, salicylate of bismuth, and salol have been recommended. Some of these cases obtain relief from thorough irrigation of the colon at bedtime. IV. DILATATION OF THE STOMACH (Gastrectasis). Etiology.—This may occur either as an acute or a chronic con- dition. Acute dilatation is rarely seen, though it occurs whenever enormous quantities of food and drink are quickly ingested. Occasionally this leads to extreme paralytic dilatation, and Fagge has described two cases which came on in this way, one of which proved fatal. Chronic dilatation results from : (a) Narrowing of the pylorus or of the duodenum by the cicatrization of an ulcer, hypertrophic stenosis of the pylorus (whether cancerous or simple), congenital stricture, or occa- sionally by pressure from without of a tumor or of a floating kidney. Without any organic disease the pylorus may be tilted up by adhesion to the liver or gall-bladder, or the stomach may be so dilated that the pylorus is dragged down and kinked. (£) Relative or absolute insufficiency of the muscular power of the stomach, due on the one hand to repeated over- filling of the organ with food and drink (Ueheranstrengung des Magens, Striimpell), and on the other to atony of the coats induced by chronic inflammation or degeneration or impaired nutrition, the result of consti- tutional affections, as cancer, tuberculosis, anaemia, etc. The most extreme forms are met with in the first group, and most commonly as a sequence of the cicatricial contraction of an ulcer. There may be considerable stenosis without much dilatation, the obstruction being compensated by hypertrophy of the muscular coats. Considerable atten- tion has been directed in Germany by Litten, Ewald, and others to the association of dilatation with dislocation of the right kidney. Two well- marked instances have come under my observation among a very large number of cases of movable kidney, but in neither was the dilatation ex- treme. In the second group, due to atony of the muscular coats, we must dis- tinguish between instances in which the stomach is simply enlarged and DILATATION OF THE STOMACH. 391 those with actual dilatation, the conditions which Ewald characterized as megastrie and gastrectasis respectively. The size of the stomach varies greatly in different individuals, and the maximum capacity of a normal organ Ewald places at about 1,600 c. c. Measurements above this point indicate absolute dilatation. Atonic dilatation of the stomach may result from weakness of the coats, due to repeated overdistention or to chronic catarrh of the mucous membrane, or to the general muscular debility which is associated with chronic wasting disorders of all sorts. The combination of chronic gastric catarrh with overfeeding and excessive drinking is one of the most fruit- ful sources of atonic dilatation, as pointed out by Naunyn. The condition is frequently seen in diabetics, in the insane, and in beer-drinkers. In Germany this form is very common in men employed in the breweries. Possibly muscular weakness of the coats may result in some cases from disturbed innervation. Dilatation of the stomach is most frequent in middle-aged or elderly persons, but the condition is not uncommon in children, especially in association with rickets. Symptoms.—These are very variable and depend upon the cause and the degree of dilatation. Naturally the features in cancer of the pylorus would be very different from those met with in an excessive drinker. Dyspepsia is present in nearly all cases, and there are feelings of distress and uneasiness in the region of the stomach. The patient may complain much of hunger and thirst and eat and drink freely. The most character- istic symptom is the vomiting at intervals of enormous quantities of liquid and of food, amounting sometimes to four or more litres. The material is often of a dark-grayish color, with a characteristic sour odor due to the organic acids present, and contains mucus and remnants of food. On standing it separates into three layers, the lowest consisting of food, the middle of a turbid, dark-gray fluid, and the uppermost of a brownish froth. The microscopical examination shows a large variety of bacteria, yeast fungi, and the sarcina ventriculi. There may also be cherry stones, plum stones, and grape seeds. The acid may be absent, diminished, normal, or in excess, depending upon the cause of the dilatation. The fermentation produces lactic, butyric, and, possibly, acetic acids and various gases. In consequence of the small amount of fluid which passes from the stomach or is absorbed there are constipation, scanty urine, and extreme dryness of the skin. The general nutrition of the patient suffers greatly; there is loss of flesh and strength, and in some cases the most extreme emaciation. A very remarkable symptom which occurs occasionally is tetany, first described by Kussmaul. Physical Signs.—Inspection.—The abdomen may be large and promi- nent, the greatest projection occurring below the navel in the standing posture. In some instances the outline of the distended stomach can be plainly seen, the small curvature a couple of inches below the ensiform 392 DISEASES OF THE DIGESTIVE SYSTEM. cartilage, and the greater curvature passing obliquely from the tip of the tenth rib on the left side, toward the pubes, and then curving upward to the right costal margin. Too much stress cannot be laid on the impor- tance of inspection. In ten of thirteen cases of dilated stomach in my wards during one year the diagnosis was made de visu. Active peristalsis may be seen in the dilated organ, the waves passing from left to right. Occasionally anti-peristalsis may be seen. In cases of stricture, particu- larly of hypertrophic stenosis, as the peristaltic wave reaches the pylorus, the tumor-like thickening can sometimes be distinctly seen through the thin abdominal wall. To stimulate the peristalsis the abdomen may be flipped with a wet towel, or inflation may be practised with tartaric acid and bicarbonate of soda. Palpation.—The peristalsis may be felt, and usually in stenosis the tumor is evident at the pylorus. The resistance of a dilated stomach is peculiar, and has been aptly compared to that of an air cushion. Bi- manual palpation elicits a splashing sound—clapotage—which is, of course, not distinctive, as it can be obtained whenever there is much liquid and air in the organ, but it cannot be obtained in a healthy person two or three hours after eating. The splashing may be very loud, and the patient may produce it himself by suddenly depressing the diaphragm, or it may be readily obtained by shaking him. A tube passed into the stomach may be felt externally through the skin, a procedure no longer recommended by Leube, who suggested it. The gurgling of gas through the pylorus may be felt. Percussion.—The note is tympanitic over the greater portion of a dilated stomach; in the dependent part the note is dull. In the upright position the percussion should be made from above downward, in the left parasternal line, until a change in resonance is reached. The line of this should be marked, and the patient examined in the recumbent position, when it will be found to have altered its level. When this is on a line with the navel or below it, dilatation of the stomach may generally be assumed to exist. The fluid may be withdrawn from the stomach with a tube, and the dulness so made to disappear, or it may be increased by pouring in more fluid. In cases of doubt the organ may be artificially distended with carbonic-acid gas. A teaspoonful of bicarbonate of soda is first given in a little water, and then the same quantity of tartaric acid. The most accurate method of determining the size of the stomach is by inflation through a stomach-tube with a Davidson’s syringe. Pacanowski has shown that the greatest vertical diameter of gastric resonance in the normal stomach varies from 10 to 14 cm. in the male and is about 10 cm. in the female. Auscultation.—The clapotement or succussion can be obtained readily. Frequently a curious sizzling sound is present, notunlike that heard when the ear is placed over a soda-water bottle when first opened. It can be heard naturally, and is usually evident when the artificial gas is being DILATATION OF THE STOMACH. 393 generated. The heart sounds may sometimes be transmitted with great clearness and with a metallic quality. Mensuration may be used by passing a hard sound into the stomach until the greater curvature is reached. Normally it rarely passes more than 60 cm., measured from the teeth, but in cases of dilatation it may pass as much as 70 cm. Diagnosis.—The diagnosis can usually be made without much diffi- culty by attention to these methods of examination. Curious errors, how- ever, are on record, one of the most remarkable of which was the con- founding of dilated stomach with an ovarian cyst; even after tapping and the removal of portions of food and fruit seeds, abdominal section wras performed and the dilated stomach opened. The prognosis is bad in cases in which there is stenosis of the pylorus, either simple or can- cerous. Treatment.—In the cases due to atony careful regulation of the diet and proper treatment of the associated catarrh will suffice to effect a cure. Strychnine, ergot, and iron are recommended. Washing out the stomach is of great service, though we do not see such striking and imme- diate results in this form. In cases of mechanical obstruction the stomach should be emptied and thoroughly washed, either with warm water or with an antiseptic solution. We accomplish in this way three important things : We remove the weight, which helps to distend the organ; we remove the mucus and the stagnating and fermenting material which irritates and in- flames the stomach and impedes digestion; and we cleanse the inner sur- face of the organ by the application of water and medicinal substances. The patient can usually be taught to wash out his own stomach, and in a case of dilatation from simple stricture I have known the practice to be followed daily for three years with great benefit. The rapid reduction in the size of the stomach is often remarkable, the vomiting ceases, the food is taken readily, and in many cases the general nutrition improves rapidly. As a rule, once a day is sufficient, and it may be practised either the first thing in the morning or before going to bed. So soon as the fermentative processes have been checked lukewarm water alone should be used. The food should be taken in small quantities at frequent intervals, and should consist of scraped beef, Leube’s beef solution, and tender meats of all sorts. Fatty and starchy articles of diet are to be avoided. Liquids should be taken sparingly. When the condition becomes aggravated a resort to surgery is justifi- able. Here may be mentioned the recent statistics of gastric surgery. Pyloric stenosis is the common condition. Dreydorff has collected 442 cases—188 cases of pylorectomy, mortality 57’4 per cent; 215 gastro-en- terostomies, mortality 43‘3 per cent; pyloroplasty, 29 cases, mortality 20-7 per cent. On an average, after pylorectomy the patient remained free from recurrence for a little over a year. 394 DISEASES OF THE DIGESTIVE SYSTEM. V. THE PEPTIC ULCER-GASTRIC AND DUODENAL. The round, perforating or simple ulcer is usually single and occurs in the stomach and in the duodenum as far as the papilla biliaria. It proba- ably follows nutritional disturbance in a limited region of the mucosa, which results in the gradual destruction of this area by the gastric juice. The condition is usually associated with hyperacidity. Etiology.—Clinically the simple ulcer is not so frequent as the sta- tistics of post-mortems would lead us to expect; thus in the extensive rec- ords collected by Welch, ulcer, cicatrized or open, was present in about five per cent of persons dying from all causes. The scars are found more frequently than the open ulcer. Females are more frequently affected than males. Of 1,699 cases col- lected from hospital statistics by Welch, and examined post mortem, 40 per cent were in males and 60 per cent were in females. He gives the age incidence in 607 cases, of which three fourths were distributed be- tween the ages of twenty and sixty, with tolerable uniformity in the four decades. In females the largest number of cases occurs between twenty and thirty; in males, between thirty and forty. Ulcer occasionally oc- curs in children, and Goodhart has reported a case in an infant thirty hours old. Gastric ulcer is stated to be less common in this country than in Europe. In women it is frequent among servant girls, and in men who follow such occupations as shoe-making, weaving, and tailoring, possibly connect- ed, as Ilabershon suggested, with pressure on the stomach. This view has been developed by Rasmussen, who holds that pressure of the costal margin, from various causes, induces anaemia and atrophy of the mucous membrane, particularly in the region of the smaller curvature. Very rarely the disease originates from traumatism or the action of corrosive fluids. Gastric ulcer is associated in a special manner with certain dis- eases, in women with anaemia and chlorosis and with menstrual disorders. It is not infrequently met with in tuberculosis. Such cases are not, how- ever, to be mistaken for the true tuberculous ulcer, which may be found in the stomach. Many cases have occurred in connection writh disease of the heart or of the blood-vessels, a relation of special interest in connection with the embolic theory of its production. The duodenal ulcer is less common than the gastric ulcer, and occurs most frequently in males. The combined statistics of Krauss, Chvostek, Lebert, and Trier give 171 cases in males and 39 in females. In 9 cases which have come under my observation 7 wrere in males and 2 in females; one of these was in a lad of twelve. It has been found in association with tuberculosis, and may follow large superficial burns. Morbid Anatomy.—Though usually single, the ulcers may be multi- ple. In none of my cases were there more than five, but there is an instance THE PEPTIC ULCER—GASTRIC AND DUODENAL. 395 on record of thirty-four. The ulcer is situated most commonly on the posterior wall of the pyloric portion at or near the lesser curvature. It is not nearly so frequent on the anterior wall. Of 793 cases collected by Welch from hospital statistics, 288 were on the lesser curvature, 235 on the posterior wall, 95 at the pylorus, 69 on the anterior wall, 50 at the cardia, 29 at the fundus, 27 on the greater curvature. The duodenal ulcer is usually situated just outside the ring in the first portion of the gut. The ulcer varies from 1 to 10 cm. in diameter. It may he small and punched out, or it may reach an enormous size. The largest of which I have any knowledge is one reported by Peabody, which measured 19 by 10 cm. and involved all of the lesser curvature and spread over a large part of the anterior and posterior walls. The nicer is usually round or oval in shape, hut may be irregular with sinuous borders. It is often dis- tinctly terraced. In acute cases the mucous membrane is sharply cut, as if punched out by an instrument. In old cases the edge is indurated and loses the sharp margin. The floor is formed either by the submucosa, by the muscular layers, or, not infrequently, by the neighboring organs, to which the stomach has become attached. In the healing of the ulcer, if the mucosa is alone involved, the granulation tissue develops from the edges and the floor and the newly formed tissue gradually contracts and unites the margins, leaving a smooth scar. In larger ulcers which have become deep and involved the muscular coat the cicatricial contraction may cause serious changes, the most important of which is narrowing of the pyloric orifice and consequent dilatation of the stomach. In the case of a girdle ulcer, hour-glass contraction of the stomach may be produced. It is prob- able that large ulcers persist for years without any attempt at healing. The ulcer may deepen and penetrate the coats. Fortunately, in a majority of the cases, adhesions form between the stomach and adjacent organs, particularly with the pancreas, the left lobe of the liver, and the omental tissues On the anterior surface of the stomach adhesions do not so readily form, hence the great danger of the ulcer in this situation, which more readily perforates and excites a diffuse and fatal peritonitis. On the posterior wrall the ulcer penetrates directly into the lesser peri- toneal cavity, in which case it may produce an air-containing abscess with the symptoms of the condition known as subphrenic pyo-pneumothorax. In rare instances adhesions and a gastro-cutaneous fistula form, usually in the umbilical region. Fistulous communication with the colon may also occur, or a gastro-duodenal fistula. There are several instances on record of perforation into the pericardium, and at least two of rupture into the left ventricle. Perforation into the pleura may also occur. It is to be noted that general emphysema of the subcutaneous tissues occasion- ally follows perforation of a gastric ulcer. One of the most serious effects of gastric ulcer is erosion of blood-ves- sels. The haemorrhage may occur in the acutely formed ulcer or in the 396 DISEASES OF THE DIGESTIVE SYSTEM. ulceration which takes place at the base of the chronic form; it is in the latter condition that the bleeding is most common. Ulcers on the posterior wall may erode the splenic artery, but perhaps more frequently the bleeding proceeds from the artery of the lesser curve. In the case of duodenal ulcer the pancreatico-duodenal artery may bo eroded or (as in one of my cases) fatal hsemorrhage may result from the opening of the hepatic artery, or more rarely the portal vein. Interesting changes occur in the vessels. Embolism of the artery supplying the ulcerated region has been met with in several cases; in others diffuse endarteritis. Small aneurisms have been found in the floor of the ulcers by Douglas Powell, Welch, and others. The mode of the origin of the peptic ulcer has been much discussed. Ulcers have been produced in animals in many ways, both by artificial emboli and by direct chemical and mechanical irritants applied to the mu- cosa. The ulcers thus produced heal with great rapidity unless the ani- mals have been rendered anaemic by repeated abstraction of blood. Vir- chow’s view that the process may result from plugging the nutrient artery of the part, either by an embolus or by a thrombus, and the infarct so produced is destroyed by the gastric juice, has gained general acceptance. It is in conformity with Pavy’s well-known experiments and with the ana- tomical facts already mentioned, particularly with the funnel-like shape of the ulcer, and the actual demonstration, in some cases, of the plugged vessels; but this view scarcely meets all the cases, in many of which the etiology is still obscure. Mere mechanical injury to the mucous mem- brane is, however, in most cases, insufficient cause for an ulcer, for nor- mally the stomach is perfectly able to withstand such insults. Ewald concludes that certain predisposing causes play an important role in its development. He points to its frequency in conditions of amenorrhcea, chlorosis, ansemia after confinements, etc., where one may assume that the condition of the blood is not wholly normal, and also to the fact that in the majority of cases of this affection there is a hyperacidity of the gas- tric juice. One or both of these predisposing factors seem to be pres- ent in most cases, and it has been recently shown that in the various an * mi so there is an appreciable diminution in the normal alkalinity of the blood, a fact which tends to explain one of the predisposing causes in these affections, and which is in accord with the “ alkalescence theory ” of Cohnheim et al. The duodenal ulcer has an identical origin, but a few cases of acute ulcer, as already mentioned, have a curious relation with superficial burns. In one of my cases there was an ulcer in the posterior wall of the duodenum, 1*5 cm. in diameter, with overlapping edges, and not far from it was a cyst-like cavity in the submucosa associated with Brunner’s glands, and it is possible that the open ulcer, with undermined edges, resulted from the rupture of one of these cysts. Symptoms.—The condition may be met with accidentally, post mor- tem, in cases which have presented no indication of gastric disturbance. THE PEPTIC ULCER—GASTRIC AND DUODENAL. 397 In other instances the first symptoms may be due to perforation. In others again the symptoms,, for months and years, may be those of ordi- nary dyspepsia, and the ulcer may not have been suspected until the oc- currence perhaps of a sudden haemorrhage. The symptoms suggestive of peptic ulcer are: («) Dyspepsia, which may be slight and trifling or of a most aggravated character. In a con- siderable proportion of all cases nausea and vomiting occur, the latter not for two or more hours after eating. The vomitus usually contains a large amount of HC1. (b) Haemorrhage is present in at least one half of all cases. It may be slight, but more commonly is profuse, and may be in such quantities and brought up so quickly that it is fluid, bright red in color, and quite unal- tered. When the blood remains for some time in the stomach and is mixed with food it may be greatly changed, but the vomiting of a large quantity of unaltered blood is very characteristic of ulcer. Syncope may follow or death may directly result from the haemorrhage. A most extreme grade of anaemia may be produced. In either the gastric or duodenal ulcer, more commonly in the latter, the blood may be passed in the stools and not be vomited. This may occur when the haemorrhage is slight, but also when it is profuse enough to produce collapse and extreme anaemia. (c) Pain is perhaps the most constant and distinctive feature of ulcer. It varies greatly in character; it may be only a gnawing or burn- ing sensation, which is particularly felt when the stomach is empty, and is relieved by taking food, but the more characteristic form comes on in paroxysms of the most intense gastralgia, in which the pain is not only felt in the epigastrium, but radiates to the back and to the sides. These attacks are most frequently induced by taking food, and they may recur at a variable period after eating, sometimes within fifteen or twenty min- utes, at others as late as two or three hours. It is usually stated that when the ulcer is near the cardia the pain is apt to set in earlier, but there is no certainty on this point. The attacks may occur at intervals with great intensity for weeks or months at a time, so that the patient con- stantly requires morphia, then again they may disappear entirely for a prolonged period. In the attack the patient is usually bent forward, and finds relief from pressure in the epigastric region; one patient during the attack would lean over the back of a chair; another would lie flat on the floor, with a hard pillow under the abdomen. Pressure is, as a rule, grateful. It has been thought that the posture assumed during the attack would indicate the site of the ulcer, but this is very doubtful. (cl) Tenderness on pressure is a common symptom in ulcer, and pa- tients wear the waist-band very low. There may be a painful point of very limited extent, most frequently an inch or two below the ensiform cartilage. In old ulcers with thickened bases an indurated mass can usu- ally be felt in the neighborhood of the pylorus. Pressure should be made 398 DISEASES OF THE DIGESTIVE SYSTEM. with great care, as rupture of an ulcer has been induced by careless manipulation. (ie) Of general symptoms, loss of weight results from the prolonged dyspepsia, but it rarely, except in association with cicatricial stenosis of the pylorus, reaches the high grade met with in cancer. The anaemia may be extreme, and in one case of duodenal ulcer which I examined the blood count was as low as 700,000 per c. mm. There are instances, such as the one reported by Pepper and Griffith, in wdiich the extreme anaemia cannot be explained by the occurrence of haemorrhage. According to Welch, perforation occurs in about six and a half per cent of all cases. The acute, perforating form is much more common in women than in men. The symptoms are those of perforative peritonitis. In some instances the pain associated with perforation is not referred to the abdomen. In a case of H. 0. Wood’s the chief symptoms were pain in the left shoulder and excessive pain in the back on movement. Per- foration is not necessarily fatal. Several cases of recovery have been re- ported. The course of the disease is, in the majority of cases, chronic. Only a few instances run a very acute course. The following group of clinical forms, described by Welch, indicate the diversity of this affection: “ 1. Latent ulcers, with entire absence of symptoms, and revealed as open ulcers or as cicatrices at the autopsy. “ 2. Acute perforating ulcers. With or without a period of brief gas- tric disturbance, perforation occurs and causes speedy death. “ 3. Acute haemorrhagic form of gastric ulcer. After a latent or a brief course of the ulcer, profuse gastrorrhagia occurs, which may termi- nate fatally or may be followed by the symptoms of chronic ulcer. “ 4. Gastralgic-dyspeptic form. In this, which is the most common form of gastric ulcer, gastralgia, dyspepsia, and vomiting are the symptoms. Sometimes one of the symptoms predominates greatly over the others, so that Lebert distinguishes separately a gastralgic, a dyspeptic, and a vomit- ive variety. Gastralgia is the most frequent symptom. “ 5. Chronic haemorrhagic form. Gastrorrhagia is a marked symptom, and occurs usually in combination with the symptoms just mentioned. “ 6. Cachectic form. This usually corresponds only to the final stage of one of the preceding forms, but the cachexia may develop so rapidly and become so marked that the course of the disease closely resembles that of gastric cancer. “ ,7. Recurrent form. In this the symptoms of gastric ulcer disappear, and then follow intervals, often of considerable duration, in -which there is apparent cure, but the symptoms return, especially after some indiscre- tion in the mode of living. This intermittent course may continue for many years. In these cases it is probable either that fresh ulcers form or that the cicatrix of an old ulcer becomes ulcerated. '“.8. Stenotic form. By the formation of cicatricial tissue in and THE PEPTIC ULCER—GASTRIC AND DUODENAL. 399 around the ulcer, the pyloric orifice becomes obstructed and the symptoms of dilatation of the stomach develop.” The course may be very protracted, and there are cases in which the disease has persisted for over twenty years. I have reported two in- stances of peptic ulcer, probably duodenal, in which well-marked symp- toms were present, in one case for eighteen, and in the other for twelve years. Both were of the chronic haemorrhagic form. Diagnosis.—The recognition of gastric ulcer is in many cases easy, as the combination of dyspepsia, gastralgic attacks, and haematemesis is very characteristic. Of the symptoms, haemorrhage with the gastralgic attack is the most characteristic. The distinctions between ulcer and can- cer will be given later. The greatest difficulty is offered by certain cases of gastralgia, which may resemble ulcer very closely, as, with the exception of the haemorrhage, there is no single symptom which may not be present. Even with haemorrhage the case may not be clear, and no less an author- ity than the late Austin Flint made a diagnosis of recurring gastralgia in a patient who had, on and off for nine years, violent pains with vomit- ing in association with ulcer. A difficulty also results from the fact that in many instances gastralgia is one of the symtoms of nervous dyspepsia, and may exist with marked emaciation. The following points are of value in discriminating between these two conditions: (a) In ulcer the pain is more definitely connected with taking food, though this is not always the case, as in the duodenal form the gastralgic attacks may occur at night when the stomach is empty. Relief of pain after eating is certainly less common in ulcer than in gastralgia, though it is a very uncertain feature, and in certain cases the pain in ulcer is always relieved by taking food. (5) In ulcer dyspeptic symptoms are almost invariably present in the intervals between the attacks, and even when pain is absent there is slight distress. (c) Local sensitiveness in a particular spot in the epigastrium is sug- gestive of ulcer. External pressure usually aggravates the pain in ulcer, and often relieves it in gastralgia. This is, however, a very uncertain feature, as patients writhing with the pains of ulcer may press the abdo- men over the back of a chair or place a hard pillow under it. (d) The general condition and history of the patient often give the most trustworthy information. The nutrition is impaired more frequent- ly in ulcer than in gastralgia. In the former we find more commonly (in women) dysmenorrhcea and chlorosis, while in the latter there are associated nervous phenomena—hysterical manifestations or neuralgias in other regions. (e) On examination of the abdomen, not only is pain on pressure much more common in ulcer, but there may also be thickening about the pylo- rus and, in many cases, signs of dilatation of the stomach. 400 DISEASES OF THE DIGESTIVE SYSTEM. (/) Hyperacidity of the gastric juice exists with ulcer. The gastric crises which occur in affections of the spinal cord, particu- larly in locomotor ataxia, may simulate very closely the gastralgic attacks of ulcer, and as they so often exist in the preataxic stage their true nature may be overlooked; but the occurrence of lightning pains, the ocu- lar symptoms, and the absence of the knee reflex are indications usually sufficient to render the diagnosis clear. Can the gastric and duodenal ulcer be distinguished clinically ? As already stated, they originate in the same way and present the same ana- tomical characters. In the great majority of cases they cannot be sepa- rated during life, as the symptoms produced are identical. Bucquoy has suggested that the duodenal ulcer can be distinguished by the following definite characters: («) Sudden intestinal haemorrhage in an apparently healthy person, which tends to recur and produce a profound anaemia. Haemorrhage from the stomach may precede or accompany the melaena. (b) Pain in the right hypochondriac region, coming on two or three hours after eating, (c) Gastric crises of extreme violence, during which the haemorrhage is more apt to occur. Certainly the occurrence of sudden in- testinal haemorrhage with gastralgic attacks is extremely suggestive of duo- denal ulcer. W. W. Johnston has reported an instance in which he made the diagnosis on these symptoms, and in one of the Montreal cases Palmer Howard suggested correctly the presence of a duodenal ulcer on similar grounds. A patient under my care who had, during eighteen years, fre- quent attacks of hsematemesis with gastralgia had melaena repeatedly with- out vomiting blood; * but as a rule in the attacks the blood was vomited first, and did not appear in the stools until later. Occasionally this sym- ptom will he found an important aid in diagnosis. The situation of the pain is too uncertain a factor on which to lay much stress, and the char- acter of the crises is usually identical. Gall-stone colic may occasionally simulate the pains of gastric ulcer. The sudden onset and as sudden termination, the swelling and tenderness of the liver, the enlargement of the gall-bladder, if present, and the oc- currence of jaundice are points which usually make the diagnosis clear. Treatment.—Post-mortem observations show that a very large num- ber of ulcers heal completely, hut the process is slow and tedious, often requiring months, or, in severe cases, years. The following are the im- portant points in treatment: (a) Absolute rest in bed. (b) A carefully and systematically regulated diet. While theoretically it is better to give the stomach complete rest by rectal feeding, yet in practice this strict limitation is not found satisfactory. The food should he bland, easily digested, and given at stated intervals. The following dietary will be found useful: At 8 a. m. give 200 c. c. of Leube’s beef solu- * Oil the Diagnosis of Duodenal Ulcer, Medical Record, November 24, 1888. THE PEPTIC ULCER-GASTRIC AND DUODENAL. 401 tion; at 12 m., 300 c. c. of milk gruel or peptonized milk. The gruel should be made with ordinary flour or arrowroot, and is mixed with an equal quantity of milk. If necessary it may be peptonized. Buttermilk is very well borne by these patients. At 4 p. m. the beef solution again, and at 8 p. m. the milk gruel or the buttermilk. The stomach in some cases is so irritable that the smallest amount of food is not well borne. In such cases lavage may be practised, if neces- sary, every morning and evening, with mildly alkaline water, after which the beef solution is given and the feeding supplemented by the rectal in- jections. Ill effects rarely follow the careful use of the stomach tube in gastric ulcer. There are some cases which do well from the outset on a milk diet, given at regular intervals, three or four ounces every two hours. When milk is not well borne egg albumen may be substituted, or the whites of eight eggs may be alternated with Leube’s beef solution. At the end of a month, if the condition has improved, the patient may be allowed scraped beef or young chicken, perfectly fresh sweet-bread, and farina- ceous puddings made with milk and eggs. Local applications, such as warm fomentations, over the abdomen are very useful. The patient should be told that the treatment will take at least three months, and for the greater portion of the time he should be in bed. (c) Medicinal measures are of very little value in gastric ulcer, and the remedies employed do not probably benefit the ulcer, but the gastric catarrh. The Carlsbad salts are warmly recommended by von Ziems- sen. The artificial preparation (sulphate of sodium, 50; bicarbonate of sodium, 6; chloride of sodium, 3) may be substituted, of which a tea- spoonful is taken every morning. Bismuth, in doses of thirty to sixty grains three times a day, and nitrate of silver may be given, but they influence the associated conditions rather than the ulcer. The pain if severe requires opium. Unless the gastralgia is intense morphia should not be given hypodermically, as there is a very serious danger in these cases of establishing the morphia habit. Doses of an eighth of a grain, with the bicarbonate of soda and bismuth, will allay the mild attacks, but the very severe ones require the hypodermic injection of a quarter or often half a grain. Antipyrin and antifebrin may be tried, but, as a rule, are quite ineffectual. In the milder attacks Hoffman’s anodyne, or twenty or thirty drops of chloroform, or the spirits of camphor will give relief. Counter-irritation over the stomach with mustard or cantharides is often useful. For the vomiting there is no measure so successful as lavage. If in- tractable the patient must be fed per rectum. The patient will sometimes retain food which is passed into the stomach through the tube, and Leube’s beef solution or milk may be given in this way. Cracked ice, chloroform, oxalate of cerium, bismuth, hydrocyanic acid, and ingluvin may be tried. When hgemorrhage occurs the patient should be put under the influence of opium as rapidly as possible., No attempt should be made 402 DISEASES OF THE DIGESTIVE SYSTEM. to check the haemorrhage by administering medicines through the mouth; as the profuse bleeding is always from an eroded artery, frequently from one of considerable size, it is doubtful if acetate of lead, tannic and gallic acids, and the usual remedies have the slightest influence. The essential point is to give rest, which is best obtained by opium. Er- gotin may be administered hypodermically in two-grain doses. Nothing should be given by the mouth except small quantities of ice. In profuse bleeding a ligature may be applied around a leg, or a leg and arm. Not infrequently the loss of blood is so great that the patient faints. A fatal result is not, however, very common from haemorrhage. Transfusion may be necessary, or, still better, the subcutaneous infusion of saline solution. The patients usually recover rapidly from the haemorrhage and require iron in full doses, which may, if necessary, be given hypodermically. When symptoms of perforation occur laparatomy should be performed at once. Barling has collected 31 cases with 13 recoveries. In persistent haemorrhage the stomach has been opened and the bleeding surface cauter- ized with success. IV. CANCER OF THE STOMACH Etiology.—The stomach comes next to the uterus as the most fre- quent seat of primary cancer, amounting, as shown by the statistics of Welch, to 21-4 per cent in a total of over 30,000 cases. The ratio of males to females affected is about five to four. Age has an important bearing. Of 2,038 cases tabulated by this author three fourths occurred between the fortieth and the seventieth year, 24-5 per cent between the ages of forty and fifty, and 30-4 between the ages of fifty and sixty. In childhood it is extremely rare. Cancer of the stomach is a very common disease in this country, though statistics would indicate that it is rather less frequent than in Europe. With reference to heredity, Welch analyzed 1,744 cases and found that a family history was present in 243. Local conditions, such as chronic gastritis and traumatism, have been thought by some to be important factors. Cancer may develop in a simple ulcer of the stomach, but this sequence is extremely rare. It is not probable that depressing emotions, mode of life, or previous disease have any influence whatever in the causation of cancer. Morbid Anatomy.—The most common varieties of gastric cancer are the cylindrical-celled epithelioma and the encephaloid ; next in fre- quency is scirrhous, and then colloid cancer. With reference to the situa- tion of the tumor, Welch analyzed 1,300 cases, in which the distribution was as follows: Pyloric region, 791; lesser curvature, 148; cardia, 104; posterior wall, 68; the whole or greater part of the stomach, 61; multiple tumors, 45 ; greater curvature, 34; anterior wall, 30 ; fundus, 19. The medullary cancer occurs in soft masses, which involve all the coats of the stomach and usually ulcerate early. The tumor may form villous projections or cauliflower-like outgrowths. It is soft, grayish white in color, CANCER OF THE STOMACH. 403 and contains much blood. Microscopically it shows a scanty stroma, en- closing alveoli which contain irregular polyhedral and cylindrical cells. The cylindrical-celled epithelioma may also form large irregular masses, but the consistence is usually firmer, particularly at the edges of the can- cerous ulcers. Microscopically the section shows elongated tubular spaces filled with columnar epithelium, and the intervening stroma is abundant. Cysts are not uncommon in this form. The scirrhous variety is character- ized by great hardness, due to the abundance of the stroma and the limited amount of alveolar structures. It is seen most frequently at the pylorus, where it is a common cause of stenosis. It may be combined with the medullary form. It may be diffuse, involving all parts of the organ, and leading to a condition which cannot be recognized macroscopically from cirrhosis. This form has also been seen in the stomach secondary to cancer of the ovaries. The colloid cancer is peculiar in its wide-spread invasion of all the coats. It also spreads with greater frequency to the neighboring parts, and it occasionally causes extensive secondary growths of the same nature in other organs. The appearance on section is very distinctive, and even with the naked eye large alveoli can be seen filled with the trans- lucent colloid material. The term alveolar cancer is often applied to this form. Ulceration is not constantly present, and there are instances in which, with most extensive disease, digestion has been very slightly dis- turbed. There is a specimen in the Warren Museum, at the Harvard Medical School, of the most wide-spread colloid cancer, in which the stomach contained after death large portions of undigested beef-steak. Secondary cancer may also occur in the stomach. Welch has collected 37 cases, 17 of which were secondary to cancer of the breast. The cancer may produce important changes in the position and shape of the organ, particularly when the orifices are involved; thus, a cancer at the cardia may be associated with wasting of the organ and reduction in its size. The oesophagus above the obstruction may be greatly distended. On the other hand, annular cancer at the pylorus may cause stenosis and great dilatation of the organ ; not necessarily, however, as there are instances on record in which the pylorus has been extremely narrowed without any in- crease in the size of the stomach. In scirrhous cancer the organ may be very greatly thickened and contracted. The stomach may be displaced or altered in shape by the weight of the tumor, particularly in cancer of the pylorus, which has been found in every region of the abdomen, and even in the true pelvis. The mobility of the tumors is at times extraordinary and very deceptive, and they may be pushed into the right hypochondria or into the splenic region, entirely beneath the ribs. Adhesions very frequently occur, particularly to the colon, the liver, and the anterior abdominal wall. Secondary cancerous growths are very frequent, as shown by the fol- lowing analysis by Welch of 1,574 cases: Metastasis occurred in the lym- phatic glands in 551; in the liver in 475; in the peritonaeum, omentum, and intestine in 357; in the pancreas in 122; in the pleura and lung in 404 DISEASES OF THE DIGESTIVE SYSTEM. 98 ; in the spleen in 26 ; in the brain and meninges in 9 ; in other parts in 92. The lymph glands affected are usually those of the abdomen, but the cervical and inguinal glands are not infrequently attacked, and give an important clew in diagnosis. Occasionally, a secondary metastatic growth occurs subcutaneously, either at the navel or beneath the skin in the vicin- ity. In an instance recently under observation in a patient with jaundice, which developed somewhat suddenly and was believed to be catarrhal, there were no signs of enlargement of the liver or tumor of the stomach, but a nodular body developed at the navel, which on removal proved to be typi- cal scirrhus. A second case in the ward at the same time, with an obscure doubtful tumor in the left hypochondria, developed a painful nodular sub- cutaneous growth midway between the navel and the left margin of the ribs. In the extensive ulceration which occurs perforation of the stomach is not uncommon. It occurred into the peritonaeum in 17 of the 507 cases of cancer of the stomach collected by Brinton. When adhesions form, the most extensive destruction of the walls may take place without perfora- tion into the peritoneal cavity. In one instance which came under my observation a large portion of the left lobe of the liver lay within the stomach. Occasionally a gastro-cutaneous fistula is established. Perfora- tion may occur into the colon, the small bowel, the pleura, the lung, or into the pericardium. Symptoms.—Cancer of the stomach may not produce symptoms other than gradual failure of health, and death may take place from asthenia without any suspicion of the existence of malignant disease. These cases are not uncommon, particularly in elderly persons in institu- tions. In a great majority of all cases there are very definite symptoms, but the disease presents a very diverse clinical picture. Certain general features stand out with special prominence. The onset is insidious, some- times with gastric disturbance, but more commonly with impairment of health and strength. A dyspepsia which may have been troublesome for years becomes aggravated. Ewald, however, states that dyspeptic symp- toms are rare prior to the onset of gastric cancer. There are attacks of nausea and vomiting, and there is pain in the region of the stomach, which is aggravated by taking food. The patient emaciates, the anaemia becomes pronounced, and the prostration may be extreme. With slight intermissions the course is progressively downward, and from month to month the loss is striking. The face has a sallow cachectic appearance, the anaemia becomes more intense, and there may be oedema of the ankles. Blood may be present in the vomited matter. If with these general features a tumor can be felt in the region of the stomach the diagnosis is rendered certain. The course, in rapid cases, may be from three to six months, but as a rule the disease extends from eighteen months to two years. There are cases to which the term acute cancer may be applied. The patients may die in from three to eight weeks after the first onset of symptoms. CANCER OF THE STOMACH. 405 D)rspepsia is common at the outset, but in so many cases the patients have had indigestion for years that the trouble is supposed at first to be only an aggravation of the chronic complaint. Loss of the desire for food is a very frequent symptom. There are exceptional instances, how- ever, in which the appetite is retained throughout, and the functions of the stomach very slightly disturbed. Nausea is a striking feature in many cases, and is much more common than in ulcer. There may even be a sudden repulsion at the sight of food. Vomiting, which is one of the most constant symptoms of cancer of the stomach, may come on early, or only after the dyspepsia has persisted for some time. At first it is at long intervals, but subsequently it is more frequent, and may recur several times in the day. There are cases in which it comes on in paroxysms and then subsides; in other cases, it sets in early, persists with great violence, and may cause a fatal termination within a few weeks. Vomiting is more frequent when the cancer involves the orifices, particularly the pylorus, in which case it is usually delayed for an hour or more after taking the food. When the cardiac orifice is involved it may follow at a shorter interval. Extensive disease of the fundus or of the anterior or posterior wall may be present without the occurrence of vomiting. The vomited matters consist of food and mucus in a grayish or dark sour-smelling fluid. The food is sometimes very little changed, even after it has remained in the stomach for twenty-four hours. Hcemorrhcige is a frequent symptom, but the bleeding is rarely profuse; more commonly there is slight oozing, and the blood is mixed with, or altered by the secretions, and when vomited the material is dark brown or black, the so-called “ coffee-ground ” vomit. This is present in a con- siderable proportion of all cases of cancer, and is an important indication. The blood can be recognized by the microscope as shells of the red blood- corpuscles and irregular masses of altered blood pigment. In cases of doubt the spectroscope may be employed or hsemin crystals obtained. Fragments of the tumor are rarely found in the vomit, and of the numerous specimens which I have had occasion to examine I have never been able to satisfy myself of the existence of cancerous tissue. As Eosenbach states, in the material washed out with the stomach-tube un- doubted fragments may be found. The yeast fungus, various bacteria, and the sarcina ventriculi may be present, the latter not so often in cancer as in dilatation. Great stress has been laid of late years upon the absence of free hydrochloric acid in the secretions. As an outcome of the enormous number of observations which have recently been made it may be said that free hydrochloric acid is absent in a majority of cases of cancer of the stomach. This defect is associated with impairment of the secreting function of the organ. The examination should be made repeatedly, by the methods already referred to, and with our present knowledge the per- sistent absence of free IiCl in the stomach contents, taken in conjunc- 406 DISEASES OF THE DIGESTIVE SYSTEM. tion with other symptoms, may be regarded as highly suggestive of cancer. Unfortunately, the free acid may be absent in certain other conditions, such as atrophy, and occasionally in chronic gastritis, so that it is of greater value from the negative standpoint. As Kinnicutt expresses it, “ the presence of free HC1 in the stomach contents in repeated examina - tions in doubtful cases is of the greatest diagnostic value, and points very certainly to absence of cancer.” Rosenheim has recently shown that in cases in which cancer develops in the base of an old ulcer HC1 may be present throughout the course. Much importance has been laid by Boas and others on the presence of lactic acid as a diagnostic sign of cancer. After the rigid Boas test breakfast lactic acid is very rarely found in the chronic catarrhs. It may be found early before a tumor is palpable. Pain is an early and important symptom. It is very variable in situa- tion, and while most common in the epigastrium, it may be referred to the shoulders, the back, or the loins. The pain is described as dragging, burning, or gnawing in character, and very rarely occurs in severe paroxysms of gastralgia, as in gastric ulcer. As a rule, the pain is aggravated by taking food. There is usually marked tenderness on pressure in the epigastric region. It is, however, remarkable how many cases run a painless course. The physical examination of the abdomen reveals in many instances the presence of a tumor. Inspection may show a nodular mass in the epigastrium, or the outlines of a dilated stomach, with peristaltic action. In the palpation of the stomach it is important to bear in mind cer- tain anatomical points. At least two thirds of the organ lie in the left hypochondrium beneath the ribs, and so are practically out of reach. The pyloric orifice lies to the right of the median line, particularly when the stomach is full, in which case it may be reached. It is about on a level with the inner extremity of the eighth right costal cartilage. The pylorus is movable and changes considerably in position with the distention of the stomach. Practically, in health there is available for palpation only a part of the anterior surface of the stomach and the pylorus, which is sometimes, but not always, overlapped by the liver. Tumors limited to the cardia, even when extensive, cannot be felt at all. Tumors involving the fundus, the posterior wall, and the greater part of the lesser curvature cannot be detected unless very large. Tumors of the pylorus, of the anterior wall, and of a large part of the greater curvature are in accessible situations. In the examination the knees should be drawn up, and the patient asked to relax the abdominal walls as much as possible. Sometimes, when nothing can be felt on quiet breathing, a deep inspiration will force down the stomach and bring a tumor mass within reach. Examination should also be made in the knee-elbow posi- tion. Cancerous tumors of the stomach are usually felt in the epigastric region, but a mass at the pylorus may be felt in the umbilical region, or, in cases of extreme mobility, in a hypochondriac region, or, very ex- CANCER OF THE STOMACH. ceptionally, low down in the iliac region. The tumor is usually firm, hard, nodular, and painful on pressure. At the pylorus the mass may be rounded, ball-like, and readily grasped. Gas may sometimes be felt bubbling through it. Communicated pulsation from the aorta is not at all uncommon. Inflation of the stomach with gas is often a valuable aid in diagnosis. A teaspoonful of bicarbonate of soda is first given in water, followed by the same amount of tartaric acid. The distention of the stomach which follows may suffice to bring tumor masses into reach. Careful examination should be made to determine the presence of sec- ondary cancer of the liver or involvement of the lymph glands in the groins or in the supraclavicular spaces. As already mentioned, the development of nodules about the navel may give an important hint, or there may be signs of secondary involvement of the peritoneum. Intestinal symptoms are not very common. Constipation is more fre- quently present than diarrhoea, which may, however, set in and prove ob- stinate toward the end. When there is much bleeding the stools may be dark in color. A progressive anmmia is one of the most striking features of gastric cancer. As a rule the blood-count does not fall below fifty per cent. A leucocytosis is almost constantly present, and Welch has noted an instance in which the ratio of white to red corpuscles was one to twenty. There are instances in which the clinical picture is rather that of a pernicious anajmia, with reduction of the red blood-corpuscles to twenty-five per cent and marked poikilocytosis. The careful examination of the blood shows, however, rather the characters of a secondary anaemia. The condition is, moreover, an anaemia with wasting, and the layer of panniculus is not re- tained as in the ordinary forms of pernicious anaemia. Ultimately the patient develops an aspect to which the term cachectic is applied, and which is perhaps more marked in gastric cancer than in any other disease. There may be a slight yellowish tint to the skin, and it is not uncommon to see brownish stains, the cachectic chloasma. Associated with the anaemia and directly dependent upon it are the dropsical symptoms so common in this affection. GMema of the ankles and of the legs is present and may progress to a general anasarca; the cases may be mistaken for heart-disease or dropsy. There are no special cardiac symptoms; the pulse becomes rapid and feeble toward the end. The anaemia may, however, produce such palpitation and dyspnoea that the case may be regarded as cardiac. Thrombosis of a femoral vein may occur. The urine may contain a trace of albumin and, toward the close, tube- casts. Indican is often present in increased quantity, and occasionally acetone and diacetic acid. The temperature is usually normal, and toward the end, when cachexia is well marked, subnormal. There are, however, interesting paroxysmal elevations of temperature, definite chills with fever, in which the ther- mometer registers 103° or 104°, followed by profuse sweating. The rigors 408 DISEASES OF THE DIGESTIVE SYSTEM. may recur at intervals for weeks, and, if no tumor is felt, may complicate the diagnosis. In a case at the Philadelphia Hospital the paroxysms re- curred for more than six weeks. The autopsy showed a cancer of the stomach with adhesions to the colon and extensive suppuration at the base of the cancer and in a pocket between the stomach and omentum. The mind usually remains clear to the close. Naturally the patient has attacks of despondency. Toward the end delirium is common. A form of coma resembling that which occurs in diabetes is occasionally met with in gastric cancer. The patient becomes restless or excited, and gradually unconsciousness supervenes, with or without dyspnoea. It is due to the presence of some toxic agent in the blood, possibly the diace- tic acid. Among symptoms referable to the development of secondary growths those pertaining to the liver are most important. Jaundice is not uncom- mon, and there may be signs of great enlargement of the liver. Many instances which are clinically recorded as primary cancer of this organ are in reality secondary to latent cancer of the stomach. The importance of enlargement of the supra-clavicular and inguinal glands in gastric can- cer has already been emphasized. The new growths may extend to the peritonaeum and, if there is much effusion, produce ascites. Reference has been made to the perforations liable to occur in gastric cancer. The course of the disease is progressively downward. In the majority of all cases death occurs within two years, and the average duration is not more than eighteen months. In cases of scirrhus the progress is slower. Diagnosis.—When a tumor is present there is not much difficulty in determining the nature of the trouble; even in its absence the pro- gressive emaciation, the loss of energy and strength, the anaemia and cachexia, when associated with marked gastric symptoms, are almost path- ognomonic. There are many instances, however, in which a positive diag- nosis is impossible. The diseases with which cancer is most liable to be confounded are ulcer and chronic gastric catarrh, and the differential features are so well drawn in the elaborate article by my colleague Welch that I here append them : * GASTRIC CANCER. GASTRIC ULCER. CHRONIC CATARRHAL GASTRITIS. 1. Tumor is present in three fourths of the cases. 1. Tumor rare. 1. No tumor. 2. Rare under forty years of age. 2. May occur at any age after childhood. Over one half of the cases under forty years of age. 2. May occur at any age. * Op. cit., vol. ii, p. 570. CANCER OF THE STOMACH. 409 GASTRIC CANCER. GASTRIC ULCER. CIIRONIC CATARRHAL GASTRITIS. 3. Average duration about one year, rarely over two years. 3. Duration indefi- nite ; may be for sev- eral years. 3. Duration indefi- nite. 4. Gastric hemor- rhage frequent, but rarely profuse; most common in the cachec- tic stage. 4. Gastric hasrnor- rliage less frequent than in cancer, but oftener profuse; not uncom- mon when the general health is but little im- paired. 4. Gastric haemor- rliage rare. 5. Vomiting often has the peculiarities of that of dilatation of the stomach. 5. Vomiting rarely referable to dilatation of the stomach, and then only in. a late stage of the disease. 5. Vomiting may or may not be present. 6. Free hydrochloric acid usually absent from the gastric contents in cancerous dilatation of the stomach. 6. Free hydrochloric acid usually, present in the gastric contents. 6. Free hydrochloric acid may be present or absent. 7. Cancerous frag- ments may be found in the washings from the stomach or in the vomit (rare). 7. Absent. 7. Absent. 8. Secondary can- cers may be recognized in the liver, the perito- neum, the lymphatic glands, and rarely in other parts of the body. 8. Absent. 8. Absent. 9. Loss of flesh and strength and develop- ment of cachexia usu- ally more marked and more rapid than in ul- cer or in gastritis, and less explicable by the gastric symptoms. 9. Cachectic appear- ance usually less marked and of later occurrence than in cancer, and more manifestly dependent upon the gastric disor- ders. 9. When uncompli- cated, usually no ap- pearance of cachexia. 10. Epigastric pain is often more continu- ous, less dependent up- on taking food, less re 10. Pain is often more paroxysmal, more influenced by taking food, oftener relieved 10. The pain or dis- tress induced by taking food is usually less se- vere than in cancer or 410 DISEASES OF THE DIGESTIVE SYSTEM. GASTRIC CANCER. GASTEIC ULCER. CHRONIC CATARRHAL GASTRITIS. lieved by vomiting, and less localized than in ulcer. by vomiting, and more sharply localized than in cancer. ulcer. Fixed point of tenderness usually ab- sent. 11. Often referable to some known cause, such as abuse of alco- hol, gormandizing, and certain diseases, as phthisis, Bright’s dis- ease, cirrhosis of the liver, etc. 11. Causation not known. 11. Causation not known. 12. No improve- ment, or only tempo- rary inrprovement, in the course of the dis- ease. 12. Sometimes a his- tory of one or more pre- vious similar attacks. The course may be ir- regular and intermit- tent. Usually marked improvement by regula- tion of diet. 12. May be a history of previous similar at- tacks. More amenable to regulation of diet than is cancer. Treatment.—The disease is incurable and palliative measures are alone indicated. The diet should consist of readily digested substances of all sorts. Many patients do best on milk alone. Washing out of the stomach, which may be done with a soft tube without any risk, is particu- larly advantageous when there is obstruction at the pylorus, and is by far the most satisfactory means of combatting the vomiting. The excessive fermentation is also best treated by lavage. When the pain becomes se- vere, particularly if it disturbs the rest at night, morphia must be given. One eighth of a grain, combined with carbonate of soda (gr. v), bismuth (gr. v-x), usually gives prompt relief, and the dose does not always re- quire to be increased. Creosote (iU j-ij) and carbolic acid are very useful. The bleeding in gastric cancer is rarely amenable to treatment. Opera- tive measures have been advised and practised, and in exceptional in- stances there are cases in which the limited cancer could be resected with reasonable hope of recovery. Non - cancerous tumors of the stomach rarely cause inconvenience. Polypi (polyadenomata) are common and they may be numerous; as many as one hundred and fifty have been reported in one case. There is a form in which the adenoma exists as an extensive area slightly raised above the level of the mucosa—polyaclenome en nappe of the French. Sarcomata are very rare. Fibromata and lipomata have been described. Foreign bodies occasionally produce remarkable tumors of the stom- ach. The most extraordinary is the hair tumor, of which a number of HEMORRHAGE FROM THE STOMACn. 411 instances have been reported in hysterical women who have been in the habit of eating their own hair. A specimen in the. medical museum of McGill University is in two sections, which form an exact mould of the stomach. The tumors which they form are large and very puzzling and have been mistaken for cancer. In one instance the ball of hair was re- moved by a surgical operation. The tumor was thought to be a movable kidney. VIII. HEMORRHAGE FROM THE STOMACH (Hcemalemesis). Etiology.—Gastrorrhagia, as this symptom is called, may result from many conditions, some of which are local, others general. 1. In local disease in the stomach itself: (u) Cancer; (b) ulcer; (c) disease of the blood-vessels, such as miliary aneurisms of the smaller arte- ries, and. occasionally varicose veins; (d) acute congestion, as in gastritis, and possibly in vicarious haemorrhage, but both of these are extremely rare causes. 2. Passive congestion due to obstruction in the portal system. This may be either (a) hepatic, as in cirrhosis of the liver, thrombosis of the portal vein, or pressure upon the portal vein by tumor, and secondarily in cases of chronic disease of the heart and lungs; (b) splenic. Gastrorrhagia is by no means an uncommon symptom in enlarged spleen, and is ex- plained by the intimate relations which exist between the vasa brevia and the splenic circulation. 3. Toxic: (a) The poisons of the specific fevers, small-pox, measles, yellow fever; (b) poisons of unknown origin, as in acute yellow atrophy and in purpura; (c) phosphorus. 4. Traumatism: (a) Mechanical injuries, such as blows and wounds, and occasionally by the stomacli-tube; (b) the result of severe corrosive poisons. 5. Certain constitutional diseases: (a) Haemophilia; (b) profound anaemias, whether idiopathic or due to splenic enlargements or to malaria ; (c) cholaemia. 6. In certain nervous affections, particularly hysteria, and occasionally in progressive paralysis of the insane and epilepsy. 7. The blood may not come from the stomach, but flow into it. Thus it may pass from the nose or the pharynx. In haemoptysis some of the blood may find its way into the stomach. The bleeding may take place from the oesophagus and trickle into the stomach, from which it is eject- ed. This occurs in the case of rupture of aneurism and of the oesopha- geal varices. A child may draw blood with the milk from the mother’s breast even in considerable quantities and then vomit it. 8. Miscellaneous causes: Aneurism of the aorta or of its branches may rupture into the stomach. There are instances in which a patient 412 DISEASES OF TIIE DIGESTIVE SYSTEM. has a single attack of haemorrhage without even having a recurrence or without symptoms pointing to disease of the stomach. In new-born infants liaematemesis may occur alone or in connection with bleeding from other mucous membranes (see Haemorrhage in the New-born, p. 347). In medical practice, haemorrhage from the stomach occurs most fre- quently in connection with cirrhosis of the liver and ulcer of the stomach. It is more frequent in women than in men, owing to the greater preva- lence of round ulcer in the former. Morbid Anatomy.—When death has occurred from the liaemate- mesis there are signs of intense anaemia. The condition of the stomach varies extremely. The lesion is evident in cancer and in ulcer of the stomach. It is to he borne in mind that fatal haemorrhage may come from a small miliary aneurism communicating with the surface by a pin- hole perforation, or the bleeding may be due to the rupture of a sub- mucous vein and the erosion in the mucosa may be small and readily overlooked. It may require a careful and prolonged search to avoid over- looking such lesions. In the large group associated with portal obstruc- tion, whether due to hepatic or splenic disease, the mucosa is usualty pale, smooth, and shows no trace of any lesion. In cirrhosis, fatal by haemor- rhage, one may sometimes search in vain for any focal lesion to account for the gastrorrhagia, and we must conclude that it is possible for even the most profuse bleeding to occur by diapedesis. The stomach may be distended with blood and the source of the haemorrhage not apparent either in the stomach or in the the portal system. In such cases the oesophagus should be examined, as the bleeding may come from that source. In toxic cases there are invariably haemorrhages in the mucous membrane itself. Symptoms.—In rare instances fatal syncope may occur without any vomiting. In a case of the kind, in which the woman had fallen over and died in a few minutes, the stomach contained between three and four pounds of blood. The sudden profuse bleedings rapidly lead to profound anaemia. When due to ulcer or cirrhosis the bleeding usually recurs for several days. Fatal haemorrhage from the stomach is met with in ulcer, cirrhosis, enlargement of the spleen, and in instances in which an aneur- ism ruptures into the stomach or oesophagus. Gastrorrhagia may occur in splenic anaemia or in leukaemia before the condition has aroused the attention of friends or physician. The vomited blood may be fluid or clotted; it is usually dark in color, but in the basin the outer part rapidly becomes red from the action of the air. The longer blood remains in the stomach the more altered is it when ejected. The amount of blood lost is very variable, and in the course of a day the patient may bring up three or four pounds, or even more. In a case under the care of George lvoss, in the Montreal General Hospital, the HEMORRHAGE FROM THE STOMACH. 413 patient lost during seven days ten pounds, by measurement, of blood. The usual symptoms of anaemia develop rapidly, and there may be slight fever, and subsequently oedema may occur. An interesting circumstance connected with gastro-intestinal haemorrhage is the development of amau- rosis, the mode of production of which is still under discussion. Diagnosis.—In a majority of instances there is no question as to the origin of the blood. Occasionally it is difficult, particularly if the case has not been seen during the attack. Examination of the vomit readily determines whether blood is present or not. The materials vom- ited may be stained by wine, the juice of strawberries, raspberries, or cran- berries, which give a color very closely resembling fresh blood, while iron and bismuth and bile may produce a blackish color like altered blood. In such cases the microscope will show clearly the presence of the shadowy outlines of the red blood-corpuscles, and, if necessary, spectroscopic and chemical tests may be applied. Deception is sometimes practised by hysterical patients, who swallow and then vomit blood or colored liquids. With a little care such cases can usually be detected. The cases must be excluded in which the blood passes from the nose or pharynx, or in which infants swallow it with the milk. There is not often difficulty in distinguishing between haemoptysis and haematemesis, though the coughing and the vomiting are not infrequently combined. The following are points to be borne in mind in the diagnosis: 1. Previous history points to gas- tric, hepatic, or splenic disease. HH5MATEMESIS. 1. Cough or signs of some pul- monary or cardiac disease precedes, in many cases, the haemorrhage. HAEMOPTYSIS. 2. The blood is brought up by vomiting, prior to which the patient may experience a feeling of giddi- ness or faintness. 2. The blood is coughed up, and is usually preceded by a sensa- tion of tickling in the throat. If vomiting occurs, it follows the coughing. 3. The blood is usually clotted, mixed with particles of food, and has an acid reaction. It may he dark, grumous, and fluid. 3. The blood is frothy, bright red in color, alkaline in reaction. If clotted, rarely in such large co- agula, and muco pus may he mixed with it. 4. Subsequent to the attack the patient passes tarry stools, and signs of disease of the abdominal viscera may be detected. 4. The cough persists, physical signs of local disease in the chest may usually be detected, and the sputa may be blood-stained for many days. Prognosis.—Except in the case of rupture of aneurism or of large veins, haematemesis rarely proves fatal. In my experience death has fol- 414 DISEASES OF THE DIGESTIVE SYSTEM. lowed more frequently in cases of cirrhosis and. splenic enlargement than in ulcer or cancer. In ulcer it is to be remembered that in the chronic haemorrhagic form the bleeding may recur for years. The treatment of liaematemesis is considered under gastric ulcer. VII. DISEASES OF THE INTESTINES. I. DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. CATARRHAL ENTERITIS; DIARRHOEA, In the classification of catarrhal enteritis the anatomical divisions of the bowel have been too closely followed, and a duodenitis, jejunitis, ilei- tis, typhlitis, colitis, and proctitis have been recognized; whereas in a majority of cases the entire intestinal tract, to a greater or lesser extent, is involved, sometimes the small most intensely, sometimes the large bowel, but during life it may be quite impossible to say which portion is specially affected. Etiology.—The causes may be either primary or secondary. Among the causes of primary catarrhal enteritis are; {a) Improper food, one of the most frequent, especially in children, in whom it follows overeating, or the ingestion of unripe fruit. In some individuals special articles of diet will always produce a slight diarrhoea, which may not he due to a catarrh of the mucosa, but to increased peristalsis induced by the offend- ing material. (b) Various toxic substances. Many of the organic poi- sons, such as those produced in the decomposition of milk and articles of food, excite the most intense intestinal catarrh. Certain inorganic sub- stances, as arsenic and mercury, act in the same way. (c) Changes in the weather. A fall in the temperature of from twenty to thirty degrees, par- ticularly in the spring or autumn, may induce—how, it is difficult to say —an acute diarrhoea. We speak of this as a catarrhal process, the result of cold or of chill. On the other hand, the diarrhoeal diseases of children are associated in a very special way with the excessive heat of summer months. (d) Changes in the constitution of the intestinal secretions. We know too little about the succus entericus to be able to speak of influ- ences induced by change in its quantity or quality. It has long been held that an increase in the amount of bile poured into the bowel might excite a diarrhoea; hence the term bilious diarrhoea, so frequently used by the older writers. Possibly there are conditions in which an excessive amount of bile is poured into the intestine, increasing the peristalsis, and hurrying on the contents; but the opposite state, a scanty secretion, by favoring the natural fermentative processes, much more commonly causes an intestinal catarrh. Absence of the pancreatic secretion from the intestine has been associated DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHOEA. 415 in certain cases with a fatty diarrhoea, {e) Nervous influences. It is by no means clear how mental states act upon the bowels, and yet it is an old and trustworthy observation which every-day experience confirms that the mental state may profoundly affect the intestinal canal. These influences should not properly be considered under catarrhal processes, as they result simply from increased peristalsis or increased secretion, and are usually de- scribed under the heading nervous diarrhoea. In children it frequently follows fright. It is common, too, in adults as a result of emotional dis- turbances. Canstatt mentions a surgeon who always before an important operation had watery diarrhoea. In hysterical women it is seen as an occa- sional occurrence, due to transient excitement, or as a chronic, protracted diarrhoea, which may last for months or even years. Among the secondary causes of intestinal catarrh may be mentioned: (a) Infectious diseases. Dysentery, cholera, typhoid fever, pyaemia, septicaemia, tuberculosis, and pneumonia are occasionally associated with intestinal catarrh. In dysentery and typhoid fever the ulceration is in part responsible for the catarrhal condition, but in cholera it is probably a direct influence of the bacilli or of the toxic materials produced by them, (ib) The extension of inflammatory processes from adjacent parts. Thus, in peritonitis, catarrhal swelling and increased secretion are always present in the mucosa. In cases of invagination, hernia, tuberculous or cancerous ulceration, catarrhal processes are common. (c) Circulatory disturbances cause a catarrhal enteritis, usually of a very chronic character. This is common in diseases of the liver, such as cirrhosis, and in chronic affections of the heart and lungs—all conditions, in fact, which produce engorge- ment of the terminal branches of the portal vessels, {d) In the cachectic conditions met with in cancer, profound anaemia, Addison’s disease, and Bright’s disease intestinal catarrh may develop, and may terminate life. Morbid Anatomy.—Changes in the mucous membrane are not always visible, and in cases in which, during life, the symptoms of intes- tinal catarrh have been marked, neither redness, swelling, nor increased secretion—the three signs usually laid down as characteristic of catarrhal inflammation—may be present post mortem. It is rare to see the mucous membrane injected; more commonly it is pale and covered with mucus. In the upper part of the small intestine the tips of the valvulae conniventes may be deeply injected. Even in extreme grades of portal obstruction intense hyperasmia is not often seen. The entire mucosa may be softened and infiltrated, the lining epithelium swollen, or even shed, and appearing as large flakes among the intestinal contents. This is, no doubt, a post- mortem change. The lymph follicles are almost always swollen, particu- larly in children. The Peyer’s patches may be prominent and the solitary follicles in the large and small bowel may stand out with distinctness and present in the centres little erosions, the so-called follicular ulcers. This may be a striking feature in the intestine in all forms of catarrhal enteri- tis in children, quite irrespective of the intensity of the diarrhoea. 416 DISEASES OF TIIE DIGESTIVE SYSTEM. When the process is more chronic the mucosa is firmer, in some in- stances thickened, in others distinctly thinned, and the villi and follicles present a slaty pigmentation. Symptoms.—Acute and chronic forms may be recognized. The im- portant symptom of both is diarrhoea, which, in the majority of instances, is the sole indication of this condition. It is not to be supposed that diar- rhoea is invariably caused by, or associated with, catarrhal enteritis, as it may be produced by nervous and other influences. It is probable that catarrh of the jejunum may exist without any diarrhoea; indeed, it is a very common circumstance to find post mortem a catarrhal state of the small bowel in persons who have not had diarrhoea during life. The stools vary extremely in character. The color depends upon the amount of bile with which they are mixed, and they may be of a dark or blackish brown, or of a light-yellow, or even of a grayish-white tint. The consist- ence is usually very thin and watery, but in some instances the stools are pultaceous like thin gruel. Portions of undigested food can often be seen (lienteric diarrhoea), and flakes of yellowish-brown mucus. Microscopic- ally there are innumerable micro-organisms, epithelium and mucous cells, crystals of phosphate of lime, oxalate of lime, and occasionally cholesterin and Charcot’s crystals. Pain in the abdomen is usually present in the acute catarrhal enteritis, particularly when due to food. It is of a colicky character, and when the colon is involved there may be tenesmus. More or less tympanites exists, and there are gurgling noises or borborygmi, due to the rapid passage of fluid and gas from one part to another. In the very acute attacks there may be vomiting. Fever is not, as a rule, present, but there may be a slight elevation of one or two degrees. The appetite is lost, there is in- tense thirst, and the tongue is dry and coated. In very acute cases, when the quantity of fluid lost is great and the pain excessive, there may be collapse symptoms. The number of evacuations varies from four or five to twenty or more in the course of the day. The attack lasts for two or three days, or may be prolonged for a week or ten days. Chronic catarrh of the bowels may follow the acute form, or may de- velop gradually as an independent affection or as a sequence of obstruc- tion in the portal circulation. It is characterized by diarrhoea, with or without colic. The dejections vary; Avlien the small bowel is chiefly in- volved the diarrhoea is of a lienteric character, and when the colon is affected the stools are thin and mixed with much mucus. A special form of mucous diarrhoea will be subsequently described. The general nutrition of the patient in these chronic cases is greatly disturbed ; there may be much loss of flesh and great pallor. The patients are inclined'to suffer from low spirits, or hypochondriasis may develop. Diagnosis.—It is important, in the first place, to determine, if pos- sible, whether the large or small bowel is chiefly affected. In catarrh of the small bowel the diarrhoea is less marked, the pains are of a colicky DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHCEA. character, borborygmi are not so frequent, the faeces usually contain por- tions of food, and are more yellowish-green or grayish-yellow and floc- culent and do not contain much mucus. When the large intestine is at fault there may be no pain whatever, as in the catarrh of the large intes- tine associated with tuberculosis and Bright’s disease. When present, the pains are most intense and, if the lower portion of the bowel is involved, there may be marked tenesmus. The stools have a uniform soupy con- sistence, grayish in color and granular throughout, Avith here and there flakes of mucus, or they may contain very large quantities of mucus. There are no positive symptoms by which the diagnosis of duodenitis can be made. It is usually associated with acute gastritis and, if the pro- cess extends into the bile-duct, Avith jaundice. Neither jejunitis nor ileitis can be separated from general intestinal catarrh. ENTERITIS IN CHILDREN. We may recognize three forms : (1) The acute dyspeptic diarrhoea; (2) cholera infantum; and (3) acute entero-colitis. General Etiology of the Diarrhoeas of Children.—The dis- ease is most frequent in artificially fed children, and the greatest number of cases occur between the ages of six and eighteen months. A popular and well-founded belief ascribes special danger to the second summer of the infant. Infantile diarrhoea is very prevalent among the poorer classes in the large cities. It attacks, however, children with the most favorable surroundings. Two factors influence the disease, diet and temperature. An immense majority of all fatal cases are artificially fed. Of 1,943 fatal cases in Holt’s statistics, only three per cent were exclusively breast fed. Among the poor the bowel complaint in children begins with the artificial feeding. The relation of temperature to the prevalence of diarrhoeal dis- eases in children has long been recognized. The mortality curve begins to rise in May, increases in June, reaches the maximum in July, and grad- ually sinks through August and September. The maximum corresponds closely with the highest mean temperature ; yet we cannot regard the heat itself as the direct agent, but only one of several factors. Thus the mean temperature of June is only four or five degrees lower than that of July, and yet the mortality is not more than one third. Seibert, who has care- fully analyzed the mortality and the temperature, month by month, in New York, for ten years, fails to find a constant relation between the degree of heat and the number of cases of diarrhoea. Neither barometric pressure nor humidity appears to have any influence. Relation of Bacteria.—The healthy faeces of sucklings contain a number of bacteria and micrococci, the most important of which are the bacterium lactis aerogenes and the bacterium coll commune. The former is only present in the intestine after a milk diet, the milk sugar appear- ing to furnish the materials necessary for its growth. It occurs more 418 DISEASES OF THE DIGESTIVE SYSTEM. in the upper portion of the bowel, and in this region excites the fer- mentative processes in the milk. The bacterium, coli commune is found more abundantly in the lower portion of the small intestine and in the colon, and excites fermentative changes which are probably associated with certain phases of digestion. The observations of Esclierich show the re- markable simplicity of this bacterial vegetation in the healthy faeces of milk-fed children, as these two alone develop and are constant. In infan- tile diarrhoea the number of bacteria which may be isolated from the stools is remarkable. Booker has discriminated forty varieties, the greatest num- ber of which were found in the cases of cholera infantum. The two con- stant forms noted above do not disappear in the diarrhoeal stools. Xo forms have been found to bear a constant or specific relation to the diar- rhoeal fasces, such as the two above mentioned do to the healthy milk fasces. The bacteria of the proteus group are most frequent, and possess pathogenic properties. All the varieties develop and produce important changes in the milk, which have been dealt with very fully by Booker in his studies. This author concludes that in the diarrhoea of infants “ not one specific kind, but many different kinds of bacteria are concerned, and that their action is manifested more in the alteration of the food and intestinal contents and in the production of injurious products than in a direct irritation upon the intestinal wall.” With these agree the conclu- sions of Jeffries and Baginsky regarding cholera infantum. Morbid Anatomy.—We find most frequently a catarrhal swelling of the mucosa of both small and large bowel with enlargement of the lymph follicles. In more chronic cases the latter show small erosions or follicular ulcers; more rarely there is croupous enteritis affecting the lower part of the ileum and the colon. The changes in the other organs are neither numerous nor characteristic. Broncho-pneumonia occurs in many cases. The spleen may be swollen. Brain lesions are rare; the membranes and substance are often anaemic, but meningitis or thrombosis is very uncommon. Clinical Forms.—Acute Dyspeptic Diarrhoea.—The child may ap- pear in its usual health, but has an increase in the number of stools, with- out fever or special disturbance except slight restlessness at night. After persisting for a day or two the stools become more frequent and contain undigested food and curds, and are very -offensive. In other cases the dis- ease sets in abruptly with vomiting, griping pains, and fever, which may rise rapidly and reach 104° or 105°. There may be convulsions at the outset. The abdomen is sensitive, and the child lies with the legs drawn up. The stools consist of grayish or greenish-yellow fasces mixed with gas, curds, and portions of food. In children over two years of age such attacks not infrequently follow eating freely of unripe fruit or the drinking of milk which lias been tainted. With judicious treatment the children improve in a few days; but relapses are not uncommon, and in the hot weather the attack may be the starting point of a severe entero-colitis. In a de- DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRnCEA, 419 bilitated child a mild attack may prove fatal. This dyspeptic diarrhoea is distinguished sharply from cholera infantum by the character of the stools, which never have a watery, serous character. In many instances this form precedes the onset of the specific fevers, particularly during the hot weather. Cholera Infantum.—This is the counterpart in the infant of the so- called choleraic diarrhoea in the adult, and in their clinical aspects these two forms are identical. It is by no means so common as the ordinary dyspeptic diarrhoea of children, and, according to Holt, occurs only in two or three per cent of the cases of summer diarrhoea. It prevails in the hot weather and in children artificially fed or who have had pre- viously some slight dyspeptic derangement. It is characterized by vomit- ing, uncontrollable diarrhoea, and collapse. The disease sets in with vomiting, which is incessant and is excited by any attempt to take food or drink. The stools are profuse and frequent; at first faecal in character, brown or yellow in color, and finally thin, serous, and watery. The stools first passed are very offensive; subsequently they are odorless. The thin, serous stools are alkaline. There is fever, but the axillary temperature may register three or more degrees below that of the rectum. From the outset there is marked prostration; the eyes are sunken, the features pinched, the fontanelle depressed, and the skin has a peculiar ashy pallor. At first restless and excited, the child subsequently becomes heavy, dull, and listless. The tongue is coated at the onset, but subsequently becomes red and dry. As in all choleraic conditions, the thirst is insatiable; the pulse is rapid and feeble, and toward the end becomes irregular and im- perceptible. Death may occur within twenty-four hours, with symptoms of collapse and great elevation of the internal temperature. Before the end the diarrhoea and vomiting may cease. In other instances the intense symptoms subside, but the child remains torpid and semi-comatose with fingers clutched, and there may be convulsions. The head may be retract- ed and the respirations interrupted, irregular, and of the Cheyne-Stokes type. The child may remain in this condition for some days without any signs of improvement. It was to this group of symptoms in infantile diarrhoea that Marshall-Hall gave the term “ hydrencephaloid ” or spuri- ous hydrocephalus. As a rule, no changes in the brain or other organs are found, and the condition is no doubt caused by the toxic agents absorbed from the intestine. A remarkable condition of sclerema is de- scribed as a sequel of cholera infantum. The skin and subcutaneous tis- sues become hard and firm and the appearance has been compared to that of a half-frozen cadaver. Ho constant organism has been found in these cases. Baginsky con- siders the disease the result of the action on the system of the poisonous products of decomposition encouraged by the various bacteria present—a faulniss disease. The clinical picture is that produced by an acute bac- terial infection, as in Asiatic cholera. 420 DISEASES OF THE DIGESTIVE SYSTEM. The diagnosis is readily made. There is no other intestinal affection in children for which it can be mistaken. The constant vomiting, the frequent watery discharges, the collapse symptoms, and the elevated tem- perature'make an unmistakable clinical picture. The outlook in the ma- jority of cases is bad, particularly in children artificially fed. Hyperpy- rexia, extreme collapse, and incessant vomiting are the most serious symp- toms. Acute Entero-colitis.—In this form the ileum and colon are most affected, chiefly in the lymph follicles, hence the term follicular enteritis or follicular dysentery. It occurs most frequently in warm weather, in artificially fed children; but it may set in at any season of the year, and is the form of enteritis most common as a secondary complication in the specific fevers of childhood. The attack may follow the ordinary dyspeptic diarrhoea. The tem- perature increases, the stools change in character and contain traces of blood and mucus, the former usually only in streaks. The faeces are passed without any pain. The abdomen is distended and tender along the line of the colon. Vomiting may be present at the outset, but is not a characteristic feature, as in cholera infantum. The diarrhoea may be gradually checked and convalescence is established in two or three weeks; in other instances the disease becomes subacute, the fever subsides, but the diarrhoea persists and the general health of the child rapidly deteriorates. The case may drag on for five or six weeks, when improvement gradually occurs or the child is carried off by a severe intercurrent attack. In a third form of acute entero-colitis, in which anatomically the lesions are those already mentioned—namely, an intense follicular inflammation—the symptoms are of a more severe character, and the affection is sometimes spoken of as acute dysentery. It attacks children up to the third or fourth year or even older. The onset is sudden, with high fever, vomit- ing, frequent stools, which at first contain remnants of food and fasces and subsequently much mucus and some blood. There is incessant pain, which may be more severe than in any intestinal affection of childhood. The prostration is very great and the fatal termination may occur within forty-eight hours. More commonly the case lasts for a week or longer. In two cases of this sort, in one of which death occurred in forty-eight and in the other in sixty-four hours, the anatomical characters were those of the most acute follicular enteritis, characterized by great swelling of the lymph follicles, some of which already presented necrotic foci. The Cceliae Affection.—Under this heading Gee lias described an intes- tinal disorder, most commonly met with in children between the ages of one and five, characterized by the occurrence of pale, loose stools, not unlike gruel or oatmeal porridge. They are bulky, not watery, yeasty, frothy, and extremely offensive. The affection has received various names, such as diarrhoea alba or diarrhoea chylosa. It is not associated with tuberculosis or other hereditary disease. It begins insidiously and there DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRHOEA. 421 are progressive wasting, weakness, and pallor. The belly becomes doughy and inelastic. There is often flatulency. Fever is usually absent. The disease is lingering and a fatal termination is common. So far nothing is known of the pathology of the disease. Ulceration of the intestines has been met with, but it is not constant. This affection resembles somewhat the disease in adults known as the hill diarrhoea, or the white flux of India, with which the psilosis or sprue, another tropical disorder, is con- sidered identical by some writers. Certain of these tropical diarrhoeas are, as will be mentioned, associated with the presence of the anchylostoma. DIPHTHERITIC OR CROUPOUS ENTERITIS. A croupous or diphtheritic inflammation of the mucosa of the small and large intestines occurs (a) most frequently as a secondary process in the infectious diseases—pneumonia, pyaemia in its various forms, and typhoid fever; (b) as a terminal process in many chronic affections, such as Bright’s disease, cirrhosis of the liver, or cancer; and (c) as an effect of certain poisons—mercury, lead, and arsenic. There are three different anatomical pictures. In one group of cases the mucosa presents on the top of the folds a thin grayish-yellow diph- theritic exudate situated upon a deeply congested base. In some cases all grades may be seen between the thinnest film of superficial necrosis and involvement of the entire thickness of the mucosa. In the colon similar transversely arranged areas of necrosis are seen situated upon hy- peraemic patches, and it may be here much more extensive and involve a large portion of the membrane. There may be most extensive inflam- mation without any involvement of the solitary follicles of the large or small bowel. In a second group of cases the membrane has rather a croupous char- acter. It is grayish white in color, more flake-like and extensive, limited, perhaps, to the caecum or to a portion of the colon; thus, in several cases of pneumonia I found this flaky adherent false membrane, in one instance forming patches 1 to 2 cm. in diameter, which were not unlike in form to rupia crusts. In a third group the affection is really a follicular enteritis, involving the solitary glands, which are swollen and capped with an area of diph- theritic necrosis or are in a state of suppuration. Follicular ulcers are common in this form. The disease may run its course without any symptoms, and the condition is unexpectedly met with post mortem. In other instances there are diarrhoea, pain, but not often tenesmus or the passage of blood-stained mucus. In the toxic cases the intestinal symp- toms may be very marked, but in the terminal colitis of the fevers and of constitutional affections the symptoms are often trifling. The ulcerative colitis of chronic disease may be only a terminal event in these diphtheritic processes. DISEASES OF TnE DIGESTIVE SYSTEM. PHLEGMONOUS ENTERITIS. As an independent affection this is excessively rare, even less frequent than its counterpart in the stomach. It is seen occasionally in connection with intussusception, strangulated hernia, and chronic obstruction. Apart from these conditions it occurs most frequently in the duodenum, and leads to suppuration in the submucosa and abscess formation. Except when associated with hernia or intussusception the affection cannot be diagnosed. The symptoms usually resemble those of peritonitis. MUCOUS COLITIS. This affection is known by various names, such as membranous en- teritis, tubular diarrhoea, and mucous colic. It is a remarkable disease, to which much attention has been paid for several centuries. An exhaust- ive description of it is given by Woodward, in Yol. II of the Medical and Surgical Reports of the Civil War. It is an affection of the large bowel, characterized by the production of a very tenacious adherent mucus, which may be passed in long strings or as a continuous, tubular mem- brane. I have twice had opportunities of seeing this membrane in situ, closely adherent to the mucosa of the colon, but capable of separation without any lesion of the surface. Judging from the statement of Eng- lish authors as to its rarity, it would appear to be a more frequent disease in this country. According to W. A. Edwards, 80 per cent of the re- corded adult cases have been in women. It occurs occasionally in children. Of 111 cases six were under the age of ten. The cases are almost invari- ably seen in nervous or hysterical women or in men with neurasthenia. All grades of the affection occur, from the passage of a slimy mucus, like frog-spawn, to large tubular casts a foot or more in length. Microscopi- cally the casts are, as shown by Sir Andrew Clark, not fibrinous, but mucoid, and even the firmest consist of dense, opaque, transformed mucus. It is due to a derangement of the mucous glands of the colon, the nature of which is quite unknown. Symptoms.—The disease persists for years, varying extremely from time to time, and is characterized by paroxysms of pain in the abdomen, tenderness, occasionally tenesmus, and the passage of flakes or long strings of mucus, sometimes of definite casts of the bowel. The attacks last for a day or, in some instances, for ten days or two weeks. Mental emotions and worry of any sort seem particularly apt to bring on an attack. Occa- sionally errors in diet or dyspepsia precede an outbreak. Membranes are not passed with every paroxysm, even when the pains and cramps are severe. There are instances in which the morphia habit has been contracted on account of the severity of the pain. There may be marked nervous symptoms, and authors mention hysterical outbreaks, hypochondriasis, and melancholia. Mucous colitis is an important cause of enteralgia. DISEASES OF TIIE INTESTINES ASSOCIATED WITH DIARRHOEA. 423 The diagnosis is rarely doubtful, but it is important not to mistake the membranes for other substances; thus, the external cuticle of aspara- gus and undigested portions of meat or sausage-skins sometimes assume forms not unlike mucous casts, but the microscopical examination will quickly differentiate them. Twice I have known mucous colitis with se- vere pain to be mistaken for appendicitis. ULCERATIVE ENTERITIS. In addition to the specific ulcers of tuberculosis, syphilis, and typhoid fever, the following forms of ulceration occur in the bowels: (a) Follicular Ulceration.—As previously mentioned, this is met with very commonly in the diarrhceal diseases of children, and also in the sec- ondary or terminal inflammations in many fevers and constitutional disor- ders. The ulcers are small, punched out, with sharply cut edges, and they are usually limited to the follicles. With this form may be placed the catarrhal ulcers of some writers. (&) Stercoral Ulcers, which occur in long-standing cases of constipa- tion. Very remarkable indeed are the cases in which the sacculi of the colon become filled with roundea small scybala, some of which produce distinct ulcers in the mucous membrane. The faecal masses may have lime salts deposited in them, and thus form little enteroliths. (c) Simple Ulcerative Colitis.—This affection, which clinically is char- acterized by diarrhoea, is often regarded wrongly as a form of dysentery. It is not a very uncommon affection, and is most frequently met with in men above the middle period of life. The ulceration may be very exten- sive, so that a large proportion of the mucosa is removed. The lumen of the colon is sometimes greatly increased, and the muscular walls hyper- trophied. There are instances in which the bowel is contracted. Fre- quently the remnants of the mucosa are very dark, even black, and there may be polypoid outgrowths between the ulcers. These cases rarely come under observation at the outset, and it is diffi- cult to speak of the mode of origin. They are characterized by diarrhoea of a lienteric rather than of a dysenteric character. There is rarely blood or pus in the stools. Constipation may alternate with the diarrhoea. There is usually great impairment of nutrition, and the patients get weak and sallow. Perforation occasionally occurs. The disease may prove fatal, or it may pass on and become chronic. The affection was not very infrequent at the Philadelphia Hospital, and though the disease bears some resemblance to dysentery, it is to be sepa- rated from it. Some of the cases which we have learned to recognize as amoebic dysentery resemble this form very closely. An excellent descrip- tion of it is given by Hale White. Dickinson has described what he calls albuminuric ulceration of the bowels in cases of contracted kidney. (d) Ulceration from External Perforation.—This may result from the DISEASES OF THE DIGESTIVE SYSTEM. erosion of new growths or, more commonly, from localized peritonitis with abscess formation and perforation of the bowel. This is met with most fre- quently in tuberculous peritonitis, but it may occur in the abscess which follows perforation of the appendix or suppurative or gangrenous pan- creatitis. Fatal haemorrhage may result from the perforation. (e) Cancerous Ulcers.—In very rare instances of multiple cancer or sarcoma the submucous nodules break down and ulcerate. In one case the ileum contained eight or ten sarcomatous ulcers secondary to an ex- tensive sarcoma in the neighborhood of the shoulder-joint. (/) Occasionally a solitary ulcer is met with in the caecum or colon, which may lead to perforation. Two instances of ulcer of the caecum, both with perforation, have come under my observation, and in one instance a simple ulcer of the colon perforated and led to fatal perito- nitis. Diagnosis of Intestinal Ulcers.—As a rule, diarrhoea is present in all cases, hut exceptionally there may be extensive ulceration, particu- larly in the small bowel, without diarrhoea. Very limited ulceration in the colon may be associated with frequent stools. The character of the dejections is of great importance. Pus, shreds of tissue, and blood are the most valuable indications. Pus occurs most frequently in connection with ulcers in the large intestine, but when the bowel alone is involved the amount is rarely great, and the passage of any quantity of pure pus is an indication that it has come from without, most commonly from the rupture of a pericsecal abscess, or in women an abscess of the broad liga- ment. Pus may also be present in cancer of the bowel, or it may be due to local disease in the rectum. A purulent mucus may he present in the stools in cases of ulcer, but it has not the same diagnostic value. The swollen, sago-like masses of mucus which are believed by some to indicate follicular ulceration are met with also in mucous colitis. Hemorrhage is an important and valuable symptom of ulcer of the bowel, particularly if profuse. It occurs under so many conditions that taken alone it may not he specially significant, but with other coexisting circumstances it may be the most important indication of all. Fragments of tissue are occasionally found in the stools in ulcer, par- ticularly in the extensive and rapid sloughing in dysenteric processes. Definite portions of mucosa, shreds of connective tissue, and even bits of the muscular coat may be found. Pain occurs in many cases, either of a diffuse, colicky character, or sometimes, in the ulcer of the colon, very limited and Avell defined. Perforation is an accident liable to happen when the ulcer extends deeply. In the small bowel it leads to a localized or general peritonitis. In the large intestine, too, a fatal peritonitis may result, or if perforation takes place in the posterior wall of the ascending or descending colon, the production of a large abscess cavity in the retro-peritonaeum. In a case at the University Hospital, Philadelphia, there was a perforation at DISEASES OP THE INTESTINES ASSOCIATED WITH DIARRHCEA. 425 the splenic flexure of the colon with an abscess containing air and pus .—a condition of subphrenic pyo-pneumothorax. Treatment of the Previous Conditions. (a) Acute Dyspeptic Diarrhoea.—All solid food should be withheld. If vomiting is present ice may be given, and small quantities of milk and soda water may be taken. If the attack has followed the eating of large quantities of undigestible material, castor oil or calomel is advisable, but is not necessary if the patient has been freely purged. If the pain is se- vere, twenty drops of laudanum and a drachm of spirits of chloroform may be given, or, if the colic is very intense, a hypodermic of a quarter of a grain of morphia. It is not well to check the diarrhoea unless it is pro- fuse, as it usually stops spontaneously within forty-eight hours. If per- sistent, the aromatic chalk powder or large doses of bismuth (thirty to forty grains) may be given. A small enema of starch (two ounces) with twenty drops of laudanum, every six hours, is a most valuable remedy. (i) Chronic Diarrhoea, including chronic catarrh and ulcerative enter- itis. It is important, in the first place, to ascertain, if possible, the cause and whether ulceration is present or not. So much in treatment depends upon the careful examination of the stools—as to the amount of mucus, the presence of pus, the occurrence of parasites, and, above all, the state of digestion of the food—that the practitioner should pay special attention to them. Many cases simply require rest in bed and a restricted diet. Chronic diarrhoea of many months’ or even of several years’ duration may be sometimes cured by strict confinement to bed and a diet of boiled milk and albumen water. In that form in which immediately after eating there is a tendency to loose evacuations it is usually found that some one article of diet is at fault. The patient should rest for an hour or more after meals. Some- times this alone is sufficient to prevent the occurrence of the diarrhoea. In those forms which depend upon abnormal conditions in the small in- testine, either too rapid peristalsis or faulty fermentative processes, bis- muth is indicated. It must be given in large doses—from half a drachm to a drachm three times a day. The smaller doses are of little use. Naphthalin preparations here do much good, given in doses of from ten to fifteen grains (in capsule) four or five times a day. Larger doses may be needed. Salol and the salicylate of bismuth may be tried. An extremely obstinate and intractable form is the diarrhoea of hyster- ical women. A systematic rest cure will be found most advantageous, and if a milk diet is not well borne the patient may be fed exclusively on egg albumen. The condition seems to be associated in some cases with in- creased peristalsis, and in such the bromides may do good, or preparations of opium may be necessary. There are instances which prove most obsti- nate and resist all forms of treatment, and the patient may be greatly reduced. A change of air and surroundings may do more than medicines. In a large group of the chronic diarrhoeas the mischief is seated in the 426 DISEASES OF THE DIGESTIVE SYSTEM. colon and is due to ulceration. Medicines by the mouth are here of little value. The stools should be carefully watched and a diet arranged which shall leave the smallest possible residue. Boiled or peptonized milk maj be given, but the stools should be examined to see whether there is an excess of food or of curds. Meat is, as a rule, badly borne in these cases. The diarrhoea is best treated by enemata. The starch and laudanum should be tried, but when ulceration is present it is better to use astringent injections. From two to four pints of warm water containing from half a drachm to a drachm of nitrate of silver may be used. In the chronic diarrhoea which follows dysentery this is particularly advantageous. In giving large injections the patient should be in the dorsal position, with the hips elevated, and it is best to allow the injection to flow in gradually from a siphon bag. In this way the entire colon can be irrigated and the patient can retain the injection for some time. The silver injections may be very painful, but they are invaluable in all forms of ulcerative colitis. Acetate of lead, boracic acid, sulphate of copper, sulphate of zinc, and salicylic acid may be used in one per cent solutions. In mucous colitis no benefit can be expected from remedies adminis- tered by the mouth. The topical applications should be made to the mucous membrane of the colon by the enemata just mentioned, and the general nervous condition should receive appropriate treatment. In the intense forms of choleraic diarrhoea in adults associated with constant vomiting and frequent watery discharges the patient should be given at once a hypodermic of a quarter of a grain of morphia, which should be repeated in an hour if the pains return or the purging persists. This gives prompt relief, and is often the only medicine needed in the attack. The patient should be given stimulants, and, when the vomiting is allayed by suitable remedies, small quantities of milk and lime water. (c) The Diarrhoea of Children.—Hygienic management is of the first importance. The effect of a change from the hot, stifling atmosphere of a town to the mountains or the sea is often seen at once in a reduction in the number of stools and a rapid improvement in the physical condi- tion. Even in cities much may be done by sending the child into the parks or for daily excursions on the water. However extreme the condi- tion, fresh air is indicated. The child should not be too thickly clad. Many mothers, even in the warm weather, clothe their children too heavily. Bathing is of value in infantile diarrhoea, and when the fever rises above 102*5° the child should be placed in a warm bath, the temperature of which may be gradually reduced, or the child is kept in the bath for twenty minutes, by which time the water is sufficiently cooled. Much relief is obtained by the application of ice-cold cloths or of the ice-cap to the head. Irrigation of the colon with ice-cold water is sometimes favor- able, but it has not the advantage of the general bath, the beneficial effect of which is seen, not only in the reduction of the temperature, but in a general stimulation of the nervous system of the child. DISEASES OF THE INTESTINES ASSOCIATED WITH DIARRIICEA. 427 Dietetic Treatment.—In the case of a hand-fed child it is important, if possible, to get a wet-nurse. While fever is present, digestion is sure to be much disturbed, and the amount of food should be restricted. If water or barley water be given the child will not feel the deprivation of food so much. When the vomiting is incessant it is much better not to attempt to give milk or other articles of food, but let the child take the water whenever it will. In the dyspeptic diarrhoeas of infants, practically the whole treatment is a matter of artificial feeding, and there is no subject in medicine on which it is more difficult to lay down satisfactory rules. No doubt within a few years the study of the bacterial processes going on in the intestines of the child will give us most important suggestions. From his observa- tions Escherich lays down the following rules, recognizing two well- defined forms of intestinal fermentation—the acid and the alkaline: If there is much decomposition, with foul, offensive stools, the albuminous articles should be withheld from the diet and the carbohydrates given, such as dextrin foods, sugar, and milk, which, on account of its sugar, ranks with the carbohydrates. If there is acid fermentation, with sour but not fetid stools, an albuminous diet is given, such as broths and egg albumen. It is, however, by no means certain whether the reaction of the stools, upon which this author relies, is a sufficient test of the nature of the intestinal fermentation. In the dyspeptic diarrhoeas of artificially fed infants it is best, as a rule, to withhold milk and to feed the child, for the time at least, on egg albumen, broths, and beef juices. To prepare the egg albumen, the whites of two or three eggs may be stirred in a pint of water and a teaspoonful of brandy and a little salt mixed with it. The child wfill usually take this freely, and it is both stimulating and nourish- ing. It is sometimes remarkable with what rapidity a child which has been fed on artificial food and milk will pick up and improve on this diet alone. Beef-juice is obtained by pressing with a lemon-squeezer fresh steak, previously minced and either uncooked or slightly broiled. This may be given alternately with the egg albumen or it may be given alone. Mutton or chicken broth will be found equally serviceable, but it is pre- pared with greater difficulty and contains more fat. In the preparation, a pound of mutton, chicken, or beef, carefully freed from fat, is minced and placed in a pint of cold water and allowed to stand in a glass jar on ice for three or four hours. It should then be cooked over a slow fire for at least three hours, then strained, allowed to cool, the fat skimmed off, suf- ficient salt added, and it may then be given either warm or cold. These naturally prepared albumen foods are very much to be preferred to the various artificial substances. There is no form of nourishment so readily assimilated and apt to cause so little disturbance as egg albumen or the simple beef juices. The child should be fed every two hours, and in the intervals water may be freely given. It cannot be expected that, with the digestion seriously impaired, as much food can be taken as in health, DISEASES OF THE DIGESTIVE SYSTEM. and in many instances we see the diarrhoea aggravated by persistent over- feeding. When the child’s stomach is quieted and the diarrhoea checked there may he a gradual return to the milk diet. The milk should be ster- ilized, and in institutions and in cities this simple prophylactic measure is of the very first importance and is readily carried out by means of the Ar- nold steam sterilizer. The milk should be at first freely diluted—four parts of water to one of milk, which is perhaps the preferable way—or it may be peptonized. The stools should be examined daily, as important indications may be obtained from them. Milk-whey and forms of fer- mented milk are sometimes useful and may be employed when. the stom- ach is very irritable. These general directions as to food also hold good in cholera infantum. Medicinal Treatment.—The first indication in the dyspeptic diarrhoea of children is to get rid of the decomposing matter in the stomach and intestines. The diarrhoea and vomiting partially effect this, but it may be more thoroughly accomplished, so far as the stomach is concerned, by irrigation. It may seem a harsh procedure in the case of young infants, hut in reality, with a large-sized soft-rubber catheter, it is practised with- out any difficulty. By means of a funnel, lukewarm water is allowed to pass in and out until it comes away quite clear. I can speak in the very warmest manner of the good results obtained by this simple pro- cedure in cases of the most obstinate gastro-intestinal catarrh in children. In most cases the warm water is sufficient. In some hands this method has probably been carried to excess, but that does not detract from its great value in suitable cases. To remove the fermenting substances from the intestines, doses of calomel or gray powder may be administered. The castor oil is equally efficacious, but is more apt to be vomited. Irri- gation of the large bowel is useful, and not only thoroughly removes fermenting substances, but cleanses the mucosa. The child should be placed on the back with the hips elevated. A flexible catheter is passed for from six to eight inches and from a pint to two pints of water allowed to flow in from a fountain syringe. A pint will thoroughly irrigate the colon of a child of six months and a quart that of a child of two years. The water may be lukewarm, but when there is high fever ice-cold water may be used. In cases of entero-colitis there may be injections with borax, a drachm to the pint, or dilute nitrate of silver, which may be either given in large injections, as in the adult, or in injections of three or four ounces with three grains of nitrate of silver to the ounce. These often cause very great pain, and it is well in such cases to follow the silver injection with irrigations of salt solution, a drachm to a pint. We are still without a reliable intestinal antiseptic. Neither naphtha- lin, salol, resorcin, the salicylates, nor mercury meets the indications. As in the diarrhoea of adults, bismuth in large doses is often very effective, but practitioners are in the habit of giving it in doses which are quite in- sufficient. To be of any service it must be used in large doses, so that an APPENDICITIS. 429 infant a year old will take as much as two drachms in the day. The gray powder has long been a favorite in this condition and may be given in half-grain doses every hour. It is perhaps preferable to calomel, which may be used in small doses of from one tenth to one fourth of a grain every hour at the onset of the trouble. The sodium salicylate (in doses of two or three grains every two hours to a child a year old) has been recommended. In cholera infantum serious symptoms may develop with great rapidity, and here the incessant vomiting and the frequent purging render the administration of remedies extremely difficult. Irrigation of the stomach and large bowel is of great service, and when the fever is high ice-water injections may be used or a graduated bath. As in the acute choleraic diarrhoea of adults, morphia hypodermically is the remedy which gives greatest relief, and in the conditions of extreme vomiting and purging, with restlessness and collapse symptoms, this drug alone commands the situation. A child of one year may be given from to of a grain, to be repeated in an hour, and again if not better. When the vomiting is allayed, attempts may be made to give gray powder in half-grain doses with -fa of Dover’s powder. Starch ( 3 ij) and laudanum (uiij-iij) injections, if retained, are soothing and benefi- cial. The combination of bismuth with Dover’s powder will also be found beneficial. No attempt should be made to give food. Water may be allowed freely, even when ejected at once by vomiting. Small doses of brandy or champagne, frequently repeated and given cold, are sometimes retained. When the collapse is extreme, hypodermic injections of one per cent saline solution may be used as recommended in Asiatic cholera, and hypodermic injections of ether and brandy may be tried. The convales- cence requires very careful management, as many cases pass on into the condition of entero-colitis. When the intense symptoms have subsided, the food should be gradually given, beginning with teaspoonful doses of egg albumen or beef-juice. It is best to withhold milk for several days, and when used it should be at first completely peptonized or diluted with gruel. A teaspoonful of raw, scraped meat three or four times a day is often well borne. II. APPENDICITIS. Inflammation of the vermiform appendix is the most important of acute intestinal disorders. Formerly the “ iliac phlegmon ” was thought to be due to disease of the caecum—typhlitis—and of the peritonaeum cov- ering it—perityphlitis ; but we now know that with rare exceptions the caecum itself is not affected, and even the condition formerly described as stercoral typhlitis is in reality appendicitis. The recognition of the im- portance of appendicitis is due largely to the work of American physicians and surgeons—to Pepper, who described in 1883 the relapsing form; to 430 DISEASES OF THE DIGESTIVE SYSTEM. Fitz, whose exhaustive article in 1886 served to put the whole question on a rational basis ; to Willard Parker, who was the first to advocate early operation; and to Sands, Bull, McBurney, Weir, Morton, Keen, Senn, J. William White, Deaver, and others,-who have done so much to improve the operative measures for its relief. Treeves, of London, has been fore- most in advocating the proper surgical treatment of the disease. The in- terest attached to the subject is manifest by the appearance within a few \ears of a number of special monographs by Kelynack, Telamon, Fowler, Sonnenberg, and Hawkins. Anatomy.—The appendix vermiformis is a functionless relic of a large ancestral caecum. It measures usually about three inches in length, but it may be scarcely an inch. The diameter is about one fourth of an inch. In a majority of instances it has a triangular-shaped meso-ap- pendix, usually shorter than the tube, which thus becomes a little curled or bent upon itself. There is often a small lymph-gland just at the root of its mesentery. The position of the appendix is very variable. The most common direction it assumes is upward and inward, the tip pointing toward the spleen. The position next in frequency is behind the cascum, and next passing over the pelvic brim. It may be met with, however, in almost every region of the abdomen, and adherent to almost every organ in it. I have seen it in close contact with the bladder, adherent to one ovary and the broad ligament; in the central portion of the abdomen close to the navel; in contact with the gall-bladder, passing out at right angles and adherent to the sigmoid flexure to the left of the middle line of the abdomen; and in one case it entered with the cascum the inguinal caiial, curved upon itself, re-entered the abdomen, and was adherent to the wall of an abscess cavity just to the right of the promontory of the sacrum. The structure of the appendix is almost identical with that of the csecum; it is particularly rich in lymphoid tissue. The blood supply is derived from a small artery which passes along the free edge of its mesentery. Morbid Anatomy and Etiology.—The following are the most common morbid conditions : (a) Faecal Concretions.—The lumen of the appendix may contain a mould of fseces, which can readily be squeezed out. Even while soft the contents of the tube may be moulded in two or three sections with rounded ends. Concretions—enteroliths, coproliths—are also common. The mode of formation is not very clear. Possibly, as with gall-stones, the micro- organisms may have a favoring influence in their formation. They were present in 38 cases in 400 autopsies (Ribbert), and in 179 of 459 autopsies in perityphlitis collected by Renvers. The enteroliths often resemble in shape date-stones. The importance of these concretions is shown by the great frequency with which they are found in all acute inflammations of the appendix. (b) Foreign bodies are by no means so frequently met with—only twelve per cent in 152 cases of appendicitis collected by Fitz. Only two APPENDICITIS. 431 instances came under my observation in ten years’ pathological work in Montreal; in one there were eight snipe-shot and in another five apple- pips. The stones and seeds of various fruits, bits of bone, and pins have been found. It is well to bear in mind that some of the concretions bear a very striking resemblance to cherry and date stones. (c) Obliterative Appendicitis.—The entire tube is thickened, the peri- toneal surface smooth or injected, and either with adhesions from slight circumscribed peritonitis, or perfectly free. The mucosa may show noth- ing more than a shedding of epithelium with infiltration of leucocytes in the submucosa, while in more chronic cases there is almost complete de- nudation of the mucosa, which is replaced by granulation tissue. The muscular coats are thickened throughout, and the entire tube is firm and stiff, as if in a state of erection. When laid open longitudinally it at once assumes a rolled form in the reverse direction. The term catarrhal, which has been applied to this condition, is scarcely appropriate, since the changes are diffuse throughout the whole tube. In the majority of instances the term appendicitis obliterans, used by Senn, is in reality more appropriate. As Hawkins remarks, this con- dition is probably a fertile source of local peritonitis, and one may see in this stage fresh adhesions on the peritoneal surface or more extensive circumscribed peritonitis. It may, however, be, as he says, the precursor of complete immunity from such attacks. “For if by the pressure of the surrounding parts the opposed granulating surfaces are brought into contact, and if the whole organ remains at rest, union may take place, and the appendix as a source of disease then ceases to exist.” In other cases obliteration of the lumen cannot take place on account of the rigid incollapsible character of the walls, and it is this condition of chronic appendicitis which may lead to recurrences of attacks of colic and local symptoms in the right iliac fossa. McBurney lays great stress upon the narrowing of the lumen as pre- venting normal drainage of the tube and establishing conditions favorable for the development of septic processes. Obliterative appendicitis is met with in about two per cent of all sub- jects. When the stricture occurs at the caecal end of the tube the lumen may become greatly dilated, forming a cystic appendix which may reach the size of the thumb, or even the size of an ordinary sausage. The con- tents of the cyst are either a clear fluid or pus. Ulceration and perfora- tion are very apt to occur. Obliterative appendicitis may go on as an ordinary involution process without causing any symptoms, but in many instances there are attacks of pain—appendicular colic; in others, exacer- bations of fever with pain and swelling; while in others again ulceration and perforation may take place. (d) Ulcerative Appendicitis.—Local ulceration in the appendix is met with as a result of the presence of concretions or of foreign bodies, or as the result of the action of certain micro-organisms, either those normally 432 DISEASES OF THE DIGESTIVE SYSTEM. inhabiting the caecum or, under certain circumstances, the typhoid and tubercle bacilli. Faecal concretions and foreign bodies are met with in the appendix without apparently causing the slightest abrasion of its mu- cosa. In other cases the enterolith has caused atrophy of the mucous membrane with which it is in contact. In other cases again the concre- tion or foreign body may be pocketed in an ulcer at the tip of the ap- pendix, from which it may be shelled out. These conditions may be present without adhesions and without reddening of the serous surface, but one not infrequently sees thickening of the peritoneeum with adhe- sions to the adjacent parts in ulcerative appendicitis. Tuberculosis of the appendix is by no means uncommon. Ulceration in typhoid fever is also frequently met with; in a series of eighty autop- sies there were three instances of perforation of the appendix by a typhoid ulcer. An actinomycotic ulcer has also been described. (e) Necrosis and Sloughing of the Appendix—Acute Infective Appendi- citis.—Following upon the conditions described under (c) and (of), necrosis and sloughing may take place either in a limited portion of the appendix with perforation, or en masse without perforation, in both cases leading to the most intense peritonitis, localized or general. Most commonly the gangrene is localized to one spot, either at the tip or in some portion of the tube. Usually the organ is swollen; the color may be reddish brown, black, or greenish yellow. Necrosis may occur en masse, and the entire appendix may indeed slough off from the caecum and lie free in an abscess cavity. In one remarkable case operated upon by my colleague, Ilalsted, the appendix, between four and five inches in length, was shrunken, blackish brown in color, sphacelated throughout, and looked like a desiccated earthworm. These active processes leading to ulceration and necrosis are due to the action of micro-organisms, and much work has been done to deter- mine their character. Hodenpyl showed that the bacillus coli communis was present in a very large number of cases of appendicitis. In sixty- one cases of peritoneal inflammation consequent upon disease of the ap- pendix the bacillus coli communis was found in fifty-seven, and in fifty of these it was the only organism present. The streptococcus pyogenes and the staphylococcus pyogenes aureus, the proteus and bacillus pyocyaneus, have also been found. The streptococcus infection is the most virulent. Probably too much stress has been laid upon the bacillus coli communis as a cause of infective processes in and about the appendix. In many cases, with slight fresh adhesion and a little sero-fibrin, the cultures are negative. As Welch remarks, “There is reason to believe that the highly resistant colon bacillus may survive in an inflamed part after the primary organism which started the trouble has died out, or has been crowded out by the invader.” The proneness of the appendix to infective inflammation of this sort lies “ in that subtle structure which determines the degree of resistance of a tissue to disease. One man differs from another in his APPENDICITIS. 433 power of resistance; the more degenerate the man the less resistance can he exert. In like manner, one organ in a man differs from another. And in the appendix we are dealing with an organ which is degenerate and functionless from first to last, and its scanty power of resistance to bac- terial invasion is but another way of expressing this fact” (Hawkins). It has been urged that the anatomical relations of the meso-appendix and the adjacent peritoneal folds are such that distention of the caecum, or of the lower portion of the ileum, may cause dragging with torsion and interfere seriously with the blood supply of the tube. The swelling of the mucosa so induced may be an important factor in the infection of its tissues. Fowler suggests, and brings a case in support, that in some of these cases the necrosis is due to the thrombosis of a large arterial branch. Immediate Effects of the Perforation, (a) Acute General Peritonitis.— If the appendix is free, without adhesions, the perforation may lead at once to a wide-spread peritonitis. The inflammation varies much in viru- lence, depending apparently upon the infecting organism. The worst cases are those in which the streptococcus pyogenes is present. A general peritonitis is more common in the acute infective appendicitis than in the other forms. It probably results less frequently from direct perfora- tion, or sloughing of the appendix, than from extension of inflammation from a local peri-appendicular abscess. (b) Localized Peritonitis, with Abscess.—Perforation leads usually to the formation of a circumscribed intra-peritoneal abscess cavity, which varies in situation with the position of the appendix, and in size from a walnut to a cocoanut. Perhaps the most common situation is on the psoas muscle, just at the angle between the ileum and the caecum. The perforated appendix, however, may be within the pelvis, or upon the promontory of the sacrum, or lie between the coils of small bowel in the neighborhood of the umbilicus. A common situation for the large circumscribed intra-peritoneal abscess is in the iliac region midway be- tween the navel and the anterior superior spine. Perforation, adhesive peritonitis, and the production of a localized abscess may proceed without causing any serious symptoms, and the condition may be found when death has resulted from accident or from some intercurrent affection. The contents of the abscess may be a grayish yellow, thick pus, usually with a strong faecal odor; but in the old, limited, small abscesses it is usually dark gray in color, and horribly offensive. The appendix may be found free in the localized abscess; in other instances it is so covered with pus and inflammatory exudate that it is impossible to find it. While in a majority of all instances the abscess cavity, even when large, is intra- peritoneal, there may be— (c) Extensive Extra-Peritoneal Suppuration.—When an appendix per- forates, it lies, of course, in immediate contact with the peritonaeum; if on the iliac fascia, or the wall of the pelvis, or behind the caecum, the ad- DISEASES OF THE DIGESTIVE SYSTEM. hesion may take place in such a way that the perforation occurs into the retro-peritoneal tissue. In these days of operation we do not so often see the extensive retro-peritoneal abscesses due to appendix disease. The pus may pass beneath the iliac fascia and appear at Poupart’s ligament, in which situation external perforation may occur and recovery take place. The pus may be chiefly in the retro-peritoneal tissue in the flank, forming a large perinephritic abscess. In a case under the care of Gardner, of Montreal, an enormous abscess cavity developed in this situation, which contained air, pushed up the diaphragm nearly to the second rib, and pro- duced the symptoms of pneumothorax. Perforation of the pleura may occur in these cases, forming a feecal pleural fistula. The pus may extend along the psoas muscle and may perforate the hip joint, or pass to the neighborhood of the rectum, or produce multiple abscesses of the scrotum; or, passing through the obturator foramen, form a large gluteal abscess. Both the intra- and extra-peritoneal appendix abscess may perforate into the bladder or into the bowel, and recovery may follow, though there is greater danger in perforation into the latter. The appendix has been discharged per anum. Remote Effects.—The remote effects of perforative appendicitis are interesting. Hemorrhage may occur. In one of my cases the appendix was adherent to the promontory of the sacrum, and the abscess cavity had perforated in two places into the ileum. Death resulted from profuse hemorrhage. Cases are on record in which the internal iliac artery or the deep circumflex iliac artery has been opened. Suppurative pylephle- bitis may result from inflammation of the mesenteric veins near the per- forated appendix. Two instances of it have come under my notice; in one there was a small localized abscess which had resulted from the per- foration of a typhoid ulcer of the appendix. In the other case, which I saw with Machell, of Toronto, the symptoms were those of septicaemia and of suppuration in the liver. The abscess of the appendix was small and had not produced symptoms. In the healing of extensive inflammation about the margin of the pelvis the iliac veins may be greatly compressed, and one of my patients had for months oedema of the right leg, which is now permanently enlarged. The appendix may perforate in a hernial sac. Several instances of this have been recorded recently. In a case which came under my care at the University Hospital, Philadelphia, there was a hernia of the casciim in the inguinal canal. The proximal orifice of the appendix was at the ex- treme end of the hernia in the inguinal canal. The tube then curved upon itself, passed into the abdomen, and the terminal three fourths of an inch had sloughed in a small circumscribed sac situated close to the prom- ontory of the sacrum. The following additional facts may be mentioned, bearing on the Etiology: Age.—Appendicitis is a disease of young persons. According to Fitz’s APPENDICITIS. 435 statistics, more than fifty per cent of the cases occur before the twentieth year; according to Einhorn’s, sixty per cent between the sixteenth and thirtieth years. It has been met with as early as the seventh week, but it is rarely seen prior to the third year. Sex.—It is much more common in males than in females, eighty per cent of the former in the table of Fitz. In Hawkins’s series, one hundred and sixty-one were males and sixty-three females. Contrary to the gen- eral experience, the Munich figures given by Einhorn indicate a relatively greater number of women attacked. Occupation.—Persons whose wrork necessitates the lifting of heavy weights seem more prone to the disease. Trauma plays a very definite role, and in a number of cases the symptoms have followed very closely a fall or a blow. Indiscretions in diet are very prone to bring on an attack, particularly in the recurring form of the disease, in which pain in the appendix region not infrequently follows the eating of indigestible articles of food. I have been impressed, too, with the number of cases in boys in which there has been a history of gorging with peanuts. Symptoms.—In a large proportion of all cases of acute appendicitis the following symptoms are present: (1) Sudden pain in the abdomen, usually referred to the right iliac fossa; (2) fever, often of moderate grade; (3) gastro-intestinal disturbance—nausea, vomiting, and frequently constipation ; (4) tenderness or pain on pressure in the appendix region. Such a group of symptoms in a young person, particularly following an indiscretion in diet or an injury or strain, in the absence of signs of hernia, indicate the existence of appendicitis; they do not suggest in any way the nature of the lesion, whether obliterative, ulcerative, or an acute necrotic appendicitis. We may first consider more fully these general symptoms of the disease. Pain.—A sudden, violent pain in the abdomen is, according to Fitz, the most constant, first, decided symptom of perforating inflammation of the appendix, and occurred in eighty-four per cent of the cases analyzed by him. In fully half of the cases it is localized in the right iliac fossa, but it may be central, diffuse, or indeed in almost any region of the abdo- men. Even in the cases in which the pain is at first not in the appendix region, it is usually felt here within thirty-six or forty-eight hours. It may extend toward the peringeum or testicle. It is sometimes very sharp and colic-like, and cases have been mistaken for nephritic or for biliary colic. Some pa-tients speak of it as a sharp, intense pain—serous-mem- brane pain; others as a dull ache—connective-tissue pain. While a very valuable symptom, pain is at the same time one of the most misleading. Some of the forms of recurring pain in the appendix region Talamon has called appendicular colic. The condition is believed to be due to partial occlusion of the lumen, leading to violent and irregular peristaltic action of the circular and longitudinal muscles in the expulsion of the mucus. 436 DISEASES OF THE DIGESTIVE SYSTEM. Fever.—A rise in the temperature follows rapidly upon the pain, and is one of the most valuable of the symptoms of the early stage of appendi- citis. An initial chill is very rare. The fever may be moderate, from 100° to 102°; sometimes in children at the very outset the thermometer may register above 103-5°. The thermometer is one of the most trust- worthy guides in the diagnosis of acute appendicitis. Pain in the right iliac fossa without fever, in an acute attack, rarely means appendicitis. When a localized abscess has formed, and in some very virulent cases of general peritonitis, the temperature may be almost normal, but at this stage there are other symptoms which indicate the gravity of the situation. The pulse is quickened in proportion to the fever. Gastro-intestinal Disturbance.—The tongue is usually furred and moist, seldom dry. Nausea and vomiting are symptoms which may be absent, but which are commonly present in the acute perforative cases. The vomiting rarely persists beyond the second day in favorable cases. Con- stipation is the rule, but the attack may set in with diarrhoea, particularly in children. Local Signs.—Inspection of the abdomen is at first negative; there is no distention, and the iliac fossae look alike. On palpation there are usu- ally from the outset two important signs—namely, great tension of the right rectus muscle, and tenderness or actual pain on deep pressure. The muscular rigidity may be so great that a satisfactory examination cannot be made without an anaesthetic. McBurney has called attention to the value of a localized point of tenderness on deep pressure, which is situated at the intersection of a line drawn from the navel to the anterior superior spine of the ilium, with a second, vertically placed, corresponding to the outer edge of the right rectus muscle. Firm, deep, continuous pressure with one finger at this spot causes pain, often of the most exquisite char- acter. In addition to the tenderness, rigidity, and actual pain on deep pressure, there is usually to be felt in a majority of the cases an induration or swelling. In some cases this is a boggy, ill-defined mass in the situa- tion of the caecum; more commonly the swelling is circumscribed and definite, situated in the iliac fossa, two or three fingers’ breadth above Poupart’s ligament. Some have been able to feel and roll beneath the fingers the thickened appendix. The later the case comes under observa- tion the greater the probability of the existence of a well-marked tumor mass. It is not to be forgotten that there may be neither tumor mass nor induration to be felt in some of the most intensely virulent cases of per- forative appendicitis. In addition may be mentioned great irritability of the bladder, which I have known to lead to the diagnosis of cystitis. It may be a very early symptom. The urine is scanty and often contains albumin and indican. Peptonuria is of no moment. The attitude is somewhat suggestive, the decubitus is dorsal, and the right leg is semi-flexed. Examination per rectum in the early stages rarely gives any information of value, unless the APPENDICITIS. 437 appendix lies well over the brim of the pelvis, or unless there is a large abscess cavity. There are three possibilities in any case of appendicitis presenting the above symptoms: (1) Gradual recovery, (2) the formation of a local ab- scess, and (3) the development of a general peritonitis. Recovery is the rule. Out of 264 cases at St. Thomas’s Hospital with the above-mentioned clinical characters, 190 recovered. In one in- stance the appendix was removed, and in two, attempts were made to re- move it (Hawkins). There are surgeons who claim that the getting well in these cases does not mean much; that the patients have recur- rences and are constantly liable to the graver accidents of the disease. This, I feel sure, is an unduly dark picture. I have known personally numbers of cases in which, after one or two attacks, the individuals have remained in perfect health. In a case which is proceeding to recovery the pain lessens at the end of the third or fourth day, the temperature falls, the tongue becomes cleaner, the vomiting ceases, the local tenderness is less marked, and the bowels are moved. By the end of a week the acute symptoms have subsided. The entire attack may not last more than ten days. In other instances slight fever persists, and it may be two or three weeks before convalescence is established. An induration or an actual small tumor mass from the size of a walnut to that of an egg may persist—a condition in which patients are very liable to a recurrence. In these cases there is either a chronic appendicitis without perforation or involvement of the serous surface, or there is involvement of the peri- toneal surface, usually from perforation, with a sero-fibrinous exudate and an agglutination of the contiguous parts. In the cases with a well-defined tumor, whether large or small, there is almost always pus formation. Local Abscess Formation.—As a result of ulceration and perforation, sometimes following the necrosis, rarely as a sequence of the diffuse ap- pendicitis, the patient has the.train of symptoms above described; but at the end of the first week the local features persist or become aggravated. The course of the disease may be indeed so acute that by the end of the fourth or fifth day there is an extensive area of induration in the right iliac fossa, with great tenderness, and operations have shown that even at this very early date an abscess cavity may have formed. Though as a rule the fever becomes aggravated with the onset of suppuration, this is not always the case. The two most important elements in the diagnosis of abscess formation are the gradual increase of the local tumor and the aggravation of the general symptoms. Nowadays, when operation is so frequent, we have opportunities of seeing the abecess in various stages of development. Quite early the pus may lie between the caecum and the coils of the ileum, with the general peritonaeum shut off by fibrin, or there is a sero-fibrinous exudate with a slight amount of pus between the lower coils of the ileum. The abscess cavity may be small and lie on the psoas 438 DISEASES OF TIIE DIGESTIVE SYSTEM. muscle, or at the edge of the promontory of the sacrum, and never reach a palpable size. The sac, when larger, may be roofed in by the small bowel and present irregular processes and pockets leading in different directions. In larger collections in the iliac fossa the roof is generally formed by the abdominal wall. Some of the most important of the localized abscesses are those which are situated entirely within the pelvis. The various di- rections and positions into which the abscess may pass or perforate have already been referred to under morbid anatomy, but it may be here men- tioned again that, left alone, they may discharge externally, or burrow in various directions, or discharge through the rectum, vagina, or bladder. Death may be caused by septicaemia, by perforation into an artery or vein, or by pylephlebitis. General Peritonitis.—This may be caused by direct perforation of the appendix and general infection of the peritonaeum before any delimiting inflammation is excited. In a second group of cases there has been an at- tempt at localizing the infective process, but it fails, and the general peri- tonaeum becomes involved. In a third group of cases a localized focus of suppuration exists about an inflamed appendix, and from this perforation takes place. Death in appendicitis is due usually to general peritonitis. We see at operations all grades of the affection, from the mildest, in which the serous surface is injected, turbid, and sticky, but without lymph or effusion, except in the immediate neighborhood of the perforated ap- pendix. In other cases there is a fibrinous exudate gluing the coils together and a variable amount of turbid serous fluid. In other instances, as the abdomen is opened, pus wells out, and. there is a diffuse purulent inflammation of the peritongeum. It is interesting, however, to note the comparative rarity of fatal peritonitis from appendix disease in general medical work. In 450 consecutive autopsies on patients dead in my wards there was not a single instance of general peritonitis from appendix dis- ease. On the surgical side there have been admitted during the same period ten cases of diffuse peritonitis from this cause. Eight were op- erated upon; all died. In nine cases there was found a perforated and more or less gangrenous appendix, with little or no attempt at localiza- tion ; in one case rupture of an abscess caused the general peritonitis. The gravity of appendix disease lies in the fact that from the very out- set the peritonaeum may be infected ; the initial symptoms of pain, with nausea and vomiting, fever, and local tenderness, present in all cases, may indicate a wide-spread infection of this membrane. The onset is usually sudden, the pain diffuse, not always localized in the right iliac fossa, but it is not so much the character as the greater intensity of the symptoms from the outset that makes one suspicious of a general peri- tonitis. Abdominal distention, diffuse tenderness, and absence of ab- dominal movements are the most trustworthy local signs, but they are not really so trustworthy as the general symptoms. The initial nausea and APPENDICITIS. 439 vomiting persist, the pulse becomes more rapid, the tongue is dry, the urine scanty. In very acute cases, by the end of twenty-four hours the abdomen may be distended. By the third and fourth days the classical picture of a general peritonitis is well established—a distended and motionless abdomen, a rapid pulse, a dry tongue, dorsal decubitus with the knees drawn up, and an anxious, pinched, Hippocratic facies. Fever is an uncertain element. It is usually present at first, but if the physician does not see the case until the third or fourth day he should not be deceived by a temperature below 100-5°. The pulse is really a better indication than the temperature. One rarely has any doubt on the third or fourth day whether or not peritonitis exists, but it must be acknowledged that there are exceptions which trouble the judgment not a little. While on the one hand, without suggestive symptoms, a laparotomy has disclosed an unexpected general peritonitis, on the other, with severe constitutional symptoms and apparently characteristic local signs, the peritonaeum has been found smooth. Relapsing Appendicitis.—Pepper, in 1883, called attention to the remarkable liability to relapse in perityphlitis. The patient gets well and all trace of induration and tenderness disappears; then in three or four months, or earlier, he again has fever, pain, and local signs of trouble. The attacks may recur for years. The cases which recover with the per- sistence of an induration or tumor mass are most prone to relapse. There are more severe cases in which the intervals between the attacks are very short, and the patient becomes a chronic invalid. After repeated attacks, however, recovery may be perfect. The frequency of recurrence is diffi- cult to estimate. Fitz places it at 44 per cent, Hawkins at 23-6 per cent. The recent statistics of operations given by Deaver, Murphy, and others indicate how common must be this type of the disease. Bull has collected 442 operations in chronic relapsing appendicitis by eighty surgeons, with a mortality of P8 per cent, but he thinks that 5 or 6 per cent would be a fairer estimate. The morbid,condition in this form is either a simple obliterative ap- pendicitis with or without adhesions, or an adherent, perhaps perforated, appendix with a small localized abscess circumscribed by dense fibroid tissue. Diagnosis.—Appendicitis is by far the most common inflammatory condition, not only in the csecal region, but in the abdomen generally in persons under thirty. The surgeons have taught us that, almost without exception, sudden pain in the right iliac fossa, with fever and localized tenderness, with or without tumor, means appendix disease. There are certain diseases of the abdominal organs characterized by pain which are apt to be confounded with appendicitis. Biliary colic, kidney colic, and the colicky pains at the menstrual period in women have in some cases to be most carefully considered. I have not met with an instance of either renal or hepatic calculus causing any difficulty in diagnosis, but a patient was 440 DISEASES OF THE DIGESTIVE SYSTEM. admitted to my wards a few months ago with a history of very sudden onset of severe pain three days previously in the right side of the abdo- men, and with an ill-defined tumor mass low in the right flank. Fortu- nately, she was transferred at once to the surgical side for operation, and the condition proved to be an acutely distended and inflamed gall-bladder almost on the point of perforating. Disease of the tubes and pelvic peritonitis may simulate appendicitis very closely, but the history and the local examination under ether should in most cases enable the practitioner to reach a diagnosis. I have seen several cases supposed to be recurring appendicitis which proved to be tubo-ovarian disease. The Dietl’s crises in floating kidney and the odd, anomalous, condi- tion of enteroptosis in neurotic patients may cause some little difficulty. Both intussusception and internal strangulation may present very similar symptoms, and if the patient is only seen at the latter stages, when there is diffuse peritonitis and great tympany, the features may be almost identical. Faecal vomiting, which is common in obstruction, is never seen in appendicitis, and in children the marked tenesmus and bloody stools are important signs of intussusception. It is not often difficult when the cases are seen early and when the history is clear, but mistakes have been made by surgeons of the first rank. Acute haemorrhagic pancreatitis may also produce symptoms very like those of appendicitis with general peritonitis. Typhoid fever has been mistaken for appendicitis. I was told of a case recently in one of the large hospitals of this country in which the fever, the presence of a tender induration in the right iliac fossa, seemed to indicate so clearly appendix disease that an operation was performed, but the induration was found to be the swollen ileum and adjacent glands. In a person who had had pre- vious appendicitis the diagnosis might be extremely difficult, as in a case mentioned by Da Costa. Late in the convalescence of typhoid fever symptoms of appendicitis may develop, due to the perforation of an un- healed ulcer. There is a well-marked appendicular hypochondriasis. Through the pernicious influence of the daily press, appendicitis has become a sort of fad, and the physician has often to deal with patients who have a sort of fixed idea that they have the disease. The Avorst cases of this class which I have seen have been in members of our profession, and I know of at least one instance in which a perfectly normal appendix Avas removed. The question really has its ludicrous side. A Avell-known physician in a Western city having one night a bellyache, and feeling convinced that his appendix had perforated, summoned a surgeon, who quickly removed the supposed offender! Hysteria may of course simulate appendicitis very closely, and it may require a very keen judgment to make a diagnosis. Mucous colitis with enteralgia in nervous women is sometimes mis- APPENDICITIS. 441 taken for appendicitis. In two instances of the kind I have prevented proposed operation, and I have heard of cases in which the appendix has been removed. Perinephritic and pericfecal abscess from perforation of nicer, either simple or cancerous, and circumscribed peritonitis in this region from other causes, can rarely be differentiated until an exploratory incision is made. Chronic obliterative cannot always be differentiated from perforative appendicitis, and in intensity of pain, severity of symptoms, and, in rare in- stances, even in the production of peritonitis, the two may be identical. Briefly stated, localized pain in the right iliac fossa, with or without induration or tumor, the existence of McBurney’s tender point, fever, furred tongue, vomiting, with constipation or diarrhoea, indicate appendi- citis. The occurrence of general peritonitis is suggested by increase and diffusion of the abdominal pain, tympanites (as a rule), marked aggrava- tion of the constitutional symptoms, particularly elevation of fever and increased rapidity of the pulse. Obliteration of hepatic dullness is rarely present, as the peritonaeum in these cases does not often contain gas. Prognosis.—While we cannot overestimate the gravity of certain forms of appendicitis, it is well to recognize that a large proportion of all cases recover. It is the element of uncertainty in individual cases which has given such an impetus to the surgical treatment of the disease. That an inflamed appendix may heal perfectly, even after perforation, is shown by instances (post mortem) of obliterated tubes firmly imbedded in old scar tissue. We have not had a full knowledge of the natural history of the disease. As J. William White remarked last year in his address at the College of Physicians, Philadelphia, “ We are in special need of re- liable medical statistics as to this point.” These have now been supplied in the admirable monograph of Hawkins (London, 1895), in which he has analyzed the cases at St. Thomas’s Hospital, 264 in number. The work is to be commended particularly to surgeons, since, while written from the standpoint of the physician and pathologist, the author is fully alive to the surgical aspects of the disease, and does ample justice to the work of American operators. His figures are as follows: (a) Peritonitis, limited to the right iliac fossa, and not proceeding to the formation of pus, 190 cases, no deaths; (b) peritonitis, similarly localized, but ending in the formation of pus (perityphlitic abscess), 38 cases, with 10 deaths; (c) gen- eral peritonitis, 36 cases, with 27 deaths. This gives a total mortality of 14 per cent. Fifty-nine of the 264 patients had had one or more previous attacks; 45 of these had simple “ perityphlitis,” and all recovered; of 7 with abscess formation, 3 died ; of 7 with general peritonitis, 3 died. These figures compare very favorably with those collected by Porter: Removal of appendix during the attack, 19-7 per cent mortality; incision and drainage of abscess, 18T8 per cent. The statistics of individual operators give a much more favorable showing, and we may say that in acute cases 442 DISEASES OF THE DIGESTIVE SYSTEM. without generalized peritonitis, and in the localized appendicular abscess, the percentage of deaths in the hands of good surgeons is now very much lower. Dr. Bloodgood has kindly furnished me the details of the cases oper- ated upon in the wards of my colleague, Ilalsted, in the surgical depart- ment of the Johns Hopkins Hospital to June 1, 1895. Very many of these cases were admitted to my wards and transferred at once. Of 53 cases, 10 were admitted with general peritonitis, confirmed by operation or autopsy. Two only of these, moribund when admitted, were not operated upon. In all there was a perforated and gangrenous appen- dix. There were operations upon 17 cases of peri-appendicular abscess; 1 death followed from broncho-pneumonia in a patient with chronic nephritis and amyloid disease. Of 14 cases of acute appendicitis operated upon there was 1 death from wide-spread acute pneumonia on the second day. Of 12 cases of the chronic relapsing form operated on between the attacks there were no deaths. Treatment.—So impressed am I by the fact that we physicians lose lives by temporizing with certain cases of appendicitis, that I prefer, in hospital work, to have the suspected cases admitted directly to the surgical side. The general practitioner does well to remember whether his lean- ings be toward the conservative or the radical methods of treatment—that the surgeon is often called too late, never too early. There is no medicinal treatment of appendicitis. There are remedies which will allay the pain, but there are none capable in any way of con- trolling the course of the disease. Rest in bed, a light diet, measures directed to allay the vomiting—upon these all are agreed. There are two points on which the profession is very much divided, namely, the use of opium and of saline purges. The practice of giving opium in some form in appendicitis and peritonitis is almost universal with physicians. Sur- geons, on the other hand, almost unanimously condemn the practice, as obscuring the clinical picture and tending to give a false sense of security; and since they control the situation, I think we should—deferring in this matter to their judgment—give less opium, and trust to the persistent use of ice locally to relieve the pain. The use of saline purges early in the disease, which is advocated by some surgeons, is, I believe, a most injurious practice. In any given case the pain and tenderness at the outset may mean perforation of the appen- dix, and the life of the patient may depend upon whether a limiting adhe- sive inflammation is set up. Under these circumstances, anything that will stimulate active peristalsis of the bowel wall throughout its extent is certainly contra-indicated. Surgery, too, has taught us that the caecum is rarely, if ever, filled with hardened faeces, so that it is really on theoretical grounds that a saline is urged to clear this part of the bowel. I am glad to see, too, that some surgeons of the largest experience, as McBurney, state that they never employ purgatives. They are also contra-indicated,! INTESTINAL OBSTRUCTION. 443 think, when there are signs of the formation of a local abscess. If useful at all, it is when general peritonitis has been established, but then, as a rule, the mischief is done, and purgatives cannot influence the result. Operation is indicated in all cases of acute inflammatory trouble in the caecal region, whether tumor is present or not, when the general symptoms are severe, and when by the third day the features of the case point to a progressive lesio?i. The mortality from early operation under these cir- cumstances is very slight. In recurring appendicitis, when the attacks are of such severity and frequency as seriously to interrupt the patient’s occupation, the figures already given show how slight the mortality is in the hands of capable operators. Unfortunately, in hospital practice too many cases are brought in with general peritonitis—a condition in which operation is rarely suc- cessful. III. INTESTINAL OBSTRUCTION. Intestinal obstruction may be caused by strangulation, intussusception, twists and knots, strictures and tumors, and by abnormal contents. Etiology and Pathology.—(a) Strangulation.—This is the most frequent cause of acute obstruction, and occurred in thirty-four per cent of the 295 cases analyzed by Fitz,* and in thirty-five per cent of the 1,134 cases of Leichtenstern.f Of the 101 cases of strangulation in Fitz’s table, which has the special value of having been carefully selected from the literature since 1880, the following were the causes: Adhesions, 63 ; vitel- line remains, 21; adherent appendix, 6 ; mesenteric and omental slits, 6 ; peritoneal pouches and openings, 3; adherent tube, 1; peduncular tu- mor, 1. The bands and adhesions result, in a majority of cases, from for- mer peritonitis. A number of instances have been reported following operations upon the pelvic organs in women. The strangulation may be recent and due to adhesion of the bowel to the abdominal wound or a coil may be caught between the pedicle of a tumor and the pelvic wall. Such cases are only too common. Late occlusion after recovery from the operation is due to bands and adhesions. The vitelline remains are represented by Meckel’s diverticulum, which forms a finger-like projection from the ileum, usually within eighteen inches of the ileo-caecal valve. It is a remnant of the omphalo-mesenteric duct, through which, in the early embryo, the intestine communicated with the yolk-sac. The end, though commonly free, may be attached to the abdominal wTall near the navel, or to the mesentery, and a ring is thus formed through which the gut may pass. Seventy per cent of the cases of obstruction from strangulation occur * Transactions of the Congress of American Physicians and Surgeons, vol. i, 1889. The percentages of his tables are used throughout this section, f Yon Ziemssen’s Encyclopaedia of Practical Medicine. 444 DISEASES OF THE DIGESTIVE SYSTEM. in males; forty per cent of all tlie cases occur between the ages of fifteefi and thirty years. In ninety per cent of the cases of obstruction from these causes the site of the trouble is in the small bowel; the position of the strangulated portion was in the right iliac fossa in sixty-seven per cent of the cases, and in the lower abdomen in eighty-three per cent. (b) Intussusception.—In this condition one portion of the intestine slips into an adjacent portion, forming an invagination or intussusception. The two portions make a cylindrical tumor, which varies in length from a half-inch to a foot or more. The condition is always a descending intus- susception, and as the process proceeds, the middle and inner layers in- crease at the expense of the outer layer. An intussusception consists of three layers of boAvel: the outermost, known as the intussuscipiens, or re- ceiving layer; a middle or returning layer; and the innermost or entering layer. The student can obtain a clear idea of the arrangement by making the end of a glove-finger pass into the lower portion. The actual condi- tion can be very clearly studied in the post-mortem invaginations which are so common in the small bowel of children. In the statistics of Fitz, 93 of 295 cases of acute intestinal obstruction were due to this cause. Of these, 52 were in males and 27 in females. The cases are most common in early life, thirty-four per cent under one year and fifty-six per cent under the tenth year. Fo definite causes could be assigned in 42 of the cases; in the others diarrhoea or habitual constipation had existed. The site of the invagination varies. We may recognize (1) an ileo-ccecal, when the ileo-caecal valve descends into the colon. There are cases in which this is so extensive that the valve lias been felt per rectum. This form occurred in seventy-five per cent of the cases.; In the ileo-colic the lower part of the ileum passes through the ileo-cfecal valve. (2) The ileal, in which the ileum is alone involved. (3) The colic, in which it is con- fined to the large intestine. And (4) colico-rectal, in which the colon and rectum are involved. Irregular peristalsis is the essential cause of intussusception. Xotli- nagel found in the localized peristalsis caused by the faradic current that it was not the descent of one portion into the other, but the drawing up of the receiving layer by contraction of the longitudinal coat. Invagina- tion may follow any limited, sudden, and severe peristalsis. In the post-mortem examination, in a case of death from intussuscep- tion, the condition is very characteristic. Peritonitis may be present or an acute injection of the serous membrane. When death occurs early, as it may do from shock, there is little to be seen. The portion of bowel affected is large and thick, and forms an elongated tumor with a curved outline. The parts are swollen and congested, owing to the constriction of the mesentery between the layers. The entire mass may be of a deep livid-red color. If very recent there is only congestion, and perhaps a slight layer of lymph, and the intussusception can be reduced, but when it INTESTINAL OBSTRUCTION. 445 has' lasted for a few days, lymph is thrown out, the layers are glued to- gether, and the entering portion of the gut cannot be withdrawn. The anatomical condition accounts for the presence of the tumor, which exists in two thirds of all cases; and the engorgement, which results from the compression of the tnesenteric vessels, explains the frequent occurrence of blood in the discharges, which has so important a diagnostic value. If the patient survives, necrosis and sloughing of the invaginated portion may occur, and if union has taken place between the middle and outer layer, the calibre of the gut may be restored and a cure in this way ef- fected. Many cases of the kind are on record. In the Museum of the Medical Faculty of McGill University are 17 inches of small intestine,- which were passed by a lad who had had symptoms of internal strangula- tion, and who made a complete recovery. . (c) Twists and Knots.—Volvulus or twist occurred in 42 of the 295 cases. Sixty-eight per cent were in males. It is most frequent between the ages of thirty and forty. In the great majority of all cases the twist is axial and associated with an unusually long mesentery. In fifty per eent of the cases it was in the sigmoid flexure. The next most common situation is about the 'caecum, which may be twisted upon its axis or bent upon itself. As a rule, in volvulus the loop of bowel is simply twisted upon its long axis, and the portions at the end of the loop cross each other and so cause the strangulation. It occasionally happens that one portion of the bowel is twisted about another. (d) Strictures and Tumors.—These are very much less important causes of acute obstruction, as may be judged by the fact that there are only 15 instances out of the 295 cases, in 14 of which the obstruction oc- curred in the large intestine. On the other hand, they are common causes of chronic obstruction. The obstruction may result from : (1) Congenital stricture. These are exceedingly rare. Much more commonly the condition is that of com- plete occlusion, either forming the imperforate anus or the congenital defect by which the duodenum is not united to the pylorus. (2) Simple cicatricial stenosis, which results from ulceration, tuberculous or syphi- litic, more rarely from dysentery, and most rarely of all from typhoid ulceration. (3) New groioths. The malignant strictures are due chiefly to cylindrical epithelioma, which forms an annular tumor, most com- monly met with in the large bowel, about the sigmoid flexure, or the descending colon. Of benign growths, papillomata, adenomata, lipomata, and fibromata occasionally induce obstruction. (4) Compression and trac- tion. Tumors of neighboring organs, particularly of the pelvic viscera, may cause obstruction by adhesion and traction; more rarely, a coil, such as the sigmoid flexure, filled with fasces, compresses and obstructs a neighboring coil. In the healing of tuberculous peritonitis the contrac- tion of the thick exudate may cause compression and narrowing of the coils. DISEASES OP THE DIGESTIVE SYSTEM. (e) Abnormal Contents.—Foreign bodies, such as fruit stones, coins, joins, needles, or false teeth, are occasionally swallowed accidentally, or by lunatics on purpose. Round worms may become rolled into a tangled mass and cause obstruction. In reality, however, the majority of foreign bodies, such as coins, buttons, and pins, swallowed by children, cause no inconvenience whatever, but in a day or two are found in the stools. Occa- sionally such a foreign body as a pin will pass through the oesophagus and will be found lodged in some adjacent organ, as in the heart (Peabody), or a barley ear may reach the liver (Dock). Medicines, such as magnesia or bismuth, have been known to accumu- late in the bowels and produce obstruction, but in the great majority of the cases the condition is caused by faeces, gall-stones, or enteroliths. Of 44 cases, in 23 the obstruction was by gall-stones, in 19 by faeces, and in 2 by enteroliths. Obstruction by faeces may happen at any period of life. As mentioned when speaking of dilatation of the colon, it may occur in young children and persist for weeks. In faecal accumulation the large bowel may reach an enormous size and the contents become very hard. The retained masses may be channeled, and small quantities of faecal mat- ter are passed until a mass too large enters the lumen and causes obstruc- tion. There may be very few symptoms, as the condition may be borne for weeks or even for months. Obstruction by gall-stones is not very infrequent, as may be gathered from the fact that twenty-three cases were reported in the literature in eight years. Eighteen of these were in women and five in men. In six sevenths of the cases it occurred after the fiftieth year. The obstruction is usually in the ileo-caecal region, but it may be in the duodenum. These large solitary gall-stones ulcerate through the gall-bladder, usually into the small intestine, occasionally into the colon. In the latter case they rarely cause obstruction. Courvoisier has collected one hundred and thirty- one cases in the literature. Enteroliths may be formed of masses of hair, more commonly of the phosphates of lime and magnesia, with a nucleus formed of a foreign body or of hardened faeces. Nearly every museum possesses specimens of this kind. They are not so common in men as in ruminants, and, as indicated in Fitz’s statistics, are very rare causes of obstruction. Symptoms.—(a) Acute Obstruction.—Constipation, pain in the abdo- men, and vomiting are the three important symptoms. Pain sets in early and may come on abruptly while the patient is walking or, more com- monly, during the performance of some action. It is at first colicky in character, but subsequently it becomes continuous and very intense. Vom- iting follows quickly and is a constant and most distressing symptom. At first the contents of the stomach are voided, and then greenish, bile- stained material, and soon, in cases of acute and permanent obstruction, the material vomited is a brownish-black liquid, with a distinctly faecal odor. This sequence of gastric, bilious, and, finally, stercoraceous vomit- INTESTINAL OBSTRUCTION. 447 ing is perhaps the most important diagnostic feature of-acute obstruction. The constipation may be absolute, without the discharge of either faeces or gas. Very often the contents of the bowel below the stricture are dis- charged. Distention of the abdomen usually occurs, and when the large bowel is involved it is extreme. On the other hand, if the obstruction is high up in the small intestine, there may be very slight tympany. At first the'abdomen is not painful, but subsequently it may become acutely tender. The constitutional symptoms from the outset are severe. The face is pallid and anxious, and finally collapse symptoms supervene. The eyes become sunken, the features pinched, and the skin is covered with a cold, clammy sweat. The pulse becomes rapid and feeble. There may be no fever; the axillary temperature is often subnormal. The tongue is dry and parched and the thirst is incessant. The urine is high-colored, scanty, and there may be suppression, particularly when the obstruction is high up in the bowel. This is probably due to the constant vomiting and the small amount of liquid which is absorbed. The case terminates as a rule in from three to six days. In some instances the patient dies from shock or sinks into coma. (b) Symptoms of Chronic Obstruction.—When due to fsecal impaction, there is a history of long-standing constipation. There may have been discharge of mucus, or in some instances the fsecal masses have been chan- neled, and so have allowed the contents of the upper portion of the bowel to pass through. In elderly persons this is not infrequent; but examination, either per rectum or externally, in the course of the colon, will reveal the presence of hard scybalous masses. There may be retention of faeces for weeks without exciting serious symptoms. In other instances there are vomiting, pain in the abdomen, gradual distention, and finally the ejecta become faecal. The hardened masses may excite an intense colitis or even peritonitis. In stricture, whether cicatricial or cancerous, the symptoms of obstruc- tion are very diverse. Constipation gradually comes on, is extremely varia- ble, and it may be months or even years before there is complete obstruc- tion. There are transient attacks, in which from some cause the faeces accumulate above the stricture, the intestine becomes greatly distended, and in the swollen abdomen the coils can be seen in active peristalsis. In such attacks there may be vomiting, but it is very rarely of a faecal char- acter. In the majority of these cases the general health is seriously im- paired ; the patient gradually becomes anaemic and emaciated, and finally, in an attack in which the obstruction is complete, death occurs with all the features of acute occlusion or the case may be prolonged for ten or twelve days. Diagnosis.—(a) The Situation of the Obstruction.—Hernia must be excluded, which is by no means always easy, as fatal obstruction may occur from the involvement of a very limited portion of the gut in the 448 DISEASES OF TIIE DIGESTIVE SYSTEM. external ring or in the obturator foramen. Mistakes from both of these causes have come under my observation ; they were cases in which it was impossible to make a diagnosis other than acute obstruction. Timely operation would have saved both lives. A thorough rectal and vaginal examination should be made, which will give important information as to the condition of the pelvic and rectal contents, particularly in cases of intussusception, in which the descending bowel can sometimes be felt. In cases of obstruction high up the empty coils sink into the pelvis and can there be detected. Kectal exploration with the entife hand is of doubtful value. In the inspection of the abdomen there are important indications, as the special prominence in certain regions, the occurrence of definite, well-defined masses, and the presence of hypertrophied coils in active peristalsis. John Wyllie has recently called attention to the great value in diagnosis of the “ patterns of abdominal tumidity.” * In obstruction of the lower end of the large intestine not only may the horseshoe of the colon stand out plainly, when the bowel is in rigid spasm, but even the pouches of the gut may be seen. When the caecum or lower end of the ileum is obstructed the tumidity is in the lower central region, and during spasm the coils of the small bowel may stand out prominently, one above the other, either obliquely or transversely placed—the so-called “ ladder pattern.” In obstruction in the duodenum or jejunum there may only be slight distention of the upper part of the abdomen, associated usually with rapid collapse and anuria. In the ileum and caecum the distention is more in the central portion of the abdomen; the vomiting is distinctly faecal and occurs early. In obstruction of the colon, tympanites is much more extensive and general. Tenesmus is more common, with the passage of mucus and blood. The course is not so quick, the collapse does not supervene so rapidly, and the urinary secretion is not so much reduced. In obstruction from stricture or tumor the situation can in some cases be accurately localized, but in others it is very difficult. Digital examina- tion of the rectum should first be made. The rectal tube may then be passed, but it is impossible to get beyond the sigmoid flexure. In the use of the rigid tube there is danger of perforation of the bowel in the neigh- borhood of a stricture. The quantity of fluid which can be passed into the large intestine should be estimated. The capacity of the large bowel is about six quarts. The safe limits of pressure have been determined to be under ten feet in an infant and twenty feet in an adult. To thorough- ly irrigate the bowel the patient should be chloroformed and should lie on the back or on the side—best on the back, with the hips elevated. Treves suggests that the cascal region should be auscultated during the passage of the fluid. For diagnostic purposes the rectum may be inflated, either by the bellows or by the use of bicarbonate of soda and tartaric acid. In cer- * Edinburgh Hospital Reports, vol. ii. INTESTINAL OBSTRUCTION. 449 tain cases these measures give important indications as to the situation of the obstruction in the large bowel. (b) Nature of the Obstruction.—This is often difficult, not infrequent- ly impossible, to determine. Strangulation is not common in very early life. In many instances there have been previous attacks of abdominal pain, or there are etiological factors which give a clew, such as old peri- tonitis or operation on the pelvic viscera. Neither the onset nor the char- acter of the pain gives us any information. In rare instances nausea and vomiting may be absent. The vomiting usually becomes faecal from the third to the fifth day. A tumor is not common in strangulation, and was present in only one fifth of the cases. Fever is not of diagnostic value. Intussusception is an affection of childhood, and is of all forms of in- ternal obstruction the one most readily diagnosed. The presence of tumor, bloody stools, and tenesmus are the important factors. The tumor is usually sausage-shaped and felt in the region of the transverse colon. It existed in 66 of 93 cases. It was present on the first day in more than one third of the cases, on the second day in more than one fourth, and on the third day in more than one fifth. Blood in the stools occurs in at least three fifths of the cases, either spontaneously or following the use of an enema. The blood may be mixed with mucus. Tenesmus is present in one third of the cases. Faecal vomiting is not very common and was pres- ent in only 12 of the 93 instances. Abdominal tympany is a symptom of slight importance, occurring in only one third of the cases. Volvulus can rarely be diagnosed. The frequency with which it in- volves the sigmoid flexure is to-be borne in mind. The passage of a flex- ible tube or injecting fluids might in these cases give valuable indications. An absolute diagnosis can probably be made only by an abdominal section. In fcecal obstruction the condition is usually clear, as the faeces can be felt per rectum and also in the distended colon. Faecal vomiting, tym- pany, abdominal pain, nausea, and vomiting are late and are not so con- stant. In obstruction by gall-stone a few of the cases gave a previous his- tory of gall-stone colic. Jaundice was present in only two of the twenty- three cases. Pain and vomiting, as a rule, occur early and are severe, and faecal vomiting is present in two thirds of the cases. A tumor is rarely evident. (c) Diagnosis from other Conditions.—Acute enteritis with great re- laxation of the intestinal coils, vomiting, and pain may be mistaken for obstruction. In an autopsy on a case of this kind the small and large bowels were intensely inflamed, relaxed, sodden, and enormously distended. The symptoms were those of acute obstruction, but the intestine was free from duodenum to rectum. Of late years many instances have been re- ported in which peritonitis following disease of the appendix has been mistaken for acute obstruction. The intense vomiting, the general tyrm pany and abdominal tenderness, and in some instances the suddenness of 450 DISEASES OF THE DIGESTIVE SYSTEM. the onset are very deceptive, and in two cases which have come under my notice the symptoms pointed very strongly to internal strangulation. In appendix disease the temperature is more frequently elevated, the vomit- ing is never faecal, and in many cases there is a history of previous attacks in the caecal region. Acute haemorrhagic pancreatitis may produce symp- toms which simulate closely intestinal obstruction. A boy was admitted to the Johns Hopkins Hospital with a history of obstinate vomiting, in- tense abdominal pain, gradually increasing tympany, and no passage for several days. His condition seemed serious and he was transferred at once to the surgical wards. At the operation the coils were found uniformly distended and covered in places with the thinnest film of lymph. No obstruction existed, but there was a tumor-like mass surrounding the pan- creas, firm, hard, and deeply infiltrated with blood. The patient improved after the operation and recovered completely. Treatment.—Purgatives should not be given. For the pain hypo- dermics of morphia are indicated. To allay the distressing vomiting, the stomach should be washed out. Not only is this directly beneficial, but Kiissmaul claims that the abdominal distention is relieved, the pressure in the bowel above the seat of obstruction is lessened, and the violent peri- stalsis is diminished. It may be practised three or four times a day, and in some instances has proved beneficial; in others curative. Thorough irrigation of the large bowel with injections should be practised, the fluid being allowed to flow in from a siphon syringe, and the amount carefully estimated. Jonathan Hutchinson recommends that the patient be placed under an ansesthetic, the abdomen thoroughly kneaded, and a copious enema given while in the inverted position. Then, with the aid of three or four strong men, the patient is to be thoroughly shaken, first with the abdomen held downward, and subsequently in the inverted position. Inflation may also be tried, by forcing the air into the rectum with the bellows or with a Davidson’s syringe. It is a measure not without risk, as instances of rupture of the bowel have been reported. Fitz’s figures show that in the first eight years of the last decade there were thirty-three cases of recovery after injection or inflation in cases of certain or probable intussusception, and eleven deaths. In cases of acute obstruction, if these means do not prove successful by the third day, surgical measures should be resorted to, and when the obstruction seems persistent and the condi- tion serious, laparotomy should be performed at once. For the tympanites turpentine stupes and hot applications may be applied; if extreme, the bowel may be punctured with a small aspirator needle. In cases of chronic obstruction the diet must be carefully regu- lated, and opium and belladonna are useful for the paroxysmal pains. Enemata should be employed, and if the obstruction becomes complete, resort must be had to surgical measures. CONSTIPATION. 451 IV. CONSTIPATION (Costiveness). Definition.—Retention of faeces from any cause. Constipation in Adults.—The causes are varied and may be classed as general and local. General Causes.—(a) Constitutional peculiarities : Torpidity of the bowels is often a family complaint and is found more often in dark than in fair persons. (£) Sedentary habits, particularly in persons who eat too much and neglect the calls of nature, (c) Certain diseases, such as anae- mia, neurasthenia and hysteria, chronic affections of the liver, stomach, and intestines, and the acute fevers. Under this heading may appropri- ately be placed that most injurious of all habits, drug-taking. (d) Either a coarse diet, which leaves too much residue, or a diet which leaves too little, may be a cause of costiveness. Local Causes.—Weakness of the abdominal muscles in obesity or from overdistention in repeated pregnancies. Atony of the large bowel from chronic disease of the mucosa; the presence of tumors, physiological or pathological, pressing upon the bowel; enteritis; foreign bodies, large masses of scybala, and strictures of all kinds. An important local cause is atony of tbe colon, particularly of the muscles of the sigmoid flexure by which the faeces are propelled into the rectum. By far the most obstinate form is that associated with a contracted state of the bowel, which is sometimes spoken of as spasmodic constipation. This may be met with in three conditions : First, as a sequence of chronic dysentery or ulcerative colitis; second, in protracted cases of hysteria and neurasthenia in women, particularly in association with uterine disease; and, thirdly, in very old persons often without any definite cause. It may be that the sigmoid flexure and lower colon are in a condition of contraction and spasm, while the transverse and ascending parts are in a state of atony and dilatation. The most characteristic sign of this variety is the presence of hard, globu- lar masses, or more rarely small and sausage-like faeces. Symptoms.—The most persistent constipation for weeks or even months may exist with fair health. All kinds of evils have been attrib- uted to poisoning by the resorption of noxious matters from the retained faeces—copraemia—but it is not likely that this takes place to any extent. Chlorosis, which Sir Andrew Clark attributes to faecal poisoning, is not always associated with constipation, and if due to this cause should be in men, women, and children the most common of all disorders. Debility, lassitude, and mental depression are frequent symptoms in constipation, particularly in persons of a nervous temperament. Headache, loss of ap- petite, and a furred tongue may also occur. Individuals differ extraor- dinarily in this matter : one feels wretched all day without the accustomed evacuation; another is comfortable all'the week except on the day on which by purge or enema the bowels are relieved. When persistent, the accumulation of faeces leads to unpleasant, some- 452 DISEASES OF TIIE DIGESTIVE SYSTEM. times serious symptoms, such as piles, ulceration of the colon, distention of the sacculi, perforation, enteritis, and occlusion. In women, pressure may cause pain at the time of menstruation and a sensation of fulness and distention in the pelvic organs. Neuralgia of the sacral nerves may be caused by an overloaded sigmoid flexure. The faeces collect chiefly in the colon. Even in extreme grades of constipation it is rare to find dry faeces in the caecum. The faeces may form large tumors at the hepatic or splenic flexures, or a sausage-like, doughy mass above the navel, or an irregular lumpy tumor in the left inguinal region. In old persons the sacculi of the colon become distended and the scybala may remain in them and undergo calcification, forming enteroliths. In cases with prolonged retention the faecal masses become channelled and diarrhoea may occur for days before the true condition is discovered by rectal or external examination. In women who have been habitually constipated, attacks of diarrhoea with nausea and vomiting should excite suspicion and lead to a thorough examination of the large bowel. Fever may occur in tnese cases, and Meigs lias reported an instance in which the condition simulated typhoid fever. Constipation in infants is a common and troublesome disorder. The causes are congenital, dietetic, and local. There are instances in which the child is constipated from birth and may not have a natural movement for years and yet thrive and develop. An instance of the kind was in my ward recently in which a baby of seven months had never had a movement without preliminary injections. The abdomen became swollen every day, but subsided after an injection and the passage of a long catheter. No stricture could be felt. There are cases of enormous dilatation of the large bowel with persistent constipation. The condition appears sometimes to be a congenital defect. In some of these patients there may be constrict- ing bands, or, as in a case of Cheever’s, a congenital stricture. Dietetic causes are more common. In sucklings it often arises from an unnatural dryness of the small residue which passes into the colon, and it may be very difficult to decide whether the fault is in the mother’s milk or in the digestion of the child. Most probably it is the latter, as some babies may be persistently costive on natural or artificial foods. Defi- ciency of fat in the milk is believed by some writers to be the cause. In older children it is of the greatest importance that regular habits should be enjoined. Carelessness on the part of the mother in this matter often lays the foundation of troublesome constipation in after life. Impairment of the contractibility of the intestinal wall in consequence of inflammation, disturbance in the normal intestinal secretions, and mechanical obstruc- tion by tumors, twists, and intussusception are the chief local causes. Treatment.—Much may be done by systematic habits, particularly in the young. The desire to go to stool should always be granted. Exer- cise in moderation is helpful. In stout persons and in women with pend- ulous abdomens the muscles should have the support of a bandage. CONSTIPATION. 453 Friction or regularly applied massage is invaluable in the more chronic cases. A good substitute is a metal ball weighing from four to six pounds, which may be rolled over the abdomen every morning for five or ten min- utes. The diet should be light, with plenty of fruit and vegetables, par- ticularly salads and tomatoes. Oatmeal is usually laxative, though not to all; brown bread is better than that made from fine white flour. Of liquids, water and the aerated mineral waters may be taken freely. A tumblerful of cold water on rising, taken slowly, is efficacious in many cases. A glass of hot water at night may also be tried alone. A pipe or a cigar after breakfast is with many men an infallible remedy. When the condition is not very obstinate it is well to try to relieve it by hygienic and dietetic measures. If drugs must be used they should be the milder saline laxatives or the compound liquorice powder. Enemata are often necessary, and it is much preferable to employ them early than to constantly use purgative pills. Glycerine either in the form of sup- pository or as a small injection is very valuable. Half a drachm of boric acid placed within the rectum is sometimes efficacious. The injections of tepid water, with or without soap, may be used for a prolonged period with good effect and without damage. The patient should be in the dorsal position with the hips elevated, and it is best to let the fluid flow in slowly from a fountain syringe. The usual remedies employed are often useless in the constipation associated with contracted bowel. A very satisfactory measure is the olive-oil injection as recommended by Kussmaul. The patient lies on the back with the hips elevated, and with a cannula and tube from fifteen to twenty ounces of pure oil are allowed to flow slowly (or are injected) into the bowel. The operation should take at least fifteen minutes. This may be repeated every day until the intestine is cleared, and subsequently a smaller injection every few days will suffice. There are various drugs which are of special service, particularly the combination of ipecacuanha, nux vomica, or belladonna, with aloes, rhu- barb, colocynth, or podophyllin. Meigs recommends particularly the combination of extract of belladonna (gr. extract of nux vomica (gr. £), and extract of colocynth (gr. ij), one pill to be taken three times a day. In anaemia and chlorosis, a sulphur confection taken in the morn- ing, and a pill of iron, rhubarb, and aloes throughout the day, are very serviceable. In children the indications should be met, as far as possible, by hygienic and dietetic measures. In the constipation of sucklings a change in the diet of the mother may be tried, or from one to three teaspoonfuls of cream may be given before each nursing. In artificially fed children the top milk with the cream should be used. Drinking of water, barley water, or oatmeal water will sometimes obviate the difficulty. If laxatives are required, simple syrup, manna, or olive oil may be sufficient. The conical piece of soap, so often seen in nurseries, is sometimes efficacious. 454 DISEASES OF THE DIGESTIVE SYSTEM. Massage along the colon may be tried. Small injections of cold water may be used. Large injections should be avoided, if possible. If it is necessary to give a laxative by the mouth, castor oil or the fluid magnesia is the best. If there are signs of gastro-intestinal irritation, rhubarb and soda or gray powder may be given. In older children the diet should be carefully regulated. V. MISCELLANEOUS AFFECTIONS. Dilatation of the Colon.—This may be general, or localized to the sig- moid flexure. It occurs not infrequently as a transient condition, and in many cases it has an important influence, inasmuch as the distention may be ex- treme, pushing up the diaphragm and seriously impairing the action of the heart and lungs. H. Fenwick has called attention to this as occasion- ally a cause of sudden heart-failure. Dilatation of the sigmoid flexure occurs particularly when this portion of the bowel is congenitally very long. In such cases the bowel may be so distended that it occupies the greater part of the abdomen, pushing up the liver and the diaphragm. An acute condition is sometimes caused by a twist in the mesocolon. There is a chronic form in which the gut reaches an enormous size. The coats may be hypertrophied without evidence of any special organic change in the mucosa. The most remarkable instance has been reported by Formad. The patient, known as the “ balloon-man,” aged twenty- three at the time of his death, had had a distended abdomen from infancy. Post mortem the colon was found as large as that of an ox, the circum- ference ranging from fifteen to thirty inches. The weight with the con- tents was forty-seven pounds. Oases are not uncommon in children. I have had three well-marked instances under my care (Archives of Pediatrics, 1893). Affections of the Mesentery.—There are various diseases of the struc- tures embraced in the mesentery of more or less importance. (1) Haemorrhage (hcematoma).—Instances in which the bleeding is con- fined to the mesenteric tissues are rare; more commonly the condition is associated with liasmorrhagic infiltration of the pancreas and with retro- peritoneal hasmorrhage. It occurs in rupture of aneurisms, either of the abdominal aorta or of the superior mesenteric artery, in malignant forms of the infectious fevers, as small-pox, and, lastly, in individuals in whom no predisposing conditions exist. In 1887, at the Philadelphia Hospital, there was a patient in the ward of my colleague, Bruen, who had ob- scure abdominal symptoms for several days with great pain and prostra- tion. I found at the post mortem the greater portion of the mesentery and the retro-peritoneal tissues infiltrated with large blood-clots. There CONSTIPATION. 455 was no disease of the aorta or of the branches of the cceliac axis or of the mesenteric vessels. Isambard Owen has reported a case of sudden death in a woman aged sixty-seven from haemorrhage in the transverse meso- colon. (2) Affections of the Mesenteric Arteries.—(a) Aneurism (see page 718). (b) Embolism and Thrombosis—Infarction of the Bowel.—When the mesenteric vessels are blocked by emboli or thrombi the condition of in- farction follows in the territory supplied. Probably the occlusion of small vessels does not produce any symptoms, and the circulation may be re- established. If the superior mesenteric artery is blocked, a serious and fatal condition follows. Three instances have come under my observation. In one, a woman aged fifty-five was seized with nausea and vomiting, which persisted for more than a week. There was pain in the abdomen, tympanites, and toward the close the vomiting was incessant and faecal. The autopsy showed great congestion, with swelling and infiltration of the jejunum and ileum. The superior mesenteric artery was blocked at its orifice by a firm thrombus. In the second case, a woman aged seventy-five was seized with severe abdominal pain and frequent vomiting. At first there was diarrhoea; subsequently the symptoms pointed to obstruction, with great distention of the abdomen. The post mortem showed the small bowel, with the exception of the first foot of the jejunum and the last six inches of the ileum, greatly distended and deeply infiltrated with blood* The mesentery was also congested and infiltrated. The superior mesenteric artery contained a firm brownish-yellow clot. There were many recent warty vegetations on the mitral valve. In the third case, a man aged forty was suddenly seized with intense pain in the ab- domen, became faint, fell to the ground, and vomited. For a week he had persistent vomiting, severe diarrhoea, tympanites, and great pain in the abdomen. The stools were thin and at times blood-tinged. The autopsy showed an aneurism involving the aorta at the diaphragm. The superior mesenteric artery, half an inch from its origin on the sac, was blocked by a portion of the fibrinous clot of the aneurism. Watson has analyzed the symptoms in 27 cases ; in 18 there was pain, usually colicky and violent; diarrhoea occurred in 14; vomiting in 14; and abdominal distention in 12. In a majority of the cases the heart or the abdominal aorta was diseased. In one sixth of the cases the lesion was limited enough to have permitted the successful resection of the bowel. J. W. Elliot has operated upon two cases of infarction of the bowel, in one of which (thrombosis of the mesenteric veins) he successfully resected forty- eight inches. In the horse, infarction of the intestine is extremely com- mon in connection with the verminous' aneurisms of the mesenteric arteries, and is the usual cause of colic in this animal. (3) Diseases of the Mesenteric Veins.—Dilatation and sclerosis occur in cirrhosis of the liver. In instances of prolonged obstruction there may DISEASES OF THE DIGESTIVE SYSTEM. be large secular dilatations with calcification of the intima, as in a case of obliteration of the vena portas described by me. Suppuration of the mesenteric veins is not rare, and occurs usually in connection with pyle- phlebitis. The mesentery may be much swollen and is like a bag of pus, and it is only on careful dissection that one sees that the pus is really within channels representing extremely dilated mesenteric veins. Two of the three cases I have seen were in connection with local appendix abscess. (4) Disorders of the Chyle Vessels.—Varicose, cavernous, and cystic chylangiomata are met with in the mucosa and submucosa of the small intestine, occasionally of the stomach. Extravasation of chyle into the mesenteric tissues is sometimes seen. Chylous cysts are found. I saw one the size of an egg at the root of the mesentery. Bramann records a case in a man aged sixty-three in which a cyst of this kind the size of a child’s head was healed by operation. There is an instance on record of a congenital malformation of the thoracic duct in which the receptaculum formed a flattened cyst which discharged into the peritonaeum, and a chylous ascitic fluid was withdrawn on several occasions. (5) Cysts of the Mesentery.—Much attention has been directed of late years to the occurrence of mesenteric cysts, and the literature which is fully given by Delmez (Paris, Thesis, 1891) is already extensive. They may be either dermoid, hydatid, serous, sanguinous, or chylous. They occur at any portion of the mesentery, and range from a few inches in diameter to large masses occupying the entire abdomen. They are fre- quently adherent to the neighboring organs, to the liver, spleen, uterus, and sigmoid flexure. The symptoms usually are those of a progressively enlarging tumor in the abdomen. ■ Sometimes a mass develops rapidly, particularly in the haemorrhagic forms. Colic and constipation are present in some cases. The general health, as a rule, is well maintained in spite of the progres- sive enlargement of the abdomen, which is most prominent in the um- bilical region. Mesenteric cysts may persist for many years, even ten or twenty. The diagnosis is extremely uncertain, and no single feature is in any way distinctive. Augagneur gives three important signs : the great mo- bility, the situation in the middle line, and the zone of tympany in front of the tumor. Of these, the second is the only one which is at all con- stant, as when the tumors are large the mobility disappears, and at this stage the intestines, too, are pushed to one side. It is most frequently mis- taken for ovarian tumor. Movable kidney, hydronephrosis, and cysts of the omentum have also been mistaken. In certain instances puncture may be made for diagnostic purposes, but it is better to advise laparotomy for the purpose of drainage, or, if possible, enucleation may be practiced. JAUNDICE. 457 VIII. DISEASES OF THE LIVER. I. JAUNDICE (Icterus). 1. Jaundice as a Symptom.—Cases with icterus may be divided into two great groups: Those in which there is obstruction, either in the small- er or in the larger ducts—the hepatogenous form ; cases in which the jaun- dice is due to suppression of the function of the liver-cells, as in the wide- spread necrosis of acute yellow atrophy, and those in which an excess of the chromatogenous material, as in malaria, pernicious angemia, and cer- tain fevers, in which the liver function cannot keep pace with the blood destruction (haemolysis)—hcematogenous or non-obstructive jaundice. The following classification of the causes of hepatogenous jaundice is arranged by Murchison, to whose writings on the liver we owe so much: Obstruction (1) by foreign bodies within the ducts, as gall-stones and parasites; (2) by inflammatory tumefaction of the duodenum or of the lining membrane of the duct; (3) by stricture or obliteration of the duct; (4) by tumors closing the orifice of the duct or growing in its interior; (5) by pressure on the duct from without, as by tumors of the liver itself, of the stomach, pancreas, kidney, or omentum; by pressure of enlarged glands in the fissure of the liver, and, more rarely, of abdominal aneurism, fgecal accumulation, or the pregnant uterus; (6) to these may be added lowering of the blood pressure in the liver, so that the tension in the smaller bile-ducts is greater than in the blood-vessels. In this class very probably may be placed the cases resulting from mental shock or depress- ing emotions. General Symptoms of Obstructive Jaundice.—(1) Icterus, or tinting of the skin and conjunctivaB. The color ranges from a lemon-yellow in catarrhal jaundice to a deep olive-green or bronzed hue in permanent obstruction. In some instances the color of the skin is greenish black, the so-called “ black jaundice.” (2) Of other cutaneous symptoms, pruritus in the more chronic forms may be intense and cause the greatest distress. It may precede the onset of the jaundice, but as a rule it is not very marked except in cases of pro- longed obstruction. Sweating is common, and may be curiously localized to the abdomen or to the palms of the hands. Lichen, urticaria, and boils may develop, and the skin disease known as xanthelasma or vitili- goidea. The jaundice may be due to the extension of the xanthomata to the bile passages. The visceral localization of this disorder has been chiefly observed when there are numerous punctuate tubercles on the limbs (Hallopeau). (3) The secretions are colored with bile-pigment. The sweat tinges the linen; the tears and saliva and milk are rarely stained. The expecto- ration is not often tinted unless there is inflammation, as when pneumonia 458 DISEASES OF THE DIGESTIVE SYSTEM. coexists with jaundice. The urine may contain the pigment before it is apparent in the skin or conjunctiva. The color varies from light greenish yellow to a deep black-green. Gmelin’s test is made by allowing five or six drops of urine and a similar amount of common nitric acid to flow together slowly on the flat surface of a white plate. A play of colors is produced—various shades of green, yellow, violet, and red. In cases of jaundice of long standing or great intensity the urine usually contains albumin and always bile-stained tube-casts. (4) No bile passes into the intestine. The stools therefore are of a pale drab or slate-gray color, and usually very fetid and pasty. There may be constipation; in many instances, owing to decomposition, there is diarrhoea. (5) Slow pulse. The heart’s action may fall to 40, 30, or even to 20 per minute. It is particularly noticeable in the cases of catarrhal jaun- dice, and is not as a rule an unfavorable symptom. (6) Haemorrhage. Purpura, large subcutaneous extravasations, more rarely haemorrhages from the mucous membranes, occur in protracted jaundice, and in the more malignant forms. (7) Cerebral symptoms. Irritability, great depression of spirits, or even melancholia may be present. In any case of persistent jaundice special nervous phenomena may develop and rapidly prove fatal—such as sudden coma, acute delirium, or convulsions. Usually the patient has a rapid pulse, slight fever, and a dry tongue, and he passes into the so-called “ typhoid state.” These features are not nearly so common in obstructive as in febrile jaundice, but they not infrequently terminate a chronic icterus in whatever way produced. The group of symptoms has been termed cholcemia or, on the supposition that cholesterin is the poison, cholester- cemia ; but the true nature of the poison has not yet been determined. In some of the cases the symptoms may be due to uraemia. Non-obstructive jaundice may be thus classified : (1) The form in which there is wide-spread necrosis of the liver-cells and direct interference with their bile-forming function, as in acute yellow atrophy, and possibly in certain cases of hypertrophic cirrhosis. Strictly speaking, this is a hepatogenous jaundice. (2) The toxic form. The poisons of yellow fever, malaria, typhoid, epidemic jaundice, and pyaemia; snake virus, as well as chloroform, ether, phosphorus, and mercury, act by causing increased destruction of the red blood-corpuscles. More blood-pigment is set free than can be disposed of by liver, spleen, or kidneys, and the bilirubin (transformed haemoglobin) is deposited in the tissues. The symptoms of liaematogenous jaundice are not nearly so striking as in the obstructive variety. The skin has in many cases only a light lemon tint. In the severer forms, as in acute yellow atrophy, the color may be more intense, but in malaria and pernicious anaemia the tint is usually light. In these mild cases the urine may con- tain little or no bile-pigment, but the urinary pigments are considerably JAUNDICE. 459 increased. The stools are not clay-colored and may in some instances be very dark. In the toxic forms of this variety the cerebral symptoms are marked and there may be active delirium, coma, or convulsions. 2. Icterus Neonatorum.—New-born infants are liable to jaundice, which in some instances rapidly proves fatal. A mild and a severe form may be recognized. The mild icterus of the new-born is a common disease in foundling hospitals and is not very infrequent in private practice. The discoloration appears early, usually on the first or second day, and is of moderate inten- sity. The urine may be bile-stained and the fasces colorless. The nutri- tion of the child is not seriously disturbed, and in the majority of cases the jaundice disappears within two weeks. It is supposed that the dimin- ished pressure in the portal vessels, following the severance of the placental circulation, allows absorption from the bile capillaries, in which the tension is greater. Possibly too, as Quincke suggests, the ductus venosus may remain open, allowing some of the portal blood containing bile to flow into the systemic circulation. On the other hand, it is held that the jaun- dice is haematogenous and due to the destruction of large numbers of red blood-corpuscles during the first few days after birth. The severe form of icterus in the new-born may depend upon (a) con- genital absence of the common or hepatic duct, of which there are sev- eral instances on record ; (i) congenital syphilitic hepatitis; and (c) sep- tic poisoning, associated with phlebitis of the umbilical vein. This is a severe and fatal form, in which also haemorrhage from the cord may occur. Occasionally jaundice sets in and persists for many weeks, or even months, without interfering seriously with the nutrition of the child. 3. Acute Yellow Atrophy of the Liver; Malignant Jaundice; Icterus Gravis. Definition.—Jaundice associated with marked cerebral symptoms and characterized anatomically by extensive necrosis of the liver-cells with reduction in volume of the organ. Etiology.—This is a rare disease. In a somewThat varied post-mor- tem and clinical experience no instance has fallen under my observation. On the other hand, a physician may see several cases within a few years, or even within a few months, as happened to Eiess, who saw five cases within three months at the Charite, in Berlin. The disease seems to be rare in this country. No case is reported in the Transactions of the Patho- logical Societies of New York (Yols. I to III) or of Philadelphia (Vols. I to XIII). The disease is more common in women than in men. Of the 100 cases collected by Legg, 69 were in females; and of Thierfelder’s 143 cases, 88 were in women. There is a remarkable association between the disease and pregnancy, which was present in 25 of the 69 women in Legg’s statistics, and in 33 of the 88 women in Thierfelder’s collection. It is most common between the ages of twenty and thirty, but is occasionally seen in young children. It has followed fright or profound mental emo- DISEASES OF THE DIGESTIVE SYSTEM. tion. Though the symptoms produced by phosphorus poisoning closely simulate those of acute yellow atrophy, the two conditions are not iden- tical. Morbid Anatomy.—The liver is greatly reduced in size, looks thin and flattened, and sometimes does not reach more than one half or even one third of its normal weight. It is flabby and the capsule is wrinkled. Oh section the color is of a yellowish brown, yellowish red, or mottled, and the outlines of the lobules are indistinct. The yellow and dark-red portions represent different stages of the same process—the yellow an ear- lier, the red a more advanced stage. The organ may cut with considerable firmness. Microscopically the liver-cells are seen in all stages of necrosis, and in spots appear to have undergone complete destruction, leaving a fatty, granular debris with pigment grains and crystals of leucin and tyro- sin. The bile-ducts and gall-bladder are empty. Macallum and McPhedran, in a case studied with especial care, found obstruction of the fine bile capillaries between the liver-cells at the periphery of the lobules, with blocking of the remaining bile capillaries of the lobules by protoplasmic masses. They also describe some remarkable endocytes similar to those met with in the epithelial cells in Paget’s dis- ease. The changes suggest the action of some poisonous chemical com- pound, the product probably of deranged digestion, which causes rapid necrosis of the cells of the liver and of the bile capillaries. The other organs show extensive bile-staining, and there are numerous haemorrhages. The kidneys may show marked granular degeneration of the epithelium, and usually there is fatty degeneration of the heart. In a majority of the cases the spleen is enlarged. Symptoms.—In the initial stage there is a gastro-duodenal catarrh, and at first the jaundice is thought to be of a simple nature. In some in- stances this lasts only a few days, in others two or three weeks. Then severe symptoms set in—headache, delirium, trembling of the muscles, and, in some instances, convulsions. Vomiting is a constant symptom, and blood may be brought up. Haemorrhages occur into the skin or from the mucous surfaces; in pregnant women abortion may occur. With the development of the head symptoms the jaundice usually increases. Coma sets in and gradually deepens until death. The body temperature is vari- able ; in a majority of the cases the disease runs an afebrile course, though sometimes just before death there is an elevation. In some instances, however, there has been marked pyrexia. The pulse is usually rapid, the tongue coated and dry, and the patient is in a “ typhoid state.” The urine is bile-stained and often contains tube-casts. Leucin and tyrosin are constantly present ; the former as rounded disks, the latter in needle-shaped crystals, arranged either in bundles or in groups. The tyrosin may sometimes be seen in the urine sediment, but it is best first to evaporate a few drops of urine on a cover-glass. In the majority of cases no bile enters the intestines, and the stools are clay-colored. The disease AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER. 401 is almost invariably fatal. In a few instances recovery has been noted. I saw in Leube’s clinic, at Wurzburg, a case which was convalescent. Diagnosis.—Jaundice with delirium, diminution of the liver volume, delirium, and the presence of leucin and tyrosin in the urine, form a char- acteristic and unmistakable group of symptoms. Leucin and tyrosin are not, however, distinctive. They may be present in cases of afebrile jaun- dice with slight enlargement of the liver. It is not to be forgotten that any severe jaundice may be associated with intense cerebral symptoms. The clinical features in certain cases of hypertrophic cirrhosis are almost identical, but the enlargement of the liver, the more constant occurrence of fever, and the absence of leucin and tyrosin are distinguishing signs. Phosphorus poisoning may closely simulate acute yellow atrophy, particularly in the haemorrhages, jaundice, and the diminution in the liver volume, but the gastric symptoms are usually more marked, and leucin and tyrosin are stated not to occur in the urine. No known remedies have any influence on the course of the disease. II. AFFECTIONS OF THE BLOOD-VESSELS OF THE LIVER. (1) Ansemia.—On the post-mortem table, when the liver looks anaemic, as in the fatty or amyloid organ, the blood-vessels, which during life were probably well filled, can be readily injected. There are no symptoms in- dicative of this condition. (2) Hypersemia.—This occurs in two forms. (a) Active hypercemia. After each meal the rapid absorption by the portal vessels induces transient congestion of the organ, which, however, is entirely physiological; but it is quite possible that in persons who persistently eat and drink too much this active hyperacmia may lead to functional disturbance or, in the case of drinking too freely of alcohol, to organic change. The symptoms of active hyperaemia are indefinite. Possibly the sense of distress or fulness in the right hypochondrium, so often mentioned by dyspeptics and by those who eat and drink freely, may be due to this cause. There are probably diurnal variations in the volume of the liver. In cirrhosis with enlargement the rapid reduction in volume after a copi- ous haemorrhage indicates the important part which hyperaemia plays even in organic troubles. It is stated that suppression of the menses or suppres- sion of a haemorrhoidal flow is followed by hyperaemia of the liver. Andrew II. Smith has described a case of periodical enlargement of the liver. (5) Passive Congestion.—This is much more common and results from an increase of pressure in the efferent vessels or sub-lobular branches of the hepatic veins. Every condition leading to venous stasis in the right heart at once affects these veins. In chronic valvular disease, in emphysema, cirrhosis of the lung, and 462 DISEASES OF THE DIGESTIVE SYSTEM. in intrathoracic tumors mechanical congestion occurs and -finally leads to very definite changes. The liver is enlarged, firm, and of a deep-red color; the hepatic vessels are greatly engorged, particularly the central vein in each lobule and its adjacent capillaries. On section the organ presents a peculiar mottled appearance, owing to the deeply congested hepatic and the anaemic portal territories; hence the term nutmeg which has been given to this condition. Gradually the distention of the central capillaries reaches such a grade that atrophy of the intervening liver-cells is induced. Brown pigment is deposited about the centre of the lobules and the con- nective tissue is greatly increased. In this cyanotic induration or cardiac liver the organ is large in the early stage, but later it may become con- tracted. Occasionally in this form the connective tissue is increased about the lobules as well, but the process usually extends from the sublobular and central veins. The symptoms of this form are not always to be separated from those of the associated conditions. Gastro-intestinal catarrh is usually present and haematemesis may occur. The portal obstruction in advanced cases leads to ascites, which may precede the development of general dropsy. There is often slight jaundice, the stools may be clay-colored, and the urine contains bile-pigment. On examination the organ is found to be increased in size. It may be a full hand’s-breadth below the costal margin and tender on pressure. It is in this condition particularly that we meet with pulsation of the liver. We must distinguish the communicated throbbing of the heart, which is very common, from the heaving, diffuse impulse due to regurgitation into the hepatic veins, in which, when one hand is upon the ensiform cartilage and the other upon the right side at the margin of the ribs, the whole liver can be felt to dilate with each impulse. The indications for treatment in passive hyperaemia are to restore the balance of the circulation and to unload the engorged portal vessels. In cases of intense hyperaemia eighteen or twenty ounces of blood may be directly aspirated from the liver, as advised by George Harley and prac- tised by many Anglo-Indian physicians. Good results sometimes follow this hepato-phlebotomy. The prompt relief and marked reduction in the volume of the organ which follow an attack of haematemesis or bleeding from piles suggests this practice. Salts administered by Matthew Hay’s method deplete the portal system freely and thoroughly. As a rule, the treatment must be that of the condition with which it is associated. (3) Diseases of the Portal Vein.—(a) Thrombosis; Adhesive Pyle- phlebitis.—Coagulation of blood in the portal vein is rarely seen except in cirrhosis. Exceptional causes are invasion of the branches by cancer, pro- liferative peritonitis involving the gastro-liepatic omentum, and perfora- tion of the vein by gall-stones. In rare instances a complete collateral circulation is established, the thrombus undergoes the usual changes, and ultimately the vein is represented by a fibrous cord, a condition which has DISEASES OF THE BILE-PASSAGES. 463 been called pylephlebitis adhesiva. In a case of this kind which I dissect- ed the portal vein was represented by a narrow fibrous cord ; the collateral circulation, which must have been completely established for years, ulti- mately failed, ascites and haematemesis supervened and rapidly proved fatal.* The diagnosis of obstruction of the portal vein can rarely be made. A suggestive symptom, however, is a sudden onset of the most intense engorgement of the branches of the portal system. Emboli in the branches of the portal vein do not, as a rule, produce infarction, for blood reaches the lobular capillary plexus, as shown by Cohnheim and Litten, through the free anastomosis with the hepatic artery. In rare instances, however, a condition resembling infarction does occur, sometimes in small areas, at others in quite extensive territories. Septic emboli, on the other hand, may induce suppuration. (b) Suppurative pylephlebitis will be considered in the section on abscess. (4) Affections of the hepatic vein are extremely rare. Dilatation occurs in cases of chronic enlargement of the right heart, from whatever cause produced. Emboli occasionally pass from the right auricle into the hepatic veins. A rare and unusual event is stenosis of the orifices of the hepatic veins, which I met in a case of fibroid obliteration of the inferior vena cava and was associated with a greatly enlarged and indurated liver, f (5) Hepatic Artery.—Enlargement of this vessel is seen in ,cases of cirrhosis of the liver. It may be the seat of extensive sclerosis. Aneurism of the hepatic artery is rare, but instances are on record, and will be re- ferred to in the section on arteries. III. DISEASES OF THE BILE-PASSAGES. Catarrhal Jaundice. Definition.—Jaundice due to swelling and obstruction of the termi- nal portion of the common duct. Etiology.—General catarrhal inflammation of the bile-ducts is usu- ally associated with gall-stones. The catarrhal process now under consid- eration is probably always an extension of a gastro-duodenal catarrh, and the process is most intense in the pars intestinalis of the duct, which projects into the duodenum. The mucous membrane is swollen, and a plug of inspissated mucus fills the diverticulum of Vater, and the narrower portion just at the orifice, completely obstructing the outflow of bile. It is not known how wide-spread this catarrh is in the bile-passages, and whether it really passes up the ducts. It would, of course, be possible to have a catarrh of the finer ducts within the liver, which some French writ- ers think may initiate the attack, but the evidence of this is not strong, * Journal of Anatomy and Physiology, vol. xvii. f Ibid., vol. xvi. DISEASES OF THE DIGESTIVE SYSTEM. and it seems more likely that the terminal portion of the duct is always first involved. In the only instance which I have had an opportunity to examine post mortem the orifice was plugged with inspissated mucus, the common and hepatic ducts were slightly distended and contained a bile- tinged, not a clear, mucus, and there were no observable changes in the mucosa of the ducts. This catarrhal or simple jaundice results from the following causes: (1) Duodenal catarrh, in whatever way produced, most commonly fol- lowing an attack of indigestion. It is most frequently met with in young persons, but may occur at any age, and may follow not only errors in diet, but also cold, exposure, and malaria, as well as the conditions associated with portal obstruction, chronic heart-disease, and Bright’s disease. (2) Emotional disturbances may be followed by jaundice, which is believed to be due to catarrhal swelling. Cases of this kind are rare and the anatom- ical condition is unknown. (3) Simple or catarrhal jaundice may occur in epidemic form. (4) Catarrhal jaundice is occasionally seen in the in- fectious fevers, such as pneumonia, and typhoid fever. Symptoms.—There may be neither pain nor distress, and the patient’s friends may first notice the yelloAV tint, or the patient himself may observe it in the looking-glass. In other instances there are dyspep- tic symptoms and uneasy sensations in the hepatic region or pains in the back and limbs. In the ejndemic form, the onset may be more severe, with headache, chill, and vomiting. Fever is rarely present, though the temperature may reach 101°, sometimes 102°. All the 'signs of obstruct- ive jaundice already mentioned are present, the stools are clay-colored, and the urine contains bile-pigment. The jaundice has a bright-yellow tint; the greenish, bronzed color is never seen in the simple form. The pulse may be normal, but occasionally it is remarkably slow, and may fall to forty or thirty beats in the minute. The liver may be normal in size, but is usually slightly enlarged, and the edge can be felt below the costal margin. Occasionally the enlargement is more marked. The duration of the disease is from four to eight weeks. There are mild cases in which the jaundice disappears within two weeks; on the other hand, it may per- sist for three months. The stools should be carefully watched, for they give the first intimation of removal of the obstruction. The diagnosis is rarely difficult. The onset in young, comparatively healthy persons, the moderate grade of icterus, the absence of emaciation or of evidences of cirrhosis or cancer, usually make the diagnosis easy. Cases which persist for two and three months cause uneasiness, as the sus- picion is aroused that it may be more than simple catarrh. The absence of pain, the negative character of the physical examination, and the main- tenance of the general nutrition are the points in favor of simple jaundice. There are instances in which time alone can determine the true nature of the case. The possibility of Weil’s disease must be borne in mind in anomalous cases. DISEASES OF THE BILE-PASSAGES. 465 Treatment.—As a rule the patient can keep on his feet from the outset. Measures should be used to allay the gastric catarrh, if it is pres- ent. A dose of calomel may be given, and the bowels kept open subse- quently by salines. The patient should not be violently purged. Bismuth and bicarbonate of soda may be given, and the patient should drink freely of the alkaline mineral waters, of which Vichy is the best. Irrigation of the large bowel with cold water may be practised. The cold is supposed to excite peristalsis of the gall-bladder and ducts, and thus aid in the ex- pulsion of the mucus. This practice has been followed in my wards for several years, but I cannot speak warmly of the results. Cholelithiasis (Gall-Stones). Calculi are formed in the gall-bladder. Evidence is wanting to show that they are formed within the liver ducts, except in very rare instances. They may be single, in which case the stone is usually ovoid and may at- tain a very large size. Instances are on record of gall-stones measuring more than five inches in length. They may be extremely numerous, rang- ing from a score to several hundreds or even several thousands, in which case the stones are very small. When moderately numerous, they show signs of mutual pressure and have a polygonal form, with smooth facets; occasionally, however, five or six gall-stones of medium size are met with in the bladder which are round or ovoid and without facets. They are sometimes mulberry-shaped and very dark, consisting largely of bile-pig- ment. Again there are small, black calculi, rough and irregular in shape, and varying in size from sand to small shot. These are sometimes known as gall-sand. On section, a calculus contains a nucleus, which consists of bile-pigment, rarely a foreign body. The greater portion of the stone is made up of cholesterin, which may form the entire calculus and is ar- ranged in concentric laminse showing also radiating lines. Salts of lime and magnesia, bile acids, fatty acids, and traces of iron and copper are also found in them. A majority of gall-stones consist of from seventy to eighty per cent of cholesterin, in either the amorphous or the crystalline form. As above stated, it is sometimes pure, but more commonly it is mixed with the bile-pigment. The outer layer of the stone is usually harder and brownish in color, and contains a larger proportion of lime salts. The mode of formation is by no means clear. A defect in the sodium salts seems to favor the precipitation of the cholesterin and of • the bile- pigment. The lime exists in such slight quantities in the bile that it is probably a pathological product of the mucous glands of the gall-bladder. When the bile is retained long in the gall-bladder its concentration favors the deposition. Contrary to old ideas of the aseptic qualities of the bile, it is now known that the bile-passages often contain micro-organisms, and it has been suggested that their presence in the gall-bladder induces 466 DISEASES OF THE DIGESTIVE SYSTEM. changes which favor the formation of concretions. Naunyn holds that the cholesterin is chiefly the secretion of the mucous membrane of the bile- passages, and may be formed in larger amount in an angio-cholitis, caused by the irritation of bacteria. Etiology.—Three fourths of the cases of gall-stones occur in women, most frequently between the ages of thirty and sixty. Sedentary occupa- tions, particularly when combined with overindulgence in eating, seem important factors. The subjects are often stout, and usually very fond of starchy and saccharine food. The conditions which induce lithic acid also favor the development of gall-stones. Tight-lacing is regarded by Marchand as an important factor in retarding the flow of the bile. Pregnancy has a similar influence. Naunyn states that ninety per cent of women with gall-stones have borne children. Constipation and depressing mental in- fluences have been regarded as favoring circumstances. Symptoms.—In a majority of the cases, gall-stones cause no symp- toms. The gall-bladder will tolerate the presence of large numbers for an indefinite period of time, and post-mortem examinations show that they are present in twenty-five per cent of all women over sixty years of age (Naunyn). The effects of gall-stones may be considered under the following head- ings : The symptoms produced by the passage of a stone through the ducts—biliary colic ; the effects of permanent plugging of the duct; and the more remote effects, due to ulceration and perforation, and the estab- lishment of fistulae. 1. Biliary Colic.—It would appear that gall-stones may become en- gaged in the cystic or the common duct without producing pain or severe symptoms. More commonly the passage of a stone excites the violent symptoms known as biliary colic. The attack sets in abruptly with agonizing pain in the right hypochondriac region, which radiates to the shoulder, or is very intense in the epigastric and in the lower thoracic regions. It is often associated with a rigor and a rise in temperature from 102° to 103°. The pain is usually so intense that the patient rolls about in agony. There are vomiting, profuse sweating, and great depression of the circulation. There may be marked tenderness in the region of the liver, which may be enlarged, and the gall-bladder may become palpable and very tender. In other cases the fever is more marked. The spleen is enlarged (Naunyn) and the urine contains albumin with red blood-corpus- cles. Ortner, who has recently described in connection with gall-stones, the condition as cholecystitis acuta, believes that it is caused by a septic (bacterial) infection of the bile-passages. In a large number of the cases jaundice develops, but it is not a necessary symptom. Of course it does not occur during the passage of the stone through the cystic duct, but only when it becomes lodged in the common duct. Probably the intense pain is due to the slow progress in the cystic duct, in which the stone takes a rotary course owing to the arrangement of the Heisterian valve. DISEASES OF THE BILE-PASSAGES. 467 The attack varies in duration. It may last for a few hours, several days, or even a week or more. If the stone becomes impacted in the orifice of the common duct, the jaundice becomes intense; much more commonly it is a slight transient icterus. The attack of colic may be re- peated at intervals for some time, but finally the stone passes and the symptoms rapidly disappear. Occasionally accidents occur, such as rupture of the duct with fatal peritonitis. Fatal syncope during an attack, and the occurrence of re- peated convulsive seizures have come under my observation. These are, however, rare events. Palpitation and distress about the heart may be present, and occasionally a mitral murmur develops during the paroxysm; but the cardiac conditions described by some writers as coming on acutely in biliary colic are probably pre-existent in these patients. The diagnosis of acute hepatic colic is generally easy. The pain is in the upper abdominal and thoracic regions, whereas the pain in nephritic colic is in the lower abdomen. A chill, with fever, is much more frequent in biliary colic than in gastralgia, with which it is liable, at times, to be confounded. A history of previous attacks is an important guide, and the occurrence of jaundice, however slight, determines the diagnosis. To look for the gall-stones, the stools should be thoroughly mixed with water and carefully filtered through a narrow-meshed sieve. Pseudo-biliary colic is not infrequently met with in nervous women, and the diagnosis of gall- stones made. This nervous hepatic colic may be periodical, the pain in right side and radiating; sometimes associated with other nervous phe- nomena, often excited by emotion, tire, or excesses. The liver may be tender, but there are neither icterus nor inflammatory conditions. The combination of colic and jaundice, so distinctive of gall-stones, is not always present. The pains may not be colicky, but more constant and dragging in character. Of fifty cases operated upon by Eiedel, ten had not had colic, only fourteen presented a gall-bladder tumor, while a ma- jority had not had jaundice. A remarkable xanthoma of the bile passages has been found in association with hepatic colic. 2. Chronic Obstruction of the Ducts by Gall-stones.— Of the Cystic Duct.—The effects may be thus enumerated: Dilatation of the gall-bladder—hydrops vesicse felleas. This occurs much more frequently than in obstruction of the common duct. The fluid is almost invariably of a thin mucoid nature, though it may be mixed with bile. In all case, when the obstruction persists, the bile is replaced by a clear fluid. This is an important point in diagnosis, par- ticularly as a dropsical gall-bladder may form a very large tumor. The reaction is not always constant. It is either alkaline or neutral; the con- sistence is thin and mucoid. Albumin is usually present. The organ may reach an enormous size, and in one instance Tait found it occupying the greater part of the abdomen. In such cases, as is not unnatural, it has been mistaken for an ovarian tumor. The dilated gall-bladder can DISEASES OF THE DIGESTIVE SYSTEM. usually be felt below the edge of the liver, and in many instances it has a characteristic outline like a gourd. It usually projects directly downward, rarely to one side or the other, though occasionally toward the middle line. It may reach below the navel, and in persons with thin walls the outline can be accurately defined, lxiedel has called attention to a tongue- like projection of the anterior margin of the right lobe in connection with enlarged gall-bladder. It is to be remembered that distention of the gall-bladder may occur without jaundice; indeed, the greatest enlarge- ment has been met with in such cases. Gall-stone crepitus is felt when the bladder is very full of stones and its walls not very tense. It is rarely well felt unless the abdominal walls are much relaxed. It may be found in patients who have never had any symptoms of cholelithiasis. In obstruction of the common duct the gall- bladder is not necessarily greatly enlarged. Occasionally it may be much distended without the occurrence of any tumor which can be felt during life. Acute phlegmonous cystitis. This is a rare event. Only seven in- stances of it have been collected in the enormous statistics of Courvoi- sier. Perforation may occur with fatal peritonitis. Suppurative cholecystitis, empyema of the gall-bladder, is much more common, and in the great majority of cases is associated with gall-stones —41 in 55 cases (Courvoisier). There may be enormous dilatation, and over a litre of pus has been found. Perforation and the formation of abscesses in the neighborhood are not uncommon. Calcification of the gall bladder is commonly a termination of the pre- vious condition. There are two separate forms : incrustation of the mucosa with lime salts and the true infiltration of the wall with lime, the so-called ossification. A remarkable example of the latter, sent to me by Groves, of Carp, is now in the McGill Medical Museum. Atrophy of the gall-bladder. This is by no means uncommon. The organ shrinks into a small fibroid mass, not larger, perhaps, than a good- sized pea or walnut, or even has the form of a narrow fibrous string; more commonly the gall-bladder tightly embraces a stone. This condition is usually preceded by hydrops of the bladder. Occasionally the gall-bladder presents diverticula, which may be cut off from the main portion, and usually contain calculi. Obstruction of the Common Duct. The stone usually lies at the termination of the duct, just at the orifice of the papilla, within a sort of pouch formed by the diverticulum of Yater. Examined from the duodenum, it seems to be directly beneath the mu- cosa. It is as a rule single; but two, and in some instances a series of stones, may occupy the entire duct. The effect of the obstruction is dila- tation, with catarrhal or suppurative cholangitis. (1) Obstruction, with catarrhal cholangitis. The common duct may be as large as the thumb ; the hepatic duct and its branches through the liver are greatly dilated, and the distention may DISEASES OF THE BILE-PASSAGES. even be apparent beneath the liver capsule. Great enlargement of the gall-bladder is rare. The mucous membrane of the ducts may be smooth and clear, and the contents a thin, colorless mucus. Catarrhal cholangitis with gall-stones is characterized by a special symptom group: (a) Ague-like paroxysms, chills, fever, and sweating; (b) jaundice of varying intensity, which persists for months or even years, and deepens after each paroxysm; (c) at the time of the paroxysms, pains in the region of the liver with gastric disturbance. These symptoms may continue on and off for three or four years, without the development of suppurative cholangitis. In one of my cases the jaundice and recurring hepatic intermittent fever existed from July, 1879, until August, 1882 * the patient recovered and still lives. The condition has lasted from eight months to three years. The rigors are of intense severity, and the tem- perature rises to 103° or 105°. The chills may recur daily for weeks, and present a tertian or quartan type, so that they often are mistaken for malaria, with which, however, they have no connection. The jaundice is variable, and deepens after each paroxysm. The itching may be most intense. Pain, which is sometimes severe and colicky, does not always occur. There may be marked vomiting and nausea. As a rule there is no progressive deterioration of health. In the intervals between the at- tacks the temperature is normal. The clinical history and the post-mortem examinations in my cases * have shown conclusively that this condition may persist for years without a trace of suppuration within the ducts. The nature of the hepatic intermittent fever is not settled. Charcot holds that it is due to the production of a ferment in the bile-passages. Bacteriological studies have shown that in all these cases the bile-passages are infected, and the colon bacillus, the streptococcus pyogenes, and the micrococcus lanceolatus have been found. This local infection accounts for the recurring attacks of fever, and also for the proneness to secondary septic processes, endocarditis, and pericarditis. The effect upon the liver of chronic obstruction of the bile-duct is very variable. The organ is rarely enlarged, but it has been described as firm, with the connective tissue moderately increased. In none of my cases of persistent obstruction by gall-stones was the liver greatly enlarged, nor did it present macroscopically the features of cirrhosis. On this point my experience is in accord with that of Sharkey, who has recently called in question the statements of Charcot and Wickham Legg as to the occur- rence of cirrhosis under these circumstances. (2) Obstruction, with suppurative cholangitis. When suppurative cholangitis exists the mucosa is thickened, often eroded or ulcerated; there may be extensive suppuration in the ducts throughout the liver, and even empyema of the gall-bladder. Occasionally * Johns Hopkins Hospital Reports, vol. ii, No. 1, 1890. 470 DISEASES OF THE DIGESTIVE SYSTEM. the suppuration extends beyond the ducts, and there is localized liver abscess, or there is perforation of the gall-bladder with the formation of abscess between the liver and stomach. Clinically it is characterized by a fever which may be intermittent, but more commonly is remittent and without prolonged intervals of apyrexia. The jaundice is rarely so intense, nor do we see the deepening of the color after the paroxysms. There is usually greater enlargement of the liver and tenderness and more definite signs of septicaemia. The cases run a shorter course, and recovery never takes place. 3. The More Remote Effects of Gall-stones. — (a) Biliary Fistulae. These are not uncommon. There may, for instance, be abnormal com- munication between the gall-bladder and the hepatic duct or the gall- bladder and a cavity in the liver itself. More rarely perforation occurs between the common duct and the portal vein. Of this there are at least four instances on record, among them the celebrated case of Ignatius Loyola. Perforation into the abdominal cavity is not uncommon; 119 cases exist in the literature (Courvoisier), in 70 of which the rupture occurred directly into the peritoneal cavity; in 49 there was encapsulated abscess. Perforation may take place from an intrahepatic branch or from the hepatic, common, or cystic ducts. Perforation from the gall- bladder is the most common. Fistulous communications between the bile-passages and the gastroin- testinal canal are frequent. Openings into the stomach are rare. Between the duodenum and bile-passages they are much more common. Cour- voisier has collected 10 instances of communication between the ductus communis and the duodenum, and 73 cases between the gall-bladder and the duodenum. Communication with the ileum and jejunum is extremely rare. Of fistulous opening into the colon 39 cases are on record. These communications can rarely be diagnosed; they may be present without any symptoms whatever. It is probably by ulceration into the duodenum or colon that the large gall-stones escape. Occasionally fistulous communication exists between tire gall-bladder and the urinary passages, and the stones may be found in the bladder. The opening has been either into the pelvis of the kidney or, as has been supposed, the gall-bladder has become adherent in the neighbor- hood of the navel, and the stone has escaped through an open urachus. It is possible that adhesions may form between the distended gall-bladder and urinary bladder, since the former has been found adherent as low as the broad ligament. Many instances are on record of fistulas between the bile-passages and the lungs. Courvoisier has collected twenty-four cases. Bile may be coughed up with the expectoration, sometimes in considerable quantities. In only seven cases did recovery take place. In some of these the abscess formation was due to hydatids, in some to ascarides. The perforation usu- ally takes place through the lung, by a liver abscess communicating with DISEASES OF THE BILE-PASSAGES. 471 the pleura, or occasionally the abscess enters the mediastinum and per- forates a bronchus. Of all fistulous communications the external or cutaneous is the most common. Courvoisier’s statistics number 184 cases, in fifty per cent of which the perforation took place in the right hypochondrium; in twenty- nine per cent in the region of the navel. The number of stones dis- charged varied from one to two to many hundreds. Recovery took place in 78 cases; some with, some without operation. (5) Obstruction of the bowel by gall-stones. Reference has already been made to this, the frequency which appears from the fact that of 295 cases of obstruction, occurring during eight years, analyzed by Fitz, 23 were by gall-stone. Courvoisier’s statistics give a total number of 131 cases, in six of which the calculi had a peculiar situation, as in a diverticulum or in the appendix. Of the remaining 125 cases, in 70 the stone was spontaneously passed, usually with severe symptoms. The post- mortem reports show that in some of these cases even very large stones have passed per viam naturalem, as the gall-duct has been enormously dis- tended, its orifice admitting the finger freely. This, however, is extremely rare. The stones have been found most commonly in the ileum. Other Affections of the Bile-ducts. Cancer will be considered later. Stenosis or complete occlusion may follow ulceration, most commonly after the passage of a gall-stone. In these instances the obstruction is usually situated low down in the common duct. Instances of this are extremely rare. Foreign bodies, such as the seeds of various fruits, may enter the duct, and occasionally round worms crawl into it. In the Wistar- Horner Museum of the University of Pennsylvania there is a remarkable specimen showing the common and hepatic ducts enormously distended and densely packed with a dozen or more lumbricoid worms. Similar specimens exist in one of the Paris museums, and at the Royal Victoria Hospital, Netley. Liver-flukes and echinococci are rare causes of obstruc- tion in man. Obstruction hy pressure from without is more frequent. Naturally cancer of the head of the pancreas is apt to involve the terminal portion of the duct; less often cancer of the pylorus. Secondary involvement of the lymph-glands of the liver is a common cause of occlusion of the duct, and is met with in many cases of cancer of the stomach and other abdomi- nal organs. Rare causes of obstruction are aneurism of a branch of the cceliac axis or of the aorta, or pressure of very large abdominal tumors. The symptoms produced are those of chronic obstructive jaundice. At first, the liver is usually enlarged, but in chronic cases it may be reduced in size, and of a deeply bronzed color. The hepatic intermittent fever may be associated with occlusion of the duct from any cause, but it is most fre- 472 DISEASES OF THE DIGESTIVE SYSTEM. quently met with in chronic obstruction by gall-stones. Permanent occlu- sion of the duct terminates in death. In a majority of the cases the con- ditions which lead to the obstruction are in themselves fatal. Cases cf cicatricial occlusion may last for years. A patient under my care, who was permanently jaundiced for nearly three years, had a fibroid occlusion of the duct. The diagnosis of the nature of the occlusion is often very difficult. A history of colic, jaundice of varying intensity, paroxysms of pain, and in- termittent fever point to gall-stones. In cancerous obstruction the tumor mass can sometimes be felt in the epigastric region. In cases in which the lymph glands in the transverse fissure are cancerous, the primary disease may be in the pelvic organs or the rectum, or there may be a limited cancer of the stomach, which has not given any symptoms. In these cases the examination of the other lymphatic glands may he of value. In a case, recently under observation, with jaundice of seven weeks’ duration, and believed to be catarrhal (as the patient’s general con- dition was good and he was said not to have lost flesh), a small nodular mass was detected at the navel, which on removal proved to he scirrhus. Involvement of the clavicular groups of lymph glands may also be service- able in diagnosis. As already mentioned, the gall-bladder is often but little enlarged in obstruction of the common duct. Great and progressive enlargement of the liver with jaundice and moderate continued fever is more commonly met with in cancer. In hypertrophic cirrhosis a similar condition exists, but the organ is smooth and there is rarely progressive enlargement while under observation. Treatment of Gall-stones and their Effects.—In an attack of biliary colic the patient should be kept under morphia, given hypoder- mically, in quarter-grain doses. In an agonizing paroxysm it is well to give a whiff or two of chloroform until the morphia has had time to act. Great relief is experienced from the hot bath and from fomentations in the region of the liver. The patient should be given laxatives and should drink copiously of alkaline mineral waters. Olive oil has proved useless in my hands. When taken in large quantities, fatty concretions are passed with the stools, which have been regarded as calculi; and concretions due to eating pears have been also mistaken, particularly when associated with colic attacks. Since the days of Durande, whose mixture of ether and turpentine is still largely used in France, various remedies have been advised to dissolve the stones within the gall-bladder, none of which are efficacious. The diet should be regulated, the patient should take regular exercise and avoid, as much as possible, the starchy and saccharine foods. The soda salts recommended by Prout are believed to prevent the concentra- tion of the bile and the formation of gall-stones. Either the. sulphate or the phosphate may be taken in doses of from one to two drachms daily. For the intense itching, powdering with starch, strong alkaline baths DISEASES OF THE BILE-PASSAGES. 473 {hot), pilocarpin hypodermically (gr. £-£), and antipyrin (gr. viij), may be tried. Ichthyol and lanolin ointment sometimes gives relief. Expression of gall-stones from the bladder by digital manipulation, as recommended by George Harley, is a highly irrational procedure, not to be followed. So long as gall-stones remain in the bladder they do little or no harm in a great majority of cases. To force them on into the duct is to render the patient liable to severe colic or to the still more serious danger of permanent obstruction. When the cystic duct is occluded and the gall-bladder distended, an exploratory puncture may be made, as practised by the elder Pepper, in 1857, in a case of empyema of the gall-bladder, and by Bartholow in 1878. The puncture may be made either to draw otf fluid from a distended blad- der or to explore for gall-stones. Aspiration is usually a safe procedure, though a fatal result has followed. When the gall-bladder is distended and plainly palpable, to sound for stones by an exploratory puncture is justifiable, but under no other circumstances. “ The easy and safe method of sounding for impacted stones,” recommended a few years ago by a Lon- don physician, in which it is advised to thrust a sharp needle six inches long between the navel and the margin of the liver, may be characterized as one of the most extraordinary operations ever advocated, and would probably always prove fatal, as in the case of the unhappy victim upon whom it was practised. The surgical treatment of gall-stones has of late years made rapid progress. The operation of cliolecystotomy, or opening the gall-bladder and removing the stones, which was advised by Sims, has been remark- ably successful, particularly in the hands of Lawson Tait. The removal of the gall-bladder, cholecystectomy, has also been practised with success. The indications for operation are : (a) Repeated attacks of gall-stone colic, -of great severity and danger. (6) The presence of a distended gall-bladder, associated with attacks of pain or with fever. Many cases of obstruction of the cystic duct with moderate distention of the gall-bladder produce little or no inconvenience, and perfect recovery may take place with con- traction and obliteration, (c) When a gall-stone is permanently lodged in the common duct, and presents the group of symptoms above described. It must, however, be borne in mind that, contrary to the experiences of Charcot and other French writers, three of my cases recovered—one after persistence of the condition for eight months, another for three years; two died of, the effects of the prolonged jaundice, and two after operation. The question, then, of advising removal in such cases should depend largely upon the personal methods and success of the surgeon who is available. The common duct has been explored and gall-stones removed from it. The operation is necessarily much more serious and difficult than that upon the gall-bladder. DISEASES OF TIIE DIGESTIVE SYSTEM. IV. CIRRHOSIS. Definition.—A chronic disease of the liver, characterized by a gradual destruction of liver-cells and an overgrowth of connective-tissue elements, in consequence of which the organ becomes hard and usually small. Etiology.—The disease occurs most frequently in middle-aged males. It has been regarded as rare in children, except in the syphilitic form, but Palmer Howard collected 63 cases, to which list Hatfield, in a further search of the literature, has been able to add 93, so that its occurrence in early life is more common than has been supposed. The following are the recognized factors in inducing the disease: (a) Alcohol.—The abuse of spirits is the common cause. It is more frequent in countries in which strong spirits are taken than in those in which malt liquors and wines are used. The change results from the irritative effect of the strong solution of alcohol absorbed from the stomach. The fusel oil is thought to be the offending material. Similar effects are doubtless produced by other substances, such as rich, highly seasoned foods, or, as has been suggested, by ptomaines and other alkaloids. (b) Syphilis.—We have already considered (under Syphilis) the forms of cirrhosis, diffuse and gummatous, produced by this poison. (c) Cyanotic Congestion.—In cases of chronic disease of the heart and lungs the liver is in a condition of persistent venous hypersemia, in conse- quence of which the central cells of the liver lobules atrophy and there is hyperplasia of the connective tissue. (d) Malaria.—Sclerosis of the liver may follow prolonged malarial poisoning. In this country it is very rare. (e) Tuberculosis.—We have already referred to the sclerotic changes in the liver produced by tuberculosis. It rarely, if ever, induces a condition which can be recognized clinically. (/) Scarlet Fever.—The fact noted by Klein that in scarlet fever there was an infiltration with small cells, an acute interstitial hepatitis, gives a clew to the occurrence of some of the cases of cirrhosis of the liver in chil- dren. In other infectious diseases, too, such as typhoid, there are localized necrotic areas which must be replaced by connective tissue. In the cir- rhosis of early life, excluding the alcoholic and syphilitic cases, the acute infectious diseases are probably the important antecedents. (y) Rickets.—The enlargement of the liver in this disease is associated with increase in the connective tissue, which surrounds the individual lobules and produces changes in the bile-ducts (Ilodgben). (h) Antliracosis.—It occasionally happens in coal-miners that the car- bon pigment reaches the liver in large quantities, is deposited in the con- nective tissue about the portal canal, and may lead to a variety of cirrhosis, which has been described by Welch. In animals, artificial obstruction of the bile-passages results in cirrhosis, but in man there may be persistent stenosis of the common duct or ob- CIRRHOSIS. 475 struction without marked increase in the connective tissue. The causes which induce the cirrhosis which we meet at the bedside are alcohol and syphilis. Morbid Anatomy.—Practically on the post-mortem table we see cirrhosis in four well-characterized forms : (a) The Atrophic Cirrhosis of Laennec.—The organ is greatly re- duced in size and may be deformed. The weight is sometimes not more than a pound or a pound and a half. It presents numerous granula- tions on the surface; is firm, hard, and cuts with great resistance. The substance is seen to be made up of greenish-yellow islands, surrounded by grayish-white connective tissue. This yellow appearance of the liver in- duced Laennec to give it the name of cirrhosis. (&) Fatty Cirrhosis.—Even in the atrophic form the fat is increased, but in typical examples of this variety the organ is not reduced in size, but is enlarged, smooth or very slightly granular, anaemic, yellowish white in color, and resembles an ordinary fatty liver. It is, however, firm, cuts with resistance, and microscopically shows a great increase in the connect- ive tissue. This form is quite as common in this country as the atrophic variety. It occurs most frequently in beer-drinkers. (c) Hypertrophic Cirrhosis.—Enlargement of the liver occurs in the early stage of the ordinary atrophic cirrhosis, hut the increase is moderate and largely due to hyperaemia. The fatty cirrhotic liver is also large, and may reach a hand’s-breadth below the costal margin. The term hyper- trophic cirrhosis should be restricted to the form described by French writers, which is also known as biliary cirrhosis. Unfortunately, this has been used by some writers to include as well the cases in which there has been permanent occlusion of the duct, either by stricture or a calculus j the induration, however, is slight under these circumstances and hyper- trophy very rare. It seems best to limit the terms biliary and hypertropliie cirrhosis to the form characterized by permanent enlargement of the liver, a marked involvement of the smaller biliary canaliculi, and retention in an unusual degree, in comparison with atrophic cirrhosis, of the number and form of the liver-cells, in spite of the great increase of the lobular connective tissue. In this form the liver is greatly enlarged; in one of my cases it weighed seven pounds. The surface is smooth, it is exceed- ingly firm, resists cutting, and presents on section a deep greenish-yellow color. All of my cases have been in hard drinkers. (cl) Perihepatitis ; Glissonian Cirrhosis.—In this form the liver is greatly reduced in size, much altered in shape, and everywhere surrounded by a firm grayish-white membrane, sometimes of semi-cartilaginous con- sistence, varying from 10 to 15 mm. in thickness. This fibrous investment can be stripped off readily, and the liver substance may look almost nor- mal, but usually shows cirrhotic changes. The capsular .thickening may be slight, and the portal connective tissue chiefly involved. The capsule of the spleen is, as a rule, similarly affected, and both processes are asso- DISEASES OF THE DIGESTIVE SYSTEM. ciated with a proliferative peritonitis. The condition is most frequent as a result of alcohol, but occurs also in instances of cyanotic induration. The two essential elements in cirrhosis are destruction of liver-cells and obstruction to the portal circulation. In an autopsy on a case of atrophic cirrhosis the peritonaeum is usually found to contain a large quantity of fluid, the membrane is opaque, and there is chronic catarrh of the stomach and of the small intestines. The kidneys are sometimes cirrhotic, the bases of the lungs may be much com- pressed by the ascitic fluid, the heart often shows marked degeneration, and arterio-sclerosis is usually present. A remarkable feature is the asso- ciation of acute tuberculosis with cirrhosis. In seven cases of my series the patients died with either acute tuberculous peritonitis or acute tuber- culous pleurisy. Pitt states that twenty-two and a half per cent of the cases of cirrhosis dying in Guy’s Hospital during twelve years had acute tuberculosis. The compensatory circulation is usually readily demonstrated. It is carried out by the following set of vessels : (1) The accessory portal system of Sappey, of which important branches pass in the round and suspensory ligaments and unite with the epigastric and mammary systems. These vessels are numerous and small. Occasionally a large single vein, which may attain the size of the little finger, passes from the hilus of the liver in the round ligament, and joins the epigastric veins at the navel. Although this has the position of the umbilical vein, it is usually, as Sappey showed, a para-umbilical vein—that is, an enlarged vein by the side of the obliter- ated umbilical vessel. There may be produced about the navel a large bunch of varices, the so-called caput Medusae. Other branches of this system occur in the gastro-epiploic omentum, about the gall-bladder, and, most important of all, in the suspensory ligament. These latter form large branches, which anastomose freely with the diaphragmatic veins, and so unite with the vena azygos. (2) By the anastomosis between the oesoph- ageal and gastric veins. The veins at the lower end of the oesophagus may be enormously enlarged, producing varices which project on the mucous membrane. (3) The communications between the haemorrhoidal and the inferior mesenteric veins. The freedom of communication in this direction is very variable, and in some instances the haemorrhoidal veins are not much enlarged. (4) The veins of Retzius, which unite the radicles of the portal branches in the intestines and mesentery with the inferior vena cava and its branches. To this system belong the whole group of retroperitoneal veins, which are in most instances enormously enlarged, particularly about the kidneys, and which serve to carry off a considerable proportion of the portal blood. Symptoms.—(a) Of the Atrophic Form.—The most extreme grade of atrophic cirrhosis may exist without symptoms. So long as the compen- satory circulation is maintained the patient may suffer little or no incon- venience. The remarkable efticiencv of this collateral circulation is well CIRRHOSIS. 477 seen in those rare instances of permanent obliteration of the portal vein. The symptoms may be divided into two groups—obstructive and toxic. Obstructive.—The overfilling of the blood-vessels of the stomach and intestine leads to chronic catarrh, and the patients suffer with nausea and vomiting, particularly in the morning; the tongue is furred and the bowels are irregular. Haemorrhage from the stomach may be an early symptom; it is often profuse and liable to recur. It seldom proves fatal. The amount vomited may be remarkable, as in a case already referred to, in which ten pounds were ejected in seven days. Following the haemate- mesis melaena is common ; but haemorrhages from the bowels may occur for several years without haematemesis. Enlargement of the spleen occurs from the chronic congestion. The organ can usually be felt. Evidences of the establishment of the collateral circulation are seen in the enlarged epigastric and mammary veins, more rarely in the presence of the caput Medusae and in the development of haemorrhoids. The distended venules in the lower thoracic zone along the line of attachment of the diaphragm are not specially marked in cirrhosis. The most striking feature of failure in the compensatory circulation is ascites, the effusion of serous fluid into the peritoneal cavity. The conditions under which this occurs are still ob- scure. The abdomen gradually distends, may reach a large size, and con- tain as much as 15 or 20 litres. (Edema of the feet may precede or develop with the ascites. The dropsy rarely becomes general. Jaundice is usually slight, and was present in only 35 of 130 cases of cirrhosis reported by Fagge. The skin lias frequently a sallow, slightly icteroid tint. The urine is often reduced in amount, contains urates in abundance, often a slight amount of albumen, and, if jaundice is intense, tube-casts. The disease may be afebrile throughout, but in many cases, as shown by Carrington, there is slight fever, from 100° to 102-5°. Examination in the early stage of the disease may show moderate en- largement of the liver, which may be painful on pressure. At this period the patient may come under observation for dyspepsia, haematemesis, slight jaundice, or nervous symptoms. Later in the disease, the patient has an unmistakable hepatic facies; he is thin, the eyes are sunken, the conjunc- tivae watery, the nose and cheeks show distended venules, and the complex- ion is muddy or icteroid. On the enlarged abdomen the vessels are dis- tended, and a bunch of dilated veins may surround the navel. When much fluid is in the peritonaeum it is impossible to make a satisfactory ex- amination, but after withdrawal the area of liver dulness is found to be diminished, particularly in the middle line, and on deep pressure the edge of the liver can be detected, and occasionally the hard, firm, and even granular surface. The spleen can be felt in the left hypochondriac region. Examination of the anus may reveal the presence of haemorrhoids. Toxic Symptoms.—At any stage of atrophic cirrhosis the patient may develop cerebral symptoms, either a noisy, joyous delirium, or stupor, coma, or even convulsions. The condition is not infrequently mistaken for 478 DISEASES OP THE DIGESTIVE SYSTEM. uraemia. The nature of the toxic agent is not yet settled. The symptoms may develop without jaundice, and cannot be attributed to cliolaemia, and they may come on in hospital when the patient has not had alcohol for weeks. The fatty cirrhotic liver may produce symptoms similar to those of the atrophic form, but it more frequently is latent and is found accidentally in topers who have died from various diseases. The greater number of the cases clinically diagnosed as cirrhosis with enlargement come in this division. (b) Hypertrophic or biliary cirrhosis has a definite and distinctive symptomatology. The liver may be enlarged for months or even years. Jaundice persists for some time, on which point French writers lay great stress. It may, however, come on acutely with the other symptoms. It is intense, like an obstructive jaundice, but, as a rule, the stools are bile- stained. It may continue for a long time without the development of other symptoms; then delirium sets in and all the features of an acute febrile jaundice. The tongue is dry, the pulse rapid, the temperature ranges from 102° to 104°, and petechise occur on the skin. The patient may present every feature of acute yellow atrophy, including even the convulsive seizures. The attack in one of my cases proved fatal within ten days ; in another it was prolonged for three weeks. Ascites does not develop. The enlargement of the liver may be the sole diagnostic crite- rion between these cases and acute yellow atrophy. I do not know, how- ever, of the occurrence of leucin or tyrosin in the urine in this condition. (c) The perihepatitis with cirrhosis cannot be distinguished from the ordinary atrophic form. Diagnosis.—With ascites, a well-marked history of alcoholism, the hepatic facies, and haemorrhage from the stomach or bowels, the diag- nosis is rarely doubtful. If, after withdrawal of the fluid, the spleen is found to be enlarged and the liver either not palpable or, if it is en- larged, hard and regular, the probabilities in favor of cirrhosis are very great. In the early stages of the disease, when the liver is increased in size, it may be impossible to say whether it is a cirrhotic or a fatty liver. The differential diagnosis between common and syphilitic cirrhosis can sometimes be made. A marked history of sypliilis or the existence of other syphilitic lesions, with great irregularity in the surface or at the edge of the liver, are the points in favor of the latter. Thrombosis or obliteration of the portal vein can rarely be differentiated In the case of fibroid transformation of the portal vein which came under my observa- tion, the collateral circulation had been established for years, and the symptoms were simply those of extreme portal obstruction, such as occur in cirrhosis. Thrombosis of the portal vein is frequent in cirrhosis and may be characterized by a rapidly developing ascites. Prognosis.—The prognosis is, as a rule, bad. When the collateral circulation is fully established the patient may have no symptoms what- CIRRHOSIS. 479 ever. Three cases of advanced atrophic cirrhosis have died under my ob- servation of other affections without presenting during life any symptoms pointing to disease of the liver. There are instances, too, of enlargement of the liver, slight jaundice, cerebral symptoms, and even hsematemesis, in Avhich the liver becomes reduced in size, the symptoms disappear, and the patient may live in comparative comfort for many years. There are many cases, too, in which, after one or two tappings, the symptoms have disap- peared and the patients have apparently recovered. Treatment.—Ordinary cirrhosis of the liver is an incurable disease. Many writers, speaking of the curability of certain forms, show a lack of appreciation of the essential conditions upon which the symptoms depend. So far as we have any knowledge, no remedies at our disposal can alter or remove the cicatricial connective tissue which constitutes the materia peccans in ordinary cirrhosis. On the other hand, we know that extreme grades of contraction of the liver may persist for years Avitliout symptoms when the compensatory circulation exists. The so-called cure of cirrhosis means the re-establishment of this compensation; and it would be as un- reasonable to speak of healing a chronic valvular lesion when Avitli digi- talis Ave have restored the circulatory balance as it is to speak of curing cirrhosis of the liver Avhen by tapping and other measures the compensa- tion has in some Avay been restored. The patient should abstain entirely from alcohol, and, if possible, should take a milk diet, which has been highly recommended by Semmola. In any case, the diet should be nutritious, but not too rich. Measures should be employed to reduce the gastro-intestinal catarrh, and the patient should .lead a quiet, out-of-door life and keep the skin active, the boAvels regular, and the urine abundant. In non-sypliilitic cases it is useless to give either mercury or iodide of potassium. When a Avell-marked history of syphilis exists these remedies should be used, but neither of them has any more influence upon the development of a neAV growth of connective tissue in the liver than it has upon the progressive development of a scar tissue in a keloid or in an ordinary developing cicatrix. The ascites should be tapped early, and the operation may be repeated so soon as the distention becomes distressing. The continuous drainage Avitli a Southey’s tube may be employed. It is much better to resort to tapping early if after a feAV days’ trial the fluid does not subside rapidly under the use of saline purges. From half an ounce to an ounce and a half of sulphate of magnesia may be given in as little Avater as possible half an hour before breakfast. Elate- rium, the compound jalap poAvder, or the bitartrate of potash may also be employed. Digitalis and squills are often useful. In the syphilitic cases or Avhen syphilis is suspected iodide of potassium may be given in doses of from fifteen to thirty drops of the saturated solution three times a day, and mercury, Avhich is conveniently given with squills and digitalis in the form of Addison’s or Niemeyer’s pill. A case of Avell-marked syphilitic cirrhosis with recurring ascites, in which tapping Avas resorted to on eight 480 DISEASES OP TILE DIGESTIVE SYSTEM. or ten occasions, took this pill at intervals for a year with the greatest bene- fit, and subsequently had four years of tolerably good health. V. ABSCESS OF THE LIVER. Etiology.—Suppuration within the liver, either in the parenchyma or in the blood or bile passages, occurs under the following conditions: (1) The tropical abscess. In hot climates this form may develop idio- pathically, but more commonly follows dysentery. It frequently occurs among Europeans in India, particularly those who drink alcohol freely and are exposed to great heat. The relation of this form of abscess to dysen- tery is still under discussion, and Anglo-Indian practitioners are by no means unanimous on the subject. Certainly cases may develop without a history of previous dysentery, and there have been fatal cases without any affection of the large bowel. In this country the large solitary tropi- cal abscess also occurs, oftenest in the Southern States. In Baltimore it is not very infrequent, as may be judged from the fact that during two years there have been at my. clinic five cases, and I know of the occurrence of three or four additional cases during this time in the city. The relation of this form of abscess to the amoeba coli has been care- fully studied by Kartulis and exhaustively considered in a monograph by Councilman and Lafleur. The descriptions and illustrations of these authors are most convincing as to the direct etiological association of this organism with liver abscess. Clinically the patient may have amoeba coli in the stools and well-marked signs of liver abscess without marked symp- toms of dysentery and even with the faeces well formed. (2) Traumatism is an occasional cause. The injury is generally in the hepatic region. Two instances have come under my notice of it in brake- men who were injured while coupling cars. Injury of the head is not in- frequently followed by liver abscess. (3) Embolic or pyaemic abscesses are the most numerous, and may de- velop in a general pyaemia from any cause or follow foci of suppuration in the territory of the portal vessels. The infective agents may reach the liver through the hepatic artery, as in those cases in which the original focus of infection is in the area of the systemic circulation; though it may happen occasionally that the infective agent, instead of passing through the lungs, reaches the liver through the inferior vena cava and the hepatic veins. A remarkable instance of multiple abscesses of arterial origin was afforded by the case of aneurism of the hepatic artery reported by Ross and myself. Infection through the portal vein is much more common. It results from dysentery and other ulcerative affections of the bowels, appendicitis, occasionally after typhoid fever, in rectal affections, and in abscesses in the pelvis. In these cases the abscesses are multiple and, as a rule, within the branches of the portal vein—suppurative pylephlebitis. ABSCESS OF THE LIVER. 481 (4) A not uncommon cause of suppuration is inflammation of the bile- passages caused by gall-stones, more rarely by parasites—suppurative cho- langitis. In some instances of tuberculosis of the liver the affection is chiefly of the bile-ducts, with the formation of multiple tuberculous abscesses con- taining a bile-stained pus. (5) Foreign bodies and parasites. In rare instances foreign bodies, such as a needle, may pass from the stomach or gullet, lodge in the liver, and excite an abscess, or, as in several instances which have been reported, a foreign body, such as a needle or a fish-bone, may perforate a branch or the portal vein itself and induce extensive pylephlebitis. Echinococcus cysts frequently cause suppuration; the penetration of round worms into the liver less commonly; and most rarely of all the liver-fluke. Morbid Anatomy.—(a) Of the Solitary or Tropical Abscess.—This is not always single; there may be two or even more large abscess cavities, ranging in size from an orange to a child’s head. The largest-sized ab- scess may contain from three to six litres of pus and involve more than three fourths of the entire organ. In Waring’s statistics, sixty-two per cent of the cases were single. The abscess in nearly seventy per cent of the cases was in the right lobe, more toward the convexity than the con- cave side. In long-standing cases the abscess-wall may be firm and thick, but, as a rule, the cavity possesses no definite limiting membrane, and sec- tion of the wall shows an internal layer, grayish in color, shreddy, and made up of necrotic liver substance, pus-cells, and amcebas; a middle layer, brownish red in color; and an external zone of hyperasmic liver tis- sue. The pus is often reddish brown in color, closely resembling anchovy sauce. In other instances it is grayish white, mucoid, and may be quite creamy. The odor is at times very peculiar. In one instance it had the sour smell of chyme, though no connection with the stomach was found. In a recent case of amoebic dysentery there were multiple miliary abscesses in the liver, all of which contained amoebae. The bacteriological examination of the contents show that as a rule the pus is sterile (Kartulis). The termination of this form of abscess may be as follows, as noted in Waring’s 300 cases: Remained intact, fifty-six per cent; opened by operation, sixteen per cent; perforated the right pleura, nearly five per cent; ruptured into the right lung, nine per cent; ruptured into the peritonaeum, five per cent; ruptured into the colon, nearly three per cent; and there were in addition instances which rupt- ured into the hepatic and bile-vessels and into the gall-bladder. (b) Of Septic and Pycomic Abscesses.—These are always multiple, though occasionally, following injury, there may be a large solitary collec- tion of pus. In suppurative pylephlebitis the liver is uniformly enlarged. The cap- sule may be smooth and the external surface of the organ of normal appearance. In other instances, numerous yellowish-white points appear 482 DISEASES OF THE DIGESTIVE SYSTEM. beneath the capsule. On section there are isolated pockets of pus, either having a round outline or in some places distinctly dendritic, and from these the pus may be squeezed. They look like small, solitary abscesses, but, on probing, are found to communicate with the portal vein and to represent its branches, distended and suppurating. Idle entire portal sys- tem within the liver may be involved; sometimes territories are cut off by thrombi. The suppuration may extend into the main branch or even into the mesenteric and gastric veins. The pus may be fetid and is often bile- stained ; it may, however, be thick, tenacious, and laudable. In suppura- tive cholangitis there is usually obstruction by gall-stones, the ducts are greatly distended, the gall-bladder enlarged and full of pus, and the branches within the liver are extremely distended, so that on section there is an appearance not unlike that described in pylephlebitis. Suppuration about echinococcus cysts may be very extensive, forming enormous abscesses, the characters of which are at once recognized by the remnants of the cysts. Symptoms.—(a) Of the Large Solitary Abscess.—In the tropics there are instances in which the abscess appears to be latent and to run a course without definite symptoms, and death may occur suddenly from rupture. Fever, pain, enlargement of the liver, and the development of a septic condition are the important symptoms of hepatic abscess. The tempera- ture is elevated at the outset and is of an intermittent or septic type. It is irregular, and may remain normal or even subnormal for a few days; then the patient has a rigor and the temperature rises to 103° or higher. Owing to this intermittent character of the fever the cases are usually, in this latitude, mistaken for malaria. The fever may rise every afternoon without a rigor. Profuse sweating is common, particularly when the patient falls asleep. In chronic cases there may be little or no fever. At the time of writing, there is in one of my wards a patient with liver abscess which has perforated the lung who still coughs up pus, but whose temperature has been normal for weeks. The pain is variable, and is usually referred to the back or shoulder; or there is a dull aching sen- sation in the right liypochohdrium. "When turned on the left side, the patient often complains of a heavy, dragging sensation, so that he usually prefers to lie on the right side; at least, this has been the case in a major- ity of the instances which have come under my observation. Pain on pressure over the liver is usually present, particularly deep pressure at the costal margin in the nipple line. The enlargement of the liver is most marked in the right lobe, and, as the abscess cavity is usually situated more toward the upper than the un- der surface, the increase in volume is upward and to the right, not down- ward, as in cancer and the other affections producing enlargement. Per- cussion in the mid-sternal and parasternal lines may show a normal limit. At the nipple-line the curve of liver dulness begins to rise, and in the mid- ABSCESS OF THE LIVER. 483 axillary it may reach the fifth rib, while behind, near the spine, the area of dulness may be almost on a level with the angle of the scapula. Of course there are instances in which this characteristic feature is not pres- ent, as when the abscess occupies the left lobe. The enlargement of the liver may be so great as to cause bulging of the right side, and the edge may project a hand’s-breadth or more below the costal margin. In such instances the surface is smooth. Palpation is painful, and there may be fremitus on deep inspiration. In some instances fluctuation may be de- tected. Adhesions may form to the abdominal wall and the abscess may point below the margin of the ribs, or even in the epigastric region. In many cases the appearance of the patient is suggestive. The skin has a sallow, slightly icteroid tint, the face is pale, the complexion muddy, the conjunctivae are infiltrated, and often slightly bile-tinged. There is in the facies and in the general appearance of the patient a strong suggestion of the existence of abscess. There is no internal affection associated with suppuration which gives, I think, just the same hue as certain instances of abscess of the liver. Marked jaundice is rare. Diarrhoea may be present and may give an important clew to the nature of the case, particularly if amoebae are found in the stools. Constipation may occur. Remarkable and characteristic symptoms arise when the abscess in- vades the lung. The extension may occur through the diaphragm, with- out actual rupture, and with the production of a purulent pleurisy and invasion of the lung. In four cases of this kind, which have been under observation recently, the patients gradually developed a severe cough, usually of an aggravated and convulsive character, there were signs of in- volvement at the base of the right lung, defective resonance, feeble tubular breathing, and increase in the tactile fremitus; but the most characteristic feature was the presence of a reddish-brown expectoration of a brick-dust color, resembling anchovy sauce. This, which was noted originally by Budd, was present in our cases, and in addition Reese and Lafleur found in all amoeba coli identical with those which exist in the liver abscess and in the stools. They are present in variable numbers and display active amoebic movements. The brownish tint of the expectoration is due to blood-pigment and blood-corpuscles, and there may be orange-red crystals of haematoidin. The abscess may perforate externally, as mentioned already, or into the stomach or bowel; occasionally into the pericardium. The duration of this form is very variable. It may run its course and prove fatal in six or eight weeks or may persist for several years. The prognosis is serious, as the mortality is more than fifty per cent. The death-rate has been lowered of late years, owing to the greater fear- lessness with which surgeons now attack these cases. (b) Of the Pycemic Abscess and Suppurative Pylephlebitis.—Clinically these conditions cannot be separated. Occurring in a general pyaemia, no special features may be added to the case. When there is suppuration 484 DISEASES OP THE DIGESTIVE SYSTEM. within the portal vein the liver is uniformly enlarged and tender, though pain may not be a marked feature. There is an irregular, septic fever, and the complexion is muddy, sometimes distinctly icteroid. The features are indeed those of pyasmia, plus a slight icteroid tinge, and an enlarged and painful liver. The latter features alone are peculiar. The sweats, chills, prostration, and fever have nothing distinctive. Diagnosis.—Abscess of the liver may be confounded with intermit- tent fever, a common mistake in malarial regions. Practically an inter- mittent fever which resists quinine is not malarial. Laveran’s organisms are also absent from the blood. When the abscess bursts into the pleura a right-sided empyema is produced and perforation of the lung usually follows. When the liver abscess has been latent and dysenteric symptoms not marked, the condition may be considered empyema or abscess of the lung. In such cases the anchovy-sauce-like color of the pus and the presence of the amoebae will enable one to make a definite diagnosis, as has been done in cases by Lafleur. Perforation externally is readily recog- nized, and yet in an abscess cavity in the epigastric region it may be difficult to say whether it has proceeded from the liver or is in the abdominal wall. When the abscess is large, and the adhesions are so firm that the liver does not descend during inspiration, the exploratory needle does not make an up-and-down movement during aspiration. In an instance of this kind which I saw with Hearn at the Philadelphia Hospital, all the feat- ures, local and general, seemed to point to abscess in the abdominal wall, but the operation revealed a large perforating abscess cavity in the left lobe of the liver. The diagnosis of suppurating echinococcus cyst is rarely possible, except in Australia and Iceland, where hydatids are so common. In the only case which has come under my observation, the in- numerable tumors scattered throughout the abdomen and the great size of the liver led, not unnaturally, in spite of the occurrence of septic symp- toms, to the diagnosis of cancer. Perhaps the most important affection from which suppuration within the liver is to be separated is the intermittent hepatic fever associated with gall-stones. Of the cases reported a majority have been considered due to suppuration, and in two of my cases the liver had been repeatedly aspirated. Post-mortem examinations have shown conclusively that the high fever and chills may recur at intervals for years without suppuration in the ducts. The distinctive features of this condition are paroxysms of fever with rigors and sweats—which may occur with great regularity, but which more often are separated by long intervals—the deepening of the jaundice after the paroxysms, the entire apyrexia in the intervals, and the mainte- nance of the general nutrition. The time element also is important, as in some of these cases the disease has lasted for several years. Finally, it is to be remembered that abscess of the liver, in temperate climates at least, is invariably secondary, and the primary source must be carefully sought for, either in dysentery, slight ulceration of the rectum, suppurating NEW GROWTHS IN THE LIVER. 485 haemorrhoids, ulcer of the stomach, or in suppurative diseases of other parts of the body, particularly in the skull or in the bones. The presence of a leucocytosis is a most important feature in all forms of suppuration in the liver. In suspected cases, whether the liver is enlarged or not, exploratory aspiration may be performed without risk. The needle may be entered in the anterior axillary line in the lowest interspace, or in the seventh inter- space in the mid-axillary line, or over the centre of the area of dulness behind. The patient should be placed under ether, for it may be neces- sary to make several deep punctures. It is not well to use too small an aspirator. No ill effects follow this procedure, even though blood may leak into the peritoneal cavity. Extensive suppuration may exist, and yet be missed in the aspiration, particularly when the branches of the portal vein are distended with pus. Treatment.—Pyaemic abscesses and suppurative pylephlebitis are invariably fatal. Treves, however, reports a case of pyaemic abscess fol- lowing appendicitis in which the patient recovered after an exploratory operation. Surgical measures are not justified in these cases, unless an abscess shows signs of pointing. As the abscesses associated with dysen- tery are often single, they afford a reasonable hope for operation. If, however, the patient is expectorating the pus, if the general condition is good and the hectic fever not marked, it is best to defer operation, as many of these instances recover spontaneously. The large single abscesses offer the best chance for operation. The general medical treatment of the cases is that of ordinary septicaemia. VI. NEW GROWTHS IN THE LIVER. These may be cancer, either primary or secondary, sarcoma, or angioma. Etiology.—Cancer of the liver is third in order of frequency of in- ternal cancer. It is rarely primary, usually secondary to cancer in other organs. It is a disease of late adult life. According to Leichtenstern, over fifty per cent of the cases occur between the fortieth and the sixtieth years. It occasionally occurs in children. Women are attacked less fre- quently than men. It is stated by some authors that secondary cancer is more common in women, owing to the frequency of cancer of the uterus. Heredity is believed to have an influence in from fifteen to twenty per cent. In many cases trauma is an antecedent, and cancer of the bile-passages is associated in many cases with gall-stones. Cancer is stated to be less common in the tropics. Its relative proportion to other diseases may be judged from the fact that among the first three thousand patients admit- ted to the wards of the Johns Hopkins Hospital there were seven cases of cancer of the liver. 486 DISEASES OF THE DIGESTIVE SYSTEM. Morbid Anatomy.—The following forms of new growths occur in the liver and have a clinical importance: Cancer.—(1) Primary cancer, of which three forms may be recog- nized.* (a) The massive cancer, which causes great enlargement and on section shows a uniform mass of new growth, which occupies a large portion of the organ. It is grayish white, usually not softened, and is abruptly out- lined from the contiguous liver substance. (IS) Nodular cancer, in which the liver is occupied by nodular masses, some large,-some small, irregularly scattered throughout the organ. Usu- ally in one region there is a larger, perhaps firmer, older-looking mass, which indicates the primary seat, and the numerous nodules are secondary to it. This form is much like the secondary cancerous involvement, ex- cept that it seldom reaches a large size. (c) The third is the remarkable and rare variety, cancer with cirrhosis, which forms an anatomical picture perfectly unique and at first very puzzling. The liver is not much enlarged, rarely weighing more than two and a half or three kilogrammes. The surface is grayish yellow, studded over with nodular yellowish masses, resembling the projections in an ordi- nary cirrhotic liver. On section the cancerous nodules are seen scattered throughout the entire organ, varying in diameter from three to ten or more millimetres and surrounded with fibrous tissue. Histologically, the primary cancers are epitlieliomata—alveolar and trabecular. The character of the cells varies greatly. Some varieties are polymorphous; others small polyhedral; and others again contain giant cells. In rare instances, as in one described by Greenfield, the cells are cylindrical. The trabecular form of epithelioma is also known as adenoma or adeno-carcinoma. (2) Secondary Cancer.—The organ is usually enormously enlarged, and may weigh twenty pounds or more. The cancerous nodules project beneath the capsule, and can be felt during life or even seen through the thin abdominal walls. They are usually disseminated equally, though in rare instances they may be confined to one lobe. The consistence of the nodules varies; in some cases they are firm and hard and those on the surface show a distinct umbilication, due to the shrinking of the fibrous tissue in the centre. These superficial cancerous masses are still some- times spoken of as “ Farre’s tubercles.” More frequently the masses are on section grayish white in color, or haemorrhagic. Rupture of blood- vessels is not uncommon in these cases. In one specimen there was an enormous clot beneath the capsule of the liver, together with haemorrhage into the gall-bladder and into the peritonaeum. The secondary cancer shows the same structure as the initial lesion, and is usually either an alve- olar or cylindrical carcinoma. Degeneration is common in these second- * Hanot and Gilbert, fitudes sur les Maladies du Foie, Paris, 1888. NEW GROWTHS IN THE LIVER. 487 ary growths; thus the hyaline transformation may convert large areas into a dense, dry, grayish-yellow mass. Extensive areas of fatty degeneration may occur, sclerosis is not uncommon, and haemorrhages are frequent. Suppuration sometimes follows. (3) Cancer of the Bile-Passages.—Much attention has been given to this of late, and Zenker, Musser and Ames have recently published ex- haustive papers on the subject. In 100 cases collected by Musser the large proportion (3 to 1) were in females. Jaundice was present in sixty- nine per cent, and in about the same percentage there was a tumor in the region of the gall-bladder. Courvoisier has collected 100 cases, of which 83 were in men and 17 in women. The association of cancer of the bile- passages with calculi has long been recognized, and they are present in at least seven eighths of all cases. The fundus of the gall-bladder is usually involved first. The process may extend to the common or hepatic ducts, and invasion of the contiguous structures is common. The ducts may he affected primarily. Sarcoma.—Of primary sarcoma of the liver very few cases have been reported. Secondary sarcoma is more frequent, and many examples of lympho-sarcoma and myxo-sarcoma are on record, less frequently glio- sarcoma or the smooth or striped myoma. The most important form is the melano-sarcoma, which develops in the liver secondarily to sarcoma of the eye or of the skin. Very rarely melano-sarcoma develops primarily in the liver. Of the reported cases Hanot excludes all but one. In this form the liver is greatly enlarged, is either uniformly infiltrated with the cancer, which gives the cut surface the appearance of dark granite, or there are large nodular masses of a deep black or marbled color. There are usually extensive metastases, and in some instances every organ of the body is involved. Nodules of melano- sarcoma of the skin may give a clew to the diagnosis. Other Forms of Liver Tumor.—One of the commonest tumors in the liver is the angioma, which occurs as a small, reddish body the size of a walnut, and consists simply of a series of dilated vessels. Occasionally in children angiomata have developed and produced large tumors. Cysts are occasionally found in the liver, either single, which are not very uncommon, or multiple, when they usually coexist with congenital cystic kidneys. Symptoms.—It is often impossible to differentiate primary and sec- ondary cancer of the liver unless the primary seat of the disease is evident, as in the case of scirrhus of the breast, or cancer of the rectum, or of a tumor in the stomach, which can be felt. As a rule, cancer of the liver is associated with progressive enlargement; but there are cases of primary nodular cancer, and in the cancer with cirrhosis the organ may not be enlarged. Gastric disturbance, loss of appetite, nausea, and vomiting are frequent. Progressive loss of flesh and strength may be the first symp- toms. Pain or a sensation of uneasiness in the right hypochondriac region 488 DISEASES OF THE DIGESTIVE SYSTEM. may be present, but enormous enlargement of the liver may occur without the slightest pain. Jaundice, which is present in at least one half of the cases, is usually of moderate extent, unless the common duct is occluded. Ascites is rare, except in the form of cancer with cirrhosis, in which the clinical picture is that of the atrophic form. Pressure by nodules on the portal vein or extension of the cancer to the peritonaeum may also induce ascites. Inspection shows the abdomen to be distended, particularly in the upper zone. In late stages of the disease, when emaciation is marked, the cancerous nodules can be plainly seen beneath the skin, and in rare instances even the umbilications. The superficial veins are enlarged. On palpation the liver is felt, a hand’s-breadth or more below the costal margin, descending with each inspiration. The surface is usually irregular, and may present large masses or smaller nodular bodies, either rounded or with central depressions. In instances of diffuse infiltration the liver may be greatly enlarged and present a perfectly smooth surface. The growth is progressive, and the edge of the liver may ultimately extend below the level of the navel. Although generally uniform and producing enlarge- ment of the whole organ, occasionally, when the tumor develops from the left lobe, it may form a solid mass, which occupies the epigastric region. By percussion the outline can be accurately limited and the progressive growth of tumor estimated. The spleen is rarely enlarged. Pyrexia is present in many cases, usually a continuous fever, ranging from 100° to 102°; it may be intermittent with rigors. This may be associated with the cancer alone, or, as in one of my cases, with suppuration. (Edema of the feet, from anaemia, usually supervenes. Cancer of the liver kills in from three to fifteen months. Diagnosis.—The diagnosis is easy when the liver is greatly enlarged and the surface nodular. The smoother forms of diffuse carcinoma may at first be mistaken for fatty or amyloid liver, but the presence of jaun- dice, the rapid enlargement, and the more marked cachexia will usually suffice to differentiate it. Perhaps the most puzzling conditions occur in the rare cases of enlarged amyloid liver with irregular gummata. The large echinococcus liver may present a striking similarity to carcinoma, but the projecting nodules are usually softer, the disease lasts much longer, and the cachexia is not marked. Hypertrophic cirrhosis may at first be mistaken for carcinoma, as the jaundice is usually deep and the liver very large; but the absence of a marked cachexia and wasting, and the painless, smooth character of the enlargement are points against cancer. When in doubt in these cases, aspiration may be safely performed, and positive indication may be gained from the materials so obtained. In large, rapidly growing secondary cancers the superficial rounded masses may almost fluctuate and these soft tumor-like projections may contain blood. The form of cancer with cirrhosis can scarcely be separated from atrophic cirrhosis itself. Perhaps FATTY LIVER. 489 the wasting is more extreme and more rapid, but the jaundice and the ascites are identical. Melano-sarcoma causes great enlargement of the organ. There are frequently symptoms of involvement of other viscera, as the lungs, kidneys, or spleen. Secondary tumors may develop on the skin. A very important symptom, not present in all cases, is melanuria, the passage of a very dark-colored urine, which may, however, when first voided, be quite normal in color. The existence of a melano-sarcoma of the eye, or the history of blindness in one eye, with subsequent extirpa- tion, may indicate at once the true nature 6f the hepatic enlargement. The secondary tumors may develop some time after the extirpation of the eye, as in a case under the care of J. C. Wilson, at the Philadelphia Hos- pital, or, as in a case under Tyson at the same institution, the patient may have a sarcoma of the choroid which had never caused any symp- toms. Primary cancer of the gall-bladder can rarely be diagnosed. It may be greatly dilated and readily palpable. Occasionally tumors of the kidney or a tumor of the transverse colon may be confounded with it. The treatment must be entirely symptomatic—allaying the pain, re- lieving the gastric disturbance, and meeting other symptoms as they arise. VII. FATTY LIVER. Two different forms of this condition are recognized—the fatty infil- tration and fatty degeneration. Fatty infiltration occurs, to a certain extent, in normal livers, since the cells always contain minute globules of oil. In fatty degeneration, which is a much less common condition, the protoplasm of the liver-cells is destroyed and the fat takes its place, as seen in cases of malignant jaundice and in phosphorus poisoning. Fatty liver occurs under the following conditions: (a) In association with general obesity, in which case the liver appears to be one of the store-houses of the excessive fat. (i) In conditions in which the oxida- tion processes are interfered with, as in cachexia, profound anaemia, and in phthisis. The fatty infiltration of the liver in heavy drinkers is to be attributed to the excessive demand made by the alcohol upon the oxygen. (c) Certain poisons, of which phosphorus is the most characteristic, pro- duce an intense fatty degeneration with necrosis of the liver-cells. The poison of acute yellow atrophy, whatever its nature, acts in the same way. The fatty liver is uniformly increased in size. The edge may reach below the level of the navel. It is smooth, looks pale and bloodless; on section it is dry, and renders the surface of the knife greasy. The organ may weigh many pounds, and yet the specific gravity is so low that the entire organ floats in water. The symptoms of fatty liver are not definite. Jaundice is never pres- ent ; the stools may be light-colored, but even in the most advanced grades 490 DISEASES OF THE DIGESTIVE SYSTEM. the bile is still formed. Signs of portal obstruction are rare. Haemor- rhoids are not very infrequent. Altogether, the symptoms are ill-defined, and chiefly those of the disease with which the degeneration is associated. In cases of great obesity, the physical examination is uncertain; but in phthisis and cachectic conditions, the organ can be felt, greatly enlarged, smooth, and painless. Fatty livers are among the largest met with at the bedside. VIII. AMYLOID LIVER. The waxy, lardaceous, or amyloid liver occurs as part of a general degeneration, associated with cachexias, particularly when the result of long-standing suppuration. In practice, it is found oftenest in the prolonged suppuration of tuber- culous disease, either of the lungs or of the bones. Next in order of fre- quency are the cases associated with syphilis. Here there may be ulcera- tion of the rectum, with which it is often connected, or chronic disease of the bone, or it may be present when there are no suppurative changes. It is found occasionally in rickets, in prolonged convalescence from the infec- tious fevers, and in the cachexia of cancer. The amyloid organ is large, and may attain dimensions equalled only by that of the cancerous organ. Wilks speaks of a liver weighing four- teen pounds. It is solid, firm, resistant, on section ansemic, and has a semitranslucent, infiltrated appearance. Stained with a dilute solution of iodine, the areas infiltrated with the amyloid matter assume a rich mahog- any-brown color. The precise nature of this change is still in question. It first attacks the capillaries, usually of the median zone of the lobules, and subsequently the interlobular vessels and the connective tissue. The cells are but little if at all affected. There are no characteristic symptoms of this condition. Jaundice does not occur; the stools may be light-colored, but the secretion of bile persists. The physical examination shows the organ to be uniformly en- larged and painless, the surface smooth, the edges rounded, and the con- sistence greatly increased. Sometimes the edge, even in very great enlarge- ment, is sharp and hard. The spleen also may be involved, but there are no evidences of portal obstruction. The diagnosis of the condition is, as a rule, easy. Progressive and great enlargement in connection with suppuration of long standing or with syphilis, is almost always of this nature. In rare instances, however, the amyloid liver is reduced in size. In leukcemia the liver may attain considerable size and be smooth and uniform, resembling, on physical examination, the fatty organ. The blood condition at once indicates the true nature of the case. ANOMALIES IN FORM AND POSITION OF THE LIVER. IX. ANOMALIES IN FORM AND POSITION OF THE LIVER. In transposition of the viscera the right lobe of the organ may occupy the left side. A common and important anomaly is the tilting forward of the organ, so that the long axis is vertical, not transverse. Instead of the edge of the right lobe presenting just below the costal margin, a consider- able portion of the surface of the lobe is in contact with the abdominal parietes, and the edge may be felt as low, perhaps, as the navel. This an- teversion is apt to be mistaken for enlargement of the organ. The “ lacing” liver is met with in two chief types. In one, the anterior portion, chiefly of the right lobe, is greatly prolonged, and may reach the transverse navel line, or even lower. A shallow transverse groove sepa- rates the thin extension from the main portion of the organ. The peri- toneal coating of this groove may be fibroid, and in rare instances the de- formed portion is connected with the organ by an almost tendinous mem- brane. The liver may be compressed laterally and have a pyramidal shape, and the extreme left border and the hinder margin of the left lobe may be much folded and incurved. The projecting portion of the liver, extending low in the right flank, may be mistaken for a tumor, or more frequently for a movable right kidney. Its continuity with the liver itself may not be evident on palpation or on percussion, as coils of intestine may lie in front. It descends, however, with inspiration, and usually the margin can be traced continuously with that of the left lobe of the liver. The greatest difficulty arises when this anomalous lappet of the liver is either naturally very thick and united to the liver by a very thin membrane, or when it is swollen in conditions of great congestion of the organ. The other principal type of lacing liver is quite different in shape. It is thick, broader above than below, and lies almost entirely above the trans- verse line of the cartilages. There is a narrow groove just above the an- terior border, which is placed more transversely than normal.* Movable Liver.—This rare condition has received much attention of late, and J. E. Graham, in a recent paper, has collected seventy reported cases from the literature. In a very considerable number of these there has been a mistaken diagnosis. A slight grade of mobility of the organ is found in the pendulous abdomen of enteroptosis, and after repeated ascites. The organ is so connected at its posterior margin with the inferior vena cava and diaphragm that any great mobility from this point is im- possible, except on the theory of a meso-hepar or congenital ligamentous union between these structures. The ligaments, however, may be greatly relaxed (the suspensory 7-5 centimetres, and the triangular ligament 4 cen- timetres, in one of Leube’s cases); and when the patient is in the erect posture the organ may drop down so far that its upper surface is entirely below the costal margin. The condition is rarely met with in men ; fifty- six of the cases were in women. * See P. Hertz, Abnormitaten in der Lage und Form der Bauchorgane, Berlin, 1894. 492 DISEASES OF THE DIGESTIVE SYSTEM. IX. DISEASES OF THE PANCREAS. Normal conditions of the organ must not be mistaken for disease. It is often hard, and with very distinct lobulation. Atrophy is common in old age and in wasting diseases. Microscopically, the changes of self-digestion must not be mistaken for coagulation-necrosis. I. HAEMORRHAGE. Of late years much attention has been paid to this condition, which may prove rapidly fatal and has important medico-legal bearings. F. W. Draper * has reported five cases, in all of which death occurred either sud- denly or after a very short illness. The symptoms are thus briefly sum- marized by Prince: “ The patient, who has previously been perfectly well, is suddenly taken with the illness which terminates his life. . . . When the haemorrhage occurs the patient may be quietly resting or pursuing his usual occupa- tion. The pain which ushers in the attack is usually very severe, and lo- cated in the upper part of the abdomen. It steadily increases in severity, is sharp or perhaps colicky in character. It is almost from the first ac- companied by nausea and vomiting; the latter becomes frequent and ob- stinate, but gives no relief. The patient soon becomes anxious, restless, and depressed; he tosses about, and only with difficulty can be restrained in bed. The surface is cold, and the forehead is covered with a cold sweat. The pulse is weak, rapid, and sooner or later imperceptible. The abdo- men becomes tender, the tenderness being located in the upper part of the abdomen or epigastrium. Tympanites is sometimes marked. The tem- perature in most cases is either normal or below normal. The bowels are apt to be constipated. These symptoms continue without relief; those which are most striking being the pain, vomiting, anxiousness, restless- ness, and the state of collapse into which the patient soon falls.” Post mortem, the pancreas is found uniformly infiltrated with blood. Death, as Zenker suggests, is probably due to shock through the solar plexus. The haemorrhage may occur in connection with cancer of the organ. The blood may be effused into the lesser peritonaeum, or, if from the tail, about the spleen and left kidney, forming an enormous haematoma. * Transactions of the Association of American Physicians, vol. i. ACUTE PANCREATITIS. 493 II. ACUTE PANCREATITIS. (a) Acute Haemorrhagic Pancreatitis.—The admirable studies of Fitz* have crystallized our knowledge on this subject, and brought the affection within the scope of the diagnostician. A majority of the cases occur in persons over thirty. Many of the patients had been addicted to alcohol, and many had suffered from attacks of indigestion, occasionally with severe pains and vomiting. Morbid Anatomy.—The pancreas is found enlarged, and the interlobu- lar tissue infiltrated with blood, and perhaps with clots. In some instances the contiguous tissues may also be hsemorrhagic, and the whole may form a large, firm mass, situated at the upper and back part of the abdominal cavity. The root of the mesentery, the mesocolon, and the omentum may also show haemorrhages; the other organs may be practically normal. In most instances there can be seen about the lobules areas of opaque white tissue, and upon the omentum and mesentery similar opaque, white specks, which will be referred to subsequently as the fatty necrosis of Balser. In spots the gland-cells may also be found necrotic, while there may be cases showing a marked increase in the fibrous tissue. The symptoms of this condition are remarkable. The attack sets in with violent pain in the abdomen, usually in the upper left zone, but in some instances it is general. Nausea and vomiting are present, and usually con- stipation. Tympanitic distention of the abdomen is of frequent occurrence. Fever may be present, but is an inconstant symptom. There may be early delirium. Collapse symptoms supervene, and death occurs usually from the second to the fourth day, or even earlier. The swelling and infiltration in the region of the pancreas necessarily involve the cceliac plexus, and the stretching of the nerves may account for the agonizing pain and the sud- den collapse. In a case which I have reported the semilunar ganglia were swollen, the nerve-cells indistinct, and there was an interstitial infil- tration of round cells. The Facinian corpuscles in the neighborhood of the pancreas were enormously swollen and oedematous. A diagnosis of intestinal obstruction or of acute perforative peritonitis is usually made. A correct diagnosis was made in one case by Fitz, and the possibility of the presence of this condition must be considered in all abdominal cases which come on suddenly with intense pain in the epi- gastric region, vomiting, and distention of the abdomen. Perforation of a peptic ulcer or perforation from gall-stones might produce similar symptoms, but the previous history would give important indications. In the case in which the diagnosis was made by Fitz, the patient was sud- denly seized with severe pain in the epigastrium, followed by vomiting and prostration. The abdomen was distended, temperature slightly ele- vated, and the bowels were constipated. The diagnosis lay between ob- * Middleton-Goldsmith Lecture. New York Medical Record, vol. i, 1889. 494 DISEASES OF THE DIGESTIVE SYSTEM. sfcruction, perforative peritonitis, and acute pancreatitis. Laparotomy was performed, but no obstruction found. The autopsy showed acute haemor- rhagic pancreatitis. The cases are stated to be uniformly fatal, but recovery may occur, as shown by a case which was admitted to the Johns Hopkins Hospital. Symptoms of obstruction of the bowels had persisted for three or four days, the abdomen was distended, tender, and very painful. I saw the patient on admission, concurred in the diagnosis of probable obstruction, and, as the condition was serious, ordered him to be transferred at once to the operating-room. The coils were distended and injected, and the peri- toneal cavity contained a small amount of bloody serum. No obstruction Avas found, but in the region of the pancreas and at the root of the mesen- tery there was a dense, thick, indurated mass and there were areas of fat- necrosis in both mesentery and omentum. The patient recovered, and now, live years later, remains well. The literature of the past few years shows that this affection is much more frequent than has been supposed. It has a very important clinical and medico-legal bearing. A point of interest is the relation of the fat-necrosis to pancreatic dis- ease. The areas are found in the interlobular pancreatic tissue, in the mesentery, in the omentum, and in the abdominal fatty tissue generally. In the pancreas the lobules are seen to be separated by a dead-white ne- crotic tissue, which gives a remarkable appearance to the section. In the abdominal fat the areas are usually not larger than a pin’s head ; they at once attract attention, and may be mistaken, on superficial examination, for miliary tubercles or neoplasms. They may be larger; instances have been reported in which they were the size of a hen’s egg. On section they have a soft, tallowy consistence. Langerhans has shown that this sub- stance is a combination of lime Avith certain fatty acids. They may be crusted Avith lime, and in a man, aged eighty, Avho died of Bright’s dis- ease, I found the lobules of the pancreas entirely isolated by areas of fatty necrosis Avith extensive deposition of lime salts. There is no necessary etiological relation betAveen disease of the pancreas and disseminated fatty necrosis of the abdomen. Cases have been found accidentally in laparot- omy for ovarian tumor and in instances in which the pancreas has been normal. They may be found in thin persons. The bacterium coli com- mune Avas present in two cases, Avith diphtheritic colitis, examined by Welch, though in most cases the areas of necrosis are sterile. Langer- hans produced fat-necrosis by injecting extract of pancreas into the fatty tissue of a dog; and Hildebrand has shoAvn experimentally that the fat- necroses are caused by the pancreatic juice, and by the ferment, not the trypsin. (b) Suppurative Pancreatitis.—Of twenty-two cases analyzed by Fitz, the majority occurred in adults under forty years of age; seventeen were males. Anatomically, there may be a diffuse suppuration throughout the CHRONIC PANCREATITIS. 495 organ, which is studded with small abscesses. In other instances the abscess cavity is large, and the pancreas is converted into an* irregular cyst filled with creamy pus. In more chronic cases the abscess may be circumscribed and the contents cheesy. Communications sometimes oc- cur with the duodenum, or the abscess may burst into the peritonaeum. Although the disease is usually chronic, it begins with epigastric pain, vomiting, and sometimes prostration. There is irregular fever, and death may occur in three or four weeks. In more chronic cases there is very slight fever or only occasional paroxysms. The disease may persist for weeks, months, or even for a year. The symptoms are indefinite and the condition could scarcely be made out during life. Tenderness exists in the epigastrium, or may at times extend to the left and be quite sharply localized over the position of the pancreas, but a circumscribed tumor is rare. Fat-necrosis is not often found post mortem in these cases. (c) Gangrenous Pancreatitis.—Fitz has collected fifteen cases. The pancreas may be converted into a dark, slate-colored, stinking mass, or it may lie nearly free in the omental cavity, attached only by a few shreds of fibrous tissue. Complete sequestration of the organ is not uncommon. It may be discharged as a slough from the bowels, and in two cases in which this happened recovery took place. As a rule, acute perito- nitis follows. Haemorrhagic pancreatitis may precede or be associated with it. Death occurs with symptoms of collapse, commonly in from ten to twenty days. Disseminated fat-necrosis is usually present. In some instances the totally or partially sequestrated organ may be in a large abscess cavity, which may form a palpable tumor, lying usually just above or to the left of the umbilicus. In two instances of this nature operation and drainage have been followed by recovery. 111. CHRONIC PANCREATITIS. The organ is firmer and smaller than normal, the interstitial connect- ive tissue is increased, and there is more or less change in the secreting structures. A special interest has been aroused lately in this affection, as it has been frequently found in. diabetes. There may be marked pigmen- tary changes; a similar condition has been found in the liver. Degenera- tion of the glandular elements is present in these cases. The sclerosis may be associated with calculi in the ducts. An interstitial lipoma may cause great wasting of the lobules. IV. PANCREATIC CYSTS. These commonly result from the impaction of calculi ; either biliary, lodging at the orifice of the common duct, or pancreatic, within the duct of Wirsung. Obliteration of the duct may also result from cicatricial 496 DISEASES OF THE DIGESTIVE SYSTEM. contraction and occasionally from displacement. Eighteen cases of cysts of the pa*ncreas have been collected by Senn. An injury has preceded the onset of the disease; but in many cases, as shown by Jordan Lloyd, the fluid is in the lesser peritonasum (see localized peritonitis). The chief symptoms are tumor in the epigastric region, usually median, or sometimes to one side. When large, it has occupied the whole abdominal cavity, and in such instances the diagnosis of ovarian tumor has usually been made. The tumor may develop rapidly, or may be chronic and last for many years. In some instances the tumor attained a large size within a few weeks. Pain is not necessarily present. Fatty diarrhoea did not exist in any of the cases. The stools may be clay-colored, copious, and putrescent. The diagnosis of the condition is extremely difficult, yet it seems to have been made in 7 of the 18 cases. Aspiration should be made to determine the nature of the fluid. This has varied considerably, but most frequently has been brownish or chocolate-colored. In only 6 of the 17 cases in which the nature is mentioned was the fluid of a clear serous character. It presents some, at least, of the characters of pancreatic fluid, and can emulsify fat and convert starch into sugar. The tumor formed by a pancreatic cyst “ lies in or near the epigastrium, and causes protru- sion, at first, of the upper part of the abdomen. It usually appears in the left hypochondrium, between the costal cartilages and the median line; more rarely it is felt in the vicinity of the navel. It is globular, resistant, not elastic, smooth, usually changing its position somewhat with the movements of the diaphragm, and possessing a slight degree of lateral motion” (Fitz). V. CANCER. This is usually scirrhus, and may be primary or secondary. It is not common, as may be judged by the analysis by Segre, who found in 11,492 autopsies only 132 tumors of the pancreas, 127 of which were carcinomata, 2 sarcomata, 2 cysts, and 1 syphiloma. In only 12 of the cases of carcino- ma was the disease limited to the gland. The head is commonly affected, and the disease may be limited to this part or extend to it from the stom- ach or intestines. The symptoms are variable, and a diagnosis is not often possible. There may be stearrhoea, though it is to be remembered that fatty diar- rhoea is not invariably associated with disease of the pancreas. Clay-col- ored, greasy, and loose stools may be present, with undigested food, as noted by T. J. Walker as a symptom of obstruction of the pancreatic duct. Diabetes may coexist. Although the head of the pancreas can be felt in very thin persons, the tumor masses can rarely be palpated. In the analysis of 137 cases by Da Costa, in only 13 was the tumor recognized by palpation. The general symptoms are those of internal carcinoma. PANCREATIC CALCULI. 497 Progressive emaciation, loss of strength, and dyspepsia are present. There is pain in the epigastrium, sometimes paroxysmal. When the head of the pancreas is involved jaundice is almost invariably present. The disease can scarcely ever be distinguished from cancer in the pyloric zone with involvement of the glands in the hilus of the liver. The movable character of the pyloric tumor and the absence of the hydro- chloric acid in the vomit are valuable points. Tumor of the transverse colon is more superficial and movable, is often associated with temporary obstruction, and there may be haemorrhage from the bowels. In a case with progressive emaciation, epigastric pain, and deep-seated, immobile tumor, with the presence of fatty and greasy stools and the gradual devel- opment of jaundice, the diagnosis of cancer of the pancreas is probable. As the wasting proceeds the aortic pulsation is transmitted with great force through the pancreas and transverse colon, and when a tumor is present the diagnosis of aneurism may be made; but in the latter the sac has not an up-and-down jerking pulsation, but is distensile. In doubt- ful tumors in this region the examination should also be made in the knee- elbow position. Of other new growths in the pancreas, tubercle may be mentioned as a rare occurrence; a few cases of syphiloma have been described. The treatment of new growths in the pancreas is entirely symptomatic. VI. PANCREATIC CALCULI. Concretions are occasionally met with in the pancreatic ducts leading to great dilatation and to atrophy of the gland structure. They are often numerous, and are either round in shape, or rough, spinous, and coral-like. They are usually white, often of an opaque white in color, and are com- posed chiefly of carbonate of lime. When in large numbers they cause serious dilatation of the ducts with atrophy of the gland tissue, sometimes great cystic dilatation, rarely abscess. The symptoms of pancreatic calculi are not definite. In the majority of instances they are met with accidentally. There are cases, however, in which the disease is suggested by fatty stools and the presence of glyco- suria. Possibly certain obscure forms of colic may be caused by their presence, and Minnich has reported a case in which, after an attack of colic, calculi composed of calcic carbonate and phosphate were passed in the stools. 498 DISEASES OF THE DIGESTIVE SYSTEM. X. DISEASES OF THE PEKITONJiUM. I. ACUTE GENERAL PERITONITIS. Definition.—Acute inflammation of the peritonaeum. Etiology.—The condition may be primary or secondary. (a) Primary, Idiopathic Peritonitis.—Considering how frequently the pleura and pericardium are primarily inflamed the rarity of idiopathic inflammation of the peritonaeum is somewhat remarkable. It may follow cold or exposure and is then known as rheumatic peritonitis. No instance of the kind has come under my notice. Occasionally in Bright’s disease acute peritonitis develops as a terminal event. (b) Secondary Peritonitis is due to extension of inflammation from, or perforation of one of the organs covered by the peritonaeum. Peritonitis from extension may follow inflammation of the stomach or intestines, extensive ulceration in these parts, cancer, acute suppurative inflammations of the spleen, liver, pancreas, retroperitoneal tissues, and the pelvic viscera. Perforative peritonitis is the most common, following external wounds, perforation of ulcer of the stomach or boAvels, perforation of the gall- bladder, abscess of the liver, spleen, or kidneys. Two important causes are appendicitis and suppurating inflammation about the Fallopian tubes and ovaries. There are instances in which peritonitis has followed rupture of an apparently normal Graafian follicle. The peritonitis of septicaemia and pyaemia is almost invariably the re- sult of a local process. An exceedingly acute form of peritonitis may be caused by the development of tubercles on the membrane. Morbid Anatomy.—In recent cases, on opening the abdomen the intestinal coils are distended and glued together by lymph, and the peri- tonaeum presents a patchy, sometimes a uniform injection. The exuda- tion may be : (a) Fibrinous, with little or no fluid, except a few pockets of clear serum between the coils, (b) Sero-fibrinous. The coils are cov- ered with lymph, and there is in addition a large amount of a yellowish, sero-fibrinous fluid. In instances in which the stomach or intestine is perforated this may be mixed with food or feces. (c) Purulent, in which the exudate is either thin and greenish yelloAv in color, or opaque AAdiite and creamy, (d) Putrid. Occasionally in puerperal and perforative peri- tonitis, particularly Avhen the latter has been caused by cancer, the exudate is thin, grayish green in color, and has a gangrenous odor, (e) Haemor- rhagic. This is sometimes found as an admixture in cases of acute peri- tonitis following AATounds, and occurs in the cancerous and tuberculous forms. The amount of the effusion varies from half a litre to twenty or thirty litres. There are probably essential differences betAveen the various kinds ACUTE GENERAL PERITONITIS. 499 of peritonitis, and bacteriology is beginning to give ns valuable informa- tion on this point. Much work has been done lately upon the subject, the most important by Tavel and Lanz. Of 59 cases examined by them, the streptococcus pyogenes was found alone in 30, in association in 15 ; the bacillus coli communis alone in 15, in association in 16 ; the staphylo- coccus alone in 2, in association in 6; the pneumococcus in combination in 2 cases. In a majority of instances of peritonitis from perforation the bacillus coli communis is present, usually in pure culture. Welch has found it also in peritonitis due to ulceration of the intestines without per- foration. In a very interesting case in my wards of a young woman aged eighteen, with contracted kidney and uraemia, there was an acute peri- tonitis, from which Flexner isolated the proteus vulgaris in pure culture. Two cases have been reported by Flexner in which the pneumococcus alone was present. Of other organisms which have been found may be mentioned the bacillus pyocyaneus, the anthrax bacillus, and the bacillus aerogenes capsulatus. Symptoms.—In the perforative and septic cases the onset is marked by chilly feelings or an actual rigor with intense pain in the abdomen. In typhoid fever, when the sensorium is benumbed, the onset may not be noticed. The pain is general, and is usually intense and aggravated by movements and pressure. A position is taken which relieves the tension of the abdominal muscles, so that the patient lies on the back with the thighs drawn up and the shoulders elevated. The greatest pain is usually below the umbilicus, but in peritonitis from perforation of the stomach pain may be referred to the back, the chest, or the shoulder. The respira- tion is superficial—costal in type—as it is painful to use the diaphragm. For the same reason the action of coughing is restrained, and even the movements necessary for talking are limited. In this early stage the sensi- tiveness may be great and the abdominal muscles are often rigidly con- tracted. If the patient is at perfect rest the pain may be very slight, and there are instances in which it is not at all marked, and may, indeed, be absent. The abdomen gradually becomes distended and tense and is tympanitic on percussion. • The pulse is rapid, small, and hard, and often has a peculiar wiry quality. It ranges from 110 to 150. The temperature may rise rap- idly after the chill and reach 104° or 105°, but the subsequent elevation is moderate. In some very severe cases there may be no fever throughout. The tongue at first is white and moist, but subsequently becomes dry and often red and fissured. Vomiting is an early and prominent feature and causes great pain. The contents of the stomach are first ejected, then yellowish and bile-stained fluid, and finally a greenish and, in rare in- stances, a brownish-black liquid with slight faecal odor. The bowels may be loose at the onset and then constipation follows. Frequent micturition may be present, less often retention. The urine is usually scanty and high-colored, and contains a large quantity of indican. 500 DISEASES OF THE DIGESTIVE SYSTEM. The appearance of the patient when these symptoms have fully devel- oped is very characteristic. The face is pinched, the eyes are sunken, and the expression is very anxious. The constant vomiting of fluids causes a wasted appearance, and the hands sometimes present the washer-woman’s skin. Except in cholera, we see the Hippocratic facies more frequently in this than in any other disease—“ a sharp nose, hollow eyes, collapsed temples; the ears cold, contracted, and their lobes turned out; the skin about the forehead being rough, distended, and parched ; the color of the whole face being broivn, black, livid, or lead-colored.” There are one or two additional points about the abdomen. The tympany is usually ex- cessive, owing to the great relaxation of the walls of the intestines by in- flammation and exudation. The splenic dulness may be obliterated, the diaphragm pushed up, and the apex beat of the heart dislocated to the fourth interspace. The liver dulness may be greatly reduced, or may, in the mammary line, be obliterated. It has been claimed that this is a dis- tinctive feature of perforative peritonitis, but on several occasions I have been able to demonstrate that the liver dulness in the middle and mam- mary line was obliterated by tympanites alone. In the axillary line, on the other hand, the liver dulness, though diminished, may persist. Pneumo- peritonaeum following perforation more certainly obliterates the hepatic dulness. In such cases the fluid effused prpduces a dulness in the lateral region; but with gas in the peritonaeum, if the patient is turned on the left side, a clear note is heard beneath the seventh and eighth ribs. Effusion of fluid—ascites—is usually present except in some acute, rapidly fatal cases. The flanks are dull on percussion. The dullness may be movable, though this depends altogether upon the degree of adhesions. There may be considerable effusion without either movable dulness or fluctuation. A friction-rub may be present, as first pointed out by Bright, but it is not nearly so common in acute as in chronic peritonitis. Course.—The acute diffuse peritonitis usually terminates in death. The most intense forms may kill within thirty-six or forty-eight hours; more commonly death results in four or five days, or the attack may be prolonged to eight or ten days. The pulse becomes irregular, the heart- sounds weak, the breathing shallow, there are lividity with pallor, a cold skin, with high rectal temperature—a group of symptoms indicating profound failure of the vital functions for which Gee has revived the old term UpGthymia. Occasionally death occurs with great suddenness, owing, possibly, to paralysis of the heart. Diagnosis.—In typical cases the severe pain at onset, the distention of the abdomen, the tenderness, the fever, the gradual development of effusion, collapse symptoms, and the vomiting give a characteristic picture. Careful inquiries should at once be made concerning the previous condi- tion, from which a clew can often be had as to the starting-point of *the trouble. In young adults a considerable proportion of all cases depends upon perforating appendicitis, and there may be an account of previous ACUTE GENERAL PERITONITIS. 501 attacks of pain in the iliac region, or of constipation alternating with diar- rhoea. In women the most frequent causes are suppurative processes in the pelvic viscera, either associated with salpingitis, abscesses in the broad ligaments, or acute puerperal infection. Perforation of gastric ulcer is more common also in women. It is not always easy to determine the cause. Many cases come under observation for the first time with the abdomen distended and tender, and it is impossible to make a satisfactory examination. In such instances the pelvic organs should be examined with the greatest care. In typhoid fever, if the patient is conscious, the sudden onset of pain, the development of great meteorism, and the aggra- vation of the general symptoms indicate clearly what has happened. When the patient is in deep coma, on the other hand, the perforation may be overlooked. The following conditions are most apt to be mistaken for acute peritonitis: (a) Acute Entero-colitis.—Here the pain and distention and the sen- sitiveness on pressure may be marked. The pain is more colicky in char- acter, the diarrhoea is more frequent, and the collapse is more extreme. (b) The So-called Hysterical Perito7iitis.—This has deceived the very elect, as almost every feature of genuine peritonitis, even the collapse, may be simulated. The onset may be sudden, with severe pain in the abdomen, tenderness, vomiting, diarrhoea, difficulty in micturition, and the charac- teristic decubitus. Even the temperature may be elevated. There may be recurrence of the attack. A case has been reported by Bristowe in which four attacks occurred within a year, and it was not until special hysterical symptoms developed that the true nature of the trouble was suspected. (o) Obstruction of the boivel, as already mentioned, may simulate peri- tonitis, both having pain, vomiting, tympanites, and constipation in com- mon. It may for a couple of days really be impossible to make a diagnosis in the absence of a satisfactory history. (d) Rupture of an abdominal aneurism or embolism of the superior mesenteric artery may cause symptoms which simulate peritonitis. In the latter, sudden onset with severe pain, the collapse symptoms, frequent vomiting, and great distention of the abdomen may be present. (e) I have already referred to the fact that acute haemorrhagic pan- creatitis may be mistaken for peritonitis. Lastly, a ruptured tubal preg- nancy may resemble acute peritonitis. A patient was admitted to my wards in an enfeebled condition, with a thready pulse, distended and ten- der abdomen, and signs of fluid. The attack had come on suddenly four days before, when she had been in perfect health. She looked pale, the blood count was taken and found below three millions per cubic centi- metre, with leucocytosis, a condition rather indicating anaemia from haem- orrhage. The abdomen was tapped with a fine aspirator needle and a bloody fluid withdrawn. The diagnosis of probable ruptured tubal preg- nancy was made and the patient was transferred to the gynaecological de- partment, where laparotomy was performed and the ruptured tube removed. 502 DISEASES OF THE DIGESTIVE SYSTEM. II. PERITONITIS IN INFANTS. Peritonitis may occur in the foetus as a consequence of syphilis, and may lead to constriction of the bowel by fibrous adhesions. In the new-born a septic peritonitis may extend from an inflamed cord. Distention of the abdomen, slight swelling and redness about the cord, and not infrequently jaundice are present. It is an uncommon event, and existed in only four of fifty-one infants dying of inflammation of the cord and septicaemia (Runge). During childhood peritonitis develops from causes similar to those af- fecting the adult. Perforative appendicitis is common. Peritonitis fol- lowing blows or kicks on the abdomen occurs more frequently at this period. In boys injury while playing foot-ball may be followed by diffuse peritonitis. A rare cause in children is extension through the diaphragm from an empyema. There are on record instances of peritonitis occurring in several children at the same school, and it has been attributed to sewer- gas poisoning. It was in investigating an epidemic of this kind at the Wandsworth school, in London, that Anstie received the post-mortem wound of which he died. III. LOCALIZED PERITONITIS. 1. Subphrenic Peritonitis.—The general peritonasum covering the right and left lobes of the liver may be involved in an extension from the pleura of suppurative, tuberculous, or cancerous processes. In various affections of the liver—cancer, abscess, hydatid disease, and in affections of the gall-bladder—the inflammation may be localized to the peritonaeum cover- ing the upper surface of the organ. These forms of localized subphrenic peritonitis in the greater sac are not so important in reality as those which occur in the lesser peritonaeum. The anatomical relations of this struc- ture are as follows: It lies behind and below the stomach, the gastro- hepatic omentum, and the anterior layer of the great omentum. Its lower limit forms the upper layer of the transverse meso-colon. On either side it reaches from the hepatic to the splenic flexures of the colon, and from the foramen of Winslow to the hilus of the spleen. Behind it cov- ers and is tightly adherent to the front of the pancreas. Its upper limit is formed by the transverse fissure of the liver, by that portion of the diaphragm which is covered by the lower layer of the right lateral liga- ment of the liver, and the lobus Spigelii lies bare in the cavity. The foramen of Winslow, through which the lesser communicates with the greater peritonaeum, is readily closed by inflammation. Inflammatory processes, exudates, and haemorrhages may be confined entirely to the lesser peritonaeum. The exudate of tuberculous peritonitis LOCALIZED PERITONITIS. 503 may be confined to it. Perforations of certain parts of the stomach, of the duodenum, and of the colon may excite inflammation in it alone; and in various affections of the pancreas, particularly trauma and haemorrhage, the effusion into the sac has often been confounded with cyst of this organ. “ Pathological distention of the lesser peritonaeum gives rise to a tumor in the left hypochondriac, epigastric, and umbilical regions of a somewhat characteristic shape, but which appears to vary from time to time in form and size, according to the conditions of the overlying stomach; for when the viscus is full of liquid contents it increases the area of the tumor’s dulness, while it makes its outlines less definable by pal- pation, and if the stomach is distended with gas the dull area becomes resonant and apparently the tumor may disappear altogether. The colon always lies below the tumor and never in front of or above it, as is the case in kidney enlargement ” (Jordan Lloyd). Special mention must be made of the remarkable form of sub- phrenic abscess containing air, which may simulate closely pneumo- thorax, and hence was called by Leyden Pyo-pneumothorax subphrenicus. The affection has been thoroughly studied of late years by Scheurlen, Mason, Meltzer, and Lee Dickinson. In 142 out of 170 recorded cases the cause was known. In a few instances, as in one reported by Meltzer, the subphrenic abscess seemed to have followed pneumonia. Pyothorax is an occasional cause. By far the most frequent condition is gastric ulcer, which occurred in 80 of the cases. Duodenal ulcer was the cause in six per cent. In about ten per cent of the cases the appendix was the starting-point of the abscess. Cancer of the stomach is an occasional cause. Other rare causes are trauma, which was present in one of my cases, perforation of hepatic or renal abscess, lesions of the spleen, abscess, and cysts of the pancreas. In a majority of all the cases in which the stomach or duodenum is perforated—sometimes, indeed, in the cases following trauma, as in Case 3 of my series—the abscess contains air. The symptoms of subphrenic abscess vary very considerably, depending a good deal upon the primary cause. The onset, as a rule, is abrupt, particularly when due to perforation of a gastric ulcer. There are severe pain, vomiting, often of bilious or of bloody material; respiration is em- barrassed, owing to the involvement of the diaphragm; then the con- stitutional symptoms develop associated with suppuration, chills, irregu- lar fever, emaciation. Subsequently perforation may take place into the pleura or into the lung, with severe cough and abundant purulent ex- pectoration. The conditions are so obscure that the diagnosis of subphrenic ab- scess is not often made. The perihepatic abscess beneath the arch of the diaphragm, whether to the right or left of the suspensory ligament, when it does not contain air, is almost invariably mistaken for empyema. When a pus collection of any size is in the lesser peritonaeum, the tumor 504 DISEASES OF THE DIGESTIVE SYSTEM. is formed which has the characters already mentioned in a quotation from Mr. Jordan Lloyd. The most remarkable features are those which are superadded when the abscess cavity contains air. Here, on the right side, when the abscess is in the greater peritonaeum, above the right lobe of the liver, the dia- phragm may be pushed up to the level of the second or third rib, and the physical signs on percussion and auscultation are those of pneumo- thorax, particularly the tympanitic resonance and the movable dulness. The liver is usually greatly depressed and there is bulging on the right side. Still more obscure are the cases of air-containing abscesses due to perforation of the stomach or duodenum, in which the gas is contained in the lesser peritonaeum. Here the diaphragm is pushed up and there are signs of pneumothorax on the left side. In a large majority of all the cases which follow perforation of a gastric ulcer the effusion lies be- tween the diaphragm above, the spleen, stomach, and the left lobe of the liver below. The prognosis in cases of subphrenic abscess is not very hopeful. Of the cases on record about 20 per cent only have recovered. Of the five cases which have come under my observation, three recovered after operation. 2. Appendicular.—The most frequent cause in the male of localized peritonitis is inflammation of the appendix vermiformis. The situation varies with the position of this extremely variable organ. The adhesion, perforation, and intraperitoneal abscess cavity may be within the pelvis, or to the left of the median line in the iliac region, in the lower right quadrant of the umbilical region—a not uncommon situation—or, of course, most frequently in the right iliac fossa. In the most common situation the localized abscess lies upon the psoas muscle, bounded by the caecum on the right and the terminal portion of the ileum and its mesentery in front and to the left. In many of these cases the limitation is perfect, and post-mortem records show that complete healing may take place with the obliteration of the appendix in a mass of firm scar tissue. 3. Pelvic Peritonitis.—The most frequent cause is inflammation about the uterus and Fallopian tubes. Puerperal septicaemia, gonorrhoea, and tuberculosis are the usual causes. The tubes are the starting-point in a majority of the cases. The fimbriae become adherent and closely matted to the ovary, and there is gradually produced a condition of thickening of the parts, in which the individual organs are scarcely recognizable. The tubes are dilated and filled with cheesy matter or pus, and there may be small abscess cavities in the broad ligaments. Rupture of one of these may cause general peritonitis, or the membrane may be involved by exten- sion, as in tuberculosis of these parts. CHRONIC PERITONITIS. 505 IV. CHRONIC PERITONITIS. The following varieties may be recognized: (a) Local adhesive perito- nitis, a very common condition, which occurs particularly about the spleen, forming adhesions between the capsule and the diaphragm, about the liver, less frequently about the intestines and mesentery. Points of thickening or puckering on the peritonaeum occur sometimes with union of the coils or fibrous bands. In a majority of such cases the condition is met acci- dentally post mortem. Two sets of symptoms may, however, be caused by these adhesions. When a fibrous band is attached in such a way as to form a loop or snare, a coil of intestine may pass through it. Thus, of the 295 cases of intestinal obstruction analyzed by Fitz, 63 were due to this cause. The second group is less serious and comprises cases with persistent abdominal pain of a colicky character, sometimes rendering life miserable. Instances of this kind have been successfully operated upon by Homans and H. A. Kelly. (b) Diffuse Adhesive Peritonitis.—This is a consequence of an acute inflammation, either simple or tuberculous. The peritonaeum is obliter- ated. On cutting through the abdominal wall, the coils of intestines are uniformly matted together and can neither be separated from each other nor can the visceral and parietal layers be distinguished. There may be thickening of the layers, and the liver and spleen are usually involved in the adhesions. (c) Proliferative Peritonitis.—Apart from cancer and tubercle, which produce typical lesions of chronic peritonitis, the most characteristic form is that which may be described under this heading. The essential anatomical feature is great thickening of the peritoneal layers, usually without much adhesion. The cases are sometimes found with cirrhosis of the stomach. In one instance I found it in connection with a cirrhotic condition of the caecum and the first part of th6 colon. In the inspection of a case of this kind there is usually moderate effusion, more rarely exten- sive ascites. The peritonaeum is opaque-white in color, and everywhere thickened, often in patches. The omentum is usually rolled and forms a thickened mass transversely placed between the stomach and the colon. The peritonaeum over the stomach, intestines, and mesentery is sometimes greatly thickened. The liver and spleen may simply be adherent, or there is a condition of chronic perihepatitis or perisplenitis, so that a layer of firm, almost gristly connective tissue of from one fourth to half an inch in thickness encircles these organs. Usually the volume of the liver is in consequence greatly reduced. The gastro-hepatic omentum may be con- stricted by this new growth and the calibre of the portal vein much nar- rowed. A serous effusion may be present. On account of the adhesions which form, the peritonaeum may be divided into three or four different sacs, as is more fully described under the tuberculous peritonitis. In these cases the intestines are usually free, though the mesentery is greatly 506 DISEASES OF THE DIGESTIVE SYSTEM. shortened. There are instances of chronic peritonitis in which the mes- entery is so shortened by this proliferative change that the intestines form a ball not larger than a cocoa-nut situated in the middle line, and after re- moval of the exudation can be felt as a solid tumor. The intestinal wall is greatly thickened and the mucous membrane of the ileum is thrown iuto folds like the valvulse conniventes. This proliferative peritonitis is found frequently in the subjects of chronic alcoholism. In all forms of chronic peritonitis a friction may be felt usually in the upper zone of the abdomen. In some instances of chronic peritonitis the membrane presents numer- ous nodular thickenings, which may be mistaken for tubercles. They may be scattered in numbers on the membranes, and it may be extremely difficult, without the most careful microscopical examination, to deter- mine their nature. J. F. Payne has described a case of this sort associ- ated with disseminating growths throughout the liver which were not cancerous. It has been suggested that some of the cases of tuberculous peritonitis cured by operation have been of this nature, but histological examination would, as a rule, readily determine between the conditions. Miura, in Japan, has reported a case in which these nodules contained the ova of a parasite. (d) Chronic Haemorrhagic Peritonitis.—Blood-stained effusions in the peritonaeum occur particularly in cancerous and tuberculous disease. There is a form of chronic inflammation analogous to the haemorrhagic pachymen- ingitis of the brain. It was described first by Virchow, and is localized most commonly in the pelvis. Layers of new connective tissue form on the surface of the peritonaeum with large wide vessels from which haemor- rhage occurs. This is repeated from time to time with the formation of regular layers of haemorrhagic effusion. It is rarely diffuse, more com- monly circumscribed. V. NEW GROWTHS IN THE PERITONEUM. (a) Tuberculous Peritonitis.—This has already been considered. (b) Cancer of the Peritonseum.—Although as a rule secondary to dis- ease of the stomach, liver, or pelvic organs, cases of primary cancer are occasionally found. Secondary malignant peritonitis occurs in connection with all forms of cancer. It is usually characterized by a number of round tumors scattered over the entire peritonaeum, sometimes small and miliary, at others large and nodular, with puckered centres. The disease most commonly starts from the stomach or the ovaries. The omentum is indurated, and, as in tuberculous peritonitis, forms a mass which lies transversely across the upper portion of the abdomen. Primary malig- nant disease of the peritonaeum is extremely rare. Colloid has occurred, forming enormous masses, which in one case weighed over one hundred ASCITES. 507 pounds. Cancer of this membrane spreads, either by the detachment of small particles which are carried in the lymph currents and by the move- ments to distant parts, or by contact of opposing surfaces. It occurs more frequently in women than in men, and more commonly at the later period of life. The diagnosis of cancer of the peritonaeum is easy with a history of a local malignant disease; as when it occurs with ovarian tumor or with cancer of the pylorus. In cases in which there is no evidence of a primary lesion the diagnosis may be doubtful. The clinical picture is usually that of chronic ascites with progressive emaciation. There may be no fever. If there is much effusion nothing definite can be felt on ex- amination. After tapping, irregular nodules or the curled omentum may be felt lying transversely across the upper portion of the abdomen. Un- fortunately, this tumor upon which so much stress is laid occurs as fre- quently in tuberculous peritonitis and may be present in a typical manner in chronic proliferative form, so that in itself it has no special diagnostic value. Multiple nodules, if large, indicate cancer, particularly in persons above middle life. Nodular tuberculous peritonitis is most frequent in children. The presence about the navel of secondary nodules and indu- rated masses is more common in cancer. Inflammation, suppuration, and the discharge of pus from the navel rarely occur except in tuberculous disease. Considerable enlargement of the inguinal glands may be present in cancer. The nature of the fluid in cancer and in tubercle may be much alike. It may be haemorrhagic in both; more often in the latter. The histological examination in cancer may show large multinuclear cells- or groups of cells—the sprouting cell-groups of Foulis—which are extremely suggestive. The colloid cancer may produce a totally different picture; instead of ascitic fluid, the abdomen is occupied by the semi-solid gelati- nous substance, and is firm, not fluctuating. And, lastly, there are instances of echinococci in the peritonaeum which may simulate cancer very closely. I have reported a case of this kind, in which the enlarged liver and the innumerable nodular masses in the peri- tonaeum naturally led to this diagnosis. VI. ASCITES (Hydro-peritonaeum). Definition. — The accumulation of serous fluid in the peritoneal cavity. Etiology.—(1) Local Causes.—(a) Chronic inflammation of the peri- tonaeum, either simple, cancerous, or tuberculous, (b) Portal obstruction in the terminal branches within the liver, as in cirrhosis, or by compression of the vein in the gastro-hepatic omentum, either by proliferative perito- nitis, by new growths, or by aneurism, (c) Tumors of the abdomen. The solid growths of the ovaries may cause considerable ascites, which may 508 DISEASES OP THE DIGESTIVE SYSTEM. completely mask the true condition. The enlarged spleen in leukaemia, less commonly in malaria, may be associated with recurring ascites. (2) General Causes.—The ascites is part of a general dropsy, the re- sult of mechanical effects, as in heart-disease, chronic emphysema, and cirrhosis of the lung. In cardiac lesions the effusion is sometimes con- fined to the peritonaeum, in which case it is due to secondary changes in the liver, or it has been suggested to be connected with a failure of the suction action of this organ, by which the peritonaeum is kept dry. Ascites occurs also in the dropsy of Bright’s disease, and in hydraemic states of the blood. Symptoms.—A gradual uniform enlargement of the abdomen is the characteristic symptom of ascites. The physical signs are usually distinct- ive. (a) Inspection.—According to the amount of fluid the abdomen is protuberant and flattened at the sides. With large effusions, the skin is tense and may present the lineae albicantes. Frequently the navel itself and the parts about it are very prominent. In many cases the superficial veins are enlarged and a plexus joining the mammary vessels can be seen. Sometimes it can be determined by pressure on these veins that the cur- rent is from below upward. In some instances, as in thrombosis or oblit- eration of the portal vein, these superficial abdominal vessels may be ex- tensively varicose. About the navel in cases of cirrhosis there is occa- sionally a large bunch of distended veins, the so-called caput Medusae. (b) Palpation.—Fluctuation is obtained by placing the fingers of one hand upon one side of the abdomen and by giving a sharp tap on the op- posite side with the other hand, when a wave is felt to strike as a definite shock against the applied fingers. Even comparatively small quantities of fluid may give this fluctuation shock. When the abdominal walls are thick or very fat, an assistant may place the edge of the hand or a piece of card-board in the front of the abdomen. A different procedure is adopted in palpating for the solid organs in case of ascites. Instead of plac- ing the hand flat upon the abdomen, as in the ordinary method, the pads of the fingers only are placed lightly upon the skin, and then by a sudden depression of the fingers the fluid is displaced and the solid organ or tumor may be felt. By this method of “ dipping ” or displacement, as it is called, the liver may be felt below the costal margin, or the spleen, or sometimes solid tumors of the omentum or intestine. (c) Percussion.—In the dorsal position with a moderate quantity of fluid in the peritonaeum the flanks are dull, while the umbilical and epi- gastric regions, into which the intestines float, are tympanitic. This area of clear resonance may have an oval outline. Having obtained the lateral limit of the dulness on one side, if the patient then turns on the opposite side, the fluid gravitates to the dependent part and the uppermost flank is now tympanitic. In moderate effusions this movable dulness changes greatly in the different postures. Small amounts of fluid, probably under a litre, would scarcely give movable dulness, as the pelvis and the renal ASCITES. 509 regions hold a considerable quantity. In such cases it is best to place the patient in the knee-elbow position, when a dull note will be determined at the most dependent portion. By careful attention to these details mis- takes are usually avoided. The following are among the conditions which may be mistaken for dropsy: Ovarian tumor, in which the sac develops, as a rule, unilaterally, though when large it is centrally placed. The dulness is anterior and the resonance is in the flanks, into which the intestines are pushed by the cyst. Examination per vaginam may give important indications. In those rare instances in which gas develops in the cyst the diagnosis may be very diffi- cult. Succussion has been obtained in such cases. A distended bladder may reach above the umbilicus. In such instances some urine dribbles away, and suspicion of ascites or a cyst is occasionally entertained. I once saw a trochar thrust into a distended bladder, which was supposed to be an ovarian cyst, and it is stated that John Hunter tapped a bladder, sup- posing it to be ascites. Such a mistake should be avoided by careful catheterization prior to any operative procedures. And lastly, there are large pancreatic or hydatid cysts in the abdomen which may simulate ascites. Nature of the Ascitic Fluid.—Usually this is a clear serum, light yel- low in the ascites of anaemia and Bright’s disease, often darker in color in cirrhosis of the liver. The specific gravity is low, seldom more than 1-010 or 1-015. In the fluid of ovarian cysts the specific gravity is high, 1-020 or over. It is albuminous and sometimes coagulates spontaneously. Haemor- rhagic effusion usually occurs in cancer and tuberculosis, and occasionally in cirrhosis. I have already referred to the instances of haemorrhagic effu- sion in connection with ruptured tubal pregnancy. A chylous, milky ex- udate is occasionally found. Busey has collected thirty-three cases from the literature. There are, as Quincke has pointed out, two distinct varie- ties, a fatty and a chylous, which may be distinguished by the microscope, as in the former there are distinct fat-globules. These cases have been sometimes connected with peritoneal or mesenteric cancer. In the true chylous ascites the fluid is turbid and milky. In some of the cases, as in Whitla’s, a perforation of the thoracic duct has been found. The condi tion does not necessarily follow obliteration of the thoracic duct. Mild grades of chylous ascites, which are occasionally found clinically, may be due to the fact that the patient upon a milk diet has a permanent lipaemia, such as is present in young animals and in diabetics, in whom the liquor sanguinis is always fatty. Under such circumstances an exu- date may contain enough of the molecular base of the chyle to produce turbidity of the fluid. Some of the cases have been associated with filariasis. Treatment of the Previous Conditions. — (a) Acute Peri- tonitis.—Rest is enjoined upon the patient by the severe pain which fol- lows the slightest movement, and he should be propped in the position 510 DISEASES OF THE DIGESTIVE SYSTEM. whicli gives him greatest relief. For the pain morphia should be injected hypodermically in full doses. In an adult it is better to give a third or half a grain at once, and 'subsequently at intervals repeat it in smaller doses, as are necessary. The action of the drug should be carefully watched and the patient should not be allowed to pass into such a degree of unconsciousness that he cannot be aroused. The respiration and the condition of the pupils also give valuable information. The amount of opium which has been given in certain instances is remarkable, and indi- cates a tolerance of the drug. The doses given by the late Alonzo Clark, of New York, may be truly termed heroic. Austin Flint notes that a patient under the care of this physician took “ in the first twenty-four hours,' of opium and the sulphate of morphia, a quantity equivalent to 106 grains of opium; in the second twenty-four hours she took 472 grains; on the third day, 236 grains; on the fourth day, 120 grains; on the fifth day, 54 grains; on the sixth day, 22 grains; on the seventh day, 18 grains; after which the treatment was suspended.” It is unnecessary to use these enormous doses, as, even when the pain is most intense, from a third to a half grain of morphia every few hours will usually keep the patient thoroughly under the influence of the drug. In a robust, strong patient, seen at the outset, twenty leeches applied over the abdomen will give great relief. Local applications—either hot turpentine stupes or cloths wrung out of ice-water—may be laid upon the abdomen. The patients sometimes declare that they are greatly relieved by the latter. The question of the use of purgatives in peritonitis has of late been warmly discussed. Lawson Tait and other gynaecologists have used the saline purges with the greatest benefit in post-operation peritonitis. Theo- retically it appears correct to give salines in concentrated form, which cause a rapid and profuse exosmosis of serum from the intestinal vessels, relieving the congestion and reducing the oedema, which is one important factor in causing the meteorism. It is also urged that the increased peri- stalsis prevents the formation of adhesions. In reading the reports of these successful cases, one is not always convinced, however, that peritonitis actually existed. Still, in cases of acute peritonitis due to extension or following operation or in septic conditions the judgment of many careful men is decidedly in favor of the use of salines. I cannot speak from per- sonal experience on this question. The majority of cases of peritonitis which come under the care of the physician follow lesions of the abdominal viscera or are due to perforation of ulcer of the stomach, the ileum, or the appendix. In such cases, particularly in the large group of appendix cases, to give saline purgatives is, to say the least, most injudicious treatment. The safety of the patient lies in the restriction of the peristalsis and the localization of the inflammation, for which purpose opium alone is of service. In these instances rectal injections should be employed to relieve the large bowel. No symptom in acute peritonitis is more serious than ASCITES. 511 the tympanites, and none is more difficult to meet. The use of the long tube and injections containing turpentine may be tried. Drugs by the mouth cannot be retained. For the vomiting, ice and small quantities of soda water may be em- ployed. The patient should be fed on milk, but if the vomiting is dis- tressing it is best not to attempt to give food by the mouth, but to use small nutrient enemata. In all cases of peritonitis it is best to have a sur- geon in consultation early in the disease, as the question of operation may come up at any moment. I have already mentioned the conditions under which laparotomy is indicated in perforative appendicitis. The acute purulent cases, particularly those in which the streptococci occur, usually die; but although the results of operative interference in this form have not as yet been very brilliant, the condition, we must remember, is almost hopeless, and too often there has been unnecessary delay in calling in sur- gical aid. In the acute forms of tuberculous peritonitis operation appears to be more hopeful, but they are not always successful. (b) Chronic Peritonitis.—For the cases of chronic proliferative peri- tonitis very littie can be done. The treatment is practically that of ascites. In all these forms, when the distention becomes extreme, tapping is indi- cated. The treatment of tuberculous peritonitis has fallen largely into the hands of the surgeons, and the results in many cases are very good. According to the statistics of Maurange,* of 71 cases, 28 survived the operation for more than a year. Of 26 additional cases which I have col- lected,! 14 were dead at the time of the report. Within two years and three months there were six operations performed at the Johns Hopkins Hospital in tuberculous peritonitis, with four recoveries. (c) Ascites.—The treatment depends somewhat on the nature of the case. In cirrhosis early and repeated tapping may give time for the estab- lishment of the collateral circulation, and temporary cures have followed this procedure. Permanent drainage with Southey’s tube, incision, and washing out the peritonaeum have also been practised. In the ascites of heart and renal disease the cathartics are most satisfactory, particularly the bitartrate of potash, given alone or with jalap, and the large doses of salts given an hour before breakfast with as little water as possible. These sometimes cause rapid disappearance of the effusion, but they are not so successful in ascites as in pleurisy with effusion. The stronger cathartics may sometimes be necessary. The ascites forming part of the general anasarca of Bright’s disease will receive consideration under another section. * Paris Thesis, 1889. f On Tuberculous Peritonitis, Johns Hopkins Hospital Reports, 1890. SECTION IV. DISEASES OF THE RESPIRATORY SYSTEM. I. DISEASES OF THE NOSE. I. ACUTE CORYZA. Acute catarrhal inflammation of the upper air-passages, popularly known as a “ catarrh ” or a “ cold,” is usually an independent affection, hut may precede the development of another disease. Etiology.—It prevails most extensively in the changeable weather of the spring and early winter, and may occur in epidemic form, many cases developing in a community within a few weeks. These outbreaks are very like, though less intense than the epidemic influenza, cases of which may begin with symptoms of ordinary coryza. The disease probably de- pends upon a micro-organism. Irritating fumes, such as those of iodine or ammonia, also may cause an acute catarrh of the nose. Symptoms.—The patient feels indisposed, perhaps chilly, has slight headache, and sneezes frequently. In severe cases there are pains in the back and limbs. There is usually slight fever, the temperature rising to 101°. The pulse is quick, the skin is dry, and there are all the features of a feverish attack. At first the mucous membrane of the nose is swollen, “ stuffed up,” and the patient has to breathe through the mouth. A thin, clear, irritating secretion flows, and makes the edges of the nostrils sore. The mucous membrane of the tear-ducts is swollen, so that the eyes weep and the conjunctiva? are injected. With the nasal catarrh there is slight soreness of the throat and stiffness of the neck; the pharynx looks red and swollen, and sometimes the act of swallowing is painful. The larynx also may be involved, and the voice becomes husky or is even lost. If the inflammation extends to the Eustachian tubes there may be impairment of the hearing. Owing to the swelling of the nasal mucosa, the sense of smell and, in part, the sense of taste are lost. In more severe cases there are bronchial irritation and cough. Occasionally there is an outbreak of labial or nasal herpes. Usually within thirty-six hours the nasal secretion becomes turbid and more profuse, the swelling of the mucosa subsides, the patient gradually becomes able to breathe through the nostrils, and within CHRONIC NASAL CATARRn. 513 four or five days the symptoms disappear, with the exception of the in- creased discharge from the nose and upper pharynx. There are rarely any bad effects from a simple coryza. When the attacks are frequently repeated the disease may become chronic. The diagnosis is always easy, but caution must be exercised lest the initial catarrh of measles or severe influenza should be mistaken for the simple coryza. Treatment.—Many cases are so mild that the patients are able to be about and to attend to their work. If there are fever and constitutional disturbance, the patient should be kept in bed and should take a simple fever mixture, and at night a drink of hot lemonade and a full dose of Dover’s powder. Many persons find great benefit from the Turkish bath. For the distressing sense of tightness and pain over the frontal sinuses, cocaine is very useful and sometimes gives immediate relief. The four- per-cent solution may be injected into the nostrils, or cotton-wool soaked in the solution may be inserted into them. Later, the snuff recommended by Ferrier is advantageous, composed, as it is, of morphia (gr. ij), bismuth ( 3 iv), acacia powder ( 3 ij). This may occasionally be blown or snuffed into the nostrils. The fluid extract of hamamelis, “ snuffed ” from the hand every two or three hours, is much better. Coryza is rarely serious in itself, but renders the subject more susceptible to other affections. The attacks should therefore never be slighted, and in young children and in the old especial care should be taken during convalescence. II. CHRONIC NASAL CATARRH (Rhinitis simplex; Rhinitis hypertrophica ; Rhinitis atrophica). In simple chronic catarrh there is increased irritability of the mucous membrane, particularly of the erectile tissue on the septum and turbinated bones. There is a tendency to frequent stoppage of one or both nostrils and the patient very easily catches cold. The secretion is at first clear and afterward thick and tenacious. The sense of smell is not specially disturbed at this stage. With the mirror the mucous membrane looks congested and swollen and the veins may be distended. In hypertrophic rhinitis, which is usually a sequel of the former con- dition, the nasal passages are obstructed, chiefly by enlargement of the lower turbinated bodies and swelling of the mucous membrane of the sep- tum. Very often there is hypertrophy of the adenoid tissue in the vault of the pharynx and of the mucous membrane about the orifices of the Eustachian tubes. The two conditions frequently go together as ex- pressed in the designation, chronic naso-pharyngeal catarrh. The symp- toms of this hypertrophic rhinitis may be local or general. The most important local symptom is the obstruction of the passage of air through the nostrils, so that the patients become mouth-breathers. 514 DISEASES OF THE RESPIRATORY SYSTEM. During the day this may not be very distressing, but at night the mouth and throat get extremely dry and the sleep is disturbed. The voice be- comes nasal in quality and in advanced cases, when the Eustachian tubes are obstructed, there may be deafness. It should ever be borne in mind by the practitioner that a very large proportion of all cases of deafness origi- nate in chronic naso-pharyngeal catarrh. The general symptoms in these cases, particularly in children, are of the greatest importance, and have been considered more fully under chronic pharyngeal catarrh and mouth- breathing. Suffice it here to say that there is produced in children a char- acteristic facies, associated often with mental dulness and changes in the form of the thorax. Atrophic rhinitis, which is also known under the names coryza fetida and ozEena, may be a sequence of the hypertrophic form. Ozaena is only a symptom, and is met with in many ulcerative conditions of the nostrils, particularly as a result of syphilis, foreign bodies, caries and necrosis of the bones, and glanders. Fortunately, the atrophic form by no means necessarily follows the hypertrophic stage. The cases are much more fre- quent in women than in men, and usually occur early in life. The mucous membrane is thin and covered with grayish crusts which, when removed, show a slightly excoriated surface, but true ulcers are rarely seen. The erectile tissue is completely atrophied by a process of slow connective-tissue growth, or, as J. N. Mackenzie calls it, a cirrhosis. The mucous mem- brane of the pharynx is usually dry and glazed. The symptoms are most distinctive, owing to the horrible odor which comes from the nose, and of which, fortunately, the patient is himself unconscious, because the sense of smell is lost. The secretion, which is puriform, dries and forms large crusts, which are dislodged by picking or which gradually fall off. The cause of the offensive odor has been much discussed—whether it is due to a special organism or to specially favorable conditions for the growth and development of the germs of putrefaction. Probably the latter view is correct. The treatment of hypertrophic rhinitis consists in the thorough cleans- ing of the nasal passages, the removal of the pharyngeal growths, and the reduction of the hypertrophied nasal mucosa. It is best to use a simple douche, in order to keep the membrane absolutely clean. The Birming- ham nasal douche is the most simple and satisfactory, and may be filled with alkaline and antiseptic or deodorizing solutions. One of the most satisfactory is the bicarbonate of soda (1| drachm), listerine (6 drachms), and water (1 ounce). Operative procedures are necessary in a majority of the cases, and the practitioner should early call to his assistance the specialist. It is sad to think of the misery which has been entailed upon thousands of people owing to neglect of naso-pharyngeal catarrh by parents and physicians. The treatment of atrophic rhinitis comes more properly under the special monographs. AUTUMNAL CATARRH. 515 III. AUTUMNAL CATARRH (Hay Fever). An affection of the upper air-passages, often associated with asthmatic attacks, due to the action of certain stimuli upon a hypersensitive mucous membrane. This affection was first described in 1819 by Bostock, who called it catarrhus cestivus. Morrill Wyman, of Cambridge, Mass., wrote a mono- graph on the subject, and described two forms, the “ June cold,” or “ rose cold,” which comes on in the spring, and the autumnal form which, in this country, does not develop until August and September, and never persists after a severe frost. Blakley studied its connection with the pol- len of various grasses and flowers. The late George M. Beard made many careful observations on the disease. Until recently this form of ca- tarrh was believed to result exclusively from the action of certain irritants on the mucous membrane of the nose, particularly the pollen of plants, which, as the experiments of Blakley showed, play an important role in the disease. Other emanations also may induce an attack, as in the case of the late Austin Flint, who was liable to coryza, or even asthma, if he slept on a certain sort of feather pillow. This, however, is only one factor in the disease. A second, most important one, was discovered in the con- dition of the nasal mucous membrane in these cases. Voltolini, of Breslau, in 1871, observed the cure of a case of asthma by the removal of a nasal poly- pus. Since that date the observations of Hack, in Germany, and particu- larly of Daly, of. Pittsburg; Roe, of Rochester; John 1ST. Mackenzie, of Baltimore; and Harrison Allen, of Philadelphia, have demonstrated the association of asthmatic attacks with nasal disease. Daly discovered that in a large proportion of the cases of hay asthma there was local disease of the mucous membrane of the nose, the cure of which rendered the pa- tient insusceptible to conditions previously exciting the attacks. This has been abundantly confirmed. Still identical lesions exist in many people who never suffer with the disease, so that there must be a third factor, a neurotic constitution. In the etiology of hay fever, then, these three ele- ments prevail—a nervous constitution, an irritable nasal mucosa, and the stimulus. The disease affects certain families, particularly, it is said, those with a neurotic taint. The peculiarity may occur through several generations. It is certainly more common in the United States than in Europe, and much more common in the United States than in Canada. The United States Hay Fever Association now numbers thousands of members. Dwellers in cities are more subject than residents in the country. The structural peculiarities of the nasal mucous membrane are those of hyper- trophic rhinitis. Harrison Allen states that the inferior turbinated bones lie well above the floor of the nostrils, which renders the mucous mem- brane more liable to irritation from inhaled substances. Deflection of the septum, hypertrophy of the soft parts, and excessive hyperesthesia, so that 516 DISEASES OF THE RESPIRATORY SYSTEM. the mere touch with a probe may be sufficient to induce an attack, are common conditions. Symptoms.—These are, in a majority of the cases, very like those of ordinary coryza. There may, however, be much more headache and dis- tress, and some patients become very low-spirited. Cough is a common symptom and may be very distressing. Paroxysms of asthma may develop, so like as to be indistinguishable from the ordinary bronchial form. The two conditions may indeed alternate, the patient having at one time an attack of common hay fever and at another, under similar circumstances, an attack of bronchial asthma. Of the immediate exciting causes of the attack, unquestionably in a majority of the cases coming on in the autumn there is an association with the presence of pollen in the atmosphere, but this is only one of a host of exciting causes. In certain persons the par- oxysms may develop at any season from sudden changes in the tempera- ture. An attack may even come on through association of ideas. The well-known experiment of J. N. Mackenzie, of inducing an attack in a susceptible person by offering her an artificial rose to smell, strikingly illustrates the neurotic element in the disease. Treatment.—This may be comprised under three heads : First, since the disease appears in many instances to be a form of chronic neurosis, remedies which improve the stability of the nervous system may he em- ployed—such as arsenic, phosphorus, and strychnia. Second, climatic. Dwellers in the cities of the Atlantic sea-board and of the Central States enjoy complete immunity in the Adirondacks and White Mountains. As a rule the disease is aggravated by residence in agricultural districts. The dry mountain air is unquestionably the best; there are cases, however, which do well at the seaside. Third, the thorough local treatment of the nose, particularly the destruction of the vessels and sinuses over the sensitive areas. IV. EPISTAXIS. Etiology.—Bleeding from the nose may result from local or consti- tutional conditions. Among local causes may be mentioned traumatism, picking or scratching the nose, new growths, and the presence of foreign bodies. In chronic nasal catarrh bleeding is not infrequent. The blood may come from one or both nostrils. The flow may he profuse after an injury, but is soon checked and is very rarely fatal. Occasionally profuse and fatal haemorrhage occurs as a result of injury to the skull. In a re- markable case of this kind, coming on some weeks after the receipt of the injury, I found that there had been a fracture across the sphenoid bone and an erosion had taken place into the carotid artery, just where it runs closest to the sphenoidal sinuses. The young man had completely recov- ered from the effects of the injury, and the fatal haemorrhage took place as he was stooping over to wash his face. EPISTAXIS. 517 Among general conditions with which nose-bleeding is associated, the following are the most important: It occurs with great frequency in grow- ing children, particularly about the age of puberty; more frequently in the delicate than in the strong and vigorous. Epistaxis is a very common event in persons of so-called plethoric habit. It is stated sometimes to precede, or to indicate a liability to, apoplexy, but this is very doubtful. In venous engorgement, due to heart or pulmonary disease, epistaxis is not common and there may be a most extreme grade of cyanosis without its occurrence. In balloon and mountain ascensions, in the very rarefied atmosphere, haemorrhage from the nose is a common event. In haemo- philia the nose ranks first of the mucous membranes from which bleeding arises. It occurs in all forms of chronic anaemias. It precedes the onset of certain fevers, more particularly typhoid, with which it seems associated in a special manner. Vicarious epistaxis has been described in cases of suppression of the menses. Lastly, it is said to be brought on by certain psychical impressions, but the observations on this point are not trust- worthy. The blood in epistaxis results from capillary oozing or diapedesis. The mucous membrane is deeply congested and there may be small ecchy- moses. The bleeding area is usually in the respiratory portion of one nos- tril and upon the cartilaginous septum. Symptoms.—Slight haemorrhage is not associated wfith any special features. When the bleeding is protracted the patients have the more serious manifestations of loss of blood. In the slow dripping which takes place in some instances of haemophilia, there may he formed a remarkable blood tumor projecting from one nostril and extending even below the mouth. Death from ordinary epistaxis is very rare. The more blood is lost, the greater is the tendency to clotting with spontaneous cessation of the bleeding. The diagnosis is usually easy. One point only need be mentioned; namely, that bleeding from the posterior nares occasionally occurs during sleep and the blood trickles into the pharynx and may he swallowed. If vomited, it maj be confounded with hsematemesis; or, if coughed up, with haemoptysis. Treatment.—In a majority of the cases the bleeding ceases of itself. Various simple measures may he employed, such as holding the arms above the head, the application of ice to the nose, or the injection of cold or hot water into the nostrils. Astringents, such as zinc, alum, or tannin, may be used; and the -old-fashioned and sometimes successful remedy, a cobweb, may be introduced into the nostrils. If the bleeding comes from an ulcerated surface, an attempt should be made to apply chromic acid or to cauterize. If the bleeding is at all severe and obstinate, the posterior nares should be plugged. Ergot may be given internally or hypodermi- cally. DISEASES OF THE RESPIRATORY SYSTEM. II. DISEASES OF TIIE LARYKX. 1, ACUTE CATARRHAL LARYNGITIS. This may come on as an independent affection or in association with general catarrh of the upper respiratory passages. Etiology.—Many cases are due to catching cold or to overuse of the voice; others develop in consequence of the inhalation of irritating gases. It may occur in the general catarrh associated with influenza and measles. Very severe laryngitis is excited by traumatism, either injuries from with- out or the lodgment of foreign bodies. It may be caused by the action of very hot liquids or corrosive poisons. Symptoms.—There is a sense of tickling referred to the larynx; the cold air irritates and, owing to the increased sensibility of the mucous membrane, the act of inspiration may be painful. There is a dry cough, and the voice is altered. At first it is simply husky, but soon phonation becomes painful, and finally the voice may be completely lost. In adults the respirations are not increased in frequency, but in children dyspnoea is not uncommon and may occur in spasmodic attacks. If much oedema accompanies the inflammatory swelling, there may be urgent dyspnoea. The laryngoscope shows a swollen and tumefied mucous membrane of the larynx, particularly the ary-epiglottidean folds. The vocal cords have lost their smooth and shining appearance and are reddened and swollen. Their mobility also is greatly impaired, owing to the infiltration of the adjoining mucous membrane and of the muscles. A slight mucoid exudation covers the parts. The constitutional symptoms are not severe. There is rarely much fever, and in many cases the patient is not seriously ill. Occasionally cases come on with greater intensity, the cough is very distressing, deglutition is painful, and there may be urgent dyspnoea. Diagnosis.—There is rarely any difficulty in determining the nature of a case if a satisfactory laryngoscopic examination can be made. The severer forms may simulate oedema of the glottis. When the loss of voice is marked, the case may be mistaken for one of nervous aphonia, but the laryngoscope would decide the question at once. Much more difficult is the diagnosis of acute laryngitis in children, particularly in the very young, in whom it is so hard to make a proper examination. From ordi- nary laryngismus it is to be distinguished by the presence of fever, the mode of onset, and particularly the coryza and the previous symptoms of hoarseness or loss of voice. Membranous laryngitis may at first be quite impossible to differentiate, but in a majority of cases of this affection there are patches on the pharynx and early swelling of the cervical glands. The symptoms, too, are much more severe. Treatment.—Rest of the larynx should be enjoined, so far as pho- nation is concerned. In cases of any severity the patient should be kept CEDEMATOUS LARYNGITIS. 519 in bed. The room should be at an even temperature and the air saturated with moisture. Early in the disease, if there is much fever, aconite and citrate of potash can be given, and for the irritating painful cough a full dose of Dover’s powder at night. An ice-bag externally often gives great relief. II. CHRONIC LARYNGITIS. Etiology.—The cases usually follow repeated acute attacks. The most common causes are overuse of the voice, particularly in persons whose occupation necessitates shouting in the open air. The con- stant inhalation of irritating substances, as tobacco-smoke, may also cause it. Symptoms.—The voice is usually hoarse and rough and in severe cases may be almost lost. There is usually very little pain ; only the un- pleasant sense of tickling in the larynx, which causes a frequent desire to cough. With the largyngoscope the mucous membrane looks swollen, but much less red than in the acute condition. In association with the granu- lar pharyngitis, the mucous glands of the epiglottis and of the ventricles may be involved. Treatment.—The nostrils should be carefully examined, since in some instances chronic laryngitis is associated with and even dependent upon obstruction to the free passage of air through the nose. Local appli- cation must be made directly to the larynx, either with a brush or by means of a spray. Among the remedies most recommended are the solu- tions of nitrate of silver, chlorate of potash, perchloride of zinc, and tannic acid. Insufflations of bismuth are sometimes useful. Among directions to be given are the avoidance of heated rooms and loud speaking, and abstinence from tobacco and alcohol. The throat should not be too much muffled, and morning and evening the neck should be sponged with cold water. III. CEDEMATOUS LARYNGITIS. Etiology.—(Edema of the glottis, or, more correctly, of the struct- ures which form the glottis, is a very serious affection which is met with (a) as a rare sequence of ordinary acute laryngitis, whether due to cold or to the application of irritants. (£) In chronic diseases of the larynx, as syphilis or tubercle, (c) In severe inflammatory diseases like diphtheria, in erysipelas of the neck, and in various forms of cellulitis, (f?) Occa- sionally in the acute infectious diseases—scarlet fever, typhus, or typhoid. In Bright’s disease, either acute or chronic, there may be a rapidly devel- oping oedema. Symptoms.—There is dyspnoea, increasing in intensity, so that with- in an hour or two the condition becomes very serious. There is sometimes marked stridor in respiration. The voice becomes husky and disappears. 520 DISEASES OF THE RESPIRATORY SYSTEM. The laryngoscope shows enormous swelling of the epiglottis, which can sometimes be felt Avith the finger or even seen Avhen the tongue is strongly depressed with a spatula. The ary-epiglottidean folds are the seat of the chief swelling and may almost meet in the middle line. Occasionally the oedema is below the true cords. The diagnosis is rarely difficult, inasmuch as even without the laryn- goscope the swollen epiglottis can be seen or felt with the finger. The disease is very fatal. Treatment.—An ice-bag should be placed on the larynx and the patient given ice to suck. If the symptoms are urgent, the throat should be sprayed with a strong solution of cocaine, and the sAvollen epiglottis scarified. If relief does not folloAV, tracheotomy should immediately be performed. The high rate of mortality is due to the fact that this opera- tion is as a rule too long delayed. IV. SPASMODIC LARYNGITIS {Laryngismus stridulus). Spasm of the glottis is met with in many affections of the larynx, but there is a special disease in children which has received the above-men- tioned names. Etiology.—A purely nervous affection, without any inflammatory condition of the larynx, it occurs in children between the ages of six months and three years, and is most commonly seen in connection with rickets. It is also associated with tetany. Often the attack comes on when the child has been crossed or scolded. Mothers sometimes call the attacks “ passion fits ” or attacks of “ holding the breath.” It was sup- posed at one time that they were associated with enlargement of the thymus, and they therefore received the name of thymic asthma. The actual condition of the larynx during a paroxysm is a spasm of the adductors, but the precise nature of the influences causing it is not yet known, whether centric or reflex from peripheral irritation. The disease is not so common in America as in England. Symptoms.—The attacks may come on either in the night nr in the day ; often just as the child awakes. There is no -cough, no hoarseness, but the respiration is arrested and the child struggles for breath, the face gets congested, and then, with a sudden relaxation of the spasm, the air is drawn into the lungs with a high-pitched crowing sound, which has given to the affection the name of “ child-crowing."” Convulsions may occur during an attack or there may be carpo-pedal spasms. Death may, but rarely does, occur during the attack. "With the -cyanosis the spasm relaxes and respiration begins. The attacks may recur with great fre- quency throughout the -day. Treatment.—The gums should be carefully examined and, if swol- len and hot, freely lanced. The bowels should be carefully regulated and as these children are usually delicate or rickety nourishing diet and TUBERCULOUS LARYNGITIS. 521 cod-liver oil should be given. By far the most satisfactory method of treatment is the cold sponging. In severe cases, two or three times a day the child should be placed in a warm bath and the back and chest thor- oughly sponged for a minute or two with cold water. Since learning this practice from Linger, at the University Hospital, I have seen many cases in which it proved successful. It may be employed wdien the child is in a paroxysm, though if the attack is severe and the lividity is great it is much better to dash cold water into the face. Sometimes the introduc- tion of the finger far back into the throat will relieve the spasm. Spasmodic croup, believed to be a functional spasm of the muscles of the larynx, is an affection seen most commonly between the the ages of two and five years. According to Trousseau’s description, the child goes to bed well, and about midnight or in the early morning hours awakes with oppressed breathing, harsh, croupy cough, and perhaps some huskiness of voice. The oppression and distress for a time are very serious, the face is congested, and there are signs of approaching cyanosis. The attack passes off abruptly, the child falls asleep and awakes the next morning feeling perfectly well. These attacks may be repeated for several nights in suc- cession, and usually cause great alarm to the parents. Whether this is en- tirely a functional spasm is, I think, doubtful. There are instances in which the child is somewhat hoarse through the day, and has slight ca- tarrhal symptoms and a brazen, croupy cough. There is probably slight ■catarrhal laryngitis with it. These cases are not infrequently mistaken for true croup, and parents are sometimes unnecessarily disturbed by the serious view which the physician takes of the case. Too often the poor ■child, deluged with drugs, is longer in recovering from the treatment than he would be from the disease. To allay the spasm a whiff of chloroform may be administered, which will in a few moments give relief, or the child may be placed in a hot bath. A prompt emetic, such as zinc or wine of ipecac, will usually relieve the spasm, and is specially indicated if the child has overloaded the stomach through the day. V. TUBERCULOUS LARYNGITIS. Etiology.—Tubercles may develop primarily in the laryngeal mu- cosa, but in the great majority of cases the affection is secondary to pul- monary tuberculosis, in which it is met with in a variable proportion of from eighteen to thirty per cent. Laryngitis may occur very early in pulmonary tuberculosis. There may be well-marked involvement of the larynx with signs of very limited trouble at one apex. These are cases which, in my experience, run a very unfavorable course. Morbid Anatomy.'—The mucosa is at first swollen and presents scattered tubercles, which seem to begin in the neighborhood of the blood- vessels. By their fusion small tuberculous masses arise, which caseate aud 522 DISEASES OF TIIE RESPIRATORY SYSTEM. finally ulcerate, leaving shallow irregular losses of substance. The ulcers are usually covered with a grayish exudation, and there is a general thick- ening of the mucosa about them, which is particularly marked upon the arytenoids. The ulcers may erode the true cords and finally destroy them, and passing deeply may cause perichondritis with necrosis and occasionally exfoliation of the cartilages. The disease may extend laterally and involve the pharynx, and downward over the mucous membrane covering the cricoid cartilage toward the oesophagus. Above, it may reach the posterior wall of the pharynx, and in rare cases extend to the fauces and tonsils. The epiglottis may be entirely destroyed. There are rare instances in which cicatricial changes go on to such a degree that stenosis of the larynx is induced, a remarkable specimen of which I saw some years ago wfith J. Solis-Cohen. Symptoms.—The first indication is slight huskiness of the voice,, which finally deepens to hoarseness, and in advanced stages there may be complete loss of voice. There is something very suggestive in the early hoarseness of tuberculous laryngitis. My attention has frequently been directed to the lungs simply by the quality of the voice. The cough is in part due to involvement of the larynx. Early in the disease it is not very troublesome, hut when the ulceration is extensive it becomes husky and ineffectual. Of the symptoms of laryngeal tubercu- losis, none is more aggravating than the dysphagia, which is met with par- ticularly when the epiglottis is involved, and when the ulceration has extended to the pharynx. There is no more distressing or painful compli- cation in phthisis. In instances in which the epiglottis is in great part destroyed, with each attempt to take food there are distressing paroxysms of cough, and even of suffocation. With the laryngoscope there is seen early in the disease a pallor of the mucous membrane, which also looks thickened and infiltrated, particularly that covering the arytenoid cartilages. The tuberculous ulcers are very characteristic. They are broad and shallow, with gray bases and ill-defined outlines. The vocal cords are infiltrated and thickened, and ulceration is very common. The diagnosis of tuberculous laryngitis is rarely difficult, as it is usu- ally associated with well-marked pulmonary disease. In case of doubt some of the secretion from the base of an ulcer should be removed and examined for bacilli. Treatment.—Physicians pay scarcely sufficient attention to the laryngeal complications of consumption. The ulcers should he sprayed and kept thoroughly cleansed. Solutions of tannic acid, nitrate of silver, or sulphide of zinc may he employed. The insufflation, two or three times a day, of a powder of iodoform, with morphia, after thoroughly cleansing the ulcers Avith a spray, relieves the pain in a majority of the cases. Co- caine (four per cent solution) applied Avitli the atomizer will often enable the patient to SAvalloAV his food comfortably. There are, howreArer, distress- SYPHILITIC LARYNGITIS. 523 ing cases of extensive laryngeal and pharyngeal ulceration in which even cocaine loses its good effects. When the epiglottis is lost the difficulty in swallowing becomes very great. Wolfenden states that this may be obvi- ated if the patient hangs his head over the side of the bed and sucks milk through a rubber tubing from a mug placed on the floor. VI. SYPHILITIC LARYNGITIS. Syphilis attacks the larynx with great frequency. It may result from the inherited disease or be a secondary or tertiary manifestation of the ac- quired form. Symptoms.—In secondary syphilis there is occasionally erythema of the larynx, which may go on to definite catarrh, but has nothing charac- teristic. The process may proceed to the formation of superficial whitish ulcers, usually symmetrically placed on the cords or ventricular bands. Mucous patches and condylomata are rarely seen. The symptoms are practically those of slight loss of voice with laryngeal irritation, as in the simple catarrhal form. The tertiary laryngeal lesions are numerous and very serious. True gummata, varying in size from the head of a pin to a small nut, develop in the submucous tissue most commonly at the base of the epiglottis. They go through the changes characteristic of these structures and may either break down, producing extensive and deep ulceration, or—and this is more characteristic of syphilitic laryngitis—in their healing form a fibrous tissue which shrinks and produces stenosis. The ulceration is apt to extend deeply and involve the cartilage, inducing necrosis and exfolia- tion, and even haemorrhage from erosion of the arteries. (Edema may suddenly prove fatal. The cicatrices which follow the sclerosis of the gummata or the healing of the ulcers produce great deformity. The epi- glottis, for instance, may be tied down to the pharyngeal wall or to thu epiglottic folds, or even to the tongue ; and eventually a stenosis results, which may necessitate tracheotomy. The laryngeal symptoms of inherited syphilis have the usual course of these lesions and appear either early, within the first five or six months, or after puberty; most commonly in the former period. Of 76 cases, J. N. Mackenzie found that 63 occurred within the first year. The gummatous infiltration leads to ulceration, most commonly of the epiglottis and in the ventricles, and the process may extend deeply and involve the carti- lage. Cicatricial contraction may also occur. The diagnosis of syphilis of the larynx is rarely difficult, since it occurs most commonly in connection with other symptoms of the disease. Treatment.—The administration of constitutional remedies is the most important, and under mercury and iodide of potassium the local symptoms may rapidly be relieved. The tertiary laryngeal manifestations are always serious and difficult to treat. The deep ulceration is specially 524 DISEASES OF THE RESPIRATORY SYSTEM. hard to combat, and the cicatrization may necessitate tracheotomy, or the gradual dilatation, as practised by Schroetter. III. DISEASES OF THE BRONCHI. I. ACUTE BRONCHITIS. Acute catarrhal inflammation of the bronchial mucous membrane is a very common disease, rarely serious in healthy adults, but very fatal in the old and in the young, owing to associated pulmonary complications. It is bilateral and affects either the larger and medium sized tubes or the smaller bronchi, in which case it is known as capillary bronchitis. We shall speak only of the former, as the latter is part and parcel of broncho-pneumonia. Etiology.—Acute bronchitis is a common sequence of catching cold, and is often nothing more than the extension downward of an ordinary coryza. It occurs most frequently in the changeable weather of early spring and late autumn. Its association with cold is well indicated by the popular expression “ cold on the chest.” It may prevail as an epi- demic apart from influenza, of which it is an important feature. Acute bronchitis is associated with many other affections, notably measles. It is by no means rare at the onset of typhoid fever and malaria. It is present also in asthma and whooping-cough. The bronchitis of Bright’s disease, gout, and heart-disease is usually a chronic form. It attacks persons of' all ages, but most frequently the young and the old. There are individuals who have a special disposition to bronchial catarrh, and the slightest exposure is apt to bring on an attack. Persons who live an out-of-door life are usually less subject to the disease than those who follow sedentary occupations. The affection is probably microbic, though we have as yet no definite evidence upon this point. Morbid Anatomy.—The mucous membrane of the trachea and bronchi is reddened, congested, and covered with mucus and muco-pus, which may be seen oozing from the smaller bronchi, some of which are dilated. The finer changes in the mucosa consist in desquamation of the ciliated epithelium, swelling and cedema of the submucosa, and infiltration of the tissue with leucocytes. The mucous glands are much swollen. Symptoms.—The symptoms of an ordinary “ cold ” accompany the onset of an acute bronchitis. The coryza extends to the tubes, and may also affect the larynx, producing hoarseness, which in many cases is marked. A chill is rare, but there is invariably a sense of oppression, with heavi- ness and languor and pains in the bones and back. In mild cases there is scarcely any fever, but in severer forms the range is from 101° to 103°. ACUTE BRONCHITIS. 525 The bronchial symptoms set in with a feeling of tightness and rawness beneath the sternum and a sensation of oppression in the chest. The cough is rough at first, cutting and sore, and often of a ringing character. It comes on in paroxysms which rack and distress the patient extremely. During the severe spells the pain may be very intense beneath the sternum and along the attachments of the diaphragm. At first the cough is dry, but in a few days the secretion becomes muco-purulent and abundant, and finally purulent. With the loosening of the cough great relief is experi- enced. The sputum is made up largely of pus-cells, with a variable number of the large round alveolar cells, many of which contain carbon grains, while others have undergone the myelin degeneration. Physical Signs.—The respiratory movements are not greatly increased in frequency unless the fever is high. There are instances, however, in which the breathing is rapid and when the smaller tubes are involved there is dyspnoea. On palpation the bronchial fremitus may often be felt. On auscultation in the early stage, piping sibilant rales are everywhere to be heard. They are very changeable, and appear and disappear with cough- ing. With the relaxation of the bronchial membranes and the greater abundance of the secretion, the rales change and become mucous and bub- bling in quality. The course of the disease depends on the conditions under which it develops. In healthy adults, by the end of a week the fever subsides and the cough loosens. In another week or ten days convalescence is fully established. In young children the chief risk is in the extension of the process downward. In measles and whooping-cough, the ordinary bron- chial catarrh is very apt to descend to the finer tubes, which become di- lated and plugged with muco-pus, inducing areas of collapse, and finally broncho-pneumonia. This extension is indicated by changes in the physi- cal signs. Usually at the base the rales are subcrepitant and numerous and there may be areas of defective resonance and of feeble or distant tu- bular breathing. In the aged and debilitated there are similar dangers if the process extends from the larger to the smaller tubes. In old age the bronchial mucosa is less capable of expelling the mucus, which is more apt to sag to the dependent parts and induce dilatation of the tubes with extension of the inflammation to the contiguous air-cells. The diagnosis of acute bronchitis is rarely difficult. Although the mode of onset may be brusque and perhaps simulate pneumonia, yet the absence of dulness and blowing breathing, and the general character of the bronchial inflammation, renders the diagnosis simple. The complica- tion of broncho-pneumonia is indicated by the greater severity of the symp- toms, particularly the dyspnoea, the defective color, and the physical signs. Treatment.—In mild cases, household measures suffice. The hot foot-bath, or the warm bath, a drink of hot lemonade, and a mustard plas- ter on the chest will often give relief. For the dry, racking cough, the symptom most complained of by the patient, Dover’s powder is the best DISEASES OF THE RESPIRATORY SYSTEM. remedy. It is a popular belief that quinine, in full doses, will check an oncoming cold in the chest, but this is doubtful. It is a common custom when persons feel the approach of a cold to take a Turkish bath, and though the tightness and oppression may be relieved by it, there is in a majority of the cases great risk. Some of the severest cases of bronchitis which 1 have seen have followed this initial Turkish bath. No doubt, if the person could go to bed directly from the bath, its action would be beneficial, but there is great risk of catching additional “ cold ” in going home from the bath. Relief is obtained from the unpleasant sense of rawness by keeping the air of the room saturated with moisture, and in this dry stage the old-fashioned mixture of the wines of antimony and ipe- cacuanha with liquor ammonii acetatis and nitrous ether is useful. If the pulse is very rapid, tincture of aconite may be given, particularly in the case of children. For the cough, when dry and irritating, opium should be freely used in the form of Dover’s powder. Of course, in the very young and the aged care must be exercised in the use of opium, par- ticularly if the secretions are free; but for the distressing, irritative cough, which keeps the patient awake, no remedy can take its place. As the cough loosens and the expectoration is more abundant, the patient becomes more comfortable. In this stage it is customary to ply the patient with expec- torants of various sorts. Though useful occasionally, they should not be given as a matter of routine. A mixture of squills, ammonia, and senega is a favorite one with many practitioners at this stage. In the acute bronchitis of children, if the amount of secretion is large and difficult to expectorate, or if there is dyspnoea and the color begins to get dusky, an emetic (a tablespoonful of ipecac wine) should be given at once and repeated if necessary. II. CHRONIC BRONCHITIS. Etiology.—This affection may follow repeated attacks of acute bron- chitis, hut it is most commonly met with in chronic lung affections, heart- disease, gout, and renal disease. It is frequent in the aged; the young rarely are affected. Climate and season have an important influence. It is the winter cough of the old man, which recurs with regularity as the weather gets cold and changeable. Morbid Anatomy.—The bronchial mucosa presents a great variety of changes, depending somewhat upon the disease with which chronic bronchitis is associated. In some cases the mucous membrane is very thin, so that the longitudinal bands of elastic tissue stand out prominently. The tubes are dilated and the muscular and glandular tissues are atrophied and the epithelium is in great part shed. In other instances the mucosa is thickened, granular, and infiltrated. There may be ulceration, particularly of the mucous follicles. Bronchial CHRONIC BRONCHITIS. 527 dilatations are not uncommon and emphysema is a constant accompani- ment. Symptoms.—In the form met with in old men, associated with em- physema, gout, or heart-disease, the chief symptoms are as follows : Short- ness of breath, which may not be noticeable except on exertion. The patients “ puff and blow ” on going up hill or up a flight of stairs. This is due not so much to the chronic bronchitis itself as to associated emphysema or even to cardiac weakness. They complain of no pain. The cough is varia- ble, changing with the weather and with the season. During the summer they may remain free, but each succeeding winter the cough comes on with severity and persists. There may be only a spell in the morning, or the chief distress is at night. The sputum in chronic bronchitis is very varia- ble. In cases of the so-called dry catarrh there is no expectoration. Usu- ally, however, it is abundant, muco-purulent, or distinctly purulent in character. There are instances in which the patient coughs up for years a thin fluid sputum. There is rarely fever. The general health may be good and the disease may present no serious features apart from the lia- bility to induce emphysema and bronchiectasy. In many cases it is an incurable affection. Patients improve and the cough disappears in the summer time only to return during the winter months. Physical Signs.—The chest is usually distended, the movements are limited, and the condition is often that which we see in emphysema. The percussion note is clear or hyperresonant. On auscultation, expiration is prolonged and wheezy and rhonchi of various sorts are heard—some high- pitched and piping, others deep-toned and snoring. Crepitation is com- mon at the bases. Clinical Varieties.—The description just given is of the ordinary chronic bronchitis which occurs in connection with emphysema and heart- disease and in many elderly men. There are certain forms which merit spe- cial description : (a) On several occasions I have.met with a form of chronic bronchitis, particularly in women, which comes on between the ages of twenty and thirty and may continue indefinitely without serious impair- ment of the health. In one case, a lady of fifty, with a phthisical family history, began to cough when she was twenty-five, and since then has had more or less cough every day without intermission. It has not seriously impaired her health, though she has never been strong. Once or twice she has had attacks of eczema. The cough is chiefly in the morning, is apt tc be brought on by too much conversation, and is quite independent of the weather. The daily amount of expectoration is not great, rarely more than from four to six ounces. It is muco-purulent in character. The examination of the chest is negative—no emphysema, no rdles. I have met several such instances which seem to form a type of chronic bronchitis, though it is difficult to say upon what the condition depends. (b) Bronchorrlicea.—Excessive bronchial secretion is met with under several conditions. It must not he mistaken for the profuse expectoration 528 DISEASES OF THE RESPIRATORY SYSTEM. of bronchiectasy. The secretion may be very liquid and watery—bronclior- rhcea serosa. More oommonly, it is purulent though thin, and with green- ish or yellow-green masses. It may be thick and uniform. This profuse bronchial secretion is usually a manifestation of chronic bronchitis and may lead to dilatation of the tubes and ultimately to fetid bronchitis. In the young the condition may persist for years without impairment of health and without apparently damaging the lungs. (c) Putrid Bronchitis.—Fetid expectoration is met with in connection with bronchiectasis, gangrene, abscess, or with decomposition of secretions within phthisical cavities and in an empyema which has perforated the lung. There are instances in which, apart from any of these states, the expectoration has a fetid character. The sputa are abundant, usually thin, grayish white in color, and they separate into an upper fluid layer capped with frothy mucus and a thick sediment in which may sometimes be found dirty yellow masses the size of peas or beans—the so-called Dit- trich’s plugs. The affection is very rare apart from the above-mentioned conditions. In severe cases it leads to changes in the bronchial walls, pneumonia, and often to abscess or gangrene. Metastatic brain abscess has followed putrid bronchitis in a certain number of cases. (d) Dry Catarrh.— Catarrlie sec of Laennec is a not uncommon form, characterized by paroxysms of coughing of great intensity, with little or no expectoration. It is usually met with in elderly persons with emphy- sema, and is one of the most obstinate of all varieties of bronchitis. In England the damp cold of the unwarmed houses is responsible in great part for the prevalence of chronic bronchitis among the aged and weak. An equable, warm temperature is of the first importance to all persons prone to the disease. Treatment.—By far the most satisfactory method of treating the recurring winter bronchitis is change of climate. Removal to a southern latitude may prevent the onset. Southern France, southern California, and Florida furnish winter climates in which the subjects of chronic bronchitis live with the greatest comfort. All cases of prolonged bronchial irritation are benefited by change of air. The first endeavor in treating a case of chronic bronchitis is to ascer- tain, if possible, whether there are constitutional or local affections with which it is associated. In many instances the urine is found to be highly acid, perhaps slightly albuminous, and the arteries are stiff. In the form associated with this condition, sometimes called gouty bronchitis, the at- tacks seem related to the defective renal elimination, and to this condition the treatment should be first directed. In other instances there are heart- disease and emphysema. In the form occurring in old men much may be done in the way of prophylaxis. Septuagenarians should read Oliver Wen- dell Holmes’s* “De Senectute” with reference to the care of the health. * Over the Tea-cups, Boston, 1890. BRONCHIECTASIS. 529 There is no doubt that with prudence even in our changeable winter weather much may be done to prevent the onset of chronic bronchitis. Woollen undergarments should be used and especial care should be taken in the spring months not to change them for lighter ones before the warm weather is established. Cure is seldom effected by medicinal remedies. There are instances in which iodide of potassium acts with remarkable benefit, and it should always be given a trial in cases of paroxysmal bronchitis of obscure origin. When the secretion is excessive muriate of ammonia and senega are useful. Stimulating expectorants are contraindicated. When the heart is feeble, the combination of digitalis and strychnia is very beneficial. Turpentine, the old-fashioned remedy so warmly recommended by the Dublin physi- cians, has in many quarters fallen undeservedly into disuse. Preparations of tar, creasote, and terebene are sometimes useful. Of other balsamic remedies, sandal-wood, the compound tincture of benzoin, copaiba, balsam of Peru or tolu may be used. Inhalations of eucalyptus and of the spray of ipecacuanha wine are often very useful. If fetor be present, carbolic acid in the form of spray (ten to twenty per cent solution) will lessen the odor, or thymol (1 to 1,000). In full-blooded men, when venous engorgement exists and shortness of breath, the abstraction of twenty to thirty ounces of blood will afford prompt relief. III. BRONCHIECTASIS. Etiology.—Dilatation of the bronchi occurs under the following conditions: (1) As a congenital defect or anomaly. Such eases are ex- tremely rare, commonly unilateral. Grawitz has described the condition as bronchiectasis universalis. Welch has met an instance in a young girl. (2) In connection with inflammation of the bronchi, particularly when this leads to weakness of the walls with the accumulation of secre- tion. Under this category come the dilatation met with in chronic bron- chitis and emphysema, the dilated bronchi in chronic phthisis, in the catarrhal pneumonias of children, and particularly the dilitation which results from the presence of foreign bodies in the air-tubes or from pressure, as of an aneurism on one bronchus. (3) In extreme contraction of the lung tissue, whether due to interstitial pneumonia or to compres- sion by pleural adhesions, bronchial dilatation is a common though not a constant accompaniment. Unquestionably the weakening of the bronchial wall is the most impor- tant, probably the essential, factor in inducing bronchiectasy, since the wall is then not able to resist the pressure of air in severe spells of coughing and in straining. In some instances the mere weight of the accumulated secretion may he sufficient to distend the terminal tubules, as is seen in compression of a bronchus by aneurism. Morbid Anatomy.—Two chief forms are recognized—the cylin- drical and the saccular—which may exist together in the same lung. The 530 DISEASES OF THE RESPIRATORY SYSTEM. condition may be general or partial. Universal bronchiectasis is always unilateral. It occurs in rare congenital cases and is occasionally seen as a sequence of interstitial pneumonia. The entire bronchial tree is repre- sented by a series of sacculi opening one into the other. The walls are smooth and possibly without ulceration or erosion except in the dependent parts. The lining membrane of the sacculi is usually smooth and glisten- ing. The dilatations may form large cysts immediately beneath the pleura. Intervening between the sacculi is a dense cirrhotic lung tissue. The partial dilatations—the saccular and cylindrical—are common in chronic phthisis, particularly at the apex, in chronic pleurisy at the base, and in emphysema. Here the dilatation is more commonly cylindrical, sometimes fusiform. The bronchial mucous membrane is much in- volved and sometimes there is a narrowing of the lumen. Occasionally one meets with a single saccular bronchiectasy in connection with chronic bronchitis or emphysema. Some of these look like simple cysts, with smooth walls, without fluid contents. Histologically the bronchi which are the seat of dilatation show im- portant changes. In the large, smooth dilatations the cylindrical is re- placed by a pavement epithelium. The muscular layer is stretched, atro- phied, and the fibres separated ; the elastic tissue is also much stretched and separated. In the large saccular bronchiectasies and in some of the cylindrical forms, due to retained secretions, the lining membrane is ulcer- ated. The contents of some of the larger bronchiectatic cavities are hor- ribly fetid. Symptoms.—In the limited dilatations of phthisis, emphysema, and chronic bronchitis, the symptoms are in great part those of the original disease, and the condition often is not suspected during life. In extensive saccular bronchiectasy the characters of the cough and expectoration are distinctive. The patient will pass the greater part of the day without any cough and then in a severe paroxysm will bring up a large quantity of sputum. Sometimes change of the position will bring on a violent attack, probably due to the fact that some of the secretion flows from the dilatation to a normal tube. The daily spell of coughing is usually in the morning. The expectoration is in many in- stances very characteristic. It is grayish or grayish brown in color, fluid, purulent, with a peculiar acid, sometimes fetid, odor. Placed in a conical glass, it separates into a thick granular layer below and a thin mucoid in- tervening layer above, which is capped by a brownish froth. Microscopi- cally it consists of pus-corpuscles, often large crystals of fatty acids, which are sometimes in enormous numbers over the field and arranged in bunches. Ilasmatoidin crystals are sometimes present. Elastic fibres are seldom found except when there is ulceration of the bronchial walls. Tubercle bacilli are not present. In some cases the expectoration is very fetid and has all the characters of that described under fetid bronchitis. Nummular expectoration, such as comes from phthisical cavities, is not BRONCHIAL ASTHMA. 531 common. Haemorrhage may occur, but in my experience it has been rare. Abscess of the brain has in a few instances followed the bronchiectasis. Rheumatoid affections may develop (Gerhardt). The diagnosis is not possible in a large number of the cases. In the extensive sacculated forms, unilateral and associated with interstitial pneu- monia or chronic pleurisy, the diagnosis is easy. There is contraction of the side, which in some instances is not at all extreme. The cavernous signs may be chiefly at the base and may vary according to the condition of the cavity, whether full or empty. There may be the most exquisite amphoric phenomena and loud resonant rales. The condition persists for years and is not inconsistent with tolerably active life. The patients fre- quently show signs of marked embarrassment of the pulmonary circula- tion. There is cyanosis on exertion, the finger-tips are clubbed, and the nails incurved. A condition very difficult to distinguish from bronchiec- tasy is a limited pleural cavity communicating with a bronchus. Treatment.—Medical treatment is not satisfactory, since it is impos- sible to heal the cavity. I have practised the injection of antiseptic fluids in some instances with benefit. Intratracheal injections have been very warmly recommended of late. With a suitable syringe a drachm may be injected twice a day of the following solution : Menthol 10 parts, guaia- col 2 parts, olive oil 88 parts. In suitable cases drainage of the cavities may be attempted, particularly if the patient is in fairly good condition. For the fetid secretion turpentine may be given, or terebene, and inhala- tions used of carbolic acid or thymol. IV. BRONCHIAL ASTHMA Asthma is a term which has been applied to various conditions associ- ated with dyspnoea—hence the names cardiac and renal asthma—but its use should be limited to the affection known as bronchial or spasmodic asthma. Etiology.—All writers agree that there is in a majority of cases of bronchial asthma a strong neurotic element. Many regard it as a neu- rosis in which, according to one view, spasm of the bronchial muscles, according to the other, turgescence of the mucosa, results from disturbed innervation, pneumogastric or vaso-motor. Of the numerous theories the following are the most important: (1) That it is due to spasm of the bronchial muscles, a theory which has perhaps the largest number of adherents. The original experiments of C. J. 13. Williams, upon which it is largely based, have not, however, been confirmed of late years. (2) That the attack is due to swelling of the bronchial mucous mem- brane—fluctionary hyperaemia (Traube), vaso-motor turgescence (Weber), diffuse hyperaemic swelling (Clark). (3) That in many cases it is a special form of inflammation of the smaller bronchioles—bronchiolitis exudativa (Cursclimann). Other theo- 532 DISEASES OF THE RESPIRATORS SYSTEM. ries which may he mentioned are that the attack depends on spasm of the diaphragm or on reflex spasm of all the inspiratory muscles. As already mentioned, the so-called hay fever is an affection which has many resemblances to bronchial asthma, with which the attacks may alter- nate. In the suddenness of onset and in many of their features these dis- eases have the same origin and differ only in site, as suggested by Sir Andrew Clark and now generally acknowledged by specialists. Making due allowance for anatomical differences, if the structural changes occur- ring in the nasal mucous membrane during an attack of hay fever were to occur also in various parts of the bronchial mucosa, their presence there would afford a complete and adequate explanation of the facts observed during a paroxysm of bronchial asthma (Clark). With this statement I fully agree, but the observations of Curschmann have directed attention to a feature in' asthma which has been neglected; namely, that in a ma- jority of the cases it is associated with an exudation, such as might be supposed to come from a turgescent mucosa and which is of a very charac- teristic and peculiar character. The hyperaemia and swelling of the mu- cosa and the extremely viscid, tenacious mucus explain well the hindrance to inspiration and expiration and also the quality of the rales. Some general facts with reference to etiology may be mentioned. The affection sometimes runs in families, particularly those with irritable and unstable nervous systems. The attack may be associated with neuralgia or, as Salter mentions, even alternate with epilepsy. Men are more fre- quently affected than women. The disease often begins in childhood and sometimes lasts until old age. One of its most striking peculiarities is the bizarre and extraordinary variety of circumstances which at times induce a paroxysm. Among these local conditions climate or atmosphere are most important. A person may be free in the city and invariably suffer from an attack when he goes into the country, or into one special part of the country. Such cases are by no means uncommon. Breathing the air of a particular room or a dusty atmosphere may bring on an attack. Odors, particularly of flowers and of hay, or emanations from animals, as the horse, dog, or cat, may at once cause an outbreak. Fright or violent emotion of any sort may bring on a paroxysm. Uterine and ovarian troubles were formerly thought to induce attacks and may do so in rare instances. Diet, too, has an important influence, and in persons subject to the disease severe paroxysms may be induced by overloading the stomach, or by taking certain articles of food. Chronic cases, in which the attacks recur year after year, gradually become associated with emphysema, and every fresh “ cold ” induces a paroxysm. And lastly, many cases of bron- chial asthma are associated with affections of the nose, particularly with hypertrophic rhinitis and nasal polypi. According to some specialists of large experience, all cases of bronchial asthma have some affection of the upper air-passages, but I am convinced from personal observation that this is erroneous. Still physicians must acknowledge the debt which we BRONCHIAL ASTHMA. 533 owe to Voltolini, Hack, Daly, Roe, and others who have shown the close connection which exists between affections of the naso-pharynx and many cases of bronchial asthma. Briefly stated then, bronchial asthma is a neurotic affection, character- ized by hypersemia and turgescence of the mucosa of the smaller bronchial tubes and a peculiar exudate of mucin. The attacks may be due to direct irritation of the bronchial mucosa or may be induced reflexly, by irritation of the nasal mucosa, and indirectly, too,, by reflex influences, from stom- ach, intestines, or genital organs. Symptoms.—Premonitory sensations precede some attacks, such as chilly feeling, a sense of tightness in the chest, flatulence, passage of a large quantity of urine, or great depression of spirits. Nocturnal attacks are common. After a few hours’ sleep, the patient is aroused with a dis- tressing sense of want of breath and a feeling of great oppression in the chest. Soon the respiratory efforts become violent, all the accessory mus- cles are brought into play, and in a few minutes the patient is in a par- oxysm of the most intense dyspnoea. The face is pale, the expression anxious, speech is impossible, and in spite of the most strenuous inspira- tory efforts very little air enters the lungs. Expiration is prolonged and also wheezy. The number of respirations, however, is not much increased. The asthmatic fit may last from a few minutes to several hours. When severe, the signs of defective aeration soon appear, the face becomes be- dewed with sweat, the pulse is small and quick, the extremities get cold, and just as the patient seems to be at his worst, the breathing begins to get easier, and often with a paroxysm of coughing relief is obtained and he sinks exhausted to sleep. The relief may be but temporary and a sec- ond attack may soon come on. In a majority of the cases even in the intervals between the asthmatic fits the respiration is somewhat embar- rassed. > The cough is at first very tight and dry and the expectoration is expelled with the greatest difficulty. The physical signs during an attack are very characteristic. On in- spection the thorax looks enlarged, barrel-shaped, and is fixed, the amount of expansion being altogether disproportionate to the intensity of the in- spiratory movements. The diaphragm is lowered and moves but slightly. Inspiration is short and quick, expiration prolonged. Percussion may not reveal any special difference, but there is sometimes marked hyperreso- nance, particularly in cases which have had repeated attacks. On auscultation, with inspiration and expiration, there are innumer- able sibilant and sonorous rales of all varieties, piping and high-pitched, low-pitched and grave. Later in the attack there are moist rales. The sputum in bronchial asthma is quite distinctive, unlike that which occurs in any other affection. Early in the attack it is brought up with great difficulty and is in the form of rounded gelatinous masses, the so- called uperles ” of Laennec. Though ball-like, they can be unfolded and really represent moulds in mucus of the smaller tubes. The entire expec- 534 DISEASES OF TIIE RESPIRATORY SYSTEM. toration may be made lip of these somewhat translucent-looking pellets, floating in a small quantity of thin mucus. Some of them are opaque. Often with the naked eye a twisted spiral character can be seen, particu- larly if the sputum is spread on a glass with a black background. Micro- scopically, many of these pellets have a spiral structure, which renders them among the most remarkable bodies met with in sputum. It is not a little curious that they should have been practically overlooked until described a few years ago by Curschmann. Under the microscope the spirals are of two forms. In one there is simply a twisted, spirally ar- ranged mucin, in which are entangled cells, derived probably from the smaller bronchi and alveoli, often in all stages of fatty degeneration. The twist may be loose or tight. The second form is much more peculiar. In the centre of a tightly coiled skein of mucin fibrils with a few scattered cells is a filament of extraordinary clearness and translucency, probably composed of transformed mucin. As Curschmann suggests, these spirals are doubtless formed in the finer bronchioles and constitute the product of an acute bronchiolitis. It is difficult to explain their spiral nature. I do not know of any observations upon the course of the currents produced by the ciliated epithelium in the bronchi, but it is quite possible that their action may be rotatory, in which case, particularly when combined with spasm of the bronchial muscles, it is possible to conceive that the mucus formed in the tube might be compelled to assume a spiral form. Within two or three days the sputum changes entirely in character; it becomes muco-purulent and Cursclimann’s spirals are no longer to be found. They occur in all instances of true bronchial asthma in the early period of the attack. There are, in addition, in many cases, the pointed, octahedral crystals described by Leyden and sometimes called asthma crystals. They are identical with the crystals found in the semen and in the blood in leuksemia. At one time they were supposed, by their irritating character, to induce the paroxysms. The course of the disease is very variable. In severe attacks the par- oxysms recur for three or four nights or even more, and in the intervals and during the day there may be wheezing and cough. Early in the disease the patient may be free in the morning, without cough or much distress, and the attacks may appear at first to be of a purely nervous character. In the long-standing cases emphysema almost invariably develops, and while the pure asthmatic fits diminish in frequency the chronic bronchitis and shortness of breath become aggravated. We have no knowledge of the morbid anatomy of true asthma. Death during the attack is unknown. In long-standing cases the lesions are those of chronic bronchitis and emphysema. Treatment.—The asthmatic attack usually demands immediate and prompt treatment, and remedies should be administered which experience lias shown are capable of relieving the condition of the bronchial mucosa. A few whiffs of chloroform will produce prompt though temporary relaxa- FIBRINOUS BRONCHITIS. 535 tion. In a child with very severe attacks, resisting all the usual remedies, the treatment by chloroform gave immediate and finally permanent relief. Perles of nitrite of amyl may be broken on the handkerchief or from two to five drops of the solution may be placed upon cotton-wool and inhaled. Strong stimulants given hot or a dose of spirits of chloroform in hot whisky will sometimes induce relaxation. More permanent relief is given by the hypodermic injection of morphia or of morphia and cocaine com- bined. In obstinate and repeatedly recurring attacks this has proved a very satisfactory plan. The sedative antispasmodics, such as belladonna, henbane, stramonium, and lobelia, may be given in solution or used in the form of cigarettes. Nearly all the popular remedies either in this form or in pastilles contain some plant of the order solcinacece, with nitrate or chlorate of potash. Excellent cigarettes are now manufactured and asthmatics try various sorts, since one form benefits one patient, another form another patient. Nitre paper made with a strong solution of nitrate of potash is very serviceable. Filling a room with the fumes of this paper prior to retiring will sometimes ward off a nocturnal attack. I have known several patients to whom tobacco smoke inhaled was quite as potent as the prepared cigarettes. The use of compressed air in the pneumatic cabinet is very beneficial; oxygen inhalations may be also tried. In preventing the recurrence of the attacks there is no remedy so useful as iodide of potassium, which sometimes acts like a specific. From ten to twenty grains three times a day is usually sufficient. Particular attention should be paid to the diet of asthmatic patients. A rule which experience generally compels them to make is to take the heavy meals in the early part of the day and not retire to bed before gas- tric digestion is completed. As the attacks are often induced by flatu- lency, the carbohydrates should not be allowed. Coffee is a more suitable drink than tea. In respect to climate it is very difficult to lay down rules for asthmatics. The patients are often much better in the city than in the country. The high and dry altitudes are certainly more beneficial than the sea-shore; but in protracted cases, with emphysema as a secondary complication, the rarefied air of high altitudes is not advantageous. In young persons I have known a residence for six months in Florida or southern California to be followed by prolonged freedom from attacks. V. FIBRINOUS BRONCHITIS. An acute or chronic affection, characterized by the formation in cer- tain of the bronchial tubes of fibrinous casts, which are expelled in parox- ysms of dyspnoea and cough. In several diseases fibrinous moulds of the bronchi are formed, as in diphtheria and croup (with extension into the trachea and bronchi), in 536 DISEASES OF THE RESPIRATORY SYSTEM. pneumonia, and occasionally in phthisis—conditions which, however, have nothing to do with true fibrinous bronchitis. These casts are not to be confounded with the blood-casts which occur occasionally in haemoptysis. Etiology.—Nothing is known of its causation. It occurs more fre- quently in males. It is met with at all periods of life, but is more common between the ages of twenty and forty. It has been known to attack several members of the same family. Cases have been described occurring together as if due to some endemic influence (Pichini). The cases are rare, particu- larly in hospital practice. The attacks occur most commonly in the spring months. An association with tuberculosis has been frequently noted. Model, in an article from Baumler’s clinic, states that tuberculosis was present in ten of twenty-one post-mortems. It has been met with also in connection with skin-diseases, such as pemphigus, impetigo, and herpes. The attacks appeared to be related in some cases to the menstrual period. Several instances have been described with heart-disease, but it seems probable that in all these conditions the connection was not causal. Symptoms.—Acute cases are rare. They may set in with high fevers, rigors, severe paroxysms of cough, and perhaps with hsemoptysis. The clinical picture resembles acute bronchitis, and only the expulsion of the membranous casts gives the characteristic features to the case. It is much more serious than the chronic form and fatal termination is not uncommon. N. S. Davis has reported two fatal cases. In some of the acute cases there has been affection of the tonsils, and it is possible that the disease may have been truly diphtheritic in character and due to ex- tension of the membrane into the trachea and bronchi. The casts in these cases are not only more extensive, but they also do not present the lami- nated structure characteristic of true plastic bronchitis. A patient may have a single attack without any recurrence, but in the chronic form the attacks come on at varying intervals and the disease may last for ten or even twenty years. Instances are on record in which the paroxysms have occurred at definite intervals for many months. The at- tacks may recur weekly or a period of a year or more may intervene. The onset is marked by bronchitic symptoms, not necessarily with fever. The cough becomes distressing and paroxysmal in character ; the sputa may be blood-stained and the patient brings up rounded, ball-like masses, which, when disentangled, are found to be moulds of bronchi; the haemorrhage may be profuse. In one of the two cases which I have seen it invariably accompanied the attack, and the whitish dendritic casts of the tubes were always entangled in the blood and clots. Urgent dyspnoea and cyanosis may be present in severe attacks. The physical signs are those of a severe bronchitis. It may occasionally be possible to determine the weakened or suppressed breath sounds in the affected territory and there may be deficient expansion or even retraction of the chest wall in a corresponding area, but this is in reality very difficult, and twice prior to the expulsion of the casts I failed to determine by physical examination the affected region. CIRCULATORY DISTURBANCES IN THE LUNGS. As mentioned, the casts are usually rolled up and mixed with mucus or blood. When unravelled in water they present a complete mould of a secondary or tertiary bronchus with its ramifications. The size of the cast may vary with different attacks, but, as has often been noticed, the form and size may be identical at each attack as if precisely the same bronchial area was involved each time. The casts are hollow, laminated, the size of the lumen varying with the number and thickness of the laminas. Some- times they are almost solid. Transverse sections show a beautiful concen- tric arrangement. The fibrin appears in places to retain its fibrillary structure ; in others, as in diphtheritic membrane, it lias undergone the hyaline transformation. Leucocytes are imbedded in the meshes. In the centre, particularly in the smaller casts, it is not uncommon to see alveolar epithelium with numerous carbon particles. Leyden’s crystals are some- times found and occasionally Curschmann’s spirals. The pathology of the disease is obscure. The membrane is identical with that to which the term croupous is applied, and the obscurity relates not so much to the mechanism of the production, which is probably the same as in other mucous surfaces, as to the curious limitation of the affec- tion to certain bronchial territories and the remarkable recurrence at stated or irregular intervals throughout a period of many years. In the acute cases the treatment should be that of ordinary acute bron- chitis. We know of nothing which can prevent the recurrence of the attacks in the chronic form. In the uncomplicated cases there is rarely any danger during the paroxysm, even though the symptoms may be most distressing and the dyspnoea and cough very severe. Inhalations of ether, steam, or atomized lime-water aid in the separation of the membranes. Pilocarpine might be useful, as in some instances it increases the bronchial secretion. The employment of emetics may be necessary, and in some cases they are effective in promoting the removal of the casts. IY. DISEASES OF THE LUNGS. 1. CIRCULATORY DISTURBANCES IN THE LUNGS. Congestion.—There are two forms of congestion of the lungs—active and passive. (1) Active Congestion of the Lungs.—Much doubt and confusion still exist on this subject. French writers, following Woillez, regard it as an independent primary affection (malaclie de Woillez), and in their diction- aries and text-books allot much space to it. English and American authors more correctly regard it as a symptomatic affection. Active flux- ion to the lungs occurs with increased action of the heart, and when very hot aii or irritating substances are inhaled. In diseases which interfere 538 DISEASES OF THE RESPIRATORY SYSTEM. locally with the circulation the capillaries in the adjacent unaffected por- tions may be greatly distended. The importance, however, of this collat- eral fluxion, as it is called, is probably exaggerated. In a whole series of pulmonary affections there is this associated congestion—in pneumonia, bronchitis, pleurisy, and tuberculosis. The symptoms of active congestion of the lungs are by no means defi- nite. The description given by Woillez and by other French writers is of an affection which is difficult to recognize from anomalous or larval forms of pneumonia. The chief symptoms described are initial chill, pain in the side, dyspnoea, moderate cough, and temperature from 101° to 103°. The physical signs are defective resonance, feeble breathing, sometimes bronchial in character, and fine r&les. A majority of clinical physicians would undoubtedly class such cases under inflammation of the lung. In many epidemics the abnormal and larval forms are specially prevalent. This is no doubt the condition to which Porcher, of Charlestown, called attention a short time ago as a “ hitherto undescribed affection of the lungs.” The occurrence of an intense and rapidly fatal congestion of the lung, following extreme heat or cold or sometimes violent exertion, is recognized by some authors. Kenforth, the oarsman, is said to have died from this cause during the race at Halifax. Leuf has described cases in which, in association with drunkenness, exposure, and cold, death occurred suddenly, or within twenty-four hours, and the only lesion found has been an ex- treme, almost haemorrhagic, congestion of the lungs. It is by no means certain that in these cases death really occurs from pulmonary congestion in the absence of specific statements with reference to the coronary ar- teries. Several times in sudden death from disease of these vessels I have seen great engorgement of the lungs though not the extreme grade men- tioned by Leuf. I have no personal knowledge of cases such as he describes. (2) Passive Congestion.—Two forms of this may be recognized, the mechanical and the hypostatic. {a) Mechanical congestion occurs whenever there is an obstacle to the return of the blood to the heart. It is a common event in many affections of the left heart. The lungs are voluminous, russet brown in color, cut- ting and tearing with great resistance. On section they show at first a brownish-red tinge, and then the cut surface, exposed to the air, becomes rapidly of a vivid red color from oxidation of the abundant lnemoglobin. This is the condition known as brown induration of the lung. Histologi- cally it is characterized by (a) great distention of the alveolar capillaries; (/?) increase in the connective-tissue elements of the lung; (y) the pres- ence in the alveolar walls of many cells containing altered blood-pigment, (8) in the alveoli numerous epithelial cells containing blood-pigment in all stages of alteration, which are also found in great numbers in the sputum. CIRCULATORY DISTURBANCES IN THE LUNGS. 539 It occasionally happens that this mechanical hyperaemia of the lung results from pressure of tumors. So long as compensation is maintained the mechanical congestion of the lung in heart-disease does not produce any symptoms, but with enfeebled heart action the engorgement becomes marked and there are dyspnoea, cough, and expectoration, with the char-, acteristic alveolar cells. (b) Hypostatic congestion. In fevers and adynamic states generally it is very common to find the bases of the lungs deeply congested, a condi- tion induced partly by the effect of gravity, the patient lying recumbent in one posture for a long time, but chiefly by weakened heart action. That it is not an effect of gravity alone is shown by the fact that a healthy person may remain in bed an indefinite time without its occurrence. The term hypostatic congestion is applied to it. The posterior parts of the lung are dark in color and engorged with blood and serum; in some in- stances to such a degree that the alveoli no longer contain air and portions of the lung sink in water. The term splenization and hypostatic pneu- monia have been given to these advanced grades. It is a common affec- tion in protracted cases of typhoid fever and in long debilitating illnesses. In ascites, meteorism, and abdominal tumors the bases of the lungs may be compressed and congested. In this connection must be mentioned the form of passive congestion met with in injury to, and organic disease of, the brain. In cerebral apoplexy the bases of the lungs are deeply en- gorged, not quite airless, but heavy, and on section drip with blood and serum. I have twice seen this condition in an extreme grade throughout the lungs in death from morphia poisoning. In some instances the lung tissue has a blackish, gelatinous, infiltrated appearance, almost like diffuse pulmonary apoplexy. Occasionally this congestion is most marked in, and even confined to, the hemiplegic side. In prolonged coma the hypostatic congestion may be associated with patches of consolidation, due to the aspiration of portions of food into the air-passages. The symptoms of hypostatic congestion are not at all characteristic, and the condition has to be sought for by careful examination of the bases of the lungs, wheii slight dulness, feeble, sometimes blowing, breathing and liquid rales can be detected. The treatment of congestion of the lungs is usually that of the condi- tion with which it is associated. In the intense pulmonary engorgement, which may possibly occur primarily, and which is met with in heart-disease and emphysema, free bleeding should be practised. From twenty to thirty ounces of blood should he taken from the arm, and if the blood does not flow freely and the condition of the patient is desperate, aspiration of the right auricle may be performed. , (Edema.—In all forms of intense congestion of the lungs there is a transudation of serum from the engorged capillaries chiefly into the air- cells, but also into the alveolar walls. Not only is it very frequent in con- gestion, but also with inflammation, with new growths, infarcts, and tuber- 540 DISEASES OF THE RESPIRATORY SYSTEM. cles. When limited to the neighborhood of an affected part, the name collateral oedema is sometimes applied to it. General oedema occurs under conditions very similar to those met with in congestion. It is very often, no doubt, a terminal event, occurring with the death agony. It is seen in typical form in the cachexias, in death from anaemia, also in chronic Bright’s disease, disease of the heart, and cerebral affections. The oedematous lung is heavy, looks watery, pits on pressure, and from the cut surface a large quantity of clear and, in cases of congestion, bloody serum flows freely ; the tissue may even have a gelatinous, infiltrated ap- pearance. The condition is much more common at the bases, hut it may exist throughout the entire lung. The pathology of pulmonary oedema is not always clear. Two factors usually prevail in extreme cases—increased tension within the pulmonary system and a diluted blood plasma. The increased tension alone is net capable of producing it. The experiments of Welch seem to indicate that the essential factor lies in a disproportion- ate weakness of the left ventricle, so that the blood accumulates in the lung capillaries until transudation occurs, a view which satisfactorily ex- plains certain cases, particularly the terminal oedemas. The symptoms of oedema of the lungs are often only an aggravation of those already existing, and are due to the primary disease, whether car- diac, renal, or general. There are usually increasing dyspnoea and cough, and on examination there may he defective resonance and large liquid r&les at the bases. There are cases in which the oedema comes on with great suddenness, and in chronic Bright’s disease it may prove rapidly fatal. In the cases of so-called inflammatory oedema fever is always present, and often signs, more or less marked, of pneumonia. The treatment of oedema of the lung is practically that of the condi- tions with which it is associated. In the acute cases active catharsis, and, if there is cyanosis, free venesection should be resorted to. Pulmonary Haemorrhage.—This occurs in two forms—bronclio-pul- monary hcemorrliage, sometimes called bronchorrhagia, in which the blood is poured out into the bronchi and is expectorated, and pulmonary apo- plexy or pneumorrhagia, in which the haemorrhage takes place into the air-cells and the lung tissue. 1. Broncho-pulmonary Hcemorrliage ; IJcemoptysis.—Spitting of blood, to which the term haemoptysis should be restricted, results from a variety of conditions, among which the following are the most important: (a) In young healthy persons haemoptysis may occur without warning, and after continuing for a few days disappear and leave no ill traces. There may be at the time of the attack no physical signs indicating pulmonary disease. In such cases good health may be preserved for years and no further trouble occur. These cases are not very uncommon. In Ware’s impor- tant contribution to this subject,* of 386 cases of haemoptysis noted in * On Haemoptysis as a Symptom, by John Ware, M. D. CIRCULATORY DISTURBANCES IN THE LUNGS. 541 private practice 62 recovered and pulmonary disease did not subsequently develop in them. I know three professional men who had haemoptysis as students, and who now, at periods of from fifteen to eighteen years subse- quently, remain in perfect health. (b) Haemoptysis in pulmonary tubercu- losis. So frequently are these conditions associated that in the lay mind spit- ting of blood and consumption are almost synonymous. The Hippocratic aphorism, “ From a spitting of blood there is a spitting of pus,” is repeated throughout the literature of more than twenty centuries. It occurs either early in the disease, before there are any obvious physical signs, or after the development of well-marked local lesions. Unquestionably in a majority of the cases in which subsequent to haemoptysis phthisis occurs tubercles were already present in the lung. The haemorrhage is bronchial and associated with a limited focus of disease. When the pulmonary lesion is more ad- vanced the haemoptysis results either from erosion of a branch of the pulmonary artery or from rupture of an aneurismal dilatation of the same, (c) In connection with certain diseases of the lung, as pneumonia (in the initial stage) and cancer, occasionally in gangrene, abscess, and bronchiec- tasis, haemoptysis occurs, (d) Haemoptysis is met with in many heart affections, particularly mitral lesions. It may be profuse and recur at intervals for years. (e) In ulcerative affections of the larynx, trachea, or bronchi. Sometimes the haemorrhage is profuse and rapidly fatal, as when an ulcer erodes a large branch of the pulmonary artery, an accident which I have known to happen in a case of chronic bronchitis with em- physema. (/) Aneurism is an occasional cause of haemoptysis. It may be sudden and rapidly fatal when the sac bursts into the air-passages. Slight bleeding may continue for weeks or even longer, due to pressure on the mucous membrane, erosion of the lung, or in some cases the sac “ weeps ” through the exposed laminae of fibrin. (g) Vicarious haemor- rhage, which occurs in rare instances in cases of interrupted menstruation. The instances are well authenticated. Flint mentions a case which he had had under observation for four years, and Hippocrates refers to it in the aphorism, “ Haemoptysis in a woman is removed by an eruption of the menses.” Periodical haemoptysis has also been met vrith after the removal of both ovaries. Even fatal haemorrhage has occurred from the lung during menstruation when no lesion was found to account for it. (h) There is a form of recurring haemoptysis in arthritic subjects to which Sir Andrew Clark has called special attention and which also is described by French writers. The cases occur in persons over fifty years of age who usually present signs of the arthritic diathesis. It rarely leads to fatal issue and subsides without inducing pulmonary changes, (i) Haemoptysis recurs sometimes in malignant fevers and in purpura haemorrhagica. Lastly, there is endemic haemoptysis, due to the Distomum Westermanni in the bron- chial tubes, an affection which is confined to parts of China and Japan. Symptoms.—Haemoptysis sets in as a rule suddenly. Often with- out warning the patient experiences a warm, saltish taste as the mouth 542 DISEASES OF THE RESPIRATORY SYSTEM. fills with blood. Coughing is usually induced. There may be only an ounce or so brought up before the bleeding stops, or the bleeding may continue for days, the patient bringing up small quantities. In other instances, particularly when a large vessel is eroded or an aneurism bursts, the amount is large, and the patient after a few attempts coughing shows signs of suffocation and death is produced by inundation of the bronchial system. Fatal haemorrhage may even occur into a large cavity in a patient debilitated by phthisis without the production of haemoptysis. I dissected a case of this kind at the Philadelphia Hospital. The blood from the lungs generally has characters which render it readily distin- guishable from the blood which is vomited. It is alkaline in reaction, frothy, and mixed with mucus, and when coagulation occurs air-bubbles are present in the clot. Blood-moulds of the smaller bronchi are sometimes seen. Patients can usually tell whether the blood has been brought up by coughing or by vomiting, and in a majority of cases the history gives im- portant indications. In paroxysmal hsemoptysis connected with menstrual disturbances the practitioner should see that the blood is actually coughed up, since deception may be practised. Naturally, the patient is at first alarmed at the occurrence of bleeding, but, unless very profuse, as when due to rupture of an aortic aneurism in a pulmonary cavity, the danger is rarely immediate. The attacks, however, are apt to recur for a few days and the sputa may remain blood-tinged for a longer period. In the great majority of cases the haemorrhage ceases spontaneously. It should be re- membered that some of the blood may be swallowed and produce vomit- ing, and, after a day or two, the stools may he dark in color. It is not well during an attack of haemoptysis to examine the chest. It was for- merly thought that haemorrhage exercised a prejudicial effect and excited inflammation of the lungs, but this is not often the case. (2) Pulmo7iary Apoplexy ; Ilcemorrhagic Infarct.—In this condition the blood is effused into the air-cells and interstitial tissue. It is rarely indeed diffuse, breaking the parenchyma as the brain tissue is broken in cerebral apoplexy. Sometimes, in disease of the brain, in septic condi- tions, and in the malignant forms of fevers, the lung tissue is uniformly infiltrated with blood and has, on section, a black, gelatinous appearance. As a rule, the haemorrhage is limited and results from the blocking of a branch of the pulmonary artery either by a thrombus or an embolus. The condition is most common in chronic heart-disease. Although the pulmonary arteries are terminal ones, blocking is not always followed by infarction; partly because the wide capillaries furnish sufficient anasto- mosis, and partly because the bronchial vessels may keep up the circula- tion. The infarctions are chiefly at the periphery of the lung, usually wedge-shaped, with the base of the wedge toward the surface. When re- cent, they are dark in color, hard and firm, and look on section like an ordinary blood-clot. Gradual changes go on, and the color becomes a reddish brown. The pleura over an infarct is usually inflamed. A mi- CIRCULATORY DISTURBANCES IN THE LUNGS. 543 croscopical section shows the air-cells to be distended with red blood-cor- puscles, which may also be in the alveolar walls. The infarcts are usually multiple and vary in size from a walnut to an orange. Very large ones may involve the greater part of a lobe. In the artery passing to the affected territory a thrombus or an embolus is found. The globular thrombi, formed in the right auricular appendix, play an important part in the production of haemorrhagic infarction. In many cases the source of the embolus cannot be discovered, and the infarct may have resulted from thrombosis in the pulmonary artery, but, as before mentioned, it is not infrequent to find total obstruction of a large branch of a pulmonary artery without haemorrhage into the corresponding lung area. The fur- ther history of an infarction is variable. It is possible that in some in- stances the circulation is re-established and the blood removed. More commonly, if the patient lives, the usual changes go on in the extravasated blood and ultimately a pigmented, puckered, fibroid patch results. Slough- ing may occur with the formation of a cavity. Occasionally gangrene results. In a case at the University Hospital, Philadelphia, a gangrenous infarct ruptured and produced fatal pneumothorax. The symptoms of pulmonary apoplexy are by no means definite. The condition may be suspected in chronic heart-disease when haemoptysis occurs, particularly in mitral stenosis, but the bleeding may be due to the extreme engorgement. When the infarcts are very large, and particularly in the lower lobe, in which they most commonly occur, there may be signs of consolidation with blowing breathing. Treatment of Pulmonary Haemorrhage.—In the treatment of haemoptysis it is important to remember the condition of the pulmo- nary circulation and the nature of the lesions associated with the haemor- rhage. The pressure within the pulmonary artery is considerably less than that in the aortic system. We have as yet very imperfect knowledge of the circumstances which influence the lesser circulation in man. Researches, particularly those of Bradford, indicate that the system is under vaso- motor control, but our knowledge of the mutual relations of pressure m the aorta and in the pulmonary artery, under varying conditions, is still very imperfect. Experiments with drugs seem to show that there may he an influence on systemic blood-pressure without any on the pulmonary, and the pressure in the one may rise while it falls in the other, or it may rise and fall in both together. In Andrew’s Harveian Oration these rela- tions are thoroughly described, and a statement is made, based on Brad- ford’s experiments, as to the action on the pulmonary blood-pressure of many of the drugs employed in haemoptysis. Thus ergot, the remedy perhaps most commonly used, causes a distinct rise in the pulmonary blood-pressure, while aconite produces a definite fall. The anatomical condition in haemoptysis is either hyperaemia of the bronchial mucosa (or of the lung tissue) or a perforated artery. In the 544 DISEASES OF THE RESPIRATORY SYSTEM. latter case the patient often passes rapidly beyond treatment, though there are instances of the most profuse haemorrhage which must have come from a perforated artery or a ruptured aneurism in which recovery has occurred. Practically, for treatment, we should separate these cases, as the remedies which would be applicable in a case of congested and bleeding mucosa would he as much out of place in a case of haemorrhage from ruptured aneurism as in a cut radial artery. When the blood is brought up in quantities—in mouthfuls at a time—it is almost certain either that an aneurism has ruptured or a vessel has been eroded. In the instances in which the sputa are blood-tinged or when the blood is in smaller quanti- ties, bleeding comes by diapedesis from hyperaemic vessels. In such cases the haemorrhage may be beneficial in relieving the congested blood-vessels. The indications are to reduce the frequency of the heart-beats and to lower the blood-pressure. By far the most important measure is absolute quiet of body, such as can only be secured by rest in bed and seclusion. In the majority of cases of mild haemoptysis this is sufficient. Even when the patient insists upon going about, the bleeding may stop spon- taneously. The diet should be light and unstimulating. Alcohol should not be used. The patient may, if he wishes, have ice to suck. Small doses of aromatic sulphuric acid may be given, but unless the bleeding is protracted styptic and astringent medicines are not indicated. For cough, which is always present and disturbing, opium should be freely given, and is of all medicines most serviceable in haemoptysis. Digitalis should not be used, as it raises the blood-pressure in the pulmonary artery. Aconite, as it lowers the pressure, may be used when there is much vascu- lar excitement. Ergot, tannic acid, and lead, which are so much em- ployed, have, I believe, little or no influence in haemoptysis. Ergot, accord- ing to Bradford, produces distinct rise in the pulmonary blood-pressure. One of the most satisfactory means of lowering the blood-pressure is purga- tion, and when the bleeding is protracted salts may be freely given. In profuse haemoptysis, such as comes from erosion of an artery or the rupt- ure of an aneurism, a fatal result is common, and yet post-mortem evi- dence shows that thrombosis may occur with healing in a rupture of con- siderable size. The fainting induced by the loss of blood is probably the most efficient means of promoting thrombosis, and it was on this principle that formerly patients were bled from the arm, or from both arms, as in the case of Laurence Sterne. Ligatures, or Esmarch’s bandages, placed around the legs may serve temporarily to check the bleeding. The ice- bag on the sternum is of doubtful utility. In a protracted case Cayley in- duced pneumothorax, but without effect. Briefly, then, we may say that cases of haemorrhage from rupture of aneurism or erosion of a blood-vessel usually prove fatal. The fainting induced by the loss of blood is beneficial, and, if the patient can be kept alive for twenty-four hours, a thrombus of sufficient strength to prevent further bleeding may form. The chief danger is the inundation of the PNEUMONIA. bronchial system with the blood, so that while the haemorrhage is profuse the cough should be encouraged. Opium should not then be used, and stimulants should be given with caution. In the other group, in which the haemorrhage comes from a congested area and is limited, the patient gets Avell if kept absolutely quiet, and fatal haemorrhage probably never occurs from this source. Best, reduc- tion of the blood-pressure by minimum diet, purging, if necessary, and the administration of opium to allay the cough are the main indications. II. PNEUMONIA (Lobar, Croupous, or Fibrinous Pneumonia ; Pneumonitis ; Lung Fever.) Definition.—An infectious disease caused by the micrococcus lan- ceolatus (pneumococcus, diplococcus pneumoniae), which excites a local inflammation in the lungs, and, by its toxines, constitutional disturbance of varying intensity. The fever terminates abruptly by crisis. Secondary infective processes are common. Etiology.—Pneumonia is one of the most wide-spread of acute dis- eases. Hospital statistics show that the ratio to other admissions is in the proportion of twenty to thirty per thousand. It prevails at all ages. Children are quite as susceptible to it as adults, and it is the special enemy of old age. Males are more frequently affected than females. Dwellers in cities and persons whose occupations are as- sociated with exposure, hardship, and cold are most liable to the disease. Contrary to the general rule in infectious diseases, newcomers and immi- grants seem less susceptible than the native inhabitants. Debilitating causes of all sorts render individuals more susceptible. Alcoholism is per- haps the most potent predisposing factor. Persons weakened by disease are especially prone to it; thus we find many cases in connection with chronic Bright’s disease, diabetes, the chronic affections of the nervous system, and protracted fevers. One important predisposing cause is a pre- vious attack. No acute disease recurs with such frequency. Instances are on record of individuals who have had ten or more attacks. Climate does not appear to have much influence. The disease pre- vails equally in cold and in hot countries, but it is stated that on this continent it is more prevalent in the Southern than in the Northern States. More important is the influence of season. Statistics everywhere show that more persons are attacked from December to May than in the summer and autumn. Seitz’s large statistics of 5,905 cases in Munich give 32 per cent in winter, 36-8 per cent in spring, 15*3 per cent in sum- mer, and 15-7 per cent in autumn. Seibert gives February and March for New York. Bell’s statistics of the Montreal General Hospital show practically the same distribution, but it is worth noting that during January, the coldest month of the year, in which the mean temperature DISEASES OF THE RESPIRATORY SYSTEM. for ten years was 13'75° F., the percentage was comparatively low. Janu- ary, however, is a month with very slight variations in temperature, and it seems that the sudden changes characteristic of March, April, and May are the important climatic factors which predispose to pneumonia. Her- ringham places the “ pneumonia season ” in London from the end of March to the end of June. Of other factors, cold has been thought to be one of the most impor- tant, and for years was regarded as the efficient cause of the disease. Un- doubtedly the disease sometimes promptly follows a sudden chilling or wetting, but in a large majority of cases no such history can be obtained. Pneumonia follows traumatism with great frequency, more particu- larly injury of the chest. Litten has called special attention to this con- tus ion-pneum onia. A change of opinion has of late taken place as to the nature of pneu- monia, which is now almost universally regarded as a specific infectious disease, depending upon a micro-organism. Among general circum- stances favoring this view, is the occurrence of pneumonia in epidemic form, a fact recognized by Laennec and by Grisolle. Many house epi- demics have been described within the past twenty years. On several occasions I have known two, three, and even four persons admitted to hospital from the same house. In 1887 I saw, with Graham, of Toronto, a local outbreak in which three members of a family were consecutively attacked with the most malignant pneumonia. There are instances on record in which as many as ten residents in one house have been attacked. Of late years many epidemics in towns have been reported. Still more striking are the epidemics which have been described in prisons and gar- risons, of which one of the most remarkable is that reported by W. B. Iiodman, of Frankfort, Kentucky. In one year there occurred in a prison population of 735, 118 cases, with 25 deaths. The prison was much over- crowded at the time. Similar epidemics have been described in Europe. At the penitentiary at Amberg, from the 1st of January to the 1st of June, there were 161 cases of pneumonia, with a mortality of over twenty- eight per cent. The micrococcus lanceolatus (diplococcus pneumoniae) of Fraenkel is now believed by competent authorities to be the specific agent of the dis- ease. It is identical with the micrococcus which Pasteur and Sternberg found in the saliva of certain individuals and which produces septicaemia in the rabbit. It occurs occasionally in the nose, the larynx, and the Eustachian tube. According to Netter’s observations, it is present in the buccal secretion in twenty per cent of healthy persons. It persists for months, or even years, in the saliva of persons who have had pneumonia. The researches of Fraenkel, Weichselbaum, Gamaleia, and others show that it is by far the most constant organism in pneumonia, and that it occurs in the secondary processes of the disease, such as pleurisy, endocarditis, pericarditis, and meningitis. In ten cases recently examined at the PNEUMONIA. 547 pathological laboratory of the Johns Hopkins Hospital by my colleague Welch, this organism was present in all; in six as pure cultures in the lung, in four together with pus organisms. In the sputum it may be demonstrated by treating the ordinary cover-glass preparations with gla- cial acetic acid and then, without washing off the acid, dropping on aniline oil and gentian-violet, which is to be poured off and renewed two or three times. The organism is seen to be a somewhat elliptical lance-shaped coccus occurring in pairs, hence the term diplococcus. It is usually en- capsulated. According to the dominant view, pneumonia is an infective disease caused by this diplococcus, which has its seat of election in and produces its chief effects on the lung, and which can, under favoring circumstances, invade other parts of the body—the pleura, meninges, and endocardium. This microbe may possibly attack these parts without the intervention of inflammation of the lung, as it has been found in meningitis and pleurisy independent of pneumonia. It is a wide-spread organism, at times pres- ent, as before stated, in the buccal secretions of healthy persons. It is not improbable that the various predisposing causes, such as cold, exhaustion, and debility, lower the vitality and render the individual susceptible, thus changing the character of the tissue-soil so that the virus can grow and produce its specific effects. On this view, pneumonia may be regarded as a local disease, produced by inhalation of the diplococci, which induce, by their toxines, as in other local diseases, such as erysipelas and diphtheria, constitutional disturbance of varying degrees of intensity. By the further invasion of the parasites a pneumococcus septicaemia may be produced, with secondary infective processes in other organs.* Recently from Leyden’s clinic very interesting studies have been issued by the brothers Klemperer on the production of immunity and upon the cure of pneumonia. Immunity is readily obtained in animals either by subcutaneous or intravenous injections of large quantities of the fil- tered bouillon cultures, or by the injection of the glycerine extract. The immunity, though rarely lasting more than six months, was transmitted to the offspring born within this period. Still more interesting are their observations upon the cure of the experimentally produced disease. They found that the serum and fluids of the body of an animal which had been rendered immune had the property not only of producing immunity when introduced into the circulation of another susceptible animal, but actually of curing the disease after infection had been in progress for some time. In infected animals with a body temperature of from 40° to 41° C., the fever fell to normal in twenty-four hours after the injection of serum of another animal which possessed immunity. They believe that * See on the question of etiology the elaborate essay of Wells, Journal of the Amer- ican Medical Association, 1889. 548 DISEASES OF THE RESPIRATORY SYSTEM. the pneumococcus produces a poisonous albumin (pneumotoxiu) which when introduced into the circulation of an animal causes elevation of temperature and the subsequent production in the body of a substance (antipneumotoxin) which possesses the power of neutralizing the poison- ous albumin which is formed by the bacteria. In man they hold that during the pneumonic process there is a constant absorption into the cir- culation of this poisonous albumin produced by the bacteria in the lungs. This continues until eventually the same antidotal substance is produced in the circulation that has been seen to occur experimentally. It is then that the crisis occurs. The bacteria are neither destroyed nor is their power to produce the poisonous albumin lessened; but the third factor, the antitoxic element, now exists and neutralizes the toxic substances as they are produced. They demonstrated that the serum of the blood of patients after the crisis of pneumonia contained the antitoxic substance and was capable, in a fair number of cases, of curing the disease when in- jected into infected animals. They have made preliminary observations upon patients with a view of inducing the crisis by the injection of the blood serum of persons convalescent from pneumonia, and which conse- quently contains the antitoxic body. In six cases of pneumonia the effect of the injections was favorable. The general results of experimental work has confirmed these observations; but no satisfactory progress has been made in establishing a rational serum-therapy for the disease in man. Morbid Anatomy.—Since the time of Laennec, pathologists have recognized three stages in the inflamed lung—engorgement, red hepatiza- tion, and gray hepatization. In the stage of engorgement the lung tissue is deep red in color, firmer to the touch, and more solid, and on section the surface is bathed with blood and serum. It still crepitates, though not so distinctly as healthy lung, and excised portions float. The air-cells can be dilated bv in- sufflation from the bronchus. Microscopical examination shows the capillary vessels to be greatly distended, the alveolar epithelium swollen, and the air-cells occupied by a variable number of blood-corpuscles and detached alveolar cells. In the stage of red hepatization the lung tissue is solid, firm, and airless. If the entire lobe is involved it looks volumi- nous, and shows indentations of the ribs. On section the surface is dry, reddish brown in color, and has lost the deeply congested appearance of the first stage. One of the most remarkable features is the friability; in striking contrast to the healthy lung, which is torn with difficulty, a hepatized organ can be readily broken by the finger. Careful inspection shows that the surface is distinctly granular, the granulations represent- ing fibrinous plugs filling the air-cells. The distinctness of this appear- ance varies greatly with the size of the alveoli, which are about 0T0 mm. in diameter in the infant, 0T5 or 0T6 in the adult, and from O20 to 0-25 in old age. On scraping the surface with a knife a reddish viscid serum is PNEUMONIA. 549 removed, containing small granular masses. The smaller bronchi often contain fibrinous plugs. If the lung has been removed before the heart, it is not uncommon to find solid moulds of clot filling the blood-vessels. Microscopically, the air-cells are seen to be occupied by coagulated fibrin in the meshes of which are red blood-corpuscles, polynuclear leucocytes, and alveolar epithelium. The alveolar walls arh infiltrated and leucocytes are seen in the interlobular tissues. Cover-glass preparations from the exudate, and thin sections show, as a rule, the diplococci already referred to, many of which are contained within cells. Staphylococci and strep- tococci may also be seen in some cases. In the stage of gray hepatization the tissue has changed from a reddish-brown to a grayish-white color. The surface is moister, the exudate obtained on scraping is more turbid, the granules in the acini are less distinct, and the lung tissue is still more friable. Histologically, in gray hepatization, it is seen that the air-cells are densely filled with leucocytes, the fibrin network and the red blood- corpuscles have disappeared. A more advanced condition of gray hepa- tization is that known as purulent infiltration, in which the lung tissue is softer and bathed with a purulent fluid. The stage of gray hepatization appears to be the first step in the process of resolution. The exudate is softened, the cell elements are disintegrated and rendered capable of absorption. When the purulent infiltration of the lung tissue reaches the grade sometimes seen post mortem, it is probable that resolution could not take place. Small abscess cavities may arise, and by their fusion larger ones. Often in one lung, or even in one lobe, the various stages of the process may be seen, and the passage of the engorgement into red hepatization and of the latter into the gray stage can be readily traced. The general details of the morbid anatomy of pneumonia may be gathered from the following facts, based on 100 autopsies, made by me at the General Hospital, Montreal: In 51 cases the right lung was affected; in 32, the left; in 17, both organs. In 27 cases the entire lung, with the exception, perhaps, of a narrow margin at the apex and anterior border, was consolidated. In 34 cases, the lower lobe alone was involved; in 13 cases, the upper lobe alone. When double, the lower lobes were usually affected together, but in three instances the lower lobe of one and the upper lobe of the other were attacked. In three cases also, both upper lobes were affected. Occasionally the disease involves the greater part of both lungs; thus, in one instance the left organ with the exception of the anterior border was uniformly hepatized, while the right was in the stage of gray hepatization, except a still smaller poition in the corresponding region. In a third of the cases, red and gray hepatization existed together. In 22 instances there was gray hepatization. As a rule the un- affected portion of the lung is congested or cedematous. When the greater portion of a lobe is attacked, the uninvolved part may be in a state of almost gelatinous oedema. The unaffected lung is usually congested, particularly 550 DISEASES OF THE RESPIRATORY SYSTEM. at the posterior part. This, it must be remembered, may be largely due to post-mortem subsidence. The uninflamed portions are not always con- gested and cedematous. The upper lobe may be dry and bloodless when the lower lobe is uniformly consolidated. The average weight of a normal lung is about 600 grammes, while that of an inflamed organ may be 1,500, 2,000, or even 2,500 gramnies. The bronchi contain, as a rule, at the time of death a frothy serous fluid, rarely the tenacious mucus so characteristic of pneumonic sputum. The mucous membrane is usually reddened, rarely swollen. In the affected areas the smaller bronchi often contain fibrinous plugs, which may extend into the larger tubes, forming perfect casts. The bronchial glands are swollen and may even be soft and pulpy. The pleural surface of the inflamed lung is invariably involved when the process becomes superficial. Commonly, there is only a thin sheeting of exudate, producing slight turbidity of the membrane. In only two of the hundred instances the pleura was not involved. In some cases the fibrinous exudate may form a creamy layer an inch in thickness. A serous exudation of variable amount is not uncommon. Lesions in other Organs.—The heart is distended with firm, tenacious coagula, which can be withdrawn from the vessels as dendritic moulds. In no other acute disease do we meet with coagula of such solidity and firmness. The distention of the right chambers of the heart is particu- larly marked. The left chambers are rarely distended to the same degree. The spleen is often enlarged, though in only 35 of the 100 cases was the weight above 200 grammes. The kidneys show parenchymatous swelling, turbidity of the cortex, and, in a very considerable proportion of the cases —twenty-five per cent—chronic interstitial changes. Pericarditis is not infrequent, and occurs more particularly with pneu- monia of the left side and with double pneumonia. In 5 of the 100 autop- sies it was present, and in 4 of them the lappet of lung overlying the peri- cardium with its pleura was involved. Endocarditis is more frequent and occurred in 16 of the 100 cases. In 5 of these the endocarditis was of the simple character; in 11 the lesions were ulcerative. Fatty degeneration of the heart is not common except in protracted cases. Meningitis is not infrequently found, and in many cases is associated with malignant endocarditis. It was present in 8 of the 100 autopsies. Of twenty cases of meningitis in ulcerative endocarditis fifteen occurred in pneumonia. The meningeal inflammation in these cases is usually cortical. Croupous or diphtheritic inflammation may occur in other parts. A croupous colitis, as pointed out by Bristowe, is not very uncommon. It occurred in 5 of my 100 post-mortems. It is usually a thin, flaky exuda- tion, most marked on the tops of the folds of the mucous membrane. In one case there was a patch of croupous gastritis, covering an area of 12 by 8 cm., situated to the left of the cardiac orifice. PNEUMONIA. 551 The liver shows parenchymatous changes and often extreme engorge- ment of the hepatic veins. Symptoms.—Abruptly, or preceded by a day or two of indisposi- tion, the patient has a severe chill, lasting from ten to thirty minutes. In no acute disease is an initial chill so constant or so severe. The fever rises cprickly. There is pain in the side, often of an agonizing character. A short, dry, painful cough soon develops, and the respirations are in- creased in frecpiency. When seen on the second or third day the patient presents an appearance which may be cpiite pathognomonic. lie lies flat in bed, often on the affected side; the face is flushed, particularly the cheeks; the breathing is hurried ; the alae nasi dilate with each inspira- tion ; the eyes are bright, the expression is anxious, and there is a frequent short cough which makes the patient wince and hold his side. The ex- pectoration is blood-tinged and extremely tenacious. The temperature rises rapidly to 104° or 105°. The pulse is full and bounding and the pulse-respiration ratio much disturbed. Examination of the lung shows the physical signs of consolidation—blowing breathing and fine rales. After persisting for from seven to ten days the crisis occurs, and with a fall in the temperature the patient passes from a condition of extreme dis- tress and anxiety to one of comparative comfort. The fever of pneumonia rises abruptly with the chill, during which the rectal temperature may be high. In children and in cases without chill the rise is more gradual. The temperature reaches 104° or 105° and is continuous, with a variation of a degree to a degree and a half. If a two-hour record is kept the diurnal variations are seen to follow the normal type. In children and healthy adults the fever is usually higher than in old persons and drunkards. After continuing for from five to nine days the temperature falls abruptly, forming what is known as the crisis, so characteristic in a large proportion of the cases. In from five to twelve hours, or even in an hour (S. West), the temperature may fall six or eight degrees. The crisis may occur as early as the third day or as late as the twelfth or fourteenth. A pseudo-crisis may occur on the fifth day or earlier. Defervescence may take place gradually by lysis. In cases of delayed resolution the fever may persist for weeks. Respiratory Symptoms.—Pain of an agonizing character is an early and distressing symptom. It is usually referred to the nipple or axillary regions of the affected side. In exceptional cases it may be in the abdo- men or flank, or even beneath the shoulder-blade. Deep inspiration and cough aggravate it. Dyspnoea is a very prominent feature. The respira- tions may be from forty to sixty in the minute and in exceptional cases and in children may rise to eighty. To produce this shortness of breath many factors combine—the fever, the loss of function in a considerable area of lung tissue, and the excessive pain in the side, which makes it im- possible to draw a deep breath. There may be nervous factors at work, as with the crisis the number of respirations may fall nearly to normal, 552 DISEASES OF THE RESPIRATORY SYSTEM. while the consolidation of the lung still persists. The type of breathing in pneumonia is peculiar and almost distinctive. The inspirations are black, temperature; RED, pulse; BLUE, RESPIRATION short and superficial. Expiration is often associated with a short grunt. The ratio between the respirations and pulse may be 1 to 2, or even 1 to Chart XIV.—Fever, pulse, and respirations in lobar pneumonia. PNEUMONIA. 553 1-5. In no other disease do we see such marked disturbance in the pulse- respiration ratio, and this is sometimes an aid in diagnosis. The cough is also very characteristic—frequent, short, restrained, and associated with great pain in the side. It is at first dry, hard, and with- out expectoration. In old persons and drunkards and in those debilitated by long illness there may be no cough. The sputum is mucoid at first, but within twenty-four hours shows special features. A brisk haemoptysis may be an initial symptom. Pneumonic sputum is viscid, tenacious, and blood-tinged. The gummous viscidity, together with the red blood-cor- puscles in various stages of alteration, give pathognomonic characters to the sputa, unknown in any other disease. The rusty tinge becomes more marked as the disease progresses, and so tenacious is the expectoration that it has to be wiped from the lips of the patient, and a spit-cup, half full, may be inverted without spilling. Toward the close it becomes more liquid and is more readily expelled. In low types of the disease the sputum may be fluid and dark brown, resembling prune juice. The amount is very variable. In children and old people there may be none; ordinarily, however, there are from 100 to 300 c. c. daily. After the crisis the quantity is variable ; abundant in some cases, absent in others. Micro- scopically, the sputum contains red blood-corpuscles in all stages of de- generation, alveolar epitheliu’m, diplococci and other micro-organisms, cell-moulds of the alveoli, and, in some cases, small fibrinous casts of the bronchioles. The latter are sometimes plainly visible to the naked eye. Physical Signs.—Inspection may not at first show any difference be- tween the two sides, though usually if the lower lobe of a lung is involved the movement is less on the affected side. Later, when consolidation has occurred, particularly if it is massive, this deficient expansion is very marked. Mensuration may show a definite increase in the volume of the side involved. The intercostal spaces are not obliterated. Palpation in- dicates still more clearly the lack of expansion, and a pleural friction may be felt. Tactile fremitus is increased. These signs are all more marked when consolidation is established. Percussion.—In the stage of engorgement the note is higher pitched and may have a somewhat tympanitic quality, the so-called Skoda’s reso- nance. This can often be obtained over the lung tissue just above a con- solidated area. When the lung is hepatized, the percussion note is flat, the quality of the flatness varying a good deal from a note which has in it a certain tympanitic quality to absolute dulness. There is not the wooden flatness of effusion and the sense of resistance is not so great. During resolution the tympanitic quality of the percussion note may return. For weeks or months after convalescence there may be a higher-pitched note on the affected side. Auscultation.—Quiet, suppressed breathing in the affected part is often a marked feature in the early stage, and is always suggestive. Very early there is heard at the end of inspiration the fine crepitant rale, a series of 554 DISEASES OF THE RESPIRATORY SYSTEM. minute cracklings heard close to the ear, and perhaps not audible until a full breath is drawn. Whether this is a fine pleural crepitus or is pro- duced in the air-cells and finer bronchi is still an open question. At this stage, before consolidation has occurred, the breath-sounds may be, as before mentioned, much feebler than in health, but on drawing a long breath they may have a harsh quality, to which the term broncho-vesicular has been applied. In the stage of red hepatization and when dulness is well defined, the respiration is tubular, similar to that heard in health over the larger bronchi. With this blowing breathing there may be no rales, and it may present an intensity unknown in any other pulmonary affec- tion. It is simply the propagation of the laryngeal and tracheal sounds through the bronchi and the consolidated lung tissue. The permeability of the bronchi is essential to its production. Tubular breathing is absent in certain cases of massive pneumonia in which the larger bronchi are completely filled Avith exudation. When resolution begins mucous rales of all sizes can be heard. At first they are small and have been called the redux-crepitus. Tlie voice-sounds are transmitted through the consoli- dated lung with great intensity. This bronchophony may have a curious nasal quality to which the term asgophony has been given. Circulatory Symptoms.—During the chill the pulse is small, but in the succeeding fever it becomes full and bounding. In cases of moderate severity it ranges from 100 to 116. It is not often dicrotic. In strong, healthy individuals and in children there may be no sign of failing pulse throughout the attack. With extensive consolidation the left ventricle may receive a very much diminished amount of blood and the pulse in consequence may be small. In the old and feeble the pulse may be small and rapid from the outset. The heart-sounds are usually loud and clear. During the in- tensity of the fever, particularly in children, bruits are not uncommon both in the mitral and in the pulmonary areas. The second sound over the pulmonary artery is accentuated. Attention to this sign gives a valu- able indication as to the condition of the lesser circulation. With disten- tion of the right chambers and failure of the right ventricle to empty itself completely the pulmonary second sound becomes much less distinct. When the right heart is engorged there may be an increase in the dulness to the right of the sternum. With gradual heart-failure and signs of dilatation the long pause is greatly shortened, the sounds approach each other in tone and have a foetal character (embryocardia). Blood.—Anaemia is rarely seen. There is in most cases a leucocytosis, which appears early, persists, and disappears with the crisis. The leuco- cytes may number from twelve to forty or fifty thousand, even more, per cubic millimetre. The fall in the leucocytes is often slower than the drop in the fever, particularly when resolution is delayed. A point of consider- able prognostic importance is that in malignant pneumonia the leucocy- tosis is absent, and in any case the continuous absence may be regarded as PNEUMONIA. 555 an unfavorable sign. A striking feature in the blood-slide is the richness and density of the fibrin network. This corresponds to the great increase in the fibrin elements, which has long been known to occur in pneumonia, the proportion rising from four to ten parts per thousand. Hayem de- scribes the blood-plates as greatly increased. The diplococci can very rarely be demonstrated in the blood. The gastro-intestinal symptoms are those associated with an ordinary sthenic fever. Vomiting is not frequent at the outset. There is naturally loss of appetite. The tongue is white and furred, and, in cases of a low type, rapidly becomes dry. Constipation is more common than diarrhoea, which does prevail, however, in some epidemics. The spleen is usually enlarged, and the edge can be felt during a deep inspiration. Except in cases of extreme engorgement of the right heart, the liver is usually not increased in volume. Among cutaneous symptoms one of the most interesting is the associa- tion of herpes with pneumonia. Not excepting malaria, we see labial herpes more frequently in this than in any other disease, occurring, as it does, in from twelve to forty per cent of the cases. It is supposed to be of favorable prognosis, and figures have been quoted in proof of this asser- tion. It may also occur on the nose or on the genitals. Its significance and relation to the disease are unknown. It is scarcely necessary to men- tion the theory which has been advanced, that it is an external expression of a neuritis which involves the pneumogastric and induces the pneumo- nia. At the height of the disease sweats are not common, but at the crisis they may be profuse. Redness of one cheek is a phenomenon long recog- nized in connection with pneumonia, and is usually on the same side as the disease. The urine presents the usual febrile characters of high color, high spe- cific gravity, high density, and increased acidity. The nitrogenous ele- ments, urea and uric acid, are notably increased. The chlorides are absent, or greatly reduced, during the height of the fever—due, it is sup- posed, to the amount exuded in the hepatized lung. At the crisis there may be marked increase in the amount of urine, which is heavily laden with urates and extractives. When jaundice occurs there is bile-pigment. A trace of albumin is present in a large proportion of the cases. It is rarely of serious significance, and seldom associated with tube-casts. Cerebral Symptoms.—As an initial symptom, headache is common. Consciousness is usually retained throughout, even in severe cases. In children convulsions are common, and in at least one half the cases usher in the disease. There may be violent maniacal symptoms in the adult. I once performed an autopsy in a case of this kind in which there was no suspicion whatever that the disease was other than acute mania. In drunk- ards the symptoms from the outset may be those of delirium tremens, in which disease it should be an invariable rule, even if fever is not present, to examine the lungs. These patients are apt to wander about, and must 556 DISEASES OF THE RESPIRATORY SYSTEM. be carefully watched. The preliminary excitement and delirium may give place to hebetude, which deepens to coma. It is not possible to decide in these cases whether meningitis is present or not, since it is usually cortical, and there are no symptoms of pressure on the nerves. In only one of eight instances was there involvement of the base, rendering clear the diagnosis of meningitis. These cases of so-called cerebral pneumonia are frequently associated with very high fever. In senile and alcoholic pneu- monia, however, the temperature may be low and yet brain symptoms very pronounced. Mental disturbance may persist during and after con- valescence, and insanity develops in a few cases. It is currently stated that apex pneumonia is more often complicated with severe delirium, but it has not been so in my experience. Complications.—Many of these seem to depend directly on the in- vasion of the body by the diplococci. As already mentioned, pleurisy is an inevitable event when the inflam- mation reaches the surface of the lung, and thus can scarcely be termed a complication. But there are cases in which the pleuritic features take the first place—cases to which the term pleuro-pneumonia is applicable. The exudation may be sero-fibrinous with copious effusion, differing from that of an ordinary acute pleurisy in the greater richness of the fibrin, which may form thick, tenacious, curdy layers. Pneumonia on one side with extensive pleurisy on the other is sometimes a puzzling complication to diagnose and an aspirator needle may be required to settle the ques- tion. The bacteriological examination of the fluid has demonstrated, in a large number of cases, the presence of the pneumococcus. Of late, special attention has been paid to the frequency with which empyema compli- cates pneumonia. Effusion may not have been suspected during the height of the disease, but after the temperature has been normal for some days a slight rise occurs and the irregular fever persists. Dulness con- tinues at the base, or may have extended. The breathing is feeble and there are no rdles. Such a condition may be closely simulated, of course, by the thickened pleural layers which are so commonly found after the pneumonia. The question should be settled at once by the introduction of the needle. It is by no means an uncommon complication, and many cases of empyema supposed to be primary are in reality secondary to a slight pneumonia. Pericarditis is more common in the pneumonia of children, particu- larly when double, and it is said with the pneumonia of the left side. It was present, as I stated, in five of my one hundred autopsies. Though usually plastic, there may be much serous effusion. There is rarely any difficulty in the diagnosis, but when the pneumonia involves the portion of lung covering the pericardium, there may be difficulty in determining, by physical signs, the existence of fluid. The increase in the dyspnoea, the greater feebleness of the pulse, and the gradual suppression of the heart-sounds will give the most valuable indications. In some instances PNEUMONIA. 557 the fluid is purulent. Though a very serious event, it is surprising how often recovery takes place even in the most desperate cases of pneumonia complicated with pericarditis. I remember that the late Dr. Murchison some years ago commented upon this feature in a case at St. Thomas’s Hospital. Endocarditis is still more frequent, and in my one hundred autopsies was present in sixteen. I called attention in the Goulstonian lectures for 1885 to the great frequency of this complication. Of 209 cases of malig- nant endocarditis collected from the literature, 54 cases occurred in this disease. Subsequent observations have fully confirmed this statement. It may be said that with no acute febrile disease is endocarditis so frequently associated. It is much more common in the left heart than in the right. It is particularly liable to attack persons with old valvular disease. There may be no symptoms indicative of this complication even in very severe cases. It may, however, be suspected in cases (1) in which the fever is protracted and irregular; (2) when signs of septic mischief arise, such as chills and sweats; (3) when embolic phenomena appear. The frequent complication of meningitis with the endocarditis of pneumonia, which has already been mentioned, gives prominence to the cerebral symptoms in these cases. The physical signs may be very deceptive. There are in- stances in which no cardiac murmurs have been heard. In others the de- velopment under observation of a loud, rough murmur, particularly if diastolic, is extremely suggestive. Changes in the myocardium are not uncommon, rarely more, however, than cloudy swelling of the fibres; but in some instances there is fatty change. Ante-mortem heart-clots are rare in pneumonia, even in the extreme grade of dilatation of the right chamber. In not a single instance of my autopsies were there globular thrombi in the auricles or in apices of the ventricles. In protracted cases thrombi occasionally form in the veins. A rare complication is embolism of one of the larger arteries. I saw an instance in Montreal of embolism of the femoral artery at the height of pneumonia, which necessitated amputation at the thigh. The patient re- covered. Transient aphasia has been met with in a few instances, setting in abruptly with or without hemiplegia. By far the most important complication is the pneumonic meningitis, which varies much at different times and in different places. My Mont- real experience is rather exceptional, as eight per cent of the fatal cases had this complication. It usually comes on at the height of the fever and in the majority of the cases is not recognized unless, as before mentioned, the base is involved, which is not common. Meningitis may develop later in the disease and is then more easily diagnosed. Associated as it so often is with ulcerative endocarditis, there may be embolism of the cerebral arteries, including hemiplegia. Among rare complications may be men- tioned peripheral neuritis, of which several instances have been described. I saw one well-marked instance, following pneumonia and influenza, in the 558 DISEASES OF THE RESPIRATORY SYSTEM. spring of 1890. There was neuritis of the left arm with considerable wasting. Serious gastric complications are rare. A croupous gastritis has already- been mentioned. The croupous colitis may induce severe diarrhoea. Jaundice is one of the most interesting complications of pneumonia and occurs with curious irregularity in different outbreaks of the disease. It sets in early, is rarely very intense, and has not the characters of obstruct- ive jaundice. There are cases in which it assumes a very serious form. The mode of production is not well ascertained. It does not appear to bear any definite relation to the degree of hepatic engorgement and it is certainly not due to catarrh of the ducts. Possibly it may be, in great part, haematogenous. Parotitis occasionally occurs, commonly in association with endocar- ditis. A rare complication of pneumonia is an arthritis resembling rheuma- tism, which may come on gradually during the disease or in the conva- lescence. Bright's disease does not often follow pneumonia. Peritonitis is ex- ceedingly rare. Relapse in pneumonia is so uncommon that some good observers have doubted its occurrence. I have never seen an instance in which I was certain that there was a definite relapse. There are cases in which from the ninth to the eleventh day the fever subsides, and after the tempera- ture has been normal for a day or two, a rise occurs and fever may persist for another ten days or even two weeks. Though this might be termed a relapse, it is more correct to regard it as an instance of an anomalous course of delayed resolution. Wagner, who has studied the subject care- fully, says that in his large experience of 1,100 cases he met with only 3 doubtful cases. When it does occur, the attack is usually abortive and mild. Recurrence is more common in pneumonia than in any other acute disease. Rush gives an instance in which there were twenty-eight attacks. Other authorities narrate cases of eight, ten, and even more attacks. Formerly it was much disputed whether ordinary lobar pneumonia ever terminated in pulmonary phthisis. These are really cases of tuber- culo-pneumonic phthisis the onset of which may resemble acute pneu- monia. Clinical Varieties.—A number of different forms of pneumonia have been recognized, such as malignant, adynamic, bilious, malarial, rheu- matic, and the like, but they scarcely require a full description. A mala- rial pneumonia is described and is thought to be very prevalent in some parts of this country. Although I have seen during the past seven years several hundred cases of malaria and am familiar with the bronchial trou- ble so commonly associated with it, I have yet to see an instance of pneu- monia which seemed in any way connected with paludism. The so-called PNEUMONIA. 559 rheumatic pneumonia has, so far as I know, no peculiarities; nor has rheumatism, I think, any special relation to the disease. The term typhoid pneumonia is commonly used to designate cases with adynamic symptoms and it is to be distinguished from those cases in which typhoid fever begins with a definite pneumonia, the so-called pneumo-typlms of foreign writers. Epidemic pneumonia is, as a rule, more fatal and may display minor peculiarities which differ in different epidemics. In some the cerebral complications are marked; in others, the cardiac. There may be diarrhoea. The pneumonia which occurs with influenza, and was so common in the last epidemic, presents no special features other than the peculiarities of onset. Perhaps, also, it was more severe and more fatal. In diabetic patients pneumonia runs a rapid and severe course, ending sometimes in abscess or gangrene. In the subjects of chronic alcoholism the onset of pneumonia is insidious, the symptoms may be masked, the fever slight, and the clinical picture may be that of delirium tremens. So latent is the disease in some of these cases that the thermometer alone may indi- cate the presence of an acute disease. At the extremes of life pneumonia presents certain well-marked features. It is sometimes seen in the new-born. In infants it very often sets in with a convulsion. The summit of the lung seems more frequently involved than in adults and the cerebral symptoms are more marked throughout. The torpor and coma, particularly if they follow convulsions, and the preliminary stage of excitement, may lead to the diagnosis of meningitis. Holt has recently published figures which indi- cate that lobar pneumonia is not uncommon in infants under two years of age. Pneumonic sputum is rarely seen in children. In old age pneumonia may be latent, coming on without chill; the cough and expectoration are slight, the physical signs ill-defined and changeable, and the constitutional symptoms out of all proportion to the extent of the local lesion. When pneumonia is prevailing extensively, particularly in jails and garrisons, cases are found which have some of the initial symptoms of the disease—perhaps a slight chill, moderate fever, and a few indefinite local signs. This is the so-called larval pneumonia. Apex pneumonia is said to be more often associated with adynamic features and with marked cerebral symptoms. The expectoration and cough may be slight. I can- not say that in my experience the cerebral symptoms in adults have been more marked in this form, nor do I think it necessarily graver than if situated at the base. The creeping or migratory pneumonia successively involves one lobe after the other and is a peculiar and well-recognized variety. Double pneumonia presents no peculiarities other than the greater dan- ger connected with it. The term massive pneumonia is applied to the rare condition in which not alone the air-cells but the bronchi of the entire 560 DISEASES OF TILE RESPIRATORY SYSTEM. lobe or even of the lung are filled with the fibrinous exudate. The aus- cultatory signs are absent; there is neither fremitus nor tubular breath- ing, and on percussion the lung is absolutely flat. It closely resembles pleurisy with effusion. The moulds of the bronchi may be expectorated in violent fits of coughing. Prognosis.—In a disease which carries off one in every four or five of those attacked the prognosis in a large number of cases is necessarily grave. In children and in healthy adults the outlook is good. In the debilitated, in drunkards, and in the aged the chances are against recovery. So fatal is it in the latter class that it has been termed the natural end of the old man. Many circumstances, of course, influence prognosis, par- ticularly the extent of the disease, the height of the fever, the presence of other diseases, and the occurrence of complications. When a lower lobe on one side or the lower and middle lobes of the right side are involved in a healthy adult, if there are no complications, the case usually proceeds to satisfactory resolution. Meningitis is a fatal complication. Endocarditis is extremely grave, much more so than peri- carditis, from which many cases recover. Early signs of heart-failure, dilatation of the right chamber, gradual cyanosis, and oedema of the lungs, are symptoms of the most serious character. As before stated, the danger of heart-clot is not great in pneumonia. The risk is in the extreme dis- tention of the right chamber. I believe the firm fibrinous coagula en- tangled in the columnse carneae and the valves are invariably produced during the death agony. When there are symptoms of abscess of the lung or of gangrene the prognosis is extremely bad ; yet cases are on record of recovery from both these conditions. Increasing rapidity of respiration, with difficulty in expectoration, very liquid and dark sputa, a low mutter- ing delirium, dry tongue, and failing pulse, with a suffused lividity of the face, are indicative of approaching dissolution. Death rarely occurs from direct interference with the function of respiration, though it may happen in cases of extensive double pneumonia. In a majority of cases the fatal result is brought about by gradual heart-failure, whether induced by the prolonged action of the fever, the specific action of the poison, or paralysis due to overdistension of the right ventricle. A collateral oedema of the uninvolved portion of the lung, so much spoken of, rarely, I believe, occurs in pneumonia ; nor is it likely, if the observations of Welch upon the production of this condition are correct, that in the course of pneu- monia the left ventricle can be disproportionately Aveak in comparison with the right. The absence of leucocytosis is an unfavorable sign. Termination. — Resolution, the process by which the lung is restored to its normal state, is effected partly by expectoration and partly by lique- faction and absorption of the exudate. It is not always possible to esti- mate the share respectively taken by these processes. There are cases in which a rapid resolution of extensDe consolidation takes place without any special increase in the expectoration; and, on the other hand, during PNEUMONIA. 561 resolution it is not uncommon to find in the expectoration the little plugs of fibrin and leucocytes which have been loosened from the air-cells and expelled by coughing. In a majority of cases both processes are probably at work. A variable time is taken in the restoration of the lung. Some- times within a week or ten days the dulness is greatly diminished, the breath-sounds become clear, and, so far as pliysicial signs are any guide, the lung seems perfectly restored. It is to be remembered that in any case of pneumonia with extensive pleurisy a certain amount of dulness will persist foi months, owing to thickening of the pleura. Delayed reso- lution is a condition which causes much anxiety to the physician. It may be postponed until the fourth, eighth, or even the tenth week. Usually the fever subsides, but the consolidation of the lung may persist, with great improvement in the general condition of the patient. In apex pneumonia the resolution is more apt to be retarded. It has been stated that bleeding is one cause of delayed resolution. A solid exudation can persist for weeks and yet the integrity of the lung may be ultimately re- stored. Grissole describes the lung from a patient who died on the six- tieth day in which the affected part looked not unlike the acute disease. Abscess may result from purulent infiltration of the lung tissue. It occurred in 4 of my 100 cases. Usually the lung breaks in limited areas and the abscesses are not large, but they may involve a considerable por- tion of a lobe. This most serious complication is indicated by cavern- ous signs and the expectoration of purulent material containing elastic tissue. The constitutional symptoms are usually very severe. In a large majority of the clinical cases in which abscess of the lung is believed to follow an acute pneumonia, the process has in reality been rapid tuber- culous consolidation with breaking of the lung tissue. There can, how- ever, be no reasonable doubt that abscess of the lung does occur as a rare sequence of ordinary pneumonia. Gangrene.—The presence of this complication is rendered evident by the horribly fetid odor of the expectoration, the presence of lung tissue, and crystals of fatty acids. It occurred in 3 of my 100 autopsies. Fibroid Induration.—That a chronic interstitial pneumonia may fol- low the ordinary acute disease cannot be questioned, though it is probably the rarest of all terminations. It was present in one of my 100 autopsies. The patient, aged fifty-eight, died on the thirty-second day after the initial chill. The right lung was uniformly solid, grayish in color, firm, and presented in places a translucent, smooth, homogeneous aspect. In these areas the alveolar walls were thickened and the fibrinous plugs filling the air-cells were undergoing transformation into a new growth of connective tissue. Mortality.—Pneumonia is one of the most fatal of acute diseases. Hospital statistics show that the mortality ranges from twenty to forty per cent Of 1,012 cases at the Montreal General Hospital, the mortality was 20-4 per cent. It appears to be somewhat more fatal in southern 562 DISEASES OF THE RESPIRATORY SYSTEM. climates. Of 3,969 cases treated at the Charity Hospital, New Orleans, the death rate was 28-01 per cent. It has been urged that the mortality in this disease has been steadily increasing, and attempts have been made to connect this increase with the expectant plan of treatment at present in vogue. But the careful and thorough analysis by C. N. Townsend and A. Coolidge, Jr.,* of 1,000 cases at the Massachusetts General Hospital indicates clearly that, when all circumstances are taken into consideration, this conclusion is not justified. They found that when all fatal cases over fifty years of age were omitted, and those patients who were delicate, intemperate, or the subject of some complication, there was very little variation from decade to decade, and that, excluding these cases, the rate was but little over ten per cent. In answer to the assertion that the modified treatment is in part responsible for the increased mortality, these authors show clearly that the rise in death rate took place in the period prior to 1860, when the treatment was entirely or in great part heroic. According to the recent analysis of 708 cases at St. Thomas’s Hospital by Hadden, II. W. G. McKenzie, and W. W. Ord, the mortality progress- ively increases from the twentieth year, rising from 3*7 per cent under that age to 22 per cent in the third decade, 30-8 per cent in the fourth, 47 per cent in the fifth, 51 per cent in the sixth, 65 per cent in the sev- enth decade. Of 223,730 cases collected by Wells from various sources, 40,276 died, a mortality of 18-1 per cent. Diagnosis.—No disease is more readily recognized in a large majority of the cases. The external characters, the sputa, and the physical signs combine to make one of the clearest of clinical pictures. After a study in the post-mortem room of my own and others’ mistakes, I think that the ordinary lobar pneumonia of adults is rarely overlooked. Judging from my autopsy records, I should say that errors are particularly liable to occur in the intercurrent pneumonias, in those comnlicating chronic affections, and in the disease as met with in children, the aged, and drunkards. Tuberculo-pneumonic phthisis is frequently confounded with pneumonia. Pleurisy with effusion is, I believe, not often mistaken ex- cept in children. In diabetes, Bright’s disease, chronic heart-disease, pulmonary phthisis, and cancer, an acute pneumonia often ends the scene, and is frequently overlooked. In these cases the temperature is perhaps the best index, and should, more particularly if cough develops, lead to a careful exami- nation of the lungs. The absence of expectoration and of pulmonary symptoms may make the diagnosis very difficult. In children there are two special sources of error; the disease may be entirely masked by the cerebral symptoms and the case mistaken for one of meningitis. It is remarkable in these cases how few indications there are of pulmonary trouble. The other condition is pleurisy with effusion, * Boston Medical and Surgical Journal, 1889. PNEUMONIA. which in children often has deceptive physical signs. The breathing may be intensely tubular and tactile fremitus may be present. The exploratory needle is sometimes required to decide the question. In the old and debilitated a knowledge that the onset of pneumonia is insidious, and that the symptoms are ill-defined and latent, should place the practi- tioner on his guard and make him very careful in the examination of the lungs in doubtful cases. In chronic alcoholism the cerebral symptoms may predominate and completely mask the local disease. As mentioned, the disease may assume the form of violent mania, but more commonly the symptoms are those of delirium tremens. In any case rapid pulse, rapid respiration, and fever are symptoms which should invariably excite suspicion of inflammation of the lungs. Pneumonia is rarely confounded with ordinary consumption, but to differentiate acute tuberculo-pneumonic phthisis is often difficult. The case may set in with a chill. It may be impossible to determine which condition is present until softening occurs and elastic tissue and tubercle bacilli appear in the sputum. A similar mistake is sometimes made in children. With typhoid fever, pneumonia is not infrequently confounded. There are instances of pneumonia with the local signs well marked in which the patient rapidly sinks into what is known as the typhoid state, with dry tongue, rapid pulse, and diarrhoea. Unless the case is seen from the outset it may be very difficult to determine the true nature of the malady. On the other hand, there are cases of typhoid fever which set in with symptoms of lobar pneumonia—the so-called pneumo-typhus. It may be impossible to make a differential diagnosis in such a case unless the characteristic eruption develops. Treatment.—Pneumonia is a self-limited disease, and runs its course uninfluenced in any way by medicine. It can neither be aborted nor cut short by any known means at our command. Even under the most un- favorable circumstances it will terminate abruptly and naturally, without a dose of medicine having been administered. A patient was admitted into one of my wards at the Philadelphia Hospital on the evening of the seventh day after the chill, in which he had been seen by one of my assistants, who had ordered him to go to hospital. He remained, however, in his house alone, without assistance, taking nothing but a little milk and bread and whisky, and was brought into the hospital by the police in a condition of act- ive delirium. That night his temperature was 105° and his pulse above 120. In his delirium he came near escaping through the window of the ward. The following morning—the eighth day—the crisis occurred, and at ward class his temperature was below 98°. The entire lower lobe of the right side was found involved, and he entered upon a rapid convalescence. So also, under the favoring circumstances of good nursing and careful diet, the experience of many physicians in different lands has shown that pneu- monia runs its course in a definite time, aborting sometimes spontaneously on the third or the fifth day, or continuing until the tenth or twelfth. DISEASES OF THE RESPIRATORY SYSTEM. We have, then, no specific treatment for pneumonia. The young prac- titioner may bear in mind that patients are more often damaged than helped by the promiscuous drugging, which is still only too prevalent. In cases of moderate severity a purely expectant plan may be followed—keep- ing the bowels open, regulating the diet, and, if necessary, giving a Dover’s powder at night to procure sleep. In severer cases a symptomatic plan of treatment should be pursued, meeting the indications as they arise. The first distressing symptom is usually the pain in the side, which may be relieved by local depletion—by cupping or leeching—or, better still, by a hypodermic injection of morphia. In many cases the question comes up at the outset as to the propriety of venesection. The reproach of Van Helmont, that “ a bloody Moloch presides in the chairs of medicine,” can- not be brought against the present generation of physicians. During the first five decades of this century the profession bled too much, but during the last decades we have certainly bled too little. Pneumonia is one of the diseases in which a timely venesection may save life. To be of service it should he done early. In a full-blooded, healthy man with high fever and bounding pulse the abstraction of from twenty to thirty ounces of blood is in every way beneficial, relieving the pain and dyspnoea, reducing the temperature, and allaying the cerebral symptoms, so violent in some instances. Unfortunately bleeding is now too frequently used at a late stage in the disease, when the heart is beginning to fail, the right cham- bers are dilated, the face is of a dusky hue, the respirations are very rapid, and there are signs, perhaps, of oedema of the uninvolved portions of the lungs. Though resorted to rather as a forlorn hope, it is a rational prac- tice, and, in emphysema and in heart-disease, proves satisfactory under identical hydraulic indications, but, unfortunately, in a majority of the cases of pneumonia it proves futile. Time and again, in such cases, have I urged free venesection, but in twelve hospital patients bled under these circumstances only one recovered. The indications for treatment are to lower the temperature and to support the heart. Fever alone is not, I think, hurtful; but it is difficult to differentiate the effects of fever and of the poisons circulating in the blood. It is not impossible, as some suppose, that the fever may be directly beneficial; still, high and prolonged pyrexia is undoubtedly dangerous and should be combated. Of efficient measures cold unquestionably heads the list. Perhaps the most convenient form is the application of ice-bags to the affected side—a practice long followed in Germany and now becoming prevalent in England and America, and one to be strongly commended. When the temperature is above 103° or 103-5° sponging may be resorted to, or the bath at 70°. The use of medicinal antipyretics in pneumonia is of doubtful pro- priety. Quinine has been much vaunted. Personally I cannot speak of any special advantages which I have seen from its use. From thirty to sixty grains daily will reduce the temperature, in a certain proportion of the cases, one or two degrees, but in this respect it is far below other antipy- PNEUMONIA. 565 reties. It is also not without ill effects in disturbing digestion or even causing vomiting, and, according to some writers—though this I have never noticed—inducing marked cardiac weakness and depression. Anti- pyrin, antifebrin, and plienacetin have had a thorough trial in pneumonia, and, although they still have their advocates, the general opinion of clini- cal physicians seems decidedly against their systematic employment. The progressive cardiac weakness is, after all, the most important enemy to fight in pneumonia and is emphasized by the old axiom, Sine pulsu nulla therapeia. Doubtless this is in part caused by the fever, but much more important is the toxic action of the poisons produced in the course of the disease. To these must be added the third factor, over- distention of the right chambers of the heart. We are still without an agent which can counteract the gradual influence of the poisons which develop in the course of acute febrile diseases, such as typhoid fever, pneumonia, and diphtheria, the chief effect of which is exercised upon the circulation, increasing the rapidity of the pulse and inducing a pro- gressive heart-failure. To meet this indication the general experience of physicians still points to alcohol as the most trustworthy remedy. Although some hold that alcohol in this condition is not indicated, I believe that it is in many instances the only remedy capable of tiding the patient over the most dangerous period. It should be given when the pulse becomes small, frequent, and feeble, or very compressible, and when the heart- sounds—particularly the second pulmonic sound—begin to lose their force. The amount will vary with the age of the patient and with his habits. Beginning with four to six ounces of whisky in the day the quan- tity may be increased, if necessary, to twelve or sixteen ounces. Of medicinal agentsa strychnine is one of the most valuable and has come into favor as a useful cardiac tonic. It may be given in doses of from a thirtieth to a twentieth of a grain. No certainty has as yet been reached as to the value of digitalis in the failing heart of fever. The practice is very general, but it is a drug to be used with caution. Recently it has been advocated by Petresco as having almost a specific action. When there are signs of sudden or rapid heart-failure, hypodermic injections of ether will sometimes prove most serviceable. Of other stimulants am- monia is one of the most valuable and is best given in the form of the aromatic spirits, which is quite as satisfactory and much less nauseous than the usually administered carbonate of ammonia. Camphor and musk may also be employed. Poliowing the practice which is employed in spreading erysipelas, some writers have recommended direct antiseptic injections into the lung tissue itself. Lepine has used with benefit very dilute bichloride injections. In cases of gangrene following pneumonia, it might be of advantage to use iodoform oil or bichloride solutions. The question of the use of arterial sedatives has not yet been settled. Aconite and veratrum viride and tartar emetic are largely used and loudly recommended by many physicians. I have never seen such benefit from 566 DISEASES OF THE RESPIRATORY SYSTEM. their early use as would warrant a recommendation, and when an arterial sedative is indicated in the robust, full-blooded, healthy individual, I much prefer the lancet. Expectorants are rarely of any value in pneumonia. If any one wishes to be convinced of the futility of such remedies, let him study their action on a series of cases of sthenic pneumonia, in which it would be a real gain to loosen the cough and give to the sputa a certain degree of fluidity. Nor in the stage of resolution can they be said to be of any special service. In cases of tardy resolution I have not hesitated to use pilocarpine, as sug- gested by Kiess. For the distressing cough and the pain in the side, opium in some form may be given, either the hypodermic of morphia or, for the' cough alone, Dover’s powder. There has been a feeling in the profession that opium was counter-indicated in pneumonia, but I fully agree with Loomis that it may be given with safety and with the greatest comfort to the patient. With marked cerebral symptoms an ice-cap may be used. If there is delirium, the patient should be carefully watched. For these symptoms the cold bath is by far the most efficient remedy, and it or the cold pack should be resorted to without hesitation. For the complications, in the more serious ones, such as meningitis and endocarditis, but little can be done. Pleurisy with large effusion may require aspiration. If there is doubt as to the ex- istence of fluid the exploratory needle should be used. It may be neces- sary, in pericarditis with extensive effusion, to aspirate the sac. Careful feeding forms an essential part of the treatment. The diet should be light and made up of articles which, while nourishing, are not heavy and not apt to induce flatulency. Milk or milk-whey, broths, beef-juice, and eggs constitute the main articles of food. The starchy articles, as a rule, should be excluded, because they tend to induce flatu- lency. If the milk also has this effect, it is better to use the whey and egg-white or beef-juices. Before leaving the question of diet it may be mentioned that the use of cold drinks, such as soda or Apollinaris water, not only gives relief to the distressing thirst, but also helps to reduce the fever, and may diminish slightly the viscidity of the expectoration. III. CHRONIC INTERSTITIAL PNEUMONIA (iCirrhosis of Lung—Fibroid Phthisis.) This consists in the gradual substitution to a greater or less extent of connective tissue for the normal lung. It is a fibroid change which may have its starting-point in the tissue about the bronchi and blood-vessels, the interlobular septa, the alveolar walls, or in the pleura. So diverse are the different forms and so varied the conditions under which this change occurs that a proper classification is extremely difficult. We may recog- nize, however, two chief forms—the local, which involves only a limited CHRONIC INTERSTITIAL PNEUMONIA. 567 area of the lung substance, and the diffuse, invading either both lungs or an entire organ. Etiology.—Local fibroid change in the lungs is common. It is a constant accompaniment of tubercle and in every case of phthisis the chronic interstitial changes play a very important role. In tumors, ab- scess, gummata, hydatids, and emphysema it also occurs. Fibroid pro- cesses are frequently met with at the apices of the lung and may be due either to a limited healed tuberculosis, to fibroid induration in conse- quence of pigment, or, in a few instances, may result from thickening of the pleura. Diffuse Interstitial Pneumonia is met with under the following cir- cumstances : 1. As a sequence of acute fibrinous pneumonia. Although extremely rare, this is recognized as a possible termination. From un- known causes resolution fails to take place. A gradual process of organ- ization goes on in the fibrinous plugs within the air-cells and the alveolar walls become greatly thickened by a new growth, first of nuclear and subsequently fibrillated connective tissue. Macroscopically there is pro- duced a smooth, grayish, homogeneous tissue which has the peculiar translu- cency of all new-formed connective tissue. This has been called gray in- duration. The subsequent history of this form needs more careful study. A majority of the cases terminate within a few months, and instances which have been followed from the outset are very rare. In one of Charcot’s cases, quoted by Bastian, death occurred about three months and a half after the onset of the acute disease and the lung was two thirds the normal size, grayish in color, and hard as cartilage. In the only case of the kind which has come under my observation, the pa- tient died about a month from the onset of the chill. The lung was uni- formly solid and grayish in color. In certain regions the fibrinous moulds in the air-cells were fatty, Avhile in others there were areas of a grayish translucent aspect, firm, smooth, not at all granular, and resembling recent connective tissue. Microscopically, these areas showed advanced fibroid change and great thickening of the alveolar walls, while the fibrin plugs of the air-cells were undergoing fibroid transformation. 2. Chronic Broncho-Pneumonia.—The relation of broncho-pneumonia to cirrhosis of the lung has been specially studied by Charcot, who states that it may follow the acute or subacute form of this disease. The fibrosis extends from the bronchi, which are usually found dilated. The alveolar walls are thickened and the lobules converted into firm grayish masses, in which there is no trace of normal lung tissue. This process may go on and involve an entire lobe or even the whole lung. Many of these cases are tuberculous from the outset. 3. Pleurogenous Interstitial Pneumonia.—Charcot applies this term to that form of cirrhosis of the lung which follows invasion from the pleura. Doubt has been expressed by some writers whether this really occurs. While Wilson Fox is probably correct in questioning whether an 568 DISEASES OF THE RESPIRATORY SYSTEM. entire lung can become cirrhosed by the gradual invasion from the pleura, 1 think there can be no doubt that there are instances of primitive dry pleurisy, which, as Sir Andrew Clark has pointed out, gradually com- presses the lung and at the same time leads to interstitial cirrhosis. This may be due in part to the fibroid change which follows prolonged com- pression. In some cases there seems to be a distinct connection between the greatly thickened pleura and the dense strands of fibrous tissue pass- ing from it into the lung substance. Instances occur in which one lobe or the greater part of it presents, on section, a mottled appearance, owing to the increased thickness of the interlobular septa—a condition which may exist without a trace of involvment of the pleura. In many other cases, however, the extension seems to be so definitely associated with pleu- risy that there is no doubt as to the causal connection between the two processes. In these instances the lung is removed with great difficulty, OAving to the thickness and close adhesion of the pleura to the chest wall. 4. Chronic Interstitial Pneumonia, due to inhalation of dust. Zenker has proposed the term pneumonoJconiosis for the group of diseases due to the irritating effects of dust in certain occupations, such as coal-mining, stone-cutting, axe-grinding, and working in iron dust. It is essentially a chronic broncho-pneumonia leading to fibroid induration, at first nodular and peribronchial, and finally involving large areas of the lung tissue, which are converted into dense grayish-brown or black masses. The sub- ject will receive separate consideration. The term cirrhosis should be limited strictly to those cases in which a lung is involved in the fibroid process, whether originating in the parenchyma or in the pleura. It should not be applied to fibroid phthisis of tuberculous origin. Morbid Anatomy.—The disease is unilateral; the chest of the affected side is sunken, deformed, and the shoulder much depressed. On opening the thorax the heart is seen drawn far over to the affected side. The unaffected lung is emphysematous and covers the greater portion of the mediastinum. It is scarcely credible in Iioav small a space, close to the spine, the cirrhosed lung may lie. Indeed, it may be overlooked, as happened in the case of a physician of my acquaintance, who left instruc- tions that his lung should be sent to Palmer Howard, of Montreal. It Avas reported, however, that at the autopsy no lung could be found! The adhesions between the pleural membranes may be extremely dense and thick, particularly in the pleurogenous cases; but when the disease has originated in the lung there may be little thickening of the pleura. The organ is airless, firm, and hard. It strongly resists cutting, and on section shows a grayish fibroid tissue of variable amount, through which pass the blood-vessels and bronchi. The latter may be either slightly or enor- mously dilated. There are instances in which the entire lung is converted into a series of bronchiectatic cavities and the cirrhosis is apparent only in certain areas or at the root. The tuberculous cases can usually be CHRONIC INTERSTITIAL PNEUMONIA. differentiated by the presence of an apical cavity, not bronchiectatic, and often large; and the other lung almost invariably shows tuberculous lesions. There are cases in which it is difficult to determine satisfactorily the true nature. A question of some interest in connection with chronic interstitial pneumonia is, Do softening and cavity formation ever occur apart from caseation and tuberculosis ? That is to say, are there cavities in a cirrhotic lung which may be due to a simple necrosis ? Undoubtedly, though they are rare; I have seen them in at least two instances of an- thracosis, and Charcot * refers to them as “ ulceres du poumon,” to dis- tinguish them from the abscess cavity of acute pneumonia or a tuberculous cavity. The other lung is always greatly enlarged and emphysematous. The heart is hypertrophied, particularly the right ventricle, and there may be marked atheromatous changes in the pulmonary artery. An amyloid condition of the viscera is found in some cases. Symptoms and Course.—It is essentially a chronic disease, ex- tending over a period of many years, and when once the condition is established the health may be fairly good. In a Avell-marked case the patient complains only of his chronic cough, perhaps of slight shortness of breath. In other respects he is quite well, and is usually able to do light work. The cases are commonly regarded as phthisical, though there may be scarcely a symptom of that affection except the cough. There are instances, however, of fibroid phthisis which cannot be distinguished from cirrhosis of the lung except by the presence of tubercle bacilli in the expectoration. As the bronchi are usually dilated, the symptoms and physical signs may be those of bronchiectasis. The cough is paroxysmal and the expectoration is generally copious and of muco-purulent or sero- purulent nature. It is sometimes fetid. Haemorrhage is by no means infrequent, and occurred in more than one half of the cases analyzed by Bastian. Walking on the level and in the ordinary affairs of life the patient may show no shortness of breath, but in the ascent of stairs and on exer- tion there may be dyspnoea. Physical Signs.—Inspection.—The affected side is immobile, retracted, and shrunken, and contrasts in a striking way with the voluminous sound side. The intercostal spaces are obliterated and the ribs may even over- lap. The shoulder is drawn down and from behind it is seen that the spine is bowed. The heart is greatly displaced, being drawn over by the shrinkage of the lung to the affected side. When the left lung is affected there may be a large area of visible impulse in the second, third, and fourth interspaces. Mensuration shows a great diminution in the affected side, and with the saddle-tape the expansion may be seen to be negative. The percussion note varies with the condition of the bronchi. It may be absolutely dull, particularly at the base or at the apex. In the axilla there may be a flat tympany or even an amphoric note over a large * CEuvres completes de J. M. Charcot, tome v, p. 189. 570 DISEASES OF TIIE RESPIRATORY SYSTEM. sacculated bronchus. On the opposite side the percussion note is usually liyperresonant. On auscultation the breath-sounds have either a cav- ernous or amphoric quality at the apex, and at the base are feeble, with mucous, bubbling rales. The voice-sounds are usually exaggerated. Car- diac murmurs are not uncommon, particularly late in the disease, when the right heart fails. These are, of course, the physical signs of the dis- ease when it is well established. They naturally vary considerably, ac- cording to the stage of the process. The disease is essentially chronic, and may persist for fifteen or twenty years. Death occurs sometimes from haemorrhage, more commonly from gradual failure of the right heart with dropsy, and occasionally from amyloid degeneration of the organs. The diagnosis is never difficult. It may be impossible to say, without a clear history, whether the origin is pleuritic or pneumonic. Between cases of this kind and fibroid phthisis it is not always easy to discriminate, as the conditions may be almost identical. 'When tuberculosis is present, however, even in long-standing cases, bacilli are usually present in the sputa, and there may be signs of disease in the other lung. Treatment.—It is only for an intercurrent affection or for an aggra- vation of the cough that the patient seeks relief. Nothing can be done for the condition itself. When possible the patient should live in a mild climate, and should avoid exposure to cold and damp. A distressing feature in some cases is the putrefaction of the contents of the dilated tubes, for which the same measures may be used as in fetid bronchitis. IV. BRONCHO-PNEUMONIA (Capillary Bronchitis). This is essentially an inflammation of the terminal bronchus and the air-vesicles which make up a pulmonary lobule, whence the term broncho- pneumonia. It is also known as lobular, in contradistinction to lobar pneu- monia. The term catarrhal is less applicable. The process begins in all cases with an inflammation of the capillary bronchi, which is a condition rarely if ever found without involvement of the lobular structures, so that it is now customary to consider the affections together. Etiology.—Broncho-pneumonia is as a rule a secondary affection met with under the following circumstances : 1. As a sequence of the infectious fevers—measles, diphtheria, whoop- ing-cough, scarlet fever, and, less frequently, small-pox, erysipelas, and typhoid fever. In children it forms the most serious complication of these diseases, and in reality causes more deaths than are due directly to the fevers.* In large cities it ranks next in fatality to infantile diarrhoea. Following, as it does, the contagious diseases which principally affect children, we find that a large majority of cases occur during early life. * Cyclopaedia of the Diseases of Children, vol. ii. BRONCHO-PNEUMONIA. 571 According to Morrill’s Boston statistics, it is most fatal during the first two years of life. The number of cases in a community increases or de- creases with the prevalence of measles, scarlet fever, and diphtheria. It is most prevalent in the winter and spring months. In the febrile affections of adults broncho-pneumonia is not very common. Thus in typhoid fever it is not so frequent as lobar pneumonia, though isolated areas of consoli- dation at the bases are by no means rare in protracted cases of this disease. In old people it is an extremely common affection, following debilitating causes of any sort, and supervening in the course of chronic Bright’s dis- ease and various acute and chronic maladies. 2. In the second division of this affection are embraced the cases of so-called aspiration or deglutition pneumonia. Whenever the sensitive- ness of the larynx is benumbed, as in the coma of apoplexy or urasmia, minute particles of food or drink are allowed to pass the rima, and, reach- ing finally the smaller tubes, excite an intense inflammation similar to the vagus pneumonia which follows the section of the pneumogastrics in the dog. Cases are very common after operations about the mouth and nose, after tracheotomy, and in cancer of the larynx and oesophagus. The aspirated particles in some instances induce such an intense broncho- pneumonia that suppuration or even gangrene supervenes. An inspiration broncho-pneumonia may follow haemoptysis (which has been already considered), the aspiration of material from a bronchiec- tatic cavity, and occasionally the material from an empyema which has ruptured into the lung. 3. The most common and fatal form of broncho-pneumonia is that excited by the tubercle bacillus, which has already been considered. Among general predisposing causes may be mentioned age. As just noted, it is prone to attack infants, and a majority of cases of pneumonia in children under five years of age are of this form. At the opposite extreme of life it is also common, in association with various debilitating circumstances and with the chronic diseases incident to the old. In children, rickets and diarrhoea are marked predisposing causes, and bron- cho-pneumonia is one of the most frequent post-mortem-room lesions in infants’ homes and foundling asylums. The disease prevails most exten- sively among the poorer classes. Morbid Anatomy.—On the pleural surfaces, particularly toward the base, are seen depressed bluish or blue-brown areas of collapse, between which the lung tissue is of a lighter color. Here and there are projecting portions over which the pleura may be slightly turbid or granular. The lung is fuller and firmer than normal, and, though in great part crepitant, there can be felt in places throughout the substance solid, nodular bodies. The dark depressed areas may be isolated or a large section of one lobe may be in the condition of collapse or atelectasis. Gradual inflation by a blow-pipe inserted in the bronchus will distend a great majority of these collapsed areas. On section, the general surface has a dark reddish color and usu- 572 DISEASES OF THE RESPIRATORY SYSTEM. ally drips blood. Projecting above tlie level of the section are lighter red or reddish-gray areas representing the patches of broncho-pneumonia. These may be isolated and separated from each other by tracts of unin- flamed tissue or they may be in groups or the greater part of a lobe may be involved. Study of a favorable section of an isolated patch shows: (a) A dilated central bronchiole full of tenacious purulent mucus. A fortu- nate section parallel to the long axis may show a racemose arrangement— the alveolar passages full of muco-pus. (b) Surrounding the bronchus for from 3 to 5 mm. or even more is an area of grayish-red consolidation, usually elevated above the surface and firm to the touch. Unlike the consolidation of lobar pneumonia, it may present a perfectly smooth sur- face, though in some instances it is distinctly granular. In a late stage of the disease small grayish-white points may be seen, which on pressure may be squeezed out as purulent droplets. A section in the axis of the lobule may present a somewhat grape-like arrangement, the stalk and stems representing the bronchioles and alveolar passages filled with a yellowish or grayish-white pus, while surrounding them is a reddish-brown hepatized tissue, (c) In the immediate neighborhood of this peribronchial inflam- mation the tissue is dark in color, smooth, airless, at a somewhat lower level than the hepatized portion, and differs distinctly in color and ap- pearance from the other portions of the lung. This is the condition to which the term spUnization has been given. It really represents a tissue in the early stage of inflammation, and it perhaps would be as well to give up the use of this term and also that of carnification, which is only a more advanced stage. The condition of collapse probably always precedes this, and it is difficult in some instances to tell the difference, as one shades into the other. In fact, collapse, splenization, and carnification are but pre- liminary steps in broncho-pneumonia. While, in many cases, the areas of broncho-pneumonia present a red- dish-brown color and are indistinctly granular, in others, particularly in adult?, the nodules may resemble more closely gray hepatization and the air-cells are filled with a grayish, muco-purulent material. Minute haemorrhages are sometimes seen in the neighborhood of the inflamed areas or on the pleural surfaces. Emphysema is commonly seen at the anterior borders and upper portions of the lung or in lobules adjacent to the inflamed ones. In many cases following diphtheria and measles the process is so extensive that the greater part of a lobe is involved, and it looks like a case of lobar hepatization. It has not, however, the uniform- ity of this affection, and collapsed dark strands may be seen between ex- tensive areas of hepatized tissue. There are three groups of cases: (1) Those in which the bronchitis and bronchiolitis are most marked, and in which there may be no definite consolidation, and yet on microscopical examination many of the alveolar passages and adjacent air-cells appear filled with inflammatory products. (2) The disseminated broncho-pneumonia, in which there are scattered BRONCHO-PNEUMONIA. 573 areas of peribronchial hepatization with patches of collapse, while a con- siderable proportion of the lobe is still crepitant. This is by far the most common condition. (3) Pseudo-lobar form, in which the greater portion of the lobe is consolidated, but not uniformly, for intervening strands of dark congested lung tissue separate the groups of hepatized lobules. Microscopically, the centre of the bronchus is seen filled with a plug of exudation, consisting of leucocytes and swollen epithelium. Section in the long axis may show irregular dilatations of the tube. The bronchial wall is swollen and infiltrated with cells. Under a low power it is readily seen that the air-cells next the bronchus are most densely filled, while toward the periphery of the focus the alveolar exudation becomes less. The contents of the air-cells are made up of leucocytes and swollen endo- thelial cells in varying proportion. Red corpuscles are not often present and a fibrin network is rarely seen, though it may be present in some alve- oli. In the swollen walls are seen distended capillaries and numerous leuco- cytes. As Delafield has pointed out, the interstitial inflammation of the bronchi and alveolar walls is the special feature of broncho-pneumonia. The histological changes in the aspiration or deglutition broncho- pneumonia differ from the ordinary post-febrile form in a more intense infiltration of the air-cells with leucocytes, producing suppuration and foci of softening, and even tending to gangrene. The organisms most commonly found in broncho-pneumonia are the micrococcus lanceolatus, the streptococcus pyogenes (either alone or with the first-named pneumococcus), the staphylococcus aureus et albus, and Fried- lander’s bacillus pneumonice. The Klebs-Loeffier bacillus is not infre- quently found in the secondary lesions of diphtheria. Except the pneu- mococcus these microbes are rarely found in pure cultures. In the lobular type the streptococcus is the most constant organism, in the pseudo-lobar the pneumococcus. Mixed infections are almost the rule in broncho-pneumonia. Broncho-pneumonia may terminate (1) in resolution, which when it once begins goes on more rapidly than in fibrinous pneumonia. Broncho- pneumonia of the apices, in a child, persisting for three or more weeks, particularly if it follows measles or diphtheria, is often tuberculous. In these instances, when resolution is supposed to be delayed, caseation has in reality taken place. (2) In suppuration, which is rarely seen apart from the aspiration and deglutition forms, in which it is extremely com- mon. (3) In gangrene, which occurs under the same conditions. (4) In fibroid changes—chronic broncho-pneumonia—a rare termination in the simple, a common sequence of the tuberculous, disease. Formerly it was thought that one of the most common changes in broncho-pneumonia, par- ticularly in children, was caseation; but this is really a tuberculous pro- cess, the natural termination of an originally specific broncho-pneumonia. It is of course quite possible that a broncho-pneumonia, simple in its ori- gin, may subsequently be the seat of infection by the bacillus tuberculosis. DISEASES OF THE RESPIRATORY SYSTEM. Symptoms.—Much confusion has arisen from the description of capillary bronchitis as a separate affection, whereas it is only a part, though a primary and important one, of broncho-pneumonia. At the outset it may be said that if in convalescence from measles or in whoop- ing-cough a child has an accession of fever with cough, rapid pulse, and rapid breathing, and if, on auscultation, fine rales are heard at the bases, or widely spread throughout the lungs, even though neither consolidation nor blowing breathing can ‘be detected, the diagnosis of broncho-pneu- monia may safely be made. I have never seen in a fatal case after diph- theria or measles a capillary bronchitis as the sole lesion. The onset is rarely sudden, or with a distinct chill; but after a day or so of indis- position the child gets feverish and begins to cough and to get short of breath. The fever is extremely variable; a range of from 102° to 104° is common. The skin is very dry and pungent. The cough is hard, dis- tressing, and may be painful. Dyspnoea gradually becomes a prominent feature. Expiration may be jerky and grunting. The respirations may rise as high as 60 or even 80 in the minute. Within the first forty-eight hours the percussion resonance is not impaired; the note, indeed, may be very full at the anterior borders of the lungs. On auscultation, many rales are heard, chiefly the fine subcrepitant variety, with sibilant rhonchi. There may really be no signs indicating that the parenchyma of the lung is involved, and yet even at this early stage, within forty-eight hours of the onset of the pulmonary symptoms, I have repeatedly, after diphtheria, found scattered nodules of lobular hepatization. Northrup,* in his thor- ough article on the subject, notes a case in which death occurred within the first twenty-four hours, and, in addition to the extensive involvement of the smaller bronchi, the intralobular tissue also was involved in places. The dyspnoea is constant and progressive and soon signs of deficient aera- tion of the blood are noted. The face becomes a little suffused and the finger-tips bluish. The child has an anxious expression and gradually enters upon the most distressing stage of asphyxia. At first the urgency of the symptoms is marked, but soon the benumbing influence of the car- bon dioxide on the nerve-centres is seen and the child no longer makes strenuous efforts to breathe. The cough subsides and, with a gradual increase in lividity and a drowsy restlessness, the right ventricle becomes more and more distended, the bronchial r&les become more liquid as the tubes fill with mucus, and death occurs from heart paralysis. These are the symptoms of a severe case of broncho-pneumonia, or what the older writers called suffocative catarrh. The physical signs may at first be those of capillary bronchitis, as in- dicated by the absence of dulness, the presence of fine subcrepitant and whistling r&les. In many cases death takes place before any definite pneu- monic signs are detected. When these exist they are much more frequent * Reference Handbook of the Medical Sciences, art. Broncho-Pneumonia. BRONCHO-PNEUMONIA. 575 at the bases, where there may be areas of impaired resonance or even of positive dulness. When numerous foci involve the greater part of a lobe the breathing may become tubular, but in the scattered patches of ordi- nary broncho-pneumonia, following the fevers, the breathing is more com- monly harsh than blowing. In. grave cases there is retraction of the base of the sternum and of the lower costal cartilages during inspiration, point- ing to deficient lung expansion. Diagnosis.—With lobar pneumonia it may readily be confounded if the areas of consolidation are large and merged together. It is to be re- membered that broncho-pneumonia occurs chiefly in children under five years of age, whereas lobar pneumonia in children is much more common between the ages of five and fifteen. No writer has so clearly brought out the difference between pneumonia at these periods as Gerhard,* of Philadelphia, whose papers on this subject, though published nearly sixty years ago, have the freshness and accuracy which characterize all the writ- ings of that eminent physician. Holt has recently brought forward figures to show that lobar pneumonia is not infrequent in infants under two years of age. The mode of onset is essentially different in the two affections, the one developing insidiously in the course or at the conclusion of an- other disease, the other setting in abruptly in a child in good health. In lobar pneumonia the disease is almost always unilateral, in broncho-pneu- monia bilateral. The chief trouble arises in cases of broncho-pneumo- nia, which by aggregation of the foci involves the greater part of one lobe. Here the difficulty is very great, and the physical signs may be practically identical, but in a broncho-pneumonia it is much more likely that a lesion will be found on the other side. The course of the two affections is very unlike; the lobar pneumonia in children terminates on the eighth or tenth day with abruptness, as in adults. A still more difficult question to decide is whether an existing broncho- pneumonia is simple or tuberculous. In many instances the decision can- not be made, as the circumstances under which the disease occurs, the mode of onset, and the physical signs may be identical. It has often been my experience that a case has been sent down from the children’s ward to the dead-house with the diagnosis of post-febrile broncho-pneumonia in which there was no suspicion of the existence of tuberculosis; but on sec- tion there were found tuberculous bronchial glands and scattered areas of broncho-pneumonia, some of which were distinctly caseous, while others showed signs of softening. I have already spoken fully of this in the section on tuberculosis, but it is well to emphasize the fact that there are many cases of broncho-pneumonia in children which time alone en- ables us to distinguish from tuberculosis. The existence of extensive dis- ease at the apices or central regions is a suggestive indication, and signs of softening may be detected. In the vomited matter, which is brought * American Journal of the Medical Sciences, vols. xiv and xv. 576 DISEASES OF THE RESPIRATORY SYSTEM. up after severe spells of coughing, sputum may be picked out and elastic tissue and bacilli detected. It is a superfluous refinement to make a diagnosis between capillary bronchitis and catarrhal pneumonia, for the two conditions are part and parcel of the same disease. In simple bronchitis involving the larger tubes urgent dyspnoea and pulmonary distress are rarely present and the rales are coarser and more sibilant. It must not be forgotten that, as in lobar pneumonia, cerebral symptoms may mask the true nature of the disease, and may even lead to the diagnosis of meningitis. I recall more than one instance in which it could not be satisfactorily determined whether the infant had tuberculous meningitis or a cerebral complica- tion of an acute pulmonary affection. Prognosis.—In children enfeebled by constitutional disease and pro- longed fevers broncho-pneumonia is terribly fatal, but in cases coming on in connection with whooping-cough or after measles recovery may take place in the most desperate cases. It is in this disease that the truth of the old maxim is shown—“ Kever despair of a sick child.” The death- rate in children under five lias been variously estimated at from thirty to fifty per cent. After diphtheria and measles thin, wiry children seem to stand broncho-pneumonia much better than fat, flabby ones. In adults the aspiration or deglutition pneumonia is a very fatal disease. Prophylaxis.—Much can be done to reduce the probability of attack after febrile affections. Thus, in the convalescence from measles and whooping-cough, it is very important that the child should not be exposed to cold, particularly at night, when the temperature of the room naturally falls. In a nocturnal visit to the nursery—sometimes, too, I am sorry to say, to a children’s hospital—how often one sees children almost naked, having kicked aside the bedclothes and having the night-clothes up about the arms ! The use of light flannel “ combinations ” obviates this noctur- nal chill, which is, I am sure, an important factor in the colds and pulmo- nary affections of young children, both in private houses and in institu- tions. The catarrhal troubles of the nose and throat should be carefully attended to, and during fevers the mouth should be washed two or three times a day with an antiseptic solution. Treatment.—The frequency and the seriousness of broncho-pneu- monia render it a disease which taxes to the utmost the resources of the practitioner. There is no acute pulmonary affection over which he at times so greatly despairs. On the other hand, there is not one in which he will be more gratified in saving cases which have seemed past all succor. The general arrangements should receive special attention. The room should be kept at an even temperature—about 65° to 68°—and the air should be kept moist with vapor. At the outset the bowels should be opened by a mild purge, either castor oil or small doses of calomel, one twelfth to one sixth of a grain hourly until a movement is obtained, and care should be taken throughout BRONCHO-PNEUMONIA. 577 the attack to secure a daily movement. The common saline fever mixture of citrate of potash, liquor ammonii acetatis, and aromatic spirits of am- monia may be given every two or three hours. If the disease comes on abruptly with high fever, minim or minim and a half doses of the tincture of aconite may be given with it. The pain, the distressing symptoms, and the incessant cough often demand opium, which must of course be used with care and judgment in the case of young children, but which is cer- tainly not contra-indicated and may be usefully given in the form of Dover’s powder. Blisters are now rarely if ever employed, and even the jacket poultice has gone out of fashion. For the latter, however, I con- fess to a strong prejudice, and when lightly made and frequently changed it undoubtedly gives great relief. Much more commonly we now see, both in private and in hospital practice, the jacket of cotton-batting. Ice-poultices to the chest I have seen used apparently with great bene- fit, and they are warmly recommended by many German physicians as well as by Goodhart and others in England. The diet should consist of milk, broths, and egg albumen. Milk often curds and is disagreeable. Egg-white is particularly suitable and very acceptable when given in cold water with a little sugar. It forms, indeed, an excellent medium for the ad- ministration of the stimulants. If the pulse shows signs of failing, it is best to begin early with brandy. As in all febrile affections of children, cold water should be constantly at the bedside, and the child should be encour- aged to drink freely. With these measures, in many cases the disease pro- gresses to a favorable termination, but too often other and more serious symptoms arise. Cough becomes more distressing, dyspnoea increases, the ominous rattling of the mucus can be heard in the tubes, the child’s color is not so good, and there is greater restlessness. Under these cir- cumstances stimulant expectorants—ammonia, squills, and senega—should be given. Together they make a very disagreeable dose for a young child, particularly with the carbonate of ammonia. The aromatic spirits of am- monia is somewhat better. If the carbonate is employed, it must be given in small doses, not more than a grain to an infant of eighteen months. If the child has increasing difficulty in getting up the mucus, an emetic should be given—either the wine of ipecac or, if necessary, tartar emetic. There is no necessity, however, to keep the child constantly nauseated. Enough should be given to cause prompt emesis, and the benefit results in the expulsion of mucus from the larger tubes. In this stage, too, strych- nine is undoubtedly helpful in stimulating the depressed respiratory cen- tre. With commencing cyanosis, inhalations of oxygen may be employed, sometimes with great benefit. With rapid failure of the heart, loud mucous rattles in the throat, and increasing lividity, every measure should be used to arouse the child and excite coughing. Alternate douches of hot and cold water, electricity, which I have seen applied with good results at Wiederhofer’s clinic in Vienna, and hypodermic injections of ether may be tried. For the reduc- 578 DISEASES OF THE RESPIRATORY SYSTEM. tion of temperature, particularly if cerebral symptoms are prominent, there is nothing so satisfactory as the wet pack or the cold bath. In the case of children, when the latter is used it should be graduated, beginning with a temperature which is pleasantly warm and gradually reducing it to 75° or 80°. Even when the temperature is not high, the cerebral symptoms are greatly relieved by the bath or the pack. V. EMPHYSEMA. Rupture of superficial vesicles may produce pneumothorax. In the case of deep-seated alveoli the air escapes into the interlobular connective tissue and causes a condition comparable to ordinary subcutaneous emphy- sema. It is not a very serious condition and rarely produces symptoms. It usually results from violent expiratory efforts, as in whooping-cough. The air-bubbles escape into the interlobular tissue, in which they look like little rows of beads, and when extensive, the lobules are distinctly out- lined by them (interstitial emphysema). There may be large bullae be- neath the pleura. A very rare event is the rupture close to the root of the lung and the passage of air along the trachea into the subcutaneous tissues of the neck. The condition in which the infundibular passages and the alveoli are dilated is called vesicular emphysema. A practical division may be made into compensatory, hypertrophic, and atrophic forms. I. Compensatory Emphysema Whenever a region of the lung does not expand fully in inspiration, either another portion of the lung must expand or the chest wall sink in order to occupy the space. The former almost invariably occurs. We have already mentioned that in broncho-pneumonia there is a vicarious distention of the air-vesicles in the adjacent healthy lobules, and the same happens in the neighborhood of tuberculous areas and cicatrices. In gen- eral pleural adhesions there is often compensatory emphysema, particu- larly at the anterior margins of the lung. The most advanced example of this form is seen in cirrhosis, when the unaffected lung increases greatly in size, owing to distention of the air-vesicles. A similar though less marked condition is seen in extensive pleurisy with effusion and in pneu- mothorax. At first, this distention of the air-vesicles is a simple physiological process and the alveolar walls are stretched hut not atrophied. Ulti- mately, however, in many cases they waste and the contiguous air-cells fuse, producing true emphysema. EMPHYSEMA. 579 II. Hypertrophic Emphysema. This form, also known as substantive or idiopathic emphysema, is a well - marked clinical affection, characterized by enlargement of the lungs, due to distention of the air-cells and atrophy of their walls, and clinically by imperfect aeration of the blood and more or less marked dyspnoea. Etiology.—Emphysema is the result of persistently high intra- alveolar tension acting upon a congenitally weak lung tissue. If the mechanical views which have prevailed so long as to its origin were true, the disease would certainly be much more common; since violent respira- tory efforts, believed to be the essential factor, are performed by a majority of the working classes. Strongly in favor of the view that the nutritive change in the air-cells is the primary factor is the markedly hereditary character of the disease and the frequency with which it starts early in life. These are two points upon which scarcely sufficient stress has been laid. To James Jackson, Jr., of Boston, we owe the first observations on the hereditary character of emphysema. Working under Louis’s directions, he found that in 18 out of 28 cases one or both parents were affected. I have been impressed by the frequency of its origin in childhood. It may follow recurring asthmatic attacks due to adenoid vegetations. It may develop, too, in several members of the same family. We are still ignorant as to the nature of this congenital pulmonary weakness. Cohnheim thinks it probably due to a defect in the development of the elastic-tissue fibres—a statement which is borne out by Eppinger’s obser- vations. Heightened pressure within the air-cells may be due to forcible in- spiration or expiration. Much discussion has taken place as to the part played by these two acts in the production of the disease. The inspiratory theory was advanced by Laennec and subsequently modified by Gairdner, who held that in the chronic bronchitis areas of collapse were induced, and compensatory distention took place in the adjacent lobules. This unquestionably does occur in the vicarious or compensatory emphysema, but it probably is not a factor of much moment in the form now under consideration. The expiratory theory, which was supported by Mendel- sohn and Jenner, accounts for the condition in a much more satisfactory way. In all straining efforts and violent attacks of coughing, the glottis is closed and the chest walls are strongly compressed by muscular efforts, so that the strain is thrown upon those parts of the lung least protected, as the apices and the anterior margins, in which we always find the emphysema most advanced. The sternum and costal cartilages gradually yield to the heightened intrathoracic pressure and are, in advanced cases, pushed forward, giving the characteristic rotundity to the thorax. As mentioned, the cartilages gradually become calcified. One theory of 580 DISEASES OF THE RESPIRATORY “SYSTEM. the disease is that there is a gradual enlargement of the thorax and the lungs increase in volume to fill up the space. Of other etiological factors occupation is the most important. The disease is met with in players on Avind instruments, in glass-blowers, and in occupations necessitating heavy lifting or straining. Whooping-cough and bronchitis play an important role, not so much in the changes which they induce in the bronchi as in consequence of the prolonged attacks of coughing. Morbid Anatomy.—The thorax is capacious, usually barrel-shaped, and the cartilages are calcified. On removal of the sternum, the anterior mediastinum is found completely occupied by the edges of the lungs, and the pericardial sac may not be visible. The organs are very large and have lost their elasticity, so that they do not collapse either in the thorax or when placed on the table. The pleura is pale and there is often an absence of pigment, sometimes in patches, termed by Virchow albinism of the lung. To the touch they have a peculiar, downy, feathery feel, and pit readily on pressure. This is one of the most marked features. Be- neath the pleura greatly enlarged air-vesicles may be readily seen. They vary in size from to 3 mm., and irregular bullae, the size of a Avalnut or larger, may project from the free margins. The best idea of the extreme rarefaction of the tissue is obtained from sections of a lung dis- tended and dried. At the anterior margins the structure may form an irregular series of air-chambers, resembling the frog’s lung. On careful inspection with the hand-lens, remnants of the interlobular septa or even of the alveoli may be seen on these large emphysematous vesicles. Though general throughout the organs, the distention is more marked, as a rule, at the anterior margins, and is often specially developed at the inner sur- face of the lobe near the root, where in extreme cases air-spaces as large as an egg may sometimes be found. Microscopically there is seen atrophy of the alveolar walls, by which is produced the coalescence of neighboring air-cells. In this process the capillary network disappears before the walls are completely atrophied. The loss of the elastic tissue is a special feature. It is stated, indeed, that in certain cases there is a congenital defect in the development of this tissue. The epithelium of the air-cells undergoes a fatty change, but the large distended air-spaces retain a pave- ment layer. The bronchi in emphysema sIioav important changes. In the larger tubes the mucous membrane may be rough and thickened from chronic bronchitis; often the longitudinal lines of submucous elastic tissue stand out prominently. In the advanced cases many of the smaller tubes are dilated, particularly when, in addition to emphysema, there are peribron- chial fibroid changes. Bronchiectasis is not, however, an invariable ac- companiment of emphysema, but, as Laennec remarks, it is difficult to understand why it is not more common. Of associated morbid changes the most important are found in the heart. The right chambers are EMPHYSEMA. dilated and hypertrophied, the tricuspid orifice is large, and the valve segments are often thickened at the edges. In advanced cases the cardiac hypertrophy is general. The pulmonary artery and its branches may be wide and show marked atheromatous changes. The changes in the other organs are those commonly associated with prolonged venous congestion. Symptoms.—The disease may be tolerably advanced before any special symptoms develop. A child, for instance, may be somewhat short of breath on going up-stairs or may be unable to run and play as other children without great discomfort; or, perhaps, has attacks of slight lividity. Doubtless much depends upon the completeness of cardiac com- pensation. When this is perfect, there may be no special interruption of the pulmonary circulation and, except in violent exertion, there is no interference with the aeration of the blood. In well-developed cases the following are the most important symptoms : Dyspnoea, which may be felt only on slight exertion, or may be persistent, and aggravated by in- tercurrent attacks of bronchitis. The respirations are often harsh and wheezy, and expiration is distinctly prolonged. Cyanosis of an extreme grade is more common in emphysema than in other affections with the exception of congenital heart-disease. So far as I know it is the only disease in which a patient may be able to go about and even to walk into the hospital or consulting-room with a lividity of start- ling intensity. The contrast between the extreme cyanosis and the com- parative comfort of the patient is very striking. In other affections of the heart and lungs associated with a similar degree of cyanosis the pa- tient is invariably in bed and usually in a state of orthopnoea. Bronchitis with associated cough is a frequent symptom and often the direct cause of the pulmonary distress. The contrast between emphy- sematous patients in the winter and summer is marked in this respect. In the latter they may be comfortable and able to attend to their work, but with the cold and changeable weather they are laid up with attacks of bronchitis. Finally, in fact, the two conditions become inseparable and the patient has persistently more or less cough. The acute bronchitis may produce attacks not unlike asthma. In some instances this is true spasmodic asthma, with which emphysema is frequently associated. As age advances and with successive attacks of bronchitis the condi- tion gets slowly worse. In hospital practice it is common to admit pa- tients over sixty with well-marked signs of advanced emphysema. The affection can generally be told at a glance—the rounded shoulders, barrel chest, the thin yet oftentimes muscular form, and sometimes, I think, a very characteristic facial expression. There is another group, however, of younger patients from twenty-five to forty years of age who winter after winter have attacks of intense cya- nosis in consequence of an aggravated bronchial catarrh. On inquiry we find that these patients have been short-breathed from infancy, and they DISEASES OF THE RESPIRATORY SYSTEM. belong, I believe, to a category in which there has been a primary defect of structure in the lung tissue. Physical Signs.—Inspection.—The thorax is markedly altered in shape; the antero-posterior diameter is increased and may be even greater than the lateral, so that the chest is barrel-shaped. The appearance is some- what as if the chest was in a permanent inspiratory position. The ster- num and costal cartilages are prominent. The lower zone of the thorax looks large and the intercostal spaces are much widened, particularly in the hypochondriac regions. The sternal fossa is deep, the clavicles stand out with great prominence, and the neck looks shortened from the eleva- tion of the thorax and the sternum. A zone of dilated venules may be seen along the line of attachment of the diaphragm. Though this is common in emphysema, it is by no means peculiar to it. Andrew, of Bartholomew’s Hospital, and, according to Duckworth, Laycock have called attention to it. This network in the lower thoracic region, just above the costal margin and following its curves, is a well-marked feature in many persons, and is seen not only in emphysema, but in many cases of hepatic trouble. Behind, the curve of the spine is increased and the back is remarkably rounded, so that the scapulae seem to be almost horizontal. Mensuration shows the rounded form of the chest and the very slight expansion on deep inspiration. The respiratory movements, which may look ener- getic and forcible, exercise little or no influence. The chest does not expand, but there is a general elevation. The inspiratory effort is short and quick ; the expiratory movement is prolonged. There may be retrac- tion instead of distention in the upper abdominal region during inspira- tion, and there is sometimes seen a transverse curve crossing the abdomen at the level of the twelfth rib. The apex beat of the heart is not visible, and there is usually marked pulsation in the epigastric region. The cer- vical veins stand out prominently and may pulsate. Palpation.—The vocal fremitus is somewhat enfeebled but not lost. The apex beat can rarely be felt. There is a marked shock in the lower sternal region and very distinct pulsation in the epigastrium. Percussion gives greatly increased resonance, full and drum-like—what is sometimes called hyperresonance. The note is not often distinctly tympanitic in quality. The percussion note is greatly extended, the heart dulness may be obliterated, the upper limit of liver dulness is greatly lowered, and the resonance may extend to the costal margin. Behind, a clear percussion note extends to a much lower level than normal. The level of splenic dulness, too, may be lowered. On auscultation the breath-sounds are usually enfeebled and may be masked by bronchitic rales. The most characteristic feature is the pro- longation of the expiration, and the normal ratio may be reversed—4 to 1 instead of 1 to 4. It is often wheezy and harsh and associated with coarse rdles and sibilant rhonchi. It is said that in interstitial emphysema there EMPHYSEMA. may be a friction sound heard not unlike that of pleurisy. As already noted, the cardiac impulse may be barely felt in the lower sternal region. The heart-sounds are usually clear; but in advanced cases, when there is marked cyanosis, a tricuspid regurgitant murmur may be heard. Accent- uation of the pulmonary second sound is present. The course of the disease is slow but progressive, the recurring attacks of bronchitis aggravating the condition. Death may occur from intercur- rent pneumonia, either lobar or lobular, and dropsy may supervene from cardiac failure. Occasionally death results from overdistention of the heart, with extreme cyanosis. Duckworth has called attention to fatal hasmorrhage in emphysema. It certainly is not common. In an old em- physematous patient at the Montreal General Hospital death followed the erosion of a main branch of the pulmonary artery by an ulcer near the bifurcation of the trachea. Treatment.—Practically, the measures mentioned in connection with bronchitis should be employed. No remedy is known which has any influence over the progress of the condition itself. Bronchitis is the great danger of these patients, and therefore when possible they should live in an equable climate. In consequence of the venous engorgement they are liable to gastric and intestinal disturbance, and it is particularly important to keep the bowels regulated and to avoid the flatulency which often seri- ously aggravates the dyspnoea. Patients who come into the hospital in a state of urgent dyspnoea and lividity, with great engorgement of the veins, particularly if they are young and vigorous, should be bled freely. On more than one occasion I have saved the lives of persons in this condition by venesection. Inhalation of oxygen may be used and the remedies given already mentioned in connection with bronchitis. Strychnine will be found specially useful. III. Atrophic Emphysema. This is really a senile change and is called by Sir William Jenner small- lunged emphysema. It is really a primary atrophy of the lung, coming on in advanced life, and scarcely constitutes a special affection. It occurs in “ withered-looking old persons ” who may perhaps have had a winter cough and shortness of breath for years. In striking contrast to the essen- tial or hypertrophic emphysema, the -chest in this form is small. The ribs are obliquely placed, the decrease in the -diameter being due to greatly in- creased obliquity in the position of the ribs. The thoracic muscles are usually atrophied. In advanced cases of this affection the lung presents a remarkable appearance, being converted into a series of large vesicles, on the walls of which the remnants of air-cells may be seen. It is a condition for which nothing can be done. DISEASES OF THE RESPIRATORY SYSTEM. VI. GANGRENE OF THE LUNG. Etiology.—Gangrene of the lung is not an affection per se, but oc curs in a variety of conditions when necrotic areas undergo putrefaction. It is not easy to say why sphacelus should occur in one case and not in another, as the germs of putrefaction are always in the air-passages, and yet necrotic territories rarely become gangrenous. Total obstruction of a pulmonary artery, as a rule, causes infarction, and the area shut off does not often, though it may, sphacelate. Another factor would seem to be necessary—probably a lowered tissue resistance, the result of general or local causes. It is met with (1) as a sequence of lobar pneumonia. This rarely occurs in a previously healthy person—more commonly in the de- bilitated or in the diabetic subject. (2) Gangrene is very prone to follow the aspiration pneumonia, since the foreign particles rapidly undergo putrefactive changes. Of a similar nature are the cases of gangrene due to perforation of cancer of the oesophagus into the lung or into a bronchus. (3) The putrid contents of a bronchiectatic, more commonly of a tuber- culous, cavity may excite gangrene in the neighboring tissues. The press- ure bronchiectasis following aneurism or tumor may lead to extensive sloughing. (4) Gangrene may follow simple embolism of the pulmonary artery. More commonly, however, the embolus is derived from a part which is mortified or comes from a focus of bone disease. Lastly, gan- grene of the lung may occur in conditions of debility during convales- cence from protracted fever—occasionally, indeed, without our being able to assign any reasonable cause. Morbid Anatomy.—Laennec, who first accurately described pul- monary gangrene, recognized a diffuse and a circumscribed form. The former, though rare, is sometimes seen in connection with pneumonia, more rarely after obliteration of a large branch of the pulmonary artery. It may involve the greater part of a lobe, and the lung tissue is converted into a horribly offensive greenish-black mass, torn and ragged in the centre. In the circumscribed form there is well-marked limitation between the gangrenous area and the surrounding tissue. The focus may be single or there may be two or more. The lower lobe is more commonly affected than the upper, and the peripheral more than the central portion of the lung. A gangrenous area is at first uniformly greenish brown in color; but softening rapidly takes place with the formation of a cavity with shreddy, irregular walls and a greenish, offensive fluid. The lung tissue in the immediate neighborhood shows a zone of deep congestion, often consolidation, and outside this an intense oedema. In the embolic cases the plugged artery can sometimes be found. When rapidly extending, vessels may be opened and violent haemorrhage ensue. Perforation of the pleura is not uncommon. The irritating decomposing material usually excites the most intense bronchitis. Embolic processes are not infrequent. There is a remarkable association in some cases between circumscribed GANGRENE OF THE LUNG. 585 gangrene of the lung and abscess of the brain. I have seen two such cases. One of these, a young man, an Arab, was brought to the Uni- versity Hospital, almost exsanguine from pulmonary hasmorrhage. He gradually recovered. There were very limited signs in the middle lobe of the right lung, which persisted, but no bacilli were found. There was no fetor of the breath. Weeks afterward he developed severe headache, and in a few days became comatose and died. There was a circumscribed area of healing gangrene at the margin of the lung with great increase of fibrous tissue about it. The artery going to this somewhat wedge-shaped area was obliterated. The contents of the encapsulated cavity were very fetid. There was a large limited abscess in the parieto-temporal region on the right side. Symptoms and Course.—Usually definite symptoms of local pul- monary disease precede the characteristic features of gangrene. These, of course, are very varied, depending on the nature of the trouble. The sputum is very characteristic. It is intensely fetid—usually profuse— and, if expectorated into a conical glass, separates into three layers—a greenish-brown, heavy sediment; an intervening thin liquid, which some- times has a greenish or a brownish tint; and, on top, a thick, frothy layer. Spread on a glass plate, the shreddy fragments of lung tissue can readily be picked out. Microscopically, elastic fibres are found in abundance, with granular matter, pigment grains, fatty crystals, bacteria, and lepto- thrix. It is stated that elastic tissue is sometimes absent, but I have never met with such an instance. The peculiar plugs of sputum which occur in bronchiectasy are not found. Blood is often present, and, as a rule, is much altered. The sputum has, in a majority of the cases, an intensely fetid odor, which is communicated to the breath and may permeate the entire room. It is much more offensive than in fetid bronchitis or in abscess of the lung. The fetor is particularly marked when there is free communication between the gangrenous cavities and the bronchi. On several occasions I have found, post mortem, localized gangrene, which had been unsuspected during life, and in which there had been no fetor of the breath. The physical signs, when extensive destruction has occurred, are those of cavity, but the limited circumscribed areas may be difficult to detect. Bronchitis is always present. Among the general symptoms may be mentioned fever, usually of moderate grade; the pulse is rapid, and very often the constitutional de- pression is severe. But the only special features indicative of gangrene are the sputa and the fetor of the breath. The patient generally sinks from exhaustion. Fatal haemorrhage may ensue. I have already men- tioned a case in which a haemorrhage from a circumscribed gangrene nearly proved fatal, and I have seen one fatal instance after pneumonia. Treatment.—The treatment of gangrene is very unsatisfactory. The indications, of course, are to disinfect the gangrenous area, but this is 586 DISEASES OF THE RESPIRATORY SYSTEM. often impossible. An antiseptic spray of carbolic acid may be employed. A good plan is for the patient to use over the mouth and nose an inhaler, which may be charged with a solution of carbolic acid or creosote. If the signs of cavity are distinct an attempt should be made to cleanse it by direct injections of an antiseptic solution. If the patient’s condition is good and the gangrenous region can be localized, an attempt should be made to treat it surgically. Successful cases have been reported. The general condition of the patient is always such as to demand the greatest care in the matter of diet and nursing. VII. ABSCESS OF THE LUNG. Etiology.—Suppuration occurs in the lung under the following conditions: (1) As a sequence of inflammation, either lohar or lobular. Apart from the purulent infiltration this is unquestionably rare, and even in lobar pneumonia the abscesses are of small size and usually involve, as Addison remarked, several points at the same time. On the other hand, abscess formation is extremely frequent in the deglutition and aspiration forms of lobular pneumonia. After wounds of the neck or operations upon the throat, in suppurative disease of the nose or larynx, occasionally even of the ear (Yolkmann), infective particles reach the bronchial tubes by aspiration and excite an intense inflammation which often ends in suppuration. Cancer of the oesophagus, perforating the root of the lung or into the bronchi, may produce extensive suppuration. The abscesses vary in size from a walnut to an orange, and have ragged and irregular walls, and purulent, sometimes necrotic, contents. (2) Embolic, so-called metastatic, abscesses, the result of infectious emboli, are extremely common in a large proportion of all cases of pysemia. They may occur in enormous numbers and present very definite char- acters. As a rule they are superficial, beneath the pleura, and often wedge-shaped. At first firm, grayish red in color, and surrounded by a zone of intense hypersemia, suppuration soon follows with the formation of a definite abscess. The pleura is usually covered with greenish lymph, and perforation sometimes takes place with the production of pneumo- thorax. (3) Perforation of the lung from without, lodgment of foreign bodies, and, in the right lung, perforation from abscess of the liver or suppurating echinococcus cyst are occasional causes of pulmonary abscess. (4) Suppurative processes play an important part in chronic pulmonary tuberculosis, many ) by the subsequent history—to be tuberculous; (2) in a larger proportion of those cases which come on insidiously in persons who have been in failing health or who are delicate the disease is tuberculous from the outset; (3) the acute pleurisy, which occurs as a secondary, often a terminal, event in chronic affections, such as cirrhosis of the liver, Bright’s disease, and cancer, is very frequently tuberculous. I confess that the more carefully I have studied the question the larger does the proportion appear to be of primary pleurisies of tuberculous origin. The subsequent history of cases of acute pleurisy forces us to conclude that in at least two thirds of the cases it is a curable affection. This may well be so, according to our pres- ent ideas of local tuberculous disease. One of the most interesting con- tributions to this question has been made from the records of Henry I. Bowditch, of Boston, to whom we are indebted for so many important contributions to our knowledge of pleurisy.* Of 90 cases of acute pleu- risy which had been under observation between 1849 and 1879, .32 died of or had phthisis—a percentage large enough to indicate what an impor- tant role tuberculosis plays in the etiology of this disease. Morbid Anatomy.—In sero-fibrinous pleurisy the serous exudate is abundant and the fibrin is found on the pleural .surfaces and scat- tered through the fluid in the form of flocculi. The proportion of these constituents varies a great deal. In some instances there is very little membranous fibrin; in others it forms thick, creamy layers and ex- ists in the dependent part of the fluid as whitish, curd-like masses. The fluid of sero-fibrinous pleurisy is of a lemon color, either clear or slightly turbid, depending on the number of formed elements. In some instances it has a dark-brown color. The microscopical examination of the fluid shows leucocytes, occasional swollen cells, which may possibly be derived from the pleural endothelium, shreds of fibrillated fibrin, and a variable number of red blood-corpuscles. On boiling, the fluid is found to be rich in albumen. Sometimes it coagulates spontaneously. Its composition closely resembles that of blood-serum. Cholesterin, uric acid, and sugar are occasionally found. The amount of the effusion varies from a half to four litres. The lung in acute sero-fibrinous pleurisy is more or less compressed. If the exudation is limited the lower lobe alone is atelectatic; but in an exten- sive effusion which reaches to the clavicle the entire lung will be found * Vincent Y. Bowditch, in Boston Medical and Surgical Journal, 1889. 594 DISEASES OF THE RESPIRATORY SYSTEM. lying close to the spine, dark and airless, or even bloodless—i. e., car- nified. In large exudations the adjacent organs are” displaced. In large right- sided pleurisies the liver is much depressed. Rather varying statements are made with reference to the position of the heart and as to whether or not it rotates on its axis. In a number of post-mortems I have carefully studied its position, both in pneumothorax and in large effusions, and can speak with some degree of certainty on the following points: (1) Even in the most extensive left-sided exudation there is no rotation of the apex of the heart, which in no case was to the right of the mid-sternal line; (2) the relative position of the apex and base is usually maintained; in some instances the apex is lifted, in others the whole heart lies more trans- versely ; (3) the right chambers of the heart occupy the greater portion of the front, so that the displacement is rather a definite dislocation of the mediastinum, with the pericardium, to the right, than any special twisting of the heart itself; (4) the kink or twist in the inferior vena cava described by Bartels was not present in any of the cases. Symptoms.—Prodromes are not uncommon, but the disease may set in abruptly with a chill, followed by fever and a severe pain in the side. It is remarkable, however, with what frequency the disease comes on in- sidiously. The pain in the side is the most distressing symptom, and is usually referred to the nipple or axillary regions. It must be remembered, however, that pleuritic pain may be felt in the abdomen or low down in the back, particularly when the diaphragmatic surface of the pleura is involved. It is lancinating, sharp, and severe, and is aggravated by cough. At this early stage, on auscultation, sometimes indeed on palpation, a dry friction rub can be detected. The fever rarely rises so rapidly as in pneu- monia, and does not reach the same grade. A temperature of from 102° to 103° is an average pyrexia. It may drop to normal at the end of a week or ten days without the appearance of any definite change in the physical signs, or it may persist for several weeks. The temperature of the affected is higher than that of the sound side. Cough is an early symptom in acute pleurisy, but is rarely so distressing or so frequent as in pneumonia. There are instances in which it is absent. The expectora- tion is usually slight in amount, mucoid in character, and occasionally streaked with blood. At the outset there may be dyspnoea, due partly to the fever and partly to the pain in the side. Later it results from the compression of the lung, particularly if the exudation has taken place rapidly. When, however, the fluid is effused slowly, one lung may be entirely compressed without inducing shortness of breath, except on exertion, and the patient 'will lie quietly in bed without evincing the slightest respiratory distress. When the effusion is large the patient usually prefers to lie upon the affected side. Physical Signs.—Inspection shows some degree of immobility on the affected side, depending upon the amount of exudation, and in large effu- ACUTE PLEURISY. 595 sions an increase in volume, which may appear to be much more than it really is as determined by mensuration. The intercostal spaces are oblit- erated. In right-sided effusions the apex beat may be lifted to the fourth interspace or be pushed beyond the left nipple, or may even be seen in the axilla. When the exudation is on the left side the heart’s impulse may not be visible; but if the effusion is large it is seen in the third and fourth spaces on the right side, and sometimes as far out as the nipple, or even beyond it. Palpation enables us more successfully to determine the deficient movements on the affected side, and the obliteration of the intercostal spaces, and more accurately to define the position of the heart’s impulse. In simple sero-fibrinous effusion there is rarely any oedema of the chest walls. It is scarcely ever possible to obtain fluctuation. Tactile fremitus is greatly diminished or abolished. If the effusion is slight there may be only enfeeblement. The absence of the voice vibrations in effusions of any size constitutes one of the most valuable of physical signs. In children there may be much effusion with retention of fremitus. In rare cases the vibrations may be communicated to the chest walls through localized pleural adhesions. Mensuration.—With the cyrtometer, if the effusion is excessive, a difference of from half an inch to an inch, or even, in large effusions, an inch and a half, may be found between the two sides. Allowance must be made for the fact that the right side is naturally larger than the left. With the saddle-tape the difference in expansion between the two sides can be conveniently measured. Percussion.—Early in the disease, when the pain in the side is severe and the friction murmur evident, there may be no alteration, but with the gradual accumulation of the fluid the resonance becomes defective, and finally gives place to absolute dulness. From day to day the gradual increase in height of the fluid may be studied. In a pleuritic effusion rising to the fourth rib in front, the percussion signs are usually very suggestive. In the subclavicular region the attention is often aroused at once by a tympanitic note, the so-called Skoda’s resonance, which is heard perhaps more commonly in this situation with pleural effusion than in any other condition. It shades insensibly into a flat note in the lower mammary and axillary regions. Skoda’s resonance may be obtained also behind, just above the limit of effusion. The dulness has a peculiarly resistant, wooden quality, differing from that of pneumonia and readily recognized by skilled fingers. It has long been known that when the patient is in the erect posture the upper line of dulness is not horizontal, but is higher behind than it is in front, forming a parabola. Ellis and Garland, of Boston, who have made a careful study of this question, state that the line of dulness from behind forward may sometimes be repre- sented by a curved line resembling the letter S. The condition is fully considered in Garland’s exhaustive work on Pneumo-dynamics. 596 DISEASES OF THE RESPIRATORY SYSTEM. On the right side the dulness passes without change into that of the liver. On the left side in the nipple line it extends to and may obliterate Traube’s semilunar space. If the effusion is moderate, the phenomenon of movable dulness may be obtained by marking carefully, in the sitting posture, the upper limit in the mammary region, and then in the recum- bent posture, noting the change in the height of dulness. This infallible sign of fluid cannot always be obtained. In very copious exudation the dulness may reach the clavicle and even extend beyond the sternal mar- gin of the opposite side. Auscultation.—Early in the disease a friction rub can usually be heard, which disappears as the fluid accumulates. It is a to-and-fro dry rub, close to the ear, and has a leathery, creaking character. There is another pleural friction sound which closely resembles, and is scarcely to be dis- tinguished from, the fine crackling crepitus of pneumonia. This may be heard at the commencement of the disease, and also, as pointed out in 1844 by MacDonnell, Sr., of Montreal, when the effusion has receded and the pleural layers come together again. With even a slight exudation there is weakened or distant breathing. Often inspiration and expiration are distinctly audible, though distant, and have a tubular quality. Sometimes only a puffing tubular expiration is heard, which may have a metallic or amphorie quality. Loud resonant rales accompanying this may forcibly suggest a cavity. These pseudo- cavernous signs are met with more frequently in children, and often lead to error in diagnosis. Above the line of dulness the breath-sounds are usually harsh and exaggerated, and may have a tubular quality. The vocal resonance is usually diminished or absent. The whispered voice is said to be transmitted through a serous and not through a puru- lent exudate (Baccelli’s sign). There may, however, be intensification— bronchophony. The voice sometimes has a curious nasal, squeaking char- acter, which was termed by Laennec atgopliony, from its supposed resem- blance to the bleating of a goat. In typical form this is not common, but it is by no means rare to hear a curious twang-like quality in the voice, particularly at the outer angle of the scapula. In the examination of the heart in cases of pleuritic effusion it is well to bear in mind that when the apex of the heart lies beneath the sternum there may be no impulse. The determination of the situation of the organ may rest with the position of maximum loudness of the sounds. Over the displaced organ a systolic murmur may be heard. When the lappet of lung over the pericardium is involved on either side there may be a pleuro- pericardial friction. A leucocytosis is usually present. The course of acute sero-fibrinous pleurisy is very variable. After per- sisting for a week or ten days the fever subsides, the cough and pain dis- appear, and a slight effusion may be quickly absorbed. In cases in which the effusion reaches as high as the fourth rib recovery is usually slower. Many instances come under observation for the first time, after two or ACUTE PLEURISY. 597 three weeks’ indisposition, with the fluid at a level with the clavicle. The fever may last from ten to twenty days without exciting anxiety, though, as a rule, in ordinary pleurisy from cold, as we say, the temperature in cases of moderate severity is normal within eight or ten days. Left to itself the natural tendency is to resorption; but this may take place very slowly. With the absorption of the fluid there is a redux-friction crep- itus, either leathery and creaking or crackling and rale-like, and for months, or even longer, the defective resonance and feeble breathing are heard at the base. Rare modes of termination are perforation and dis- charge through the lung, and externally through the chest wall, examples of which have been recorded by Salili. A sero-fibrinous exudate may persist for months without change, par- ticularly in tuberculous cases, and will sometimes reaccumulate after aspi- ration and resist all treatment. After persistence for more than twelve months, in spite of repeated tapping, a serous effusion was cured by inci- sion without deformity of the chest (S. West). The change of the exudate into pus will be spoken of in connection with empyema. Death is a rare termination of sero-fibrinous effusion. When one pleura is full and the heart is greatly dislocated the condition, although in a majority of cases producing remarkably little disturbance, is not without risk. Suddeyi death may occur, and its possibility under these circumstances should always be considered. I have seen two instances—one in right and the other in left sided effusion—both due, apparently, to syncope following slight exertion, such as getting out of bed. In neither case, however, was the amount of fluid excessive. Weil, who has studied carefully this accident, concludes as follows : (1) That it may be due to thrombosis or embolism of the heart or pulmonary artery, cedema of the opposite lung, or degeneration of the heart muscle; (2) such alleged causes as mechanical impediment to the cir- culation, owing to dislocation of the heart or twisting of the great vessels, require further investigation. Death may occur without any premonitory symptoms. III. Purulent Pleurisy (Empyema). Etiology.—Pus in the pleura is met with under the following con- ditions : (a) As a sequence of acute sero-fibrinous pleurisy. It is not always easy to say why, in certain cases, the exudate becomes purulent. It rarely does so in the acute pleurisies of healthy individuals. In chil- dren many cases are probably purulent from the outset. Aspiration, which is said to favor the occurrence of empyema, in my experience does so very rarely. (£) Purulent pleurisy is common as a secondary inflam- mation in various infectious diseases, among whieh scarlet fever takes the first place. It has long been known that the pleurisy superven- ing in the convalescence of this disease is almost always purulent. It should be remembered that it is latent in its onset, and that there may be no pulmonary symptoms. The pleurisy following typhoid fever is also usually purulent. Other infectious diseases—measles and whooping-cough DISEASES OF THE RESPIRATORY SYSTEM. —are more rarely followed by this complication. Of late years especial attention has been paid to the connection of pneumonia with empyema, and it has been shown that very many cases come on insiduously either in the course of or during convalescence fiom this disease ; and, lastly, a lim- ited number of tuberculous pleurisies early become purulent, (c) Em- pyema results from local causes—fracture of the rib, penetrating wounds, malignant disease of the lung or oesophagus, and, perhaps most frequently of all, the perforation of the pleura by tuberculous cavities. The bacteriology of empyema is of great importance. A sterile exu- date suggests tuberculosis. In many cases the pneumococci are present, and these, as a rule, run a very favorable course. The streptococci are found most commonly in the secondary cases in connection with septic processes. In a few instances psorosperms have been present. Morbid Anatomy.—On opening an empyema post mortem, we usually find that the effusion has separated into a clear, greenish-yellow serum above and the thick, cream-like pus below. The fluid may be scarcely more than turbid, with flocculi of fibrin through it. In other in- stances it is uniformly thick and creamy, without any fibrin. It usually has a heavy, sweetish odor, but in some instances—particularly those fol- lowing wounds—it is fetid. In cases of gangrene of the lung or pleura the pus has a horribly stinking odor. Microscopically it has the charac- ters of ordinary pus. The pleural membranes are greatly thickened, and present a grayish-white layer from 1 to 2 mm. in thickness. On the costal pleura there may be erosions, and in old cases fistulous communica- tions are common. The lung may be compressed to a very small limit, and the visceral pleura also may show perforations. Symptoms.—Purulent pleurisy may begin abruptly, with the symp- toms already described. More frequently it comes on insidiously in the course of other diseases or follows an ordinary sero-fibrinous pleurisy. There may be no pain in the chest, very little cough, and no dyspnoea, unless the side is very full. Symptoms of septic infection are rarely wanting. If in a child, there is a gradually developing pallor and weak- ness ; sweats occur, and there is irregular fever. A cough is by no means constant. The leucocytes are usually much increased; in one fatal case they numbered 115,000 per cubic millimetre. Physical Signs.—Practically they are those already considered in pleu- risy with effusion. There are, however, one or two additional points to be mentioned. In empyema, particularly in children, the disproportion between the sides may be extreme. The intercostal spaces may not only be obliterated, but may bulge. Much more frequently there is oedema of the chest walls. The network of subcutaneous veins may be very distinct. It must not be forgotten that in children the breath-sounds may be loud and tubular over a purulent effusion of considerable size. Whispered pectoriloquy is usually not heard in empyema (Baccelli’s sign). The dis- location of the heart and the displacement of the liver are more marked ACUTE PLEURISY. 599 in empyema than in sero-fibrinous effusion—probably, as Senator suggests, owing to the greater weight of the fluid. A curious phenomenon associated generally with empyema, but which may occur in the sero-fibrinous exudate, is pulsating pleurisy, first de- scribed by MacDonnell, Sr., of Montreal. Of 42 cases 39 occurred on the left side. In all but one case the fluid was purulent. Pneumothorax may be present. There are two groups of cases, the intrapleural pulsat- ing pleurisy and the pulsating empyema necessitatis, in which there is an external pulsating tumor. No satisfactory explanation has been offered how the heart impulse is thus forcibly communicated through the effusion. Empyema is a chronic affection, which in a few instances terminates naturally in recovery, but a majority of cases, if left alone, end in death. The following are some modes of natural cure: (a) By absorption of the fluid. In small effusions this may take place gradually. The chest wall sinks. The pleural layers become greatly thickened and enclose be- tween them the inspissated pus, in which lime salts are gradually deposited. Such a condition may be seen once or twice a year in the post-mortem room of any large hospital. (b) By perforation of the lung. Although in this event death may take place rapidly, by inundation of the bronchial tubes, yet in many cases it occurs gradually and recovery follows. Since 1873, when I saw a case of this kind in Traube’s clinic, and heard his remarks on the subject, I have seen a number of instances of the kind and can corroborate his statement as to the favorable termination of many of them. Empyema may discharge either by opening into the bronchus and forming a fistula, or, as Traube pointed out, by producing necrosis of the pulmonary pleura, sufficient to allow the soakage of the pus through the spongy lung tissue into the bronchi. In the first way pneumothorax usually, though not always, develops. In the second way the pus is dis- charged without formation of pneumothorax. Even with a bronchial fistula recovery is possible, (c) By perforation of the chest wall—empyema necessitatis. This is by no means an unfavorable method, as many cases recover. The perforation may occur anywhere in the chest wall, but is, as Cruveilhier remarked, more common in front. It may be anywhere from the third to the sixth interspace, usually, according to Marshall, in the fifth. It may perforate in more than one place, and there may be a fistulous communication which opens into the pleura at some distance from the external orifice. The tumor, when near the heart, may pulsate. The discharge may persist for years. In Copeland’s Dictionary is men- tioned an instance of a Bavarian physician who had a pleural fistula for thirteen years and enjoyed fairly good health. An empyema may perforate the neighboring organs, the oesophagus, peritonaeum, pericardium, or the stomach. Very remarkable cases are those which pass down the spine and along the psoas into the iliac fossa, and simulate a psoas or lumbar abscess. DISEASES OF THE RESPIRATORY SYSTEM. IV. Tuberculous Pleurisy. This has already been considered. Here it is sufficient to say that it occurs as: (a) An acute affection, accompanied by abundant sero-fibrinous fluid. In this category come certainly a proportion of the cases regarded as acute pleurisy from cold, (b) As a subacute affection, latent in its origin and insidious in its course, frequently preceding the development of or coming on concurrently with pulmonary tuberculosis. (c) As an acute pleurisy, the result of direct extension from the lung in cases of well-marked phthisis, and in which the fluid may be either sero-fibrinous or purulent, (d) Chronic adhesive tuberculous pleurisy, which may be unilateral or bilateral, unaccompanied by exudation and characterized by great thickening of the pleural membranes, in which are tubercles and caseous masses of varying sizes. The symptoms and physical signs of tuberculous pleurisy with exuda- tion do not require any description other than that already given in con- nection with the sero-fibrinous and purulent forms. V. Other Varieties of Pleurisy. Haemorrhagic Pleurisy.—A bloody effusion is met with under the fol- lowing conditions : (a) In the pleurisy of asthenic states, such as cancer, Bright’s disease, and occasionally in the malignant fevers. It is inter- esting to note the frequency with which haemorrhagic pleurisy is found in cirrhosis of the liver. It occurred in the very patient in whom Laennec first accurately described this disease. While this may be a simple haemorrhagic pleurisy, in a majority of the cases which I have seen it has been tuberculous, (b) Tuberculous pleurisy, in which the bloody effusion may result from the rupture of newly formed vessels in the soft exudate accompanying the eruption of miliary tubercles, or it may come from more slowly formed tubercles in a pleurisy secondary to extensive pulmonary disease. (c) Cancerous pleurisy, whether primary or second- ary, is frequently haemorrhagic, (d) Occasionally haemorrhagic exudation is met with in perfectly healthy individuals, in whom there is not the slightest suspicion of tuberculosis or cancer. In one such case, a large, able-bodied man, the patient was to my knowledge healthy and strong eight years afterward. And, lastly, it must be remembered that during aspiration the lung may be wounded and blood in this way get mixed with the sero-fibrinous exudate. The condition of haemorrhagic pleurisy is to be distinguished from hsemothorax, due to the rupture of aneurism or the pressure of a tumor on the thoracic veins. Diaphragmatic Pleurisy.—The inflammation may be limited partly or chiefly to the diaphragmatic surface. This is often a dry pleurisy, but there may be effusion, either sero-fibrinous or purulent, which is circum- scribed on the diaphragmatic surface. In these cases the pain is low in ACUTE PLEURISY. 601 the zone of the diaphragm and may simulate that of acute abdominal dis- ease. It may be intensified by pressure at the point of insertion of the diaphragm at the tenth rib. The diaphragm is fixed and the respiration is thoracic and short. Andral noted in certain cases severe dyspnoea and attacks simulating angina. As mentioned, the effusion is usually plastic, not serous. Serous or purulent effusions of any size limited to the dia- phragmatic surface are extremely rare. Intense subjective with trifling objective features are always suggestive of diaphragmatic pleurisy. Encysted Pleurisy.—The effusion may be circumscribed by adhesions or separated into two or more pockets or loculi, which communicate with each other. This is most common in empyema. In these cases there have usually been, at different parts of the pleura, multiple adhesions by which the fluid is limited. In other instances the recent false membranes may encapsulate the exudation on the diaphragmatic surface, for example, or the part of the pleura posterior to the mid-axillary line. The con- dition may be very puzzling during life, and present special difficulties in diagnosis. In some cases the tactile fremitus is retained along certain lines of adhesion. The exploratory needle should be freely used. Interlobar Pleurisy forms an interesting and not uncommon variety. In nearly every instance of acute pleurisy the interlobular serous surfaces are also involved and closely agglutinated together, and sometimes the fluid is encysted between them. In a recent case of this kind following pneumonia, there was between the lower and upper and middle lobes of the right side an enormous purulent collection, which looked at first like a large abscess of the lung. These collections may perforate the bronchi, and the cases present special difficulties in diagnosis. Diagnosis of Pleurisy.—Acute plastic pleurisy is readily recog- nized. In the diagnosis of pleuritic effusion the first question is, Does a fluid exudate exist ? the second, What is its nature ? In large effusions the increase in the size of the affected side, the immobility, the absence of tactile fremitus, together with the displacement of organs, give infallible indications of the presence of fluid. The chief difficulty arises in effusions of moderate extent, when the dulness, the presence of bronchophony, and, perhaps, tubular breathing may simulate pneumonia. The chief points to be borne in mind are: (a) Differences in the onset and in the general characters of the two affections, more particularly the initial chill, the higher fever, more urgent dyspnoea, and the rusty expectoration, which characterize pneumonia. (b) Certain physical signs—the more wooden character of the dulness, the greater resistance, and the marked diminu- tion or the absence of tactile fremitus in pleurisy. The auscultatory signs may be deceptive. It is usually, indeed, the persistence of tubular breath- ing, particularly the high-pitched, even amphoric expiration, heard in some cases of pleurisy, which has raised the doubt. The intercostal spaces are more commonly obliterated in pleuritic effusion than in pneumonia. As already mentioned, the displacement of organs is a very valuable sign. 602 DISEASES OP THE RESPIRATORY SYSTEM. Nowadays with the li3rpodermic needle the question is easily settled. A separate small syringe with a capacity of two drachms should be reserved for exploratory purposes, and the needle should be longer and firmer than in the ordinary hypodermic instrument. With careful preliminary disinfection the instrument can he used with impunity, and in cases of doubt the exploratory puncture should be made without hesitation. I have never seen the slightest ill effects follow its use. Cases are reported of pneumothorax resulting from it, but they are extremely rare. The hypodermic needle is especially useful in those cases in which there are pseudo-cavernous signs at the base. In cases, too, of massive pneumonia, in which the bronchi are plugged with fibrin, if the patient has not been seen from the outset, the diagnosis may be impossible with- out it. On the left side it may be difficult to differentiate a very large peri- cardial from a pleural effusion. The retention of resonance at the base, the presence of Skoda’s resonance toward the axilla, the absence of dis- location of the heart-beat to the right of the sternum, the feebleness of the pulse and of the heart-sounds, and the urgency of the dyspnoea, out of all proportion to the extent of the effusion, are the chief points to be considered. Unilateral hydro thorax, Avliich is not at all uncommon in heart-disease, presents signs identical with those of sero-fibrinous effusion. Certain tumors within the chest may simulate pleural effusion. It should be remembered that many intrathoracic growths are accompanied by exu- dation. Malignant disease of the lung and of the pleura and hydatids of the pleura produce extensive dulness, with suppression of the breath- sounds, simulating closely effusion. On the right side abscess of the liver and hydatid cysts may rise high into the pleura and produce dulness and enfeebled breathing. Often in these cases there is a friction sound, which should excite suspicion, and the upper outline of the dulness is sometimes plainly convex. In all these instances the exploratory puncture should be made. The second question, as to the nature of the fluid, is quickly decided by the use of the needle. The persistent fever, the occurrence of sweats, a leucocytosis, and the increase in the pallor suggest the presence of pus. In children the complexion is often sallow and earthy. The unexpected, however, often happens, and repeatedly, in protracted cases, even in chil- dren, when the general symptoms and the appearance of the patient has been most strongly suggestive of pus, the syringe has withdrawn clear fluid. On the other hand, effusions of short duration may be purulent, even when the general symptoms do not suggest it. The following state- ment may be made with reference to the prognostic import of the bacte- riological examination of the aspirated fluid : The presence of the pneumo- coccus is of favorable significance, as such cases usually get well rapidly, even with a single aspiration. The pus organisms—staphylococci and streptococci—are more common in empyema of septic origin, and such ACUTE PLEURISY. 603 cases are notoriously less hopeful than others. A sterile fluid indicates in a majority of instances a tuberculous origin. Treatment.—At the onset the severe pain may demand leeches, which usually give relief, but a hypodermic of morphia is more effective. The Paquelin cautery may be lightly but freely applied. It is well to administer a mercurial or saline purge. Fixing the side by careful strap- ping with long strips of adhesive plaster, which should pass well over the middle line, drawn tightly and evenly, gives great relief, and I can cor- roborate the statement of F T. Roberts as to its efficacy. Cupping, wet or dry, is now seldom employed. Blisters are of no special service in the acute stages, although they relieve the pain. The ice-bag may be used as in pneumonia. The general treatment of the early stage should be rest in bed and a liquid diet. Medicines are rarely required. A Dover’s powder may be given at night. Mercurials are not indicated. When the effusion has taken place, mustard plasters or iodine, pro- ducing slight counter-irritation, appear useful, particularly in the later stages. The following rational plan is successful in some cases. It is based upon the idea that if the blood serum is depleted or if it is kept concentrated, the liquid will be absorbed from the lymph spaces, of which the pleura is one, to equalize the loss. To. do this the patient should have the daily amount of liquid food greatly restricted. If there is no fever, a meat diet, with an egg and dry bread and eight to ten ounces of liquid in the form of milk or water, should be given. Salt articles of food may be used, but I do not think it necessary to give, as some do, doses of salt. The second element in the treatment is the active depletion of blood serum, which is effected in the way introduced by Matthew Hay. Every morning, if the patient is robust, otherwise every second morning, from half an ounce to an ounce and a half of Epsom salts is given an hour before breakfast, in as concentrated a form as is possible. This produces copious liquid discharges. I have seen large exudations disappear rapidly when this plan was followed. By acting upon the skin and kidneys, the same end may be obtained, but with much less certainty. The vapor or hot bath may be used and an occasional dose of pilocarpin. Diuretics, such as digitalis, squills, and acetate of potash, may sometimes be required. I rarely resort, however, to diuretics or diaphoretics in the treatment of pleurisy with effusion. Iodide of potassium is of doubtful benefit. Aspiration of the fluid is the most thorough and satisfactory method and should be resorted to whenever the effusion becomes large or if it re- sists the ordinary methods of treatment. The credit of introducing aspi- ration in pleuritic effusions is due to Morrill Wyman, of Cambridge, Mass., and Henry I. Bowditch, of Boston. Years prior to Dieulafoy’s work, as- piration was in constant use at the Massachusetts General Hospital and was advocated repeatedly by Bowditch. As the question is one of some historical interest, I give the author’s conclusions concerning aspiration, expressed more than forty years ago, and which practically represent 604 DISEASES OF TOE RESPIRATORY SYSTEM. the opinion of to-day : “ (1) The operation is perfectly simple, but slightly painful, and can be done with ease upon any patient in however ad- vanced a stage of the disease. (2) It should be performed forthwith in all cases in which there is complete filling up of one side of the chest. (3) He had determined to use it in any case of even moderate effusion lasting more than a few weeks and in which there should seem to be a disposition to resist ordinary modes of treatment. (4) He urged this practice upon the profession as a very important measure in practical medicine; believing that by this method death may frequently be pre- vented from ensuing either by sudden attack of dyspnoea or subsequent phthisis, and, finally, from the gradual wearing out of the powers of life or inability to absorb the fluid. (5) He believed that this operation would sometimes prevent the occurrence of those tedious cases of spon- taneous evacuation of purulent fluid and those great contractions of the chest which occur after long-continued effusion and the subsequent dis- charge or absorption of a fluid.” There is scarcely anything to be added to-day to these observations. When the fluid reaches to the clavicle the indication for aspiration is im- perative, even though the patient be comfortable and present no signs of pulmonary distress. The presence of fever is not a contra-indication; indeed, sometimes with serous exudates the temperature falls after aspi- ration. The operation is extremely simple and is practically without risk. The spot selected for puncture should be either in the seventh interspace in the mid-axilla or at the outer angle of the scapula in the eighth inter- space. The arm of the patient should be brought forward with the hand on the opposite shoulder, so as to widen the interspaces. The needle should be thrust in close to the upper margin of the rib, so as to avoid the intercostal artery, the wounding of which, however, is an excessively rare accident. The fluid should be withdrawn slowly. The amount will de- pend on the size of the exudate. If the fluid reaches to the clavicle a litre or more may be withdrawn with safety. During aspiration if the patient feels faint it is best to interrupt the operation, for sudden death has occasionally happened during the with- drawal. It is, however, a much less common accident than sudden death in cases of full pleura without operation. Cough is a symptom which frequently develops toward the close of aspiration. Though very painful it need not excite alarm. French writers have described cases of albumi- nous expectoration, associated with dyspnoea, which may come on after the tapping and prove rapidly fatal. It must be an excessively rare com- plication. The conversion of a sero-fibrinous into a purulent fluid is a danger which need not be considered. I have never met with an instance of the kind. Empyema is really a surgical affection, and I shall make only a few general remarks upon its treatment. When it has been determined by CHRONIC PLEURISY. 605 exploratory puncture that the fluid is purulent, aspiration should not be performed, except as preliminary to operation or as a temporary measure. Perhaps it is better not to have an exception to this rule, although the empyemas of children and the pneumonic empyema occasionally get well rapidly after a single tapping. It is sad to think of the number of lives which are sacrificed annually by the failure to recognize that empyema should be treated as an ordinary abscess, by free incision. The operation dates from the time of Hippocrates and is by no means serious. A ma- jority of the cases get well, providing that free drainage is obtained, and it makes no difference practically what measures are followed so long as this indication is met. The good results in any method depend upon the thoroughness with which the cavity is drained. Irrigation of the cavity is rarely necessary unless the contents are fetid. Sudden collapse has happened during irrigation and a remarkable accident is the occur- rence of convulsions. In the subsequent treatment a point of great im- portance in facilitating the closure of the cavity is the distention of the lung on the affected side. This may be accomplished by the method advised by Ralston James, which has been practised with great success in the surgical wards of the Johns Hopkins Hospital. The patient daily, for a certain length of time, increasing gradually with the increase of his strength, transfers by air-pressure water from one bottle to another. The bottles should be large, holding at least a gallon each, and by the arrange- ment of tubes, as in the Wolff’s bottle, an expiratory effort of the patient forces the water from one bottle into the other. In this way expansion of the compressed lung is systematically practised. The abscess cavity is gradually closed, partly by the falling in of the chest wall and partly by the expansion of the lung. In some instances it is necessary to resect portions of one or more ribs. The physician is often asked, in cases of empyema with emaciation, hectic and feeble rapid pulse, whether the patient could stand the opera- tion. Even in the most desperate cases the surgeon should never hesitate to make a free incision II. CHRONIC PLEURISY. This affection occurs in two forms : (1) Chronic pleurisy ivith effusion, in which the disease may set in insidiously or may follow an acute sero- fibrinous pleurisy. There are cases in which the liquid persists for months without undergoing any special alteration and without becoming purulent. Such cases have the characters which we have described under pleurisy with effusion. (2) Chronic dry pleurisy. The cases are met with (a) as a sequence of ordinary pleural effusion. When the exudate is absorbed and the layers of the pleura come together there is left between them a variable amount of fibrinous material which gradually undergoes organi- 606 DISEASES OF THE RESPIRATORY SYSTEM. zation, and is converted into a layer of firm connective tissue. This pro- cess goes on at the base, and is represented clinically by a slight grade of flattening, deficient expansion, defective resonance on percussion, and en- feebled breathing. After recovery from empyema the flattening and re- traction may be still more marked. In both cases it is a condition which can be greatly benefited by pulmonary gymnastics. In these firm, fibrous membranes calcification may occur, particularly after empyema. It is not very uncommon to find between the false membranes a small pocket of fluid forming a sort of pleural cyst. In the great majority of these -cases the condition is one which need not cause anxiety. There may be an occasional dragging pain at the base of the lung or a stitch in the side, but patients may remain in perfectly good health for years. The most advanced grade of this secondary dry pleurisy is seen in those cases of em- pyema which have been left to themselves and have perforated and ulti- mately healed by a gradual absorption or discharge of the pus, with retrac- tion of the side of the chest and permanent carnification of the lung. Traumatic lesions, such as gunshot wounds, may be followed by an identi- cal condition. Post mortem, it is quite impossible to separate the layers of the pleura, which are greatly thickened, particularly at the base, and surround a compressed, airless, fibroid lung. (b) Primitive dry pleurisy. This condition may directly follow the acute plastic pleurisy already described; but it may set in without any acute symptoms whatever, and the patient’s attention may be called to it by feeling the pleural friction. A constant effect of this primitive dry pleurisy is the adhesion of the layers. This is probably an invariable result, whether the pleurisy is primary or secondary. The organization of the thin layer of exudation in a pneumonia will unite the two surfaces by delicate bands. Pleural adhesions are extremely common, and it is rare to examine a body entirely free from them. They may be limited in extent or univer- sal. Thin fibrous adhesions do not produce any alteration in the percussion characters, and, if limited, there is no special change heard on ausculta- tion. When, however, there is general synechia on both sides the expan- sile movement of the lung is considerably impaired. We should naturally think that universal adhesions would interfere materially with the func- tion of the lungs, but practically we see many instances in which there has not been the slightest disturbance. The physical signs of total adhe- sion are by no means constant. It has been stated that there is a marked disproportion between the degree of expansion of the chest walls and the intensity of the vesicular murmur, but the latter is a very variable factor, and under perfectly normal conditions the breath-sounds, with very full chest expansion, may be extremely feeble. Is there a primitive dry pleurisy which gradually leads to great thick- ening of the membranes, and which ultimately may invade the lung and induce cirrhotic change? Upon this question neithei pathologists nor clinicians agree. I think that Sir Andrew Clark, in his Lumleian lectures CHRONIC PLEURISY. 607 at the Royal College of Physicians (1885), has made good his claim that such a disease does exist. At the outset in these cases there is a dry pleurisy, usually at one base, indicated by the usual signs; and this per- sists in spite of all treatment. There is no evidence of fluid ; the general health may not be much impaired, or there may be slight fever and dis- turbed digestion. The cases give great anxiety, owing to the natural suspicion that tuberculosis exists. In time the evidence of dulness is found at the base. There are feeble breathing and creaking, leathery friction sounds. There may be commencing retraction of the side. Clini- cally these cases are of great interest, and should, I think, be separated, on the one hand, from the condition which follows a healed empyema or old pleurisy with effusion, and, on the other, from the rare instances of primitive cirrhosis of the lung. However, in all three states there may ultimately be an almost identical clinical picture. Anatomically in these pleuritic cases the pleura, particularly that surrounding the lower lobe, sometimes the entire membrane, is thickened, the two layers are inti- mately united, and fibrinous bands passing from the pleura traverse the lung tissue, sometimes dividing it in a remarkable way into sections. The bronchi may present marked dilatations, though this is not always the case, and the lung tissue is more or less sclerosed. The cases belong to the group of chronic pneumonias called by Charcot pleurogenous. In many instances there can be no question as to their non-tuberculous nature. There are cases, however, in which, with chronic pleurogenous pneumonia in the lower lobe, there are cavity formations at the apex and tuberculous lesions in other parts. Such may, of course, be tuberculous from the outset. Lastly, there is a primitive dry pleurisy of tuberculous origin. In it both parietal and costal layers are greatly thickened—perhaps from two to three millimetres each—and present firm fibroid, caseous masses and small tubercles, while uniting these two greatly thickened layers is a reddish-gray fibroid tissue, sometimes infiltrated with serum. This may be a local process confined to one pleura, or it may be in both. I have seen two typical instances of it—one in a young, well-nourished Irish girl, who died of malignant scarlet fever, in whom one pleura was in the con- dition above described, and there were no other tuberculous lesions. The other was in a young man who died of typhoid fever, in whom both pleurae were uniformly thickened and tuberculous without any fluid exudate. These cases are sometimes associated with a similar condition of the peri- cardium and peritonaeum. Occasionally remarkable vaso-motor phenomena occur in chronic pleu- risy, whether simple or in connection with tuberculosis of an apex. Flush- ing or sweating of one cheek or dilatation of the pupil are the common manifestations. They appear to be due to involvement of the first thoracic ganglion at the top of the pleural cavity. 608 DISEASES OF THE RESPIRATORY SYSTEM. III. HYDROTHORAX. Ilydrothorax is a transudation of simple non-inflammatory fluid into the pleural cavities, and occurs as a secondary process in many affections. The fluid is clear, without any flocculi of fibrin, and the membranes are smooth. It is met with more particularly in connection with general dropsy, either renal, cardiac, or hsemic. It may, however, occur alone, or with only slight oedema of the feet. A child was admitted to the Mont- real General Hospital with urgent dyspnoea and cyanosis, and died the night after admission. She had extensive bilateral hydrothorax, which had come on early in the nephritis of scarlet fever. In renal disease hydrothorax is almost always bilateral, but in heart affections one pleura is more commonly involved. The physical signs are those of pleural effu- sion, but the exudation is rarely excessive. In kidney and heart disease, even when there is no general dropsy, the occurrence of dyspnoea should at once direct attention to the pleura, since many patients are carried off by a rapid effusion. Post-mortem records show the frequency with which this condition is overlooked. The saline purges will in many cases rapid- ly reduce the effusion, but, if necessary, aspiration should repeatedly be practised. IV. PNEUMOTHORAX {Hydro-Pneumothorax and Pyo-Pneumothorax). Air alone in the pleural cavity, to which the term pneumothorax is strictly applicable, is an extremely rare condition. It is almost invariably associated with a serous fluid—hydro-pneumothorax, or with pus—pyo- pneumothorax. Etiology.—It has usually been taught that there is an inherent tendency to pneumothorax, which is induced as soon as the pleura is opened. The experiments of S. West seem, however, to indicate the existence of a coherent force between the pleural surfaces much in excess of the elasticity of the lung, and sufficient in certain instances to main- tain these organs in contact with the thoracic wall, even when there is free access to the pleura; so that in reality force is required to overcome the normal adhesion between the pleural membranes. Pneumothorax arises : (1) In perforative wounds of the chest, in which case it is sometimes associated with extensive cutaneous emphysema. It has followed exploratory puncture with a hypodermic needle, as in two cases reported by Herman Biggs. Pneumothorax rarely follows fracture of the rib, even though the lung may be torn. (2) In perforation of the pleura through the diaphragm, usually by malignant disease of the stomach or colon. The pleura may also be perforated in cases of cancer of the oesophagus. (3) When the lung is perforated. This is'by far the most common cause, and may occur: (a) In a normal lung from rupture PXEUMOTHORAX. 609 of the air-vesicles during straining. Special attention has lately been called to this accident by S. West and De H. Hall. The air may be ab- sorbed and no ill effect follows. It does not necessarily excite pleurisy, as pointed out many years ago by Gairdner, but inflammation and effusion are the usual result, (b) From perforation due to local disease of the lung, either the softening of a caseous focus or the breaking of a tuber- culous cavity. According to S. West, ninety per cent of all the cases are due to this cause. Less common are the cases due to septic broncho- pneumonia and to gangrene. A rare cause is the breaking of a haemor- rhagic infarct in chronic heart-disease, of which I met an instance a few years ago. (c) Perforation of the lung from the pleura, which arises in certain cases of empyema and produces a pleuro-bronchial fistula. Pneumothorax occurs chiefly in adults, though cases are met with in very young children. It is more frequent in males than in females. Morbid Anatomy.—If a trocar or blow-pipe is inserted between the ribs, there may be a jet of air of sufficient strength to blow out a lighted match. On opening the thorax the mediastinum and pericardium are seen to be pushed, or rather, as Douglas Powell pointed out, drawn over to the opposite side; but, as before mentioned, the heart is not rotated, and the relation of its parts is maintained much as in the normal condition. A serous or purulent fluid is usually present, and the mem- branes are inflamed. The cause of the pneumothorax can usually be found without difficulty. In the great majority of instances it is the perforation of a tuberculous cavity or a breaking of a superficial caseous focus. The orifice of rupture may be extremely small. In chronic cases there may be a fistula of considerable size communicating with the bron- chi. The lung is usually compressed and carnified. Symptoms.—The onset is usually sudden and characterized by severe pain in the side, urgent dyspnoea, and signs of general distress, as indicated by slight lividity and a very rapid and feeble pulse. There may, however, be no urgent symptoms, particularly in cases of long- standing phthisis. On more than one occasion I have found, post mortem, a pneumothorax which was unsuspected during life. West states that even in healthy adults this latent pneumothorax may occasionally occur. The physical signs are very distinctive. Inspection shows marked enlargement of the affected side with immobility. The heart impulse is usually much displaced. On palpation the fremitus is greatly diminished or more commonly abolished. On percussion the resonance may be tym- panitic or even have an amphoric quality. This, however, is not always the case. It may be a flat tympany, resembling Skoda’s resonance. In some instances it may be a full, hyperresonant note, like emphysema; while in others—and this is very deceptive—there is dulness. These extreme variations depend doubtless upon the degree of intrapleural ten- sion. On several occasions I have known an error in diagnosis to result from ignorance of the fact that, in certain instances, the percussion note 610 DISEASES OF THE RESPIRATORY SYSTEM. may be “ muffled, toneless, almost dull ” (Walshe). There is usually dulness at the base from effused fluid, which can readily be made to change the level by altering the position of the patient. Movable dulness can be obtained much more readily in pneumothorax than in a simple pleurisy. On auscultation the breath-sounds are suppressed. Sometimes there is only a distant feeble inspiratory murmur of marked amphoric quality. The contrast between the loud exaggerated breath-sounds on the normal side and the absence of the breath-sounds on the other is very snggestive. The rales have a peculiar metallic quality, and on coughing or deep inspiration there may be what Laennec termed the metallic tinkling. The voice, too, has a curious metallic echo. What is sometimes called the coin-sound, termed by Trousseau the bruit d'airain, is very characteristic. To obtain it the auscultator should place one ear on the back of the chest wall while the assistant taps one coin on another on the front of the chest. The metallic echoing sound which is produced in this way is one of the most constant and characteristic signs of pneumo- thorax. And, lastly, the Hippocratic succussion may be obtained when the auscultator’s head is placed upon the patient’s chest and his body shaken. A splashing sound is produced, which may be audible at a dis- tance. A patient may himself notice it in making abrupt changes in posture. Of other symptoms displacement of organs is most constant. As already mentioned, the heart may be drawn over to the opposite side, and the liver greatly displaced, so that its upper surface is below the level of the costal margin, a degree of dislocation never seen in simple effusion. The diagnosis of pneumothorax rarely offers any difficulty, as the signs are very characteristic. In cases in which the percussion note is dull the condition may be mistaken for effusion. I made this mistake in a case of pulsating pleurisy, in which the pneumothorax followed heavy lifting, and it Avas not until several days later, after some of the fluid had been with- drawn, that a tympanitic note developed. Diaphragmatic hernia follow- ing a crush or other accident may closely simulate pneumothorax. In cases of very large phthisical cavities with tympanitic percussion resonance and rales of an amphoric, metallic quality the question of pneumothorax is sometimes raised. In those rare instances of total ex- cavation of one lung the amphoric and metallic phenomena may be most intense, but the absence of dislocation of the organs and of the succus- sion splash and of the coin sound suffice to differentiate this condition. While this is true in the great majority of cases, I have recently heard the bruit d’airain over large cavities of the right upper lobe. The con- dition of pyo-pneumothorax subphrenicus may simulate closely true pneu- mothorax. The prognosis in cases of pneumothorax depends largely upon the cause. The phthisical cases usually die within a few weeks. Pneumo- thorax developing in a healthy individual often ends in recovery. There are cases of phthisis in which the pneumothorax, if occurring early, seems AFFECTIONS OF THE MEDIASTINUM. 611 to arrest the progress of the tuberculosis. This appeared to be the case in a man with chronic pneumothorax who was under my care in Philadelphia for between three and four years. It may be a chronic condition, as in the case just mentioned, and a fair measure of health may be enjoyed. Treatment.—Practically these cases should be dealt with as ordinary pleurisy with effusion. Of course, when pneumothorax develops in ad- vanced phthisis the indication is to relieve the pain and distress either by morphia or chloroform; but in cases which develop early the fluid should be withdrawn by aspiration, or, if purulent, permanent drainage should be obtained. Even when the condition has seemed to be most desperate I have known recovery to take place after thorough drainage of the sac. Portions of ribs may have to be excised, and during convalescence it is well for the patient to practise expansion of the lung in the manner already mentioned. There are cases of pneumothorax in phthisis in which the general condition is so good and the inconvenience so slight that to let well enough alone seems the best course. In such an occa- sional aspiration may be performed if the fluid increases. In some of the instances the mere tapping of the chest with a fine needle, so as to allow the escape of some of the air, seems to give relief by reducing the intra- thoracic pressure. Good results are stated to have followed the method introduced by Potain, of replacing the air and fluid within the thorax by sterilized air. AFFECTIONS OF THE MEDIASTINUM. (1) Simple Lymphadenitis.—In all inflammatory affections of the bronchi and of the lungs the groups of lymph glands in the mediastinum become swollen. In the bronchitis of measles, for example, and in simple broncho-pneumonia the bronchial glands are large and infiltrated, the tissue is engorged and (edematous, sometimes intensely hypermmic. Much stress has been laid by some writers on this enlargement of the glands in the posterior mediastinum, and De Mussy held that it was an important factor in inducing paroxysms of whooping-cough. They may attain a size sufficient to induce dulness beneath the manubrium and in the upper part of the interscapular regions behind, though this is often difficult to determine.. In reality the glands lie chiefly upon the spine, and unless those which are deep in the root of the lung are large enough to induce compression of the adjacent lung tissue, I doubt if the ordinary bronchial adenopathy ever can be determined by percussion in the upper interscapu- lar region. I have never met with an instance in which the compression of either bronchus seemed to have resulted from the glands, however large. Tuberculous affection of these glands has already been considered. (2) Suppurative Lymphadenitis.—Occasionally abscess in the bronchial or tracheal lymph glands is found. It may follow the simple adenitis, but 612 DISEASES OP THE RESPIRATORY SYSTEM. is most frequently associated with the presence of tubercle. The liquid portion may gradually become absorbed and the inspissated contents un- dergo calcification. Serious accident occasionally occurs, as perforation into the oesophagus or into a bronchus. (3) Tumors; Cancer and Sarcoma.—In Hare’s elaborate study of 520 cases of disease of the mediastinum* there were 134 cases of cancer, 98 cases of sarcoma, 21 cases of lymphoma, 7 cases of fibroma, 11 cases of dermoid cysts, 8 cases of hydatid cysts, and instances of lipoma, gumma, and enchondroma. From this we see that cancer is the most common form of growth. The tumor occurred in the anterior mediastinum alone in 48 of the cases of cancer and 33 of the cases of sarcoma. The disease may be either primary in the mediastinal tissues and lymph structures or secondary. Sarcoma is more frequently primary than cancer. Males are more frequently affected than females. The age of onset is most com- monly between thirty and forty. Symptoms.—The signs of mediastinal tumor are those of intra- thoracic pressure. Dyspnwa is one of the earliest and most constant symptoms, and may be due either to pressure on the trachea or on the recurrent laryngeal nerves. It may indeed be cardiac, due to pressure upon the heart or its vessels. In a few cases it results from the pleural effusion which so frequently accompanies intrathoracic growths. Asso- ciated with the dyspnoea is a cough, often severe and paroxysmal in char- acter, with the brazen quality of the so-called aneurismal cough when a recurrent nerve is involved. The voice may also be affected from a simi- lar cause. Pressure on the vessels is common. The superior vena cava may be compressed and obliterated, and when the process goes on slowly the collateral circulation may be completely effected. Less commonly the inferior vena cava or one or other of the subclavian veins is com- pressed. The arteries are much less rarely obstructed. It is remarkable how little the aorta may be involved, though entirely surrounded by a sar- comatous or cancerous mass. There may be dysphagia, due to compres- sion of the oesophagus. In rare instances there are pupillary changes, either dilatation or contraction, due to involvement of the sympathetic. Physical Signs.—On inspection there may be orthopnoea and marked cyanosis of the upper part of the body. In such instances, if of long duration, there are signs of collateral circulation and the superficial mam- mary and epigastric veins are enlarged. In a patient with Hodgkin’s dis- ease, at present under observation and in whom during the past sixteen months there has been progressive compression and now obliteration of the superior vena cava, the entire subcutaneous tissue of the front of the thorax seems a plexus of veins and the epigastric vessels are as large as the index-finger. Such instances are, I think, more common in lymphade- noma than in sarcoma or cancer. In these cases of chronic obstruction * Fothergillian Prize Essay of the Medical Society of London, Philadelphia, 1889. AFFECTIONS OF THE MEDIASTINUM. 613 the finger-tips may be clubbed. There may be bulging of the sternum or the tumor may erode the bone and form a prominent subcutaneous growth. The rapidly growing lymphoid tumors more commonly than others per- forate the chest wall. In four of thirteen cases of Hodgkin’s disease, of which I have notes, there was mediastinal growth, and in three instances the sternum was eroded and perforated. The perforation may be on one side of the breast-bone. The projecting tumor may pulsate like an aneu- rism ; the heart may be dislocated and its impulse much out of place. Con- traction of one side of the thorax has been noted in a few instances. On palpation the fremitus is absent wherever the tumor reaches the chest wall. If pulsating, it rarely has the forcible, heaving impulse of an aneu- rismal sac. On auscultation there is usually silence over the dull region. The heart-sounds are not transmitted and the respiratory murmur is feeble or inaudible, rarely bronchial. Vocal resonance is, as a rule, absent. Signs of pleural effusion occur in a great many instances of mediastinal growth, and if in any doubt the aspirator needle should be used. The diagnosis of mediastinal tumor from aneurism is sometimes ex- tremely difficult. An interesting case reported and figured by Sokolosski, in Bd. 19 of the Deutsches Archiv fur klinische Medicin, in which Oppolzer diagnosed aneurism and Skoda mediastinal tumor, illustrates how in some instances the most skilful of observers may be unable to agree. Scarcely a sign is found in aneurism which may not be duplicated in mediastinal tumor. This is not strange, since the symptoms in both are largely due to pressure. The time element is important. If a case has persisted for more than eighteen months the disease is probably aneurism. There are, however, exceptions to this. In the case of com- pression of the vena cava mentioned above, the disease has lasted for more than two years and the patient has improved so markedly under the use of arsenic that had he no other lymphatic enlargements the diagnosis might be uncertain. By far the most valuable sign of aneurism is the diastolic shock so often to be felt, and in a majority of cases to be heard, over the sac. This is rarely, if ever, present in mediastinal growths, even when they perforate the sternum and have communicated pulsation. An- other point of importance is that in a tumor, advancing from the medias- tinum, eroding the sternum and appearing externally, if anenrismal, has forcible, heaving, and distinctly expansile pulsations. The radiating pain in the back and arms and neck is rather in favor of aneurism, as is also a beneficial influence on it of iodide of potassium. The frequency of pleural effusion in connection with mediastinal tumor is to be constantly borne in mind. It may give curiously complex characters to the physical signs—characters which are profoundly modi- fied after aspiration of the liquid. (4) Abscess of the Mediastinum.—Hare collected 115 cases of medi- astinal abscess, in 77 of which there were details sufficient to permit the analysis. Of these cases the great majority occurred in males. Forty-four 614 DISEASES OF TIIE RESPIRATORY SYSTEM. were instances of acute abscess. The anterior mediastinum is most com- monly the seat of the suppuration. The cases are most frequently associated with trauma. Some have followed erysipelas or occurred in association with eruptive fevers. Many cases, particularly the chronic abscesses, are of tuberculous origin. Of symptoms, pain behind the sternum is the most common. It may be of a throbbing character, and in the acute cases is associated with fever, sometimes with chills and sweats. If the abscess is large there may be dyspnoea. The pus may burrow into the abdomen, perforate through an intercostal space, or it may erode the sternum. In- stances are on record in which the abscess has discharged into the trachea or oesophagus. In many cases, particularly of chronic abscess, the pus becomes inspissated and produces no ill effect. The physical signs may be very indefinite. A pulsating and fluctuating tumor may appear at the border of the sternum or at the sternal notch. The absence of bruit, of the diastolic shock, and of the expansile pulsation usually enables a cor- rect diagnosis to be made. When in doubt a fine hypodermic needle may be inserted. (5) Indurative Mediastino-Pericarditis.—Harris has recently reviewed the subject. In one form there is adherent pericardium and great increase in the fibrous tissues of the mediastinum ; in another there is adherent peri- cardium with union to surrounding parts, but very little mediastinitis; in a third the pericardium may be uninvolved. The disease is rare; of twenty-two cases seventeen were in males; only two were above thirty years of age. The symptoms are essentially those of that form of adhesive pericardium which is associated with great hypertrophy and dilatation of the heart, and in which the patients present a picture of cyanosis, dysp- noea, anasarca, etc. The pulsus paradoxicus, described by Kussmaul, is not distinctive. Occasionally there is also a proliferative peritonitis. (6) Miscellaneous Affections.—In Hare’s monograph there were 7 in- stances of fibroma, 11 cases of dermoid cysts, 8 cases of hydatid cysts, and cases of lipoma and gummata. The thymus gland may be enlarged and produce the physical signs of mediastinal tumor. In children there are instances of spasm of the glottis, which is believed by some to depend upon enlargement of the thymus. Jacobi,* in his monograph, says that some instances of sudden death and also so-called thymic asthma may occasionally be referred to this cause. Beneke states that this may be due to compression of the trachea, by the enlarged thymus when the head is bent back, and calls attention to the danger of this in fat and rickety infants. Malignant tumors of the thy- mus may attain considerable size and produce signs of tumor. In rare cases mediastinal growths develop from the thyroid gland. These may be substernal in position and directly connected with the gland. Kretschy has reported a sarcoma of the thyroid four and three quarter inches in * Transactions of the Association of American Physicians, vol. iii. AFFECTIONS OF THE MEDIASTINUM. 615 length, which forms a mediastinal tumor passing to the level of the ninth dorsal vertebra. I have reported a somewhat similar instance, which de- veloped in the left lobe of the thyroid and formed an elongated mass which passed down beside the trachea to the bifurcation. (7) Emphysema of the Mediastinum.—Air in the cellular tissues of the mediastinum is met with in cases of trauma, and occasionally in fatal cases of diphtheria and in whooping-cough. It may extend to the subcutaneous tissues. Champneys has called attention to its frequency in tracheotomy, in which he says the conditions favoring the production are division of the deep fascia, obstruction to the air-passages, and inspiratory efforts. The deep fascia, he says, should not be raised from the trachea. It is often associated with pneumothorax. The condition seems by no means uncom- mon. Angel Money found it in 16 of 28 cases of tracheotomy, and in two of these pneumothorax also was present. SECTION V. DISEASES OF THE CIRCULATORY SYSTEM. I. DISEASES OF THE PERICARDIUM. I. PERICARDITIS. Pericarditis is tlie result of infective processes, primary or secondary, or arises by extension of inflammation from contiguous organs. Etiology.—Primary, so-called idiopathic, inflammation of this mem- brane is rare; but cases are met with, most commonly in children, in which there is no evidence of rheumatism or other conditions with which the disease is usually associated. Pericarditis from injury usually comes under the care of the surgeon in connection with the primary wound. Interesting cases are those in which the traumatism is from within, due to the passage of some foreign body—such as a needle, a pin, or a bone—through the oesophagus into the pericardium. As a secondary process pericarditis is met with in the following affec- tions : {a) A majority of the cases occur in connection with rheumatism. The percentage given by different authors ranges from thirty to seventy. The articular trouble may be slight or, indeed, the disease may be asso- ciated with acute tonsillitis of rheumatic subjects. Cases are recorded in which the pericarditis has preceded the articular disease, (b) Septic processes rank next to rheumatism. In the acute necrosis of bone and puerperal fever it is not uncommon, (c) Tuberculosis, in which the dis- ease may be primary or part of a general involvement of the serous sacs or associated with extensive pulmonary disease. (d) Eruptive fevers. In children, the disease is not infrequent after scarlatina. It is rarely met with in measles, small-pox, or typhoid fever. In other infective diseases, such as diphtheria and pneumonia, it is rare. Pericarditis sometimes com- plicates chorea; it was present in 19 of 73 recent autopsies which I col- lected ; in only 8 of these was arthritis present. (e) Dyscrasias. Cer- tain altered conditions of the system seem to render the pericardium more susceptible to infection. Of these gout takes the first place In chronic Bright’s disease pericarditis is by no means rare. The pericar- dite brightique of the French forms one of the most important groups of the disease in persons over fifty years of age, most frequently accom- PERICARDITIS. 617 panying the chronic interstitial form. Pericarditis has been met with also in scurvy and diabetes. Pericarditis by extension of disease from contiguous organs. In pleuro- pneumonia it forms one of the most serious complications, and was pres- ent in 5 cases in 100 post-mortems in this disease which I made at the Montreal General Hospital. It is most often met with in the pleuro- pneumonia of children and of alcoholics. The association with simple pleurisy is much less common. In ulcerative endocarditis, purulent myo- carditis, and in aneurism of the aorta pericarditis is occasionally found. It may also result from extension of disease from the bronchial glands, the ribs, sternum, vertebras, and even from the abdominal viscera. Pericarditis occurs at all ages. Cases are reported in the foetus. In the new-born it may result from septic infection through the navel. Throughout childhood the incidence of rheumatism and scarlet fever makes it a frequent affection, whereas late in life it is most often asso- ciated with tuberculosis, Bright’s disease, and gout. Males are somewhat more frequently attacked than females. Climatic and seasonal influences have been mentioned by some writers. The so-called epidemics of peri- carditis have been outbreaks of pneumonia with this as a frequent compli- cation. Anatomically as well as clinically the disease may be considered under the following divisions: 1. Acute, plastic, or dry pericarditis. 2. Pericarditis with effusion—sero-fibrinous, haemorrhagic, or purulent. 3. Chronic adhesive pericarditis (adherent pericardium). Acute Plastic Pericarditis.—This, the most common form, occurs usually as a secondary process, and is distinguished by the small amount of fluid exudation, which does not, as in the next variety, give special characters to the disease. It is a benign form and rarely, if ever, of itself proves fatal. Anatomically it may be partial or general. In the mildest grades the serous membrane looks lustreless and roughened. This is due to the presence of a thin fibrinous sheeting, which can be lifted with the knife, showing the membrane beneath to be injected or in places ecchymotic. As the fibrinous sheeting increases in thickness the constant movement of the adjacent surfaces gives to it sometimes a ridge-like, at others a honeycombed appearance. With more abundant fibrinous exudation the membranes present an appearance resembling buttered surfaces which have been drawn apart. The fibrin is in long shreds, and the heart pre- sents a curiously shaggy appearance—the so-called hairy heart of old writers—cor villosum. In mild grades the subjacent muscle looks normal; but in the more prolonged and severe cases there is myocarditis, and for 2 or 3 mm. beneath the visceral layer the muscle presents a pale, turbid appearance. DISEASES OF THE CIRCULATORY SYSTEM. Many of these acute cases are tuberculous; covered by the la)rers of lymph the granulations are easily overlooked in a superficial examination. Slight fluid exudation is invariably present, entangled in the meshes of fibrin, but there may be very thick fibrinous layers without much serous effusion. Symptoms.—The majority of cases of simple plastic pericarditis, like simple endocarditis, present no symptoms, and unless sought for there are no objective signs indicating its existence. In the post-mortem room it is not uncommon to find it in cases in which its presence has been un- suspected during life. Pain is a variable symptom, not usually intense, and in this form rarely excited by pressure. It is more marked in the early stage, and may be referred either to the prascordia or to the region of the xiphoid carti- lage. Instances are recorded of pain of an aggravated and most distress- ing character resembling angina. Fever is usually present, but it is not always easy to say how much depends upon the primary febrile affection, and how much upon the pericarditis. It is as a rule not high, rarely exceeding 102-5°. In rheumatic cases hyperpyrexia has been observed. Physical Signs.—Inspection is negative ; palpation may reveal the pres- ence of a distinct fremitus caused by the rubbing of the roughened peri- cardial surfaces. This is usually best marked over the right ventricle. It is not always to be felt, even when the friction sound on auscultation is loud and clear. Auscultation: The friction sound, due to the movement of the pericardial surfaces upon each other, is one of the most distinctive of physical signs. It is double, corresponding to the systole and diastole; but the synchronism w'ith the heart-sounds is not accurate, and the to-and- fro murmur usually outlasts the time occupied by the first and second sound. In rare instances the friction is single; more frequently it ap- pears to be triple in character—a sort of canter rhythm. The sounds have a peculiar rubbing, grating quality, characteristic when once recognized, and rarely simulated by endocardial murmurs. Sometimes instead of grating there is a creaking quality—the bruit de cuir neuf— the new- leather murmur of the French. The pericardial friction appears super- ficial, very close to the ear, and is usually intensified by pressure with the stethoscope. It is best heard over the right ventricle, the part of the heart which is most closely in contact with the front of the chest—that is, in the fourth and fifth interspaces and adjacent portions of the sternum. There are instances in which the friction is most marked at the base, over the aorta, and at the superior reflection of the pericardium. Occasionally it is best heard at the apex. It maybe limited and heard over a very narrow area, or it may be transmitted up and down the sternum. There are, however, no definite lines of transmission as in the endocardial murmur. An important point is the variability of sounds, both in position and quality; they may be heard at one visit and not at another. The maxi- mum of intensity will be found to vary with position. PERICARDITIS. 619 Diagnosis.—There is rarely any difficulty in determining the pres- ence of a dry pericarditis, for the friction sounds are distinctive. The double murmur of aortic incompetency may simulate closely the to-and- fro pericardial rub. I recall one instance at least in which this mistake was made. The constant character of the aortic murmur, the direction of transmission, the phenomena in the arteries, and the associated condi- tions of the disease should be sufficient to prevent this error. I have never known an instance in which pericarditis was mistaken for endocarditis, though writers refer to such, and give the differential diag- nosis in the two affections. The only possible mistake could be made in those rare instances of single soft, systolic, pericardial friction. Pleuro-pericardial friction is very common, and may be associated with endo-pericarditis, particularly in cases of pleuro-pneumonia. It is fre- quent, too, in phthisis. It is best heard over the left border of the heart, and is much affected by the respiratory movement. Holding the breath or taking a deep inspiration may annihilate it. The rhythm is not the sim- ple to-and-fro diastolic and systolic, but the respiratory rhythm is super- added, usually intensifying the murmur during expiration and lessening it on inspiration. In phthisis there are instances in which, with the fric- tion, a loud systolic click is heard, due to the compression of a thin layer of lung and the expulsion of a bubble of air from a small softening focus or from a bronchus. Course and Termination.—Simple fibrinous pericarditis never kills, but it occurs so often in connection with serious affections that we have frequent opportunities to see all stages of its progress. In the majority of cases the inflammation subsides and the thin fibrinous laminae gradually become converted into connective tissue, which unites the pericardial leaves firmly together. In other instances the inflammation progresses, with in- crease of the exudation, and the condition is changed from a “ dry ” to a “ moist ” pericarditis, or the pericarditis with effusion. In a few instances—probably always tuberculous—the simple plastic pericarditis becomes chronic, and great thickening of both visceral and parietal layers is gradually induced. Pericarditis with Effusion.—Though commonly a direct sequence of the dry or plastic pericarditis, of which it is sometimes called the second stage, this form presents special features and deserves separate consid- eration. It is found most frequently in association with acute rheuma- tism, tuberculosis, and septicasmia, and sets in usually with the symptoms above described, namely, prascordial pain, with slight fever or a distinct chill. In children the disease may, like pleurisy, come on without local symp- toms, and, after a week or two of failing health, slight fever, shortness of breath, and increasing pallor, the physician may find, to his astonishment, signs of most extensive pericardial effusion. These latent causes are often tu- 620 DISEASES OF THE CIRCULATORY SYSTEM. berculous. The effusion may be sero-fibrinous, hgemorrhagic, or purulent The amount varies from 200 or 300 c. c. to 2 litres. In the cases of sero- fibrinous exudation the pericardial membranes are covered with thick, creamy fibrin, which may be in ridges or honeycombed, or may present long, villous extensions. The parietal layer may be several millimetres in thickness and may form a firm, leathery membrane. The haemorrhagic exudation is usually associated with tuberculous, or with cancerous peri- carditis, or with the disease in the aged. The lymph is less abundant but both surfaces are injected and often show numerous haemorrhages. Thick, curdy masses of lymph are usually found in the dependent part of the sac. In the purulent effusion the fluid has a creamy consistency, par- ticularly in tuberculosis. In many cases the effusion is really sero-puru- lent, a thin, turbid exudation containing flocculi of fibrin. The pericardial layers are greatly thickened and covered with fibrin. When the fluid is pus, they present a grayish, rough, granular surface. Sometimes there are distinct erosions on the visceral membrane. The heart muscle in these cases becomes involved to a greater or less extent, and on section, the tissue, for a distance of from two to three millimetres, is pale and turbid, and shows evidence of fatty and granular change. En- docarditis coexists frequently, but rarely results from the extension of the inflammation through the wall of the heart. Symptoms.—Even with copious effusion the onset and course may be so insidious that no suspicion of the true nature of the disease is aroused. As in the simple pericarditis, pain may be present, either sharp and stabbing or as a sense of distress and discomfort in the cardiac region. It is more frequent with effusion than in the plastic form. Pressure at the lower end of the sternum usually aggravates it. Dyspnoea is a common and important symptom, one which, perhaps, more than any other, excites suspicion of grave disorder and leads to careful examination of heart and lungs. The patient is restless, lies upon the left side or, as the effusion increases, sits up in bed. Associated with the dyspnoea is in many cases a peculiarly dusky, anxious countenance. The pulse is rapid, small, sometimes regular, and may present the characters known as pulsus paradoxus, in which during each inspiration the pulse-beat becomes very weak or is lost These symptoms are due, in great part, to the direct mechanical effect of the fluid within the pericardium which embarrasses the heart’s action. Other pressure effects are distention of the veins of the neck, dysphagia, which may be a marked symptom, and irritative cough from compression of the trachea. Aphonia is not uncommon, due to compression or irritation of the recurrent laryngeal as it winds round the aorta. Another important pressure effect is exercised upon the left lung. In massive effusion the pericardial sac occupies such a large por- tion of the antero-lateral region of the left side that the condition has fre- quently been mistaken for pleurisy. Even in moderate grades the left PERICARDITIS. 621 lung is somewhat compressed. This is an additional element in the pro- duction of the dyspnoea. Great restlessness, insomnia, and in the later stages low delirium and coma are symptoms in the more severe cases. Delirium and marked cere- bral symptoms are associated with the hyperpyrexia of rheumatic cases, but apart from the ordinary delirium there may be peculiar mental symp- toms. The patient may become melancholic and show suicidal tendencies. In other cases the condition resembles closely delirium tremens. Sibson, who has specially described this condition, states that the majority of such cases recover. Chorea may also occur,- as was pointed out by Bright. Epilepsy is a rare complication which has occurred during paracentesis. Physical Signs.—Inspection.—In children the prsecordia bulges and with copious exudation the antero-lateral region of the left chest becomes enlarged. The intercostal spaces are prominent and there may he marked oedema of the wall. Perforation externally through a space is very rare. Owing to the compression of the lung, the expansion of the left side is greatly diminished. The diaphragm and left lobe of the liver may be pushed down and may produce a distinct prominence in the epigastric region. Palpation.—A gradual diminution and final obliteration of the cardiac shock is a striking feature in progressive effusion. The apex beat is often raised an interspace and dislocated outward. Alteration in the position of the impulse simultaneously with the position of the patient, a sign upon which Oppolzer laid great stress, cannot often be determined, as the heat may, and usually does, disappear entirely. The pericardial friction may lessen with the effusion, though it often persists at the base when no longer palpable over the right ventricle, or may be felt in the erect and not in the recumbent posture. Fluctuation can rarely, if ever, be detected. Percussion gives most important indications. The gradual distention of the pericardial sac pushes aside the margins of the lungs so that a large area comes in contact with the chest wall and gives a greatly increased percussion dulness. The form of this clulness is irregularly pear-shaped; the base or broad surface directed downward and the stem or apex directed upward toward the manubrium. A valuable sign, to which Botch called attention, is the absence of resonance in the right fifth intercostal space. Auscultation.—The friction sound heard in the early stages may dis- appear when the effusion is copious, but often persists at the base or at the limited area of the apex. It may be audible in the erect and not in the recumbent posture. With the absorption of the fluid the friction returns. One of the most important signs is the gradual weakening of the heart-sounds, which with the increase in the effusion may become so muffled and indistinct as to be scarcely audible. The heart’s action is usually increased and the rhythm disturbed. Occasionally a systolic endo- cardial murmur is heard. Early and persistent accentuation of the pul- monary second sound may be present (Warthin). DISEASES OF THE CIRCULATORY SYSTEM. Important accessory signs in large effusion are due to pressure on the left lung. The antero-lateral margin of the lower lobe is pushed aside and in some instances compressed, so that percussion in the axillary re- gion, in and just below the transverse nipple line, gives a modified per- cussion note, usually a flat tympany. Variations in the position of the patient may change materially this modified percussion area, over which on auscultation there is either feeble or tubular breathing. Course.—'Cases vary extremely in the rapidity with which the effusion takes plaoe. In every instance, when a pericardial friction murmur has been detected,. the practitioner should immediately outline with care— using the aniline pencil or nitrate of silver—the upper and lateral limits of cardiac dulness, since he will in this way have certain positive guides in determining the rate and grade of the effusion. In many instances the exudation is slight in amount, reaches a maximum within forty-eight hours, and then gradually subsides. In other instances the accumulation is more gradual and progressive, increasing for several weeks. To such cases the term chronic has been applied. The rapidity with which a sero- fibrinous effusion may be absorbed is surprising. The possibility of the absorption of purulent exudate is shown by the cases in which the peri- cardium contains semi-solid grayish masses in all stages of calcification. With sero-fibrinous effusion, if moderate in amount, recovery is the rule, with inevitable union, however, of the pericardial layers. In some of the septic cases there is a rapid formation of pus and a fatal result may follow in three or four days. More commonly, when death occurs with large effusion, it is not until the second or third week and takes place by grad- ual asthenia. Prognosis.—In the sero-fibrinous effusions the outlook is good, and a large majority of all the rheumatic cases recover. The purulent effu- sions are, of course, more dangerous; the septic cases are usually fatal, and recovery is rare in the slow, insidious tuberculous forms. Diagnosis.—Probably no serious disease is so frequently overlooked by the practitioner. Post-mortem experience shows how often pericarditis is not recognized, or goes on to resolution and adhesion without attract- ing notice. In a case of rheumatism, watched from the outset, with the attention directed daily to the heart, it is one of the simplest of diseases to diagnose; but when one is called to a case for the first time and finds perhaps an increased area of precordial dulness, it is often very hard to determine with certainty whether or not effusion is present. The difficulty usually lies in distinguishing between dilatation of the heart and pericardial effusion. Although the differential signs are simple enough on paper, it is notoriously difficult in certain cases, particularly in stout persons, to say which of the conditions exists. The points which deserve attention are: (a) The character of impulse, which in dilatation, particularly in thin- chested people, is commonly visible and wavy. PERICARDITIS. 623 (b) The shock of the cardiac sounds is more distinctly palpable in dilatation. (c) The area of dulness in dilatation rarely has a triangular form; nor does it, except in cases of mitral stenosis, reach so high along the left sternal margin or so low in the fifth and sixth interspaces without visible or palpable impulse. An upper limit of dulness shifting with the position speaks strongly for effusion. (d) In dilatation the heart-sounds are clearer, often sharp, valvular, or foetal in character; whereas in effusion the sounds are distant and muffled. (e) Rarely in dilatation is the distention sufficient to compress the lung and produce the tympanitic note in the axillary region. The number of excellent observers who have acknowledged that they have failed sometimes to discriminate between these two conditions, and who have indeed performed paracentesis cordis instead of paracentesis peri- cardii, is perhaps the best comment on the difficulties. Massive to 2 litre) exudations have been confounded with a pleu- ral effusion. On more than one occasion the pericardium has been tapped under the impression that the exudate was pleuritic. The flat tympany in the infrascapular region, the absence of well-defined movable dulness, and the feeble, muffled sounds are indicative points. If the case has been followed from day to day there is rarely much difficulty; but it is different when a case presents a large area of dulness in the antero- lateral region of the left chest, and there is no to-and-fro pericardial friction murmur. Many of the cases have been regarded as encapsulated pleural effusion. The nature of the fluid cannot positively be determined without aspi- ration ; but a fairly accurate opinion can be formed by the nature of the primary disease and the general condition of the patient. In rheumatic cases the exudation is usually sero-fibrinous; in septic and tuberculous cases it is often purulent from the outset; in senile, nephritic, and tuber- culous cases the exudation is sometimes haemorrhagic. Treatment.—The patient should have absolute quiet, mentally and bodily, so as to reduce to a minimum the heart’s action. Drugs given for this purpose, such as aconite or digitalis, are of doubtful utility. Local bloodletting by cupping or leeches is certainly advantageous in robust subjects, particularly in the cases of extension in pleuro-pneumonia. The ice-bag is of great value. It may be applied to the praecordia at first for an hour or more at a time, and then continuously. It reduces the fre- quency of the heart’s action and seems to retard the progress of an effu- sion. Blisters are not indicated in the early stage. When effusion is present, the following measures to promote absorp- tion may be adopted: Blisters to the praecordia, a practice not so much in vogue now as formerly. It is surprising, however, in some instances, how quickly an effusion will subside on their application. If the patient’s 624 DISEASES OF THE CIRCULATORY SYSTEM. strength is good, a purge every other morning may be given. The diet should be light, dry, and nutritious. In cases in which the pulse is strong and the constitutional disturbance not great, iodide of potassium may be of service, and the action of the kidneys may be promoted by the infusion of digitalis and acetate of potash. When the effusion is large, as soon as signs of serious impairment of the heart occur, as indicated by dyspnoea, small rapid pulse, dusky, anxious countenance, surgical measures should be resorted to, and paracentesis, or incision of the pericardium, at once be performed. With the sero-fibrin- ous exudate, such as commonly occurs after rheumatism, aspiration is sufficient; but when the exudate is purulent the pericardium should be freely incised and freely drained. The puncture may be made in the fourth interspace, either at the left sternal margin or 25 cm. (an inch) from it. If made in the fifth interspace it is well to puncture an inch and a half from the left sternal margin. In large effusions the pericar- dium can also be readily reached without danger by thrusting the needle upward and backward close to the costal margin in the left costo-xiplioid angle. The results of paracentesis of the pericardium have so far not been satisfactory. With an earlier operation in many instances and a more radical one in others—a free incision and not aspiration when the fluid is purulent—the percentage of recoveries will be greatly increased. Chronic Adhesive Pericarditis (Adherent Pericardium).—This con- dition follows acute pericarditis, and may be partial or universal. It is not very uncommon to meet with limited synechia over the right ven- tricle. In the mildest grades of complete adhesion the amount of con- nective tissue between the membranes is slight, and there is not much thickening. These are the instances which follow the fibrinous rheu- matic pericarditis. The most extreme thickening of the membranes is met with in the chronic tuberculous form, which has already been de- scribed, and which is much more common than indicated in the litera- ture. After the absorption of an extensive purulent or sero-purulent exudate the inspissated remnants may undergo calcification. This may be in quite a limited region, most frequently over the auricles or at the base of the heart. In extreme grades the organ is completely invested by a calcareous membrane, which in places may be from 1 to T5 cm. in thickness. The symptoms of adherent pericardium are uncertain and indefinite. A majority of the .cases are met with accidentally in the post-mortem room, and there may have been no indications whatever during life of cardiac disturbance. Enlargement of the heart is an almost constant ac- companiment of universal, and may follow even partial, adhesion, and many of the cases come under observation for the first time with failure of this hypertrophy and signs of cardiac insufficiency. The following are the important points in the diagnosis : (1) Inspection>—In children, in whom the condition is a not un- PERICARDITIS. 625 common sequence of rheumatism, the hypertrophied heart causes bulg- ing of the chest wall. The area of cardiac impulse is increased and may sometimes be seen from the third to the sixth interspace and beyond the nipple line. The strongest impulse may be to the right of the apex. The wavy character of the pulsation in the third, fourth, and fifth interspaces is not peculiar to adherent pericardium. ISTot much stress can be laid upon the fixed position of the impulse, which in great enlargement of the heart is not much influenced either by posture or respiration. A more important point is systolic retraction of the apex region. Whether this occurs without adhesion of the pericardium to the chest wall is doubtful. It is often marked, and is sometimes best appreciated by the application of the hand over the apex region, which is felt to be drawn in at the mo- ment of systole. The retraction may be most noticeable in the lower sternal region or even at the xiphoid cartilage. Following this there is sometimes a rapid rebound—the diastolic shock—which has been regarded by some as the most reliable of all signs of pericardial adhesion. Asso- ciated with this diastolic rebound is the so-called Friedrich's sign—dias- tolic collapse of the cervical veins. (2) Percussion reveals an increase in the area of cardiac dulness, par- ticularly upward as high as the second interspace. In a majority of the cases there are adhesions as well between the pleura and pericardium—in ten of thirteen cases analyzed by Ord. In some instances the dulness may reach as high as the first interspace. A sign of value is the fixed limit above and to the left of cardiac dulness, as pointed out by C. J. B. Will- iams. When the outer layer of the pericardium is adherent to the pleura this is a sign of very definite value, and the limit of dulness varies very slightly on deep inspiration. (3) On auscultation the phenomena vary extremely with the condition of the chambers. There may be no murmurs. When extreme dilatation is present the gallop or foetal rhythm occurs. A loud systolic murmur is not uncommon at the apex region, and the cases are frequently mistaken . for old mitral valve disease. (4) The pulsus paradoxus in which during inspiration the pulse- wave is small and feeble, is sometimes present, but it is not a diagnostic sign of either simple pericardial adhesion or of the cicatricial mediastino- pericarditis. Adherent pericardium with extreme dilatation of the heart may raise the suspicion of pericarditis with effusion, as the outline of dulness in both is somewhat alike. As a rule, however, the basic dulness is broader in ad- hesion, and has not the pear-shaped outline. The extent and wavy char- acter of the impulse is never so marked in large effusions, and the heart- sounds are muffled. In children, chronic adhesive pericarditis may be associated with pro- liferative peritonitis, perihepatitis, and perisplenitis, in which condition ascites may recur for months, or even for years. 626 DISEASES OF THE CIRCULATORY SYSTEM. II. OTHER AFFECTIONS OF THE PERICARDIUM. 1. Hydropericardium.—Naturally there are in the pericardial sac a few cubic centimetres of clear, citron-colored fluid, which probably repre- sents a post-mortem transudate. In certain conditions during life there may be large secretions of serum forming what is known as dropsy of the pericardium. It occurs usually in connection with general dropsy, due to kidney or heart disease ; more commonly the former. It rarely of it- self proves fatal, though when the effusion is excessive it adds to the embarrassment of the heart and the lungs, particularly when the pleural cavities are the seat of similar exudation. There are rare instances in which effusion into the pericardium occurs after scarlet fever with few, if any, other dropsical symptoms. The physical signs are those already referred to in connection with pericarditis with effusion. It is frequently overlooked. In rare cases the serum has a milky character—chylo-pericardium. 2. Hffimo-pericardium.—This condition, by no means uncommon, is met with in aneurism of the first part of the aorta, of the cardiac wall, or of the coronary arteries, and in rupture and wounds of the heart. Death usually follows before there is time for the production of symptoms other than those of rapid heart-failure due to compression. Particularly is this the case in aneurism. In rupture of the heart the patient may live for many hours or even days with symptoms of progressive heart-failure, dyspnoea, and the physical signs of effusion. As already mentioned, the inflammatory exudate of tubercle or cancer is often blood-stained. The same is true of the effusion in the peri- carditis of Bright’s disease and of old people. 3. Pneumo-pericardium.—Gas is rarely found in the pericardial sac, and is due, as a rule, to perforation from without, as in the case of stab wounds, or the result of perforation from the lungs, oesophagus, or stomach. In those cases, formerly so puzzling, in which the gas is present shortly after death (a few hours), the gas bacillus (B. aerogenes capsulatus) will be found. As a result of perforation, acute pericarditis is always excited, and the effusion rapidly becomes purulent. The physical signs are remarkable. When the effusion is copious the fluid and gas together give a movable area of percussion dullness with marked tympany in the region of the gas. On auscultation, remarkable splashing, churning, metal- lic phenomena are heard with friction and possibly feeble, distant heart- sounds. Death follows rapidly, even in thirty-six hours, as in a case (the only one which I have seen) of perforation of the pericardium in cancer of the stomach. Except as a result of injury, the condition is not one for which treatment is available. In a case of perforation from without with signs of effusion, to enlarge the wound by free incision would be justi- fiable. ENDOCARDITIS. 627 II. DISEASES OF THE HEART. 1. ENDOCARDITIS. Inflammation of the lining membrane of the heart is usually confined to the valves, so that the term is practically synonymous with valvular endocarditis. It occurs in two forms—acute, characterized by the pres- ence of vegetations with loss of continuity or of substance in the valve tissues; chronic, a slow sclerotic change, resulting in thickening, pucker- ing, and deformity. Acute Endocarditis. This occurs in rare instances as a primary, independent affection; but in the great majority of cases it is an accident in various infective pro- cesses, so that in reality the disease does not constitute an etiological entity. For convenience of description we speak of a simple or benign, and a malignant or ulcerative endocarditis, between which, however, there is no essential anatomical difference, as all gradations can be traced, and they represent but different degrees of intensity of the same process. Simple Endocarditis.—This is characterized by the presence on the valves or on the lining membrane of the chambers of minute vegetations, ranging from 1 to 4 mm. in size, with an irregular and fissured surface, giving to them a warty or verrucose appearance. Often these little cauli- flower-like excrescences are attached by very narrow pedicles. It is rare to see any swelling or infiltration of the endocardium in the neighborhood of even the smallest of the granulations, and although small capillary vessels do exist at the edges of the valves, redness, indicative of the injec- tion or distention of the vessels, is extremely rare. With time the vegeta- tions may increase greatly in size, but in what may be called simple endocarditis the size rarely exceeds that mentioned above. The finer changes in the process consist of the proliferation of the subendothelial connective-tissue elements, resulting in a small-celled infiltration. What part, if any, the endothelial cells play in this is not accurately known. The superficial elements undergo a coagulation necrosis, and fibrin is deposited from the blood, often in layers. Practically a vegetation is a small area of granulation tissue capped with fibrin. Micro-organisms are present, entangled in the granular and fibrillated fibrin, and they probably constitute an essential and constant element in all cases of simple endocarditis. The further changes in the vegetation may be either in the direction of increased proliferation of the connective-tissue elements of the valve, forming an extensive area of necrosis and the production of the condition which, from its more intense grade, we speak of as malignant or ulcerative endocarditis; or, as is more usual, healing occurs. The vegetation is 628 DISEASES OF THE CIRCULATORY SYSTEM. absorbed, and there remains a small nodular thickening of the valve. A third possibility is the dislocation of a vegetation with transference as an embolus to a distant part of the circulation. It is to be noted, however, that this untoward event is rare in acute endocarditis associated with febrile affections, whereas it is by no means uncommon in the simple endocarditis which occurs so constantly on old sclerotic valves. Anatomically, in the majority of instances of acute endocarditis, cica- trization of the granulation tissue takes place in time, with but little damage to the valve beyond slight nodular thickening. The essential danger is remote and results from the slow changes in the valve tissue, which are so apt to follow an acute inflammation. Why this should be so cannot at present be explained; but the fact remains that the simple endocarditis, harmless in itself, such as we meet with in rheumatism or in chorea, lays the foundation of subsequent organic lesions, owing to the initiation of nutritive changes leading to sclerosis with contraction and deformity. Endocarditis is much more common on the left side of the heart and involves the valvular endocardium in the great majority of cases. During foetal life the right side of the heart is often affected. The chordae ten- dinete are sometimes involved with the valves, rarely alone. The mitral valves are more often affected than the aortic. On the mitral segment the vegetations are usually on the auricular face, not at the margin, but at a distance of 2 or 3 mm., forming a row of bead-like outgrowths. So, too, on the aortic segment they are not seen on the free margin, but just below, on the ventricular face, following the margin of the so-called lunat- ed spaces. In both the valves this peculiar distribution follows, as Sibson suggests, the lines of maximum contact. Etiology.—Simple endocarditis does not constitute a disease of it- self, but is invariably found with some other affection. The general ex- perience of the profession has confirmed the original observation of Bouil- laud as to the frequency of association of simple endocarditis with acute articular rheumatism. Possibly it is nothing in the disease itself, but simply an altered state of the fluid media—a reduction perhaps of the lethal influences which they normally exert—permitting the invasion of the blood by certain micro-organisms. Tonsillitis, which in some forms is regarded as a rheumatic affection, may be complicated with endocardi- tis. Of the specific diseases of childhood it is not uncommon in scarlet fever, while it is rare in measles and chicken-pox. In diphtheria simple endocarditis is rare. It was not present in a single instance of 30 autop- sies which I made in this disease at the Montreal General Hospital. In small-pox it is not common. In typhoid fever I have met with it twice in 80 autopsies. In pneumonia both simple and malignant endocarditis are common. In 100 autopsies in this disease made at the Montreal General Hospi- tal there were 5 instances of the former. Acute endocarditis is by no ENDOCARDITIS. 629 means rare in phthisis. I have met with it in 12 cases in 216 post-mor- tems. In chorea simple warty vegetations are found on the valves in a large majority of all fatal cases, in 62 of 73 cases recently collected by me. There is no disease in which, post mortem, acute endocarditis has been so fre- quently found. And, lastly, simple endocarditis is met with in diseases associated with loss of flesh and progressive debility, as cancer, and such disorders as gout, diabetes, and Bright’s disease. A very common form is that which occurs on the sclerotic valves in old heart-disease—the so-called recurring endocarditis. Symptoms.—Neither the clinical course nor the physical signs are in any respect characteristic. The great majority of the cases are latent and there is no indication whatever of cardiac mischief. Experience has taught us that endocarditis is frequently found post mortem in persons in whom it was not suspected during life. There are certain features, however, by which its presence is indicated with a degree of probability. The patient, as a rule, does not complain of any pain or cardiac distress. In a case of acute rheumatism, for example, the symptoms to excite suspicion would be increased rapidity of the heart’s action, perhaps slight irregularity, and an increase in the fever without aggravation of the joint trouble. Kows of tiny vegetations on the mitral or on the aortic segments seem a trifling matter to excite fever and it is difficult in the endocarditis of febrile pro- cesses to say definitely in every instance that an increase in the fever de- pends upon the endocardial complication. But a study of the recurring endocarditis—which is of the warty variety, consisting of minute beads on old sclerotic valves—shows that this process may be associated, for days or weeks at a time, with slight fever ranging from 100° to Pal- pitation may be a marked feature and is a symptom upon which certain authors lay great stress. The diagnosis of the condition rests upon physical signs which are notoriously uncertain. The presence of a murmur at one or other of the cardiac areas in a case of fever is often regarded as indicative of the exist- ence of endocarditis. This extremely common mistake has arisen from the fact that the bruit de souffle or bellows murmur is common to endo- carditis and a number of other conditions which have nothing to do with it. At first there may be only a slight roughening of the first sound, which may gradually develop into a distinct murmur. Taken alone, it is, however, a very uncertain and fallacious sign. Malignant Endocarditis.—Acute endocarditis of a malignant character is met with : (a) As a primary disease of the lining membrane of the heart or of its valves. (3) As a secondary affection in acute rheumatism, pneumonia, and in various specific fevers; or as an associated condition in septic processes. 630 DISEASES OF THE CIRCULATORY SYSTExM. It is also known by the names of ulcerative, infectious, or diphtheritic endocarditis, but the term malignant seems most appropriate to charac- terize the essential clinical features of the disease. Etiology.—The existence of a primary endocarditis has been doubted; but there are instances in which persons previously in good health, without any history of affections with which endocarditis is usually associated, have been attacked with symptoms resembling severe typhus or typhoid. In one case which I saw death occurred on the sixth day and no lesions were found other than those of malignant endocarditis. Rheumatism, with which simple endocarditis is frequently associated, is not so often complicated with the malignant form. Thus, in only 24 of 209 cases the symptoms of severe endocarditis arose in the progress of acute or subacute rheumatism. In only 3 of the Montreal cases was there a history of rheumatism either before or during the attacks. Malignant endocarditis is extremely rare in chorea. Of all acute dis- eases complicated with severe endocarditis pneumonia probably heads the list. This fact, which had been referred to by several of the older writers, was brought out in a striking manner by the figures on which my lectures were based. In 11 of the 23 Montreal cases the disease came on with lobar pneumonia, while it developed with this disease in 54 of the 209 cases analyzed—indeed, the endocarditis which occurs in pneumonia seems to be of an unusually malignant type, as in 16 cases of my 100 autopsies in this disease in which this lesion was present, 11 were of this form. Meningitis was associated with endocarditis in 25 of the 209 cases, and in 15 there was also pneumonia. The affection may complicate erysipelas, septicaemia (from whatever cause), and puerperal fever and gonorrhoea. Malignant endocarditis is very rare in tuberculosis, typhoid fever, and diphtheria. It has been stated by many writers that endocarditis occurs in ague. With the unusual facilities for the study of this disease which I have had in the past seven years I have not yet met with an instance. Unquestion- ably, in the majority of these cases, the intermittent pyrexia, which has been regarded as characteristic of the ague, has depended upon the endo- carditis. In dysentery cases have been described. In small-pox and scarlet fever, with which simple endocarditis is not infrequently compli- cated, the malignant form is extremely rare. Morbid Anatomy.—The lesions may be either vegetative, ulcera- tive, or suppurative, and these forms may occur alone or in combination. Even with vegetations there is distinct necrosis and loss of the endocardial substance. More frequently there is ulceration, either superficial, involv- ing only the endocardium, or deep and distinct, leading to perforation of a valve, of a septum, or even of the heart itself. In the suppurative form the deeper tissues of the valve appear first affected and small abscesses are found at the bases of the vegetations. The vegetations may present a re- markable greenish-gray or greenish-yellow color, and when of long stand- ENDOCARDITIS. 631 ing, or even in cases which from the clinical history appear to be tolerably acute, the vegetations may be crusted with lime salts. A large vegetation of malignant endocarditis consists histologically of a granular and fibrillated fibrin, colonies of micro-organisms, and distinct granulation tissue at the base, while the subjacent endocardial layers show infiltration and proliferation. The destruction of tissue results from a gradual extension of the necrotic processes. Of organisms which have been cultivated from the vegetations, the following may be mentioned: Streptococci and staphylococci—which are the most common—micrococ- cus lanceolatus, bacillus typhi abdominalis, bacillus tuberculosis, the gono- coccus, and the bacillus anthracis. The following figures, taken from my Goulstonian lectures at the Eoyal College of Physicians, give an approximate estimate of the frequency with which in 209 cases ditferent parts of the heart were affected : Aortic and mitral valves together, 41; aortic valves alone, 53 ; mitral valves alone, 77; tricuspid in 19; the pulmonary valves in 15; and the heart wall in 33. In 9 instances the right heart alone was involved, in most cases the auric- ulo-ventricular valves. Mural endocarditis is seen most often at the upper part of the septum of the left ventricle. Next in order is the endocarditis of the left auricle on the postero-external wall. The ulcerative changes may lead to perfora- tion of a valve segment, erosion of the chordae tendineae, perforation of the septum, or even of the heart itself. A common result of the ulcera- tion is the production of valvular aneurism. In three fourths of the cases the affected valves present old sclerotic changes. The process may extend to the aorta, producing, as in one of my cases, extensive endarteritis with multiple acute aneurisms. The associated pathological changes are partly those of the primary disease to which the endocarditis is secondary and partly those due to embolism. In the endocarditis of septic processes there is the local lesion —an acute necrosis, a suppurative wound, or puerperal disease. In many cases the lesions are those of pneumonia, rheumatism, or other febrile pro- cesses. The changes due to embolism constitute the most striking feat- ures, but it is remarkable that in some instances, even with endocarditis of a markedly ulcerative character, there may be no trace of embolic processes. The infarcts may be few in number—only one or two, perhaps, in the spleen or kidney—or they may exist in hundreds throughout the various parts of the body. They may present the ordinary appearance of red or white infarcts of a suppurative character. They are most common in the spleen and kidneys, though they may be numerous in the brain, and in many cases are very abundant in the intestines. In right-sided endocar- ditis there may be infarcts in the lungs. In many of the cases there are innumerable miliary abscesses. Acute suppurative meningitis was met with in 5 of 23 of the Montreal cases, and in over ten per cent of the 209 632 DISEASES OF THE CIRCULATORY SYSTEM. cases analyzed in the literature. Acute suppurative parotitis also may occur. Symptoms.—It is difficult to give a satisfactory clinical picture of the disease because the modes of onset are so varied and the symptoms so diverse. Arising in the course of some other disease, there may be simply an intensification of the fever or a change in its character. In a ma- jority of the cases there are present certain general features, such as irregu- lar pyrexia, delirium, sweating, gradual failure of strength. Embolic processes may give special characters, such as delirium, coma or paralysis from involvement of the brain or its membranes, pain in the sides and local peritonitis from infarction of the spleen, bloody urine from implication of the kidneys, impaired vision from retinal haemorrhage, and suppuration, and even gangrene, in various parts from the distribution of the emboli. Two special types of the disease have been recognized—the septic or pygemic and the typhoid. Other cases closely resemble true intermittent fever. In some the cardiac symptoms are most prominent, while in others again the main symptoms may be those of an acute affection of the cere- bro-spinal system. The septic type is met with usually in connection with an external wound, the puerperal process, or an acute necrosis. There are rigors, sweats, irregular fevers, and all of the signs of septic infection. The heart symptoms may be completely masked by the general condition, and atten- tion called to them only on the occurrence of embolism. In a most re- markable sub-group of this type the disease may simulate a quotidian or a tertian ague. The symptoms may develop in persons with chronic heart- disease without any external lesions. These cases may be much prolonged —for three or four months, or even longer, as in a case of Bristowe’s. The existence in some of these instances of a previous genuine malaria has been a very puzzling circumstance. The typhoid type is by far the most common and is characterized by an irregular temperature, early prostration, delirium, somnolence, and coma, relaxed bowels, sweating, which may be of a most drenching char- acter, petechial and other rashes, and occasionally parotitis. The heart symptoms may be completely overlooked, and in some intances the most careful examination has failed to discover a murmur. Under the cardiac group, as suggested by Bramwell, may be consid- ered those cases in which patients with chronic valve disease are attacked with marked fever and evidence of recent endocarditis. Many such cases present symptoms of the pygemic and typhoid character and may run a most acute conrse. In others the course is chronic, lasting for weeks or months. I have reported two cases of this chronic vegetative endocardi- tis, with intermittent fever, one of more than a year’s duration. The au- topsies showed extensive vegetative and ulcerative disease of the mitral valves. ENDOCARDITIS. 633 There are cases in which it is often difficult to decide whether malignant endocarditis is present or not. Thus, a patient with aortic valve disease is under treatment for failing compensation and begins to have irregular fever with restlessness and cardiac distress; embolic phe- nomena may develop—sudden hemiplegia, j)ain in the region of the spleen, or bloody urine, or perhaps peripheral embolism. There may be a low delirium and the case may run a tolerably acute course ; but in other instances the fever subsides and recovery occurs. In what may be termed the cerebral group of cases the clinical pict- ure may simulate a meningitis, either basilar or cerebro-spinal. There may be acute delirium or, as in three of the Montreal cases, the patient may be brought into the hospital unconscious. Heineman reports an in- stance, with autopsy, in which the clinical picture was that of an acute cerebro-spinal meningitis. Certain special symptoms may be mentioned. The fever is not al- ways of a remittent type, but may be high and continuous. Petechial rashes are very common and render the similarity very strong to certain cases of typhoid and cerebro-spinal fevers. In one case the disease was thought to be haemorrhagic small-pox. Erythematous rashes are not un- common. The sweating may be most profuse, even exceeding that which occurs in phthisis and ague. Diarrhoea is not necessarily associated with embolic lesions in the intestines. Jaundice has been observed and cases are on record which were mistaken for acute yellow atrophy. The heart symptoms may be entirely latent and are not found unless a careful search be made. Even on examination there may be no mur- mur present. Instances are recorded by careful observers, in which the examination of the heart has been negative. Cases with chronic valve disease usually present, no difficulty in diagnosis. The course of the disease is varied, depending largely upon the nature of the primary trouble. Except in the disease grafted upon chronic valvulitis the course is rarely extended beyond five or six weeks. As already mentioned, there are instances in which the disease is prolonged for months. The most rapidly fatal ease on record is described by Eberth, the duration of which was scarcely two days. Diagnosis.—In many cases the detection of the disease is very diffi- cult ; in others, with marked embolic symptoms, it is easy. From simple endocarditis it is readily distinguished, though confusion occasionally occurs in the transitional stage, when a simple is developing into a malig- nant form. The constitutional symptoms are of a graver type, the fever is higher, rigors are common, and septic and typhoid symptoms develop. Perhaps a majority of the cases not associated with puerperal processes or bone disease are confounded with typhoid fever. A differential diagnosis may even be impossible, particularly when we consider that in typhoid fever infarctions and parotitis may occur. The diarrhoea and abdominal tenderness may also be present, which with the stupor and progressive DISEASES OF THE CIRCULATORY SYSTEM. asthenia make a picture not to be distinguished from this disease. Points which may guide us are : The more abrupt onset in endocarditis, the absence of any regularity of the pyrexia in the early stage of the disease, and the cardiac pain. Oppression and shortness of breath may be early symptoms in malignant endocarditis. Rigors, too, are not uncommon. Between pyaemia and malignant endocarditis there are practically no dif- ferential features, for the disease really constitutes an arterial pyaemia (Wilks). In the acute cases resembling malignant fevers, the diagnosis is usually made of typhus, typhoid, cerebro-spinal fever, or even of haemor- rhagic small-pox. The intermittent pyrexia, occurring for weeks or months, has led in some cases to the diagnosis of malaria, but this disease could now be positively excluded by the blood examination. The cases usually terminate fatally. The instances of recovery are those more subacute forms, the so-called recurring endocarditis develop- ing on old sclerotic valves in cases of chronic heart-disease. Treatment.—We know no measures by which in rheumatism, chorea, or the eruptive fevers the onset of endocarditis can be prevented. As it is probable that many cases develop, particularly in children, in mild forms of these diseases, it is well to guard the patients against taking cold and insist upon rest and quiet, and to bear in mind that of all complica- tions an acute endocarditis, though in its immediate effects harmless, is perhaps the most serious. This statement is enforced by the observations of Sibson that on a system of absolute rest the proportion of cases of rheumatism attacked by endocarditis was less than of those who were not so treated. It is doubtful whether the salicylates in rheumatism have an influence in reducing the liability to endocarditis. When the endocarditis is pres- ent we know no remedies which will definitely influence the valvular lesions. If there is much vascular excitement aconite may be given and an ice-bag placed over the heart. The salicylates are strongly advised by some writers and the sulpho- carbolates have been recommended by Sansom. In the severer cases of malignant endocarditis the treatment is practically that of septicsemia. Chronic Endocarditis. This condition, which is a sclerosis of the valve, may be primary, but is oftener secondary to acute endocarditis, particularly the rheumatic form. It is essentially a slow, insidious process which leads to deformity of the valve segment and is the foundation of chronic valvular disease. Certain poisons appear capable of initiating the change, such as alco- hol, syphilis, and gout, though we are at present ignorant of the way in which they act. A very important factor, particularly in the case of the aortic valves, is the strain of prolonged and heavy muscular exertion. In no other way can be explained the occurrence of so many cases of sclero- ENDOCARDITIS. 635 sis of the aortic valves in young and middle-aged men whose occupations necessitate the overuse of the muscles. Morbid Anatomy.—Vegetations in the form, in which they occur in acute endocarditis are not present. In the early stage, which we have frequent opportunities of seeing, the edge of the valve is a little thickened and perhaps presents a few small nodular prominences, which in some cases may represent the healed vegetations of the acute process. In the aortic valves the tissue about the corpora Arantii is first affected, producing a slight thickening with an increase in the size of the nodules. The substance of the valve may lose its translucency, and the only change noticeable is a grayish opacity and a slight loss of its delicate tenuity. In the auriculo-ventricular valves these early changes are seen just within the margin and here it is not uncommon to find swellings of a grayish- red, somewhat infiltrated appearance, almost identical with the similar structures on the intima of the aorta in arterio-sclerosis. Even early there may be seen yellow or opaque-white subintimal fatty areas. As the scle- rotic changes increase the fibrous tissue contracts and produces thickening and deformity of the segment, the edges of which become round, curled, and incapable of that delicate apposition necessary for perfect closure. A sigmoid valve, for instance, may be narrowed one fourth or even one third across its face, inducing the most extreme grade of insufficiency without any special deformity and without any definite narrowing of the arterial orifice. In the auriculo-ventricular segments a simple process of thicken- ing and curling of the edges of the valves, inducing a failure to close without forming any obstruction to the normal course of the blood-flow, is less common. Still, we meet with instances at the mitral orifice, par- ticularly in children, in which the edges of the valves are curled and thickened, producing extreme insufficiency without any material narrow- ing of the orifice. More frequently, as the disease advances, the chordae tendineae become thickened, first at the valvular ends and then along their course. The edges of the valves at their angles are gradually drawn together and there is a definite narrowing of the orifice, leading in the aorta to more or less stenosis and in the left auriculo-ventricular orifice— the two most frequently involved—to constriction. Finally, in the scle- rotic and necrotic tissues lime salts are deposited and may even reach the deeper structures of the fibrous rings, and the entire valve becomes a dense calcareous mass with scarcely a remnant of normal tissue. The chordse tendineae may gradually become shortened, greatly thickened, and in extreme cases the papillary muscles are implanted directly upon the sclerotic and deformed valve. The apices of the papillary muscles usually show marked fibroid change. In all stages of the process the vegetations of simple endocarditis may be found, and upon sclerotic valves we find the severer, ulcerative form of the disease. Chronic mural endocarditis produces cicatricial-like patches of a gray- DISEASES OF THE CIRCULATORY SYSTEM. ish-white appearance which are sometimes seen on the muscular trabecu- lae of the ventricle or in the auricles. It often occurs in association with myocarditis. The frequency with which chronic endocarditis is met with may be gathered from the following figures : In the statistics, amounting to from 12,000 to 14,000 autopsies, reported from Dresden, Wurzburg, and Prague the percentage ranged from four to nine. The relative frequency of in- volvement of the various valves is thus given in the collected statistics of Parrot: The mitral orifice was involved in 621, the aortic in 380, the tri- cuspid in 46, and the pulmonary in 11. This gives 57 instances in the right to 1,001 in the left heart. The endocarditis of the foetus is usually of the sclerotic form and in- volves the valves of the right more frequently than those of the left side. The effects of sclerotic endocarditis are practically those of chronic valvular disease, and the general influence on the work of the heart may be briefly stated as follows: The sclerosis induces insufficiency or ste- nosis, which may exist separately or in combination. The narrowing re- tards in a measure the normal outflow and the insufficiency permits the blood current to take an abnormal course. In both instances the effect is dilatation of a chamber. The result in the former case is an increase in the difficulty which the chamber has in expelling its contents through the narrow orifice; in the other, the overfilling of a chamber by blood flowing into it from an improper source, as, for instance, in mitral insuf- ficiency, when the left auricle receives blood both from the pulmonary veins and from the left ventricle. The cardiac mechanism is fully prepared to meet ordinary grades of dilatation which constantly occur during sudden exertion. A man, for instance, at the end of a hundred-yard race has his right chambers greatly dilated and his reserve cardiac power worked to its full capacity. The slow progress of the sclerotic changes brings about a gradual, not an abrupt, insufficiency, and the moderate dilatation which follows is at first overcome by the exercise of the ordinary reserve strength of the heart muscles. Gradually a new factor is introduced. The reserve power which is capable of meeting sudden emergencies in such a remarkable manner is unable to cope long with a permanent and perhaps increasing dilatation. More work has to be done and, in accordance with definite physiological laws, more power is given by increase of the muscles. The heart hyper- trophies and the effect of the valve lesion becomes, as we say, compen- sated. The equilibrium of the circulation is in this way maintained. CHRONIC VALVULAR DISEASE. 637 II. CHRONIC VALVULAR DISEASE. Aortic Incompetency. Incompetency of the aortic valves arises either from inability of the valve segments to close an abnormally large orifice or more commonly from disease of the segments themselves. This best-defined and most easily recognized of valvular lesions was first carefully studied by Corrigan, whose name it sometimes bears. Etiology and Morbid Anatomy.—It is more frequent in males than in females, affecting chiefly able-bodied, vigorous men at the middle period of life. The ratio which it bears to other valve diseases has been variously given from thirty to fifty per cent. Among the important factors in producing this condition are: (a) Congenital malformation, particularly fusion of two segments — most commonly those behind which the coronary arteries are given off. It is probable that an aortic orifice may be competent with this bicuspid state of the valves, but a great danger is the liability of these malformed segments to sclerotic endocarditis. Of seventeen cases which I have reported all presented sclerotic changes, and the majority of them had, during life, the clinical features of chronic heart-disease. (b) Acute endocarditis. This does not produce aortic incompetency unless the process passes on to ulceration and destruction, under which circumstances it is often found, and may cause a rapidly fatal issue. Sim- ple endocarditis associated with the specific fevers is not nearly so com- mon on the aortic as on the mitral segments; so also with rheumatism, ■which plays a less important role here than in mitral valve disease. (c) By far the most frequent cause of insufficiency is the slow, pro- gressive sclerosis of the segment, resulting in a curling of the edge, which lessens the working surface of the valve. This may, of course, fol- low acute endocarditis, but it is so often met with in strong, able-bodied men among the working classes, without any history of rheumatism or special febrile diseases with which endocarditis is commonly associated, that other conditions must be sought for to explain its frequency. Of these, unquestionably strain is the most important—not a sudden, forcible strain, but a persistent increase of the normal tension to which the segments are subject during the diastole of the ventricle. Of circum- stances increasing this tension, heavy and excessive use of the muscles is perhaps the most important. So often is this form of heart-disease found in persons devoted to athletics that it is sometimes called the “ athlete’s heart.” Alcohol is a second important factor, and is stated to raise con- siderably the tension in the aortic system. A combination of these two causes is extremely common. A third element in inducing chronic scle- rotic changes in these valves is syphilis. Cases are rarely seen in which other factors must not be taken into account, but the association is too 638 DISEASES OF THE CIRCULATORY SYSTEM. frequent to be accidental. That syphilis is capable of inducing arterial sclerosis is, I think, acknowledged, although the way in which it is done is not yet clear. It is interesting to note with what frequency this form of valve disease occurs in soldiers. I was struck with this fact in the Phila- delphia Hospital, to which so many veterans of the civil war are admitted. I was in the habit of enforcing upon my students the etiological lesson by a mythological reference to Bacchus and Vulcan, at whose shrines a ma- jority of the cases of aortic insufficiency have worshipped, and not a few at that of Venus. The condition of the valves is such as has already been described in chronic endocarditis. It may be noted, however, how slight a grade of curling may produce serious incompetency. Associated with the valve disease is, in a majority of the cases, a more or less advanced arterio-scle- rosis of the arch of the aorta, one serious effect of which may be a narrow- ing of the orifices of the coronary arteries. The sclerotic changes are often combined with atheroma, either in the fatty or calcareous stage. This may exist at the attached margin of the valves without inducing in- sufficiency. In other instances insufficiency may result from a calcified spike projecting from the aortic attachment into the body of the valve, and so preventing its proper closure. Some writers (Peter) have laid great stress upon the extension of the endarteritis to the valve, and would separate the instances of this kind from those of simple valvular endocar- ditis. I must say that I have not been able to recognize clinical differ- ences between these two conditions, though anatomically we may separate the cases into two groups—those with and those without arterio-sclerosis. (d) And, lastly, insufficiency may be induced by rupture of a segment —a very rare event in healthy valves, but not uncommon in disease, either from excessive strain during heavy lifting or from the ordinary endarterial strain in a valve eroded and weakened by ulcerative endo- carditis. Relative insufficiency of the sigmoid valves, due to dilatation of the aortic ring, is a rare condition. It is said to occur in extensive arterial sclerosis of the ascending portion of the arch with great dilatation just above the valves. I have myself never met with a pure instance of the kind, for in such cases I have always found the valve segments involved with the arterial coats. In aneurism just above the aortic ring, relative insufficiency of the valve may be present. It would appear from the careful measurements of Beneke that the aortic orifice, which at birth is 20 mm., increases gradually with the growth of the heart until at one and twenty it is about 60 mm. At this it remains until the age of forty, beyond which date there is a gradual increase in the size up to the age of eighty, when it may reach from 68 to 70 mm. There is thus at the very period of life in which sclerosis of the valve is most common a physiological tendency toward the production of a state of relative insufficiency. CHRONIC VALVULAR DISEASE. 639 The insufficiency may be combined with various grades of narrowing, but the majority of the cases of aortic insufficiency present no signs of stenosis. On the other hand, cases of aortic stenosis almost without exception are associated with some grade, however slight, of regurgitation. The direct effect of aortic insufficiency is the regurgitation of blood from the artery into the ventricle, causing an overdistention of the cavity and a reduction of the blood column; that is, a relative anaemia in the arterial tree. As an immediate effect of the double blood-flow into the left ventricle dilatation of the chamber occurs, and finally hypertrophy. In this way the valve defect is compensated and as with each ventricular systole a larger amount of blood is propelled into the arterial system, the regurgitation of a certain amount during diastole does not, for a time at least, seriously impair the nutrition of the peripheral parts. In this valve lesion dilatation and hypertrophy reach their most extreme limit. The heaviest hearts on record are described in connection with this affection. The so-called bovine heart, cor bovinum, may weigh 35 or 40 ounces, or even, as in a case of Dulles’s, 48 ounces. The dilatation is usually ex- treme, and is in marked contrast to the condition of the chamber in cases of pure aortic stenosis. The papillary muscles may be greatly flattened. The mitral valves are usually not seriously affected, though the edges may present slight sclerosis, and there is often relative incompetency, owing to distention of the mitral ring. Dilatation and hypertrophy of the left auricle are common, and secondary enlargement of the right heart occurs in all cases of long standing. The myocardium usually presents changes, fibroid or fatty; more commonly the former in association with disease of the coronary arteries. The arch of the aorta may present extensive arterio-sclerosis and dilatation. In rare instances, usually the rheumatic cases, the intima is perfectly smooth, and the arch with its main branches not dilated. This condition may be found post mortem even when during life there have been the most characteristic signs of enlargement of the arch and of dilatation of the innominate and right carotid. I have even known the condition of aneurism to be diagnosed when post mortem no trace of dilatation or sclerosis was found, only an extreme grade of insufficiency with enormous dilatation and hypertrophy. The coronary arteries are usually involved in the sclerosis, and their orifices may be much narrowed. Although these vessels have been shown by Martin and Sedgwick to be filled during the ventricular systole, the circulation in them must be embarrassed in aortic incompetency. They must miss the effect of the blood-pressure in the sinuses of Valsalva dur- ing the elastic recoil of the arteries, which surely aids in keeping the coronary vessels full. The arteries of the body usually present more or less sclerosis consequent upon the strain which they undergo during the forcible ventricular systole. Symptoms.—The condition is often discovered accidentally in per- sons who have not presented any features of cardiac disease. 640 DISEASES OF THE CIRCULATORY SYSTEM. Physical Signs.—Inspection shows a wide and forcible area of cardiac impulse with the apex beat in the sixth or seventh interspace, and per- haps as far out as the anterior axillary line. In young subjects the prsecordia may bulge. On palpation a thrill, diastolic in time, is occa- sionally felt, but is not common. The impulse is usually strong and heaving, unless in conditions of extreme dilatation, when it is wavy and indefinite. Percussion shows a greater increase in the area of heart dul- ness than is found in any other valvular lesion. It extends chiefly down- ward and to the left. On auscultation there is heard a murmur during diastole in the second right interspace, which is propagated with intensity toward the ensiform cartilage or down the left margin of the sternum toward the apex. In the majority of cases it is a soft, long-drawn bruit, and is of all cardiac murmurs the most reliable. It occurs during the time of, and is produced by, the reflux of blood from the aorta into the ventricle. In a large pro- portion of the cases there is also a systolic murmur heard at the aortic region, usually shorter, often rougher in quality, and which may be propa- gated upward into the neck. A common mistake is to regard this as indicating stenosis, whereas in the great majority of instances of aortic insufficiency there is no material narrowing, and the murmur is produced by roughening of the segments or of the intima of the arch. The second sound is usually obliterated, though in some instances both the murmur and the valvular sound may be distinctly heard. At the apex murmurs are also heard, either transmitted from the aortic orifice or produced at the mitral. In the majority of cases with aortic incompetency of high grade, the mitral orifice is dilated, and there is relative insufficiency of the valves. It can frequently be determined that the systolic murmur at the apex differs in quality from that at the base. A second murmur at the apex, probably produced at the mitral orifice, is not uncommon. Atten- tion was called to this by the late Austin Flint, and the murmur usually goes by his name. It has a distinctly rumbling quality, is limited in area, and is sometimes, though not always, exactly presystolic in time. The explanation of its occurrence, as given by Flint, is that in the extreme dilatation of the ventricle the mitral segments cannot during diastole be forced back against the wall, and therefore, remaining in the blood cur- rent, they produce a sort of relative narrowing, and in consequence a vibratory murmur not unlike in quality the presystolic murmur of mitral stenosis. This apex diastolic murmur of aortic insufficiency occurs in a considerable proportion of all cases. It is variable, and may disappear as the dilatation of the ventricle diminishes. There is never the loud sys- tolic shock which follows the murmur of mitral stenosis. The examination of the arteries in aortic insufficiency is of great value. Visible pulsation is more commonly seen in the peripheral vessels in this than in any other condition. The carotids may be seen to throb forcibly, the temporals to dilate, and the brachials and radials to expand with each CHRONIC VALVULAR DISEASE. 641 heart-beat. With the ophthalmoscope the retinal arteries are seen to pulsate. Not only is the pulsation evident, but the characteristic jerking quality is apparent. In the throat the throbbing carotids may lead to the diagnosis of aneurism. In many cases the pulsation can be seen in the suprasternal notch, and prominent, forcibly-throbbing vessels beneath the right sterno-mastoid muscle. The abdominal aorta may lift the epigastrium with each systole. To be mentioned with this is the capillary pulse, met very often in aortic insufficiency, and best seen in the finger-nails or by drawing a line upon the forehead, when the margin of hyperaemia on either side alternately blushes and pales. In extreme grades the face or the hand may blush visibly at each systole. It is met with also in profound anaemia, occasionally in neurasthenia, and in health in conditions of great relaxation of the peripheral arteries. Pulsation may also be present in the peripheral veins. On palpation the characteristic water-hammer or Corrigan pulse is felt. In the majority of instances the pulse wave strikes the finger forcibly with a quick jerking impulse, and immediately recedes or collapses. The characters of this are sometimes best appreciated by grasping the arm above the wrist and holding it up. On auscultation a double murmur may be heard in the carotids and subclavians when it is present at the aortic orifice. Occasionally in the carotid the second sound is distinctly audible when absent at the aortic cartilage. In the femoral artery a double murmur also may be heard sometimes, as pointed out by Duroziez. Aortic insufficiency may for years be fully compensated. Persons do not necessarily suffer any inconvenience, and the condition is often found accidentally. So long as the hypertrophy just equalizes the valvular defect there may be no symptoms and the individual may even take moderately heavy exercise without experiencing sensations of distress about the heart. The cases which last the longest are those in which the insufficiency follows endocarditis and is not a part of a general arterio- sclerosis. Coexistent lesions of the mitral valves tend early to disturb the compensation. It has scarcely been sufficiently recognized by the profes- sion at large that pure aortic insufficiency is consistent with years of aver- age health and with a tolerably active life. I know several physicians with aortic insufficiency who have been able to carry on for years large and somewhat onerous practices. One of them since the establishment of insuf- ficiency has passed successfully through two attacks of acute rheumatism. In large hospital practice, scarcely a month passes without the discovery of a case of aortic insufficiency in connection with some other affection. With the onset of myocardial changes, with increasing degeneration of the arteries, particularly with a progressive sclerosis of the arch and in- volvement of the orifices of the coronary arteries, the compensation be- comes disturbed. In advanced cases the changes about the aortic ring may be associated with alterations in the cardiac nerves and ganglia, and so introduce an important factor. 642 DISEASES OF THE CIRCULATORY SYSTEM. Headache, dizziness, flashes of light, and a feeling of faintness on ris- ing quickly are among the earliest symptoms. Palpitation and cardiac distress on slight exertion are common. Long before any signs of failing compensation pain may become a marked and troublesome feature. It is extremely variable in its manifestations. It may be of a dull, aching char- acter confined to the praecordia. More frequently, however, it is sharp and radiating, and is transmitted up the neck and down the arms, par- ticularly the left. Attacks of true angina pectoris are more frequent in this than in any other valvular disease. Anaemia is also common, much more so than in aortic stenosis or in mitral affections. More serious symptoms, as compensation fails, are shortness of breath and oedema of the feet. The attacks of dyspnoea are liable to come on at night and the patient has to sleep with the head high or even in a chair. Of respiratory symptoms cough may develop, due to the congestion of the lungs or oedema. Haemoptysis is less frequent than in mitral disease. I have reported a case in which it was profuse and believed to be due to tuberculosis of the lungs, inasmuch as the patient was admitted in a state of emaciation and profound exhaustion. General dropsy is not common, but oedema of the feet may occur early and is sometimes due to the ana3- mia, at others to the venous stasis, at times to both. Unless there is co- existing disease of the mitral valve, it is rare in pure aortic incompe- tency for the patient to die with general anasarca. Sudden death is fre- quent ; more so in this than in other valvular diseases. As compensation fails the patient takes to bed and slight irregular fever, associated usually with a recurring endocarditis, is not uncommon toward the close. Em- bolic symptoms are not infrequent—pain in the splenic region with en- largement of the organ, hsematuria, and in some cases paralysis. Dis- tressing dreams and disturbed sleep are more common in this than in other forms of valvular disease. Here may appropriately be mentioned the connection between mental symptoms and cardiac disease, as they are oftenest seen with this lesion. An admirable account of the relations between insanity and disease of the heart is to be found in Mickle’s Goulstonian lectures for 1888. In general medical practice we seldom find marked mental symptoms, except toward the close of the disease, when there may be delirium, hallucinations, and morbid impulses. It is to be remembered that in many heart cases this terminal delirium is urasmic. The irritability and peevishness some- times found in persons the subject of organic heart-disease cannot, I think, be associated with it in any special manner. We do meet insanity, break- ing out in patients with aortic and mitral disease, in the stage of compen- sation, which appears to be related definitely to the cardiac lesion. It is important to bear this in mind, for cases occasionally display suicidal tendencies. I have twice had patients throw themselves from a window of the ward. CHRONIC VALVULAR DISEASE. 643 Narrowing or stricture of the aortic orifice is not nearly so common as insufficiency. The two conditions, as already stated, may occur together, however, and probably in almost every case of stenosis there is some leakage. Etiology and Morbid Anatomy.—In the milder grades there is adhesion between the segments, which are so stiffened that during systole they cannot be pressed back against the aortic wall. The process of co- hesion between the segments may go on without great thickening, and produce a condition in which the orifice is guarded by a comparatively thin membrane, on the aortic face of which may be seen the primitive raphes separating the sinuses of Valsalva. In some instances this mem- brane is so thin and presents so few traces of atheromatous or sclerotic changes that the condition looks as if it had originated during foetal life. More commonly the valve segments are thickened and rigid, and have a cartilaginous hardness. In advanced cases they may be represented by stiff, calcified masses obstructing the orifice, through which a circular or slit-like passage can be seen. The older the patient the more likely it is that the valves will be rigid and calcified. We may speak of a relative stenosis of the aortic orifice when with normal valves and ring the aorta immediately beyond is greatly dilated. A stenosis due to involvement of the aortic ring in sclerotic and calcareous changes without lesion of the valves is referred to by some authors. I have never met with an instance of this kind. A subvalvular stenosis, the result of endocarditis in the mitro-sigmoidean sinus, usually occurs as the re- sult of a foetal endocarditis. In comparison with aortic insufficiency, ste- nosis is a rare disease. It is usually met with at a more advanced period of life than insufficiency, and the most typical cases of it are found asso- ciated with extensive calcareous changes in the arterial system in old men. When gradually produced and when there is not much insufficiency the dilatation of the left ventricle may be slight, though I think that in all cases it does occur. The walls of the ventricle become hypertro- phied, and we see in this condition the most typical instances of what is called concentric hypertrophy, in which, without much, if any, enlarge- ment of the cavity, the walls are greatly thickened, in contradistinction to the so-called eccentric hypertrophy, in which the chamber is greatly dilated as well as hypertrophied. There may be no changes in the other cardiac cavities if compensation is well maintained; but with its failure come dilatation, impeded auricular discharge, pulmonary congestion, and increased work for the right heart. The arterial changes are, as a rule, not so marked as in aortic insufficiency, for the walls have not to with- stand the impulse of a greatly increased blood-wave with each systole. On the contrary, the amount of blood propelled through the narrow orifice may be smaller than normal, though when compensation is fully estab- lished the pulse-wave may be of medium volume. Aortic Stenosis. 644 DISEASES OF THE CIRCULATORY SYSTEM. Symptoms. Physical Signs.—Inspection may fail to reveal any area of cardiac impulse. Particularly is this the case in old men with rigid chest walls and large emphysematous lungs. Under these circum- stances there may be a high grade of hypertrophy without any visible im- pulse. Even when the apex beat is visible it may be, as Traube pointed out, feeble and indefinite. In many cases the apex is seen displaced down- ward and outward, and the impulse looks strong and forcible. Palpation reveals in many cases a thrill at the base of the heart of maximum force in the aortic region. With no other condition do we meet with thrills of greater intensity. The apex beat may not be palpable under the conditions above mentioned, or there may be a slow, heaving, forcible impulse. Percussion never gives the same wide area of dulness as in aortic in- sufficiency. The extent of it depends largely on the state of the lungs, whether emphysematous or not. Auscultation.—A systolic murmur of maximum intensity at the aortic cartilage, and propagated into the great vessels, is present in aortic ste- nosis, but is by no means pathognomonic. One of the last lessons learned by the student of physical diagnosis is to recognize the fact that this sys- tolic murmur is only in comparatively rare cases produced by decided narrowing of the aortic orifice. Roughening of the valves, or the intima of the aorta, and haemic states are much more frequent causes. In aortic stenosis the murmur often has a much harsher quality, is louder, and is more frequently musical than in the conditions just mentioned. When compensation fails and the ventricle is dilated and feeble the murmur may be soft and distant. The second sound is rarely heard at the aortic cartilage, owing to the thickening and stiffness of the valve. A diastolic murmur is not uncommon, but in many cases it cannot be heard. The pulse in pure aortic stenosis is small, usually of good tension, regular, and perhaps slower than normal. The condition may be latent for an indefinite period, as long as the hypertrophy is maintained. Early symptoms are those due to defective blood-supply to the brain, dizziness, and fainting. Palpitation, pain about the heart, and anginal symptoms are not so marked as in insuffi- ciency. With degeneration of the heart-muscle and dilatation relative insufficiency of the mitral valve is established, and the patient may present all the features of engorgement in the lesser and systemic circulations, with dyspnoea, cough, rusty expectoration, and the signs of anasarca in the lower part of the body. Many of the cases in old people, without present- ing any dropsy, have symptoms pointing rather to general arterial disease. Cheyne-Stokes breathing is not uncommon with or without signs of uraemia. Diagnosis.—With an intensely rough or musical murmur of maximum intensity at the aortic region and signs of hypertrophy of the left ventricle, a thrill, and a hard, slow pulse of moderate volume and fairly good tension, CHRONIC VALVULAR DISEASE. 645 a diagnosis of aortic stenosis can be made with some degree of probability, particularly if the subject is an old man. Mistakes are common, how- ever, and a roughened or calcified valve segment, or, in some instances, a very roughened and prominent calcified plate in the aorta, and hypertrophy associated with renal disease, may produce similar symp- toms. Let me repeat that a murmur of maximum intensity at the aortic cartilage is of no importance in itself as a diagnostic sign of stenosis. Koughening of the valve, sclerosis of the intima of the arch, and anaemia are conditions more frequently associated with a systolic murmur in this region. Seldom is there difficulty in distinguishing the murmur due to anaemia, since it is rarely so intense and is not associated with thrill or with marked hypertrophy of the left ventricle. In aortic insufficiency a systolic murmur is usually present, but has neither the intensity nor the musical quality, nor is it accompanied with a thrill. With roughening and dilatation of the ascending aorta the murmur may be very harsh or musical; but the existence of a second sound, accentuated and ringing in quality, is usually sufficient to differentiate this condition. Mitral IisrcoMPETEisrcY. Etiology. — Insufficiency of the mitral valve results from: (a) Changes in the segments whereby they are contracted and shortened, usually combined with changes in the chordae tendineae, or with more or less narrowing of the orifice. (£) As a result of changes in the muscular walls of the ventricle, either dilatation, so that the valve segments fail to close an enlarged orifice, or changes in the muscular substance, so that the segments are imperfectly coapted during the systole—muscular in- competency. The common lesions producing insufficiency result from endocarditis, which causes a gradual thickening at the edges of the valves, contraction of the chordae tendineae, and union of the edges of the seg- ments, so that in a majority of the instances there is not only insuffi- ciency, but some grade of narrowing as well. Except in children, we rarely see the mitral leaflets curled and puckered without narrowing of the orifice. Calcareous plates at the base of the valve may prevent per- fect closure of one of the segments. In long-standing cases the entire mitral structures are converted into a firm calcareous ring. From this valvular insufficiency the other condition of muscular incompetency must be carefully distinguished. It is met with in all conditions of extreme dilatation of the left ventricle, and also in weakening of the muscles in prolonged fevers and in anaemia. Morbid Anatomy.—The effects of incompetency of the mitral segment upon the heart and circulation are as follows : (a) The imperfect closure allows a certain amount of blood to regurgitate from the ventricle into the auricle, so that at the end of auricular diastole this chamber con- 646 DISEASES OF THE CIRCULATORY SYSTEM. tains not only the blood which it has received from the lungs, but also that which has regurgitated from the left ventricle. This necessitates dilatation, and, as increased work is thrown upon it in expelling the aug- mented contents, hypertrophy as well. (b) With each systole of the left auricle a larger volume of blood is forced into the left ventricle, which also dilates and subsequently becomes hypertrophied. (c) During the diastole of the left auricle, as blood is regurgitated into it from the left ventricle, the pulmonary veins are less readily emptied. In consequence the right ventricle expels its contents less freely, and in turn becomes dilated and hypertrophied. (d) Finally, the right auricle also is involved, its chamber is enlarged, and its walls are increased in thickness. (e) The effect upon the pulmonary vessels is to produce dilatation both of the arteries and veins—often in long-standing cases atheromatous changes; the capillaries are distended, and ultimately the condition of brown induration is produced. Perfect compensation may be effected, chiefly through the hypertrophy qf both ventricles, and the effect upon the peripheral circulation may not be manifested for years, as a normal volume of blood is discharged from the left heart at each systole. The time comes, however, when, owing either to increase in the grade of the incompetency or to failure of the compensation, the left ventricle is unable to send out its normal volume into the aorta. Then there is over- filling of the left auricle, engorgement in the lesser circulation, embarrassed action of the right heart, and congestion in the systemic veins. For years this somewhat congested condition may be limited to the lesser circulation, but finally the right auricle becomes dilated, the tricuspid valves incom- petent, and the systemic veins are engorged. This gradually leads to the condition of cyanotic induration in the viscera and, when extreme, to dropsical effusion. Muscular incompetency, due to impaired nutrition of the mitral and papillary muscles, is rarely followed by such perfect compensation. There may be in acute destruction of the aortic segments an acute dilatation of the left ventricle with relative incompetency of the mitral segments, great dilatation of the left auricle, and intense engorgement of the lungs, under which circumstances profuse haemorrhage may result. In these cases there is little chance for the establishment of compensation. In cases of hypertrophy and dilatation of the heart, without valvular lesions, but associated with heavy work and alcohol, the insufficiency of the mitral valve may be extreme and lead to great pulmonary congestion, engorge- ment of the systemic veins, and a condition of cardiac dropsy, which cannot be distinguished by any feature from that of mitral incompetency due to lesion of the valve itself. In chronic Bright’s disease the hyper- trophy of the left ventricle may gradually fail, leading, in the later stages, to relative insufficiency of the mitral valve, and the production of a con- CHRONIC VALVULAR DISEASE. 647 dition of pulmonary and systemic congestion, similar to that induced by the most extreme grade of lesion of the valve itself. Symptoms.—During the development of the lesion, unless the in- competency comes on acutely in consequence of rupture of the valve segment or of ulceration, the compensatory changes go hand in hand with the defect, and there are no subjective symptoms. So, also, in the stage of perfect compensation, there may be the most extreme grade of mitral insufficiency with enormous hypertrophy of the heart, yet the patient may not be aware of the existence of heart trouble, and may suffer no inconvenience except perhaps a little shortness of breath on exertion or on going up-stairs. It is only when from any cause the com- pensation has not been perfectly effected, or having been so is broken abruptly or gradually, that the patients begin to be troubled. The symp- toms may be divided into two groups: (a) The minor manifestations while compensation is still good. Pa- tients with extreme incompetency often have a congested appearance of the face, the lips and ears have a bluish tint, and the venules on the cheeks may be enlarged, which in many cases is very suggestive. In long-standing cases, particularly in children, the fingers may be clubbed, and there is shortness of breath on exertion. This is one of the most constant features in mitral insufficiency, and may exist for years, even when the compensation is perfect. Owing to the somewhat congested condition of the lungs these patients have a tendency to attacks of bronchitis or haemoptysis. There may also be palpitation of the heart. As a rule, however, in well-balanced lesions in adults, this period of full compensation or latent stage is not associated with symp- toms which call the attention to an affection of the heart. (b) Sooner or later comes a period of disturbed or broken compensa- tion, in which the most intense symptoms are those of venous engorgement. There are palpitation, weak, irregular action of the heart, and signs of dilatation. Dyspnoea is an especial feature, and there may be cough. A distressing symptom is the cardiac “ sleep-start,” in which, just as the pa- tient falls asleep, he wakes gasping and feeling as if the heart was stop- ping. There is usually a slight cyanosis, and even a jaundiced tint to the skin. The most marked symptoms, however, are those of venous stasis. The overfilling of the pulmonary vessels accounts in part for the dysp- noea. There is cough, often with bloody or watery expectoration, and the alveolar epithelium containing brown pigment-grains is abundant. Drop- sical effusion usually sets in, beginning in the feet and extending to the body and the serous sacs. The liver is enlarged, and there are signs of portal congestion, gastric irritation, and catarrh of the stomach and in- testines. The urine is usually scanty and albuminous, and contains tube- casts and sometimes blood-corpuscles. With judicious treatment the com- pensation may be restored and all the serious symptoms may pass away. Patients usually have recurring attacks of this kind, and die of a genera] 648 DISEASES OF THE CIRCULATORY SYSTEM. dropsy or there is progressive dilatation of the heart, and death from asystole. Sudden death in these cases is rare. Physical Signs.—Inspection.—In children the prascordia may bulge and there may be a large area of visible pulsation. The apex beat is to the left of the nipple, in some cases in the sixth interspace, in the anterior axillary line. There may be a wavy impulse in the cervical veins which are often full, particularly when the patient is recumbent. Palpation.—A thrill is rare; when present it is felt at the apex, often in a limited area. The force of the impulse may depend largely upon the stage in which the case is examined. In full compensation it is forcible and heaving; when the compensation is disturbed, usually wavy and feeble. Percussion.—The dulness is increased, particularly in a lateral direc- tion. There is no disease of the valves which produces, in long-standing cases, a more extensive transverse area of heart dulness. It does not ex- tend so much upward along the left margin of the sternum as beyond the right margin and to the left of the nipple line. Auscultation.—At the apex there is a systolic murmur which wholly or partly obliterates the first sound. It is loudest here, and has a blow- ing, sometimes musical character, particularly toward the latter part. The murmur is transmitted to the axilla and may be heard at the back, in some instances over the entire chest. There are cases in which, as pointed out by Naunyn, the murmur is heard best along the left border of the sternum. Usually in diastole at the apex the loudly transmitted second sound may be heard. Occasionally there is also a soft, sometimes a, rough or rumbling presystolic murmur. As a rule, in cases of extreme mitral insufficiency from valvular lesion with great hypertrophy of both ventricles, there is heard only a loud blowing murmur during systole. A murmur of mitral insufficiency may vary a great deal according to the position of the patient. It may be present in the recumbent and ab- sent in the erect posture. In cases of dilatation, particularly when dropsy is present, there may be heard at the ensiform cartilage and in the lower sternal region a soft systolic murmur due to tricuspid regurgitation. An important sign on auscultation is the accentuated pulmonary second sound. This is heard to the left of the sternum in the second interspace, or over the third left costal cartilage. The pulse in mitral insufficiency, during the period of full compensa- tion, may be full and regular, often of low tension. Usually with the first onset of the symptoms the pulse becomes irregular, a feature which then dominates the case throughout. There may be no two beats of equal force or volume. Often after the disappearance of the symptoms of fail- ure of compensation the irregularity of the pulse persists. The three important physical signs then of mitral regurgitation are: (a) systolic murmur of maximum intensity at the apex, which is propa- gated to the axilla and heard at the angle of the scapula; (b) accentuation CHRONIC VALVULAR DISEASE. 649 of the pulmonary second sound ; (c) evidence of enlargement of the heart, particularly the increase in the transverse diameter, due to hypertrophy of both right and left ventricles. Diagnosis.—There is rarely any difficulty in the diagnosis of mitral insufficiency. The physical signs just referred to are quite characteristic and distinctive. Two points are to be borne in mind. First, a murmur, systolic in character, and of maximum intensity at the apex, and propa- gated even to the axilla, does not necessarily indicate incompetency of the mitral valve. There is heard in this region a large group of what are termed accidental murmurs, the precise nature of which is still doubtful. They are probably formed, however, in the ventricle, and are not associated with hypertrophy, or accentuation of pulmonary second sound. Second, it is not always possible to say whether the insufficiency is due to lesion of the valve segment or to dilatation of the mitral ring and relative incompetency. Here neither the character of the murmur, the propagation, the accentuation of the pulmonary second sound, nor the hypertrophy assists in the differentiation. The history is sometimes of greater value in this matter than the physical examination. The cases most likely to lead to error are those of the so-called idiopathic dilatation and hypertrophy of the heart (in which the systolic murmur may be of the greatest intensity), and the instances of arterio-sclerosis with dilated heart. Mitral Stenosis. Etiology.—Narrowing of the mitral orifice is usually the result of valvular endocarditis occurring in the earlier years of life; very rarely it is congenital. It is very much more common in women than in men—in 63 of 80 cases noted by Duckworth. This is not easy to explain, but there are at least two factors to be considered. Rheumatism prevails more in girls than in boys and, as is well known, endocarditis of the mitral valve is more common in rheumatism. Chorea, also, as suggested by Barlow, has an important influence, occurring more frequently in girls and often associated with endocarditis. Of 140 cases of chorea which I examined at a period more than two years subsequent to the attack, 72 cases had signs of organic heart-disease, among which were 24 instances with the physical signs of mitral stenosis. Anaemia and chlorosis, which are prevalent in girls, have been regarded as possible factors. In a number of cases, how- ever, no recognizable etiological factor can be discovered. This has been regarded by some writers as favoring the view that many of the cases are of congenital origin; but it is not improbable that with any of the febrile affections of childhood endocarditis may be associated. Whooping-cough, too, with its terrible strain on the heart-valves, may be accountable for certain cases. Congenital affections of the mitral valve are notoriously rare. While met with at all ages, stenosis is certainly more frequent in young persons. 650 DISEASES OF THE CIRCULATORY SYSTEM. Morbid Anatomy.—In a majority of instances with the stenosis there is some incompetency. The narrowing results from thickening and contraction of the tissues of the ring, of the valve segments, and of the chordae tendineae. The condition varies a good deal according to the amount of atheromatous change. In many cases the curtains are so welded together and the whole valvular region so thickened that the orifice is reduced to a mere chink—Corrigan’s button-hole contraction. In other cases the curtains are not much thickened, but narrowing has resulted from gradual adhesion at the edges, and thickening of the chordae tendineae, so that from the auricle it looks cone-like—the so-called funnel- shaped variety of stenosis. The instances in which the valve segments are very slightly deformed but in which the orifice is considerably nar- rowed, are regarded by some as possibly of congenital origin. Occa- sionally the curtains are in great part free from disease, but the nar- rowing results from large calcareous masses, which project into them from the ring. The involvement of the chordae tendineae is usually ex- treme, and the papillary muscles may be inserted directly upon the valve. In moderate grades of constriction the orifice will admit the tip of the index-finger; in more extreme forms, the tip of the little finger; and occasionally one meets with a specimen in which the orifice seems almost obliterated, as in a case which came under my notice, which only admitted a medium-sized Bowman’s probe. The heart in mitral stenosis is not greatly enlarged, rarely weighing more than 14 or 15 ounces. Occasionally, in an elderly person, it may seem slightly if at all enlarged, and again there are instances in which the weight may reach as much as 20 ounces. The left ventricle is usually small, and may look very small in comparison with the right ventricle, which forms the greater portion of the apex. In cases in which with the narrowing there is very considerable incompetency the left ventricle may be moderately dilated and hypertrophied. These changes gradually induced are associated with secondary altera- tions of great importance in the heart. The left auricle discharges its blood with greater difficulty and in consequence dilates, and its Avails reach three or four times their normal thickness. Although the auricle is by structure unfitted to compensate an extreme lesion, the probability is that for some time during the gradual production of stenosis, the increas- ing muscular power of the walls is sufficient to counterbalance the defect. Eventually the tension is increased in the pulmonary circulation, oAving to impeded outfloAV from the veins. To overcome this the right Arentricle undergoes dilatation and hypertrophy, and upon this chamber falls the Avork of equalizing the circulation. Relative incompetency of the tricuspid and congestion of systemic veins at last supervene. It is not uncommon at the examination to find Avliite thrombi in the appendix of the left auricle. Occasionally a large part of the auricle is occupied by an ante-mortem thrombus. Still more rarely the remarkable CHRONIC VALVULAR DISEASE. 651 ball thrombus is found, in which a globular concretion, varying in size from a walnut to a small egg, lies free in the auricle, two examples of which have come under my observation. Symptoms.—Physical Signs.—Inspection.—In children the lower sternum and the fifth and sixth left costal cartilages are often prominent, owing to hypertrophy of the right ventricle. The apex beat may be ill- defined. Usually, it is not dislocated far beyond the nipple line, and the chief impulse is over the lower sternum and adjacent costal cartilages. Often in thin-chested persons there is pulsation in the third and fourth left interspaces close to the sternum. When compensation fails, the prae- cordial impulse is much feebler, and in the veins of the neck there may be marked systolic regurgitation. Palpation reveals in a majority of the cases a characteristic, well- defined fremitus or thrill, which is best felt, as a rule, in the fourth or fifth interspace within the nipple line. It is of a rough, grating quality, often peculiarly limited in area, most marked during expiration, and can be felt to terminate in a sharp, sudden shock, synchronous with the im- pulse. This most characteristic of physical signs is pathognomonic of narrowing of the mitral orifice, and is perhaps the only instance in which the diagnosis of a valvular lesion can be made by palpation alone. The cardiac impulse is felt most forcibly in the lower sternum and in the fourth and fifth left interspaces. The impulse is felt very high in the third -and fourth interspaces, or in rare cases even in the second, and it has been thought that in the latter interspace the impulse is due to pulsa- tion of the auricle. It is always the impulse of the right ventricle; even in the most extreme grades of mitral stenosis, there is never such tilting forward of the auricle or its appendix as would enable it to produce an impression on the chest wall. Percussion gives an increase in the cardiac dulness to the right of the sternum and along the left margin; not usually a great increase beyond the nipple line, except in extreme cases, when the transverse dulness may reach from 5 cm. beyond the right margin of the sternum to 10 cm. beyond the nipple line. Auscultation.—In the mitral area, usually to the inner side of the apex beat and often in a very limited region, is heard a rough, vibratory or purring murmur, which terminates abruptly in the first sound. By combining palpation and auscultation the purring murmur is found to be synchronous with the thrill and the loud shock with the first sound. This is the presystolic murmur, about the time and mode of production of which so much discussion has occurred. I hold with those who regard it as oc- curring during the auricular systole. In whatever way produced, it re- mains one of the most distinctive and characteristic of murmurs and its presence is positively indicative of narrowing of the mitral orifice. The sole exception to this statement is the Flint murmur already referred to in aortic incompetency. Once, in a case of enormous enlargement of the 652 DISEASES OF THE CIRCULATORY SYSTEM. spleen, with dropsy, in which the heart was greatly pushed up, I heard a presystolic murmur of rough quality, and the mitral valves were found post mortem to be normal. The presystolic murmur may occupy the entire period of the diastole, or the middle or only the latter half, cor- responding to the auricular systole. The difference may sometimes be noted between the first and second portions of the murmur, when it occu- pies the entire time. Often there is a peculiar rumbling or echoing qual- ity, which in some instances is very limited and may be heard only over a single bell-space of the stethoscope. A systolic murmur may be heard at the apex or along the left sternal border, often of extreme softness and audible only when the breath is held. Sometimes the systolic murmur is loud and distinct and is transmitted to the axilla. The second sound in the second left interspace is loudly accentuated, sometimes reduplicated. It may be transmitted far to the left and be heard with great clearness beyond the apex. In uncomplicated cases of mitral stenosis there are usually no murmurs audible at the aortic region, at which spot the second sound is less intense than at the pulmonary area. In the lower sternum and to the right a tricuspid murmur is sometimes heard in advanced cases. Other points to be noted are the following: The unusually sharp, clear first sound which follows the presystolic murmur, the cause of which is by no means easy to explain. It can scarcely be a valvular sound pro- duced chiefly at the mitral orifice, since it may be heard with great inten- sity in cases in which the valves are rigid and calcified. It has been sug- gested by W. S. Fenwick and Overend that it is a loud “ snap ” of the tricuspid valves caused by the powerful contraction of the greatly hyper- trophied right ventricle. These physical signs, it is to be borne in mind, are characteristic only of the stage in which compensation is maintained. Finally there comes a period in which, with rupture of compensation, the presystolic murmur disappears and there is heard in the apex region a sharp first sound, or sometimes a gallop rhythm. The marked systolic shock may be present after the disappearance of the thrill and the characteristic murmur. Un- der treatment, with gradual recovery of compensation, probably with in- creasing vigor of contraction of the right ventricle and left auricle, the presystolic murmur reappears. In cases seen at this stage of the disease the nature of the valve lesion may be entirely overlooked. Stenosis of the mitral valve may for years be efficiently compensated by the hypertrophy of the right ventricle. Many persons with the char- acteristic physical signs of this lesion present no symptoms. They may for years perhaps be short of breath on going up-stairs, but are able to pass through the ordinary duties of life without discomfort. The pulse is smaller in volume than normal, but may be perfectly regular. A special danger of this stage is the recurring endocarditis. Vegetations may be whipped off into the circulation and, blocking a cerebral vessel, may cause hemiplegia or aphasia, or both. This, unfortunately, is not an uncommon CHRONIC VALVULAR DISEASE. 653 sequence in women. Patients with mitral stenosis may survive this acci- dent for an indefinite period. A woman, above seventy years of age, died in one of my wards at the Philadelphia Hospital, who had been in the almshouse, hemiplegic, for more than thirty years. The heart presented an extreme grade of mitral stenosis which had probably existed at the time of the hemiplegic attack. Failure of compensation brings in its train the group of symptoms which have been discussed under mitral insufficiency. Briefly enumerated they are: Rapid and irregular action of the heart, shortness of breath, cough, signs of pulmonary engorgement, and very frequently haemoptysis. Attacks of this kind may recur for years. Bronchitis or a febrile attack may cause shortness of breath or slight blueness. Inflammatory affections of the lungs or pleura seriously disturb the right heart, and these patients stand pneumonia very badly. Many, perhaps a majority of cases of mitral stenosis, do not have dropsy. The liver may be greatly enlarged, and in the late stages ascites is not uncommon, particularly in children. Gen- eral anasarca is most frequently met with in those cases in which there is secondary narrowing of the tricuspid orifice (Broadbent). Tricuspid-Valve Disease. {a) Tricuspid Regurgitation.—Occasionally this results from acute or chronic endocarditis with puckering; more commonly the condition is one of relative insufficiency, and is secondary to lesions of the valves on the left side, particularly of the mitral. It is met wuth also in all condi- tions of the lungs which cause obstruction to the circulation, such as cir- rhosis and emphysema, particularly in combination with chronic bron- chitis. The symptoms are those of obstruction in the lesser circulation with venous congestion in the systemic veins, such as has already been described in connection with mitral insufficiency. The signs of this con- dition are: (1) Systolic regurgitation of the blood into the right auricle and the transmission of the pulse-wave into the veins of the neck. If the regurgi- tation is slight or the contraction of the ventricle is feeble there may be no venous pulsation, but in other cases there is marked systolic pulsation in the cervical veins. That in the right jugular is more forcible than that in the left. It may be seen both in the internal and the external, particularly in the latter. Marked pulsation in these veins occurs only when the valves guarding them become incompetent. Slight oscillations are by no means uncommon, even when the valves are intact. The dis- tention of the veins is sometimes enormous, particularly in the act of coughing, when the right jugular at the root of the neck may stand out, forming an extraordinarily prominent ovoid mass. Occasionally the re- gurgitant pulse-wave may he widely transmitted and be seen in the sub- clavian and axillary veins, and even in the subcutaneous veins over the 654 DISEASES OF THE CIRCULATORY SYSTEM. shoulder, or, as in a case recently under observation, in the superficial mammary veins. Regurgitant pulsation through the tricuspid orifice may he transmitted to the inferior cava, and so to the hepatic veins, causing a systolic disten- tion of the liver. This is best appreciated by bimanual palpation, placing one hand over the fifth and sixth costal cartilages and the other in the lateral region of the liver in the mid-axillary line. The rhythmical ex- pansile pulsation may be readily distinguished, as a rule, from the systolic depression of the liver due to communicated pulsation from the left ven- tricle. (2) The second important symptom of tricuspid regurgitation is the occurrence of a systolic murmur of maximum intensity in the lower ster- num. It is usually a soft, low murmur, often to be distinguished from a coexisting mitral murmur by differences in quality and pitch, and may be heard to the right as far as the axilla. Sometimes it is very limited in its distribution. Together these two signs positively indicate tricuspid regurgitation. In addition, the percussion usually shows increase in the area of dulness to the right of the sternum, and the impulse in the lower sternal region is forcible. In the great majority of cases the symptoms are those of the associated lesions. In cirrhosis of the lung and in chronic emphysema the failure of compensation of the right ventricle with insufficiency of the tri- cuspid not infrequently leads either to acute asystole or to gradual failure with cardiac dropsy. (Z>) Tricuspid Stenosis.—This interesting condition may be either con- genital or acquired. The congenital cases are not uncommon, and are associated usually with other valvular defects which cause early death. The acquired form is not very infrequent. Bedford Fenwick collected 46 observations, of which 41 were in women. Leudet* has analyzed 117 cases. Of 101 of these in which the ages were mentioned, 80 were in women and 21 in men. A great majority of the cases were in adults, only eight being between the ages of ten and twenty. Its rarity as an isolated condition may be gathered from the fact that of 114 autopsies, in 11 only was the lesion confined to this valve. In 21 the tricuspid, mitral, and aortic segments were involved, and in 78 the tricuspid and mitral. Prac- tically the condition is almost always secondary to lesions of the left heart. The physical signs are sometimes characteristic. For instance, a pre- systolic thrill has been noted by several observers. The percussion shows dulness to be increased, particularly to the right of the sternum. On aus- cultation a presystolic murmur has been determined in certain cases, and is heard best at the root of the ensifonn cartilage, or a little to the right of it. Of general symptoms, cyanosis of the face and lips is very common, and in the late stages, when dropsy supervenes, it is apt to be intense. * Paris Thesis, 1888. CHRONIC VALVULAR DISEASE. 655 The lesion is interesting chiefly because it forms one of the most serious complications of mitral stenosis. Pulmonary Valve Disease. This is extremely rare. (a) Stenosis is almost invariably a congenital anomaly. It constitutes one of the most important of the congenital cardiac affections. The valve segments are usually united, leaving a small, narrow orifice. In the adult cases occasionally occur. In Case 608 of my post-mortem records there was extreme stenosis in a girl of eighteen, owing to great thickening and adhesion of the segments, and there were also numerous vegetations. The orifice was only two millimetres in diameter. The congenital lesion is commonly associated with patency of the ductus Botalii and imperfection of the ventricular septum. There may also be tricuspid stenosis. The physical signs are extremely uncertain. There may be a systolic murmur with a thrill heard best to the left of the sternum in the second intercostal space. This murmur may be very like a murmur of aortic stenosis, hut is not transmitted into the vessels. Naturally the pulmonary second sound is weak or obliterated, or may be replaced by a diastolic mur- mur. Usually there is hypertrophy of the right heart. (b) Pulmonary Insufficiency.—This rare affection is occasionally due to congenital malformation, particularly fusion of two of the segments. It is sometimes present, as Bramwell has shown, in cases of malignant endocarditis. Barie has collected fifty-eight cases. The physical signs are those of regurgitation into the right ventricle, but, as a rule, it is difficult to differentiate the murmur from that of aortic insufficiency, though the maximum intensity may be in the pulmonary area. The absence of the vascular features of aortic insufficiency is sug- gestive. Both Gibson and Graham Steell have called attention to the possibility of leakage through these valves in cases of great increase of pressure in the pulmonary artery, and to a soft diastolic murmur heard under these circumstances, which Steell calls “ the murmur of high pres- sure in the pulmonary artery.” Combined Valvular Lesions. These are extremely common. The mitral and aortic segments may be affected together; next in frequency comes the combination of mitral and tricuspid lesions; and then of aortic, mitral, and tricuspid. Aortic insufficiency or aortic stenosis is more frequently combined with mitral incompetency than aortic stenosis with mitral stenosis, or mitral stenosis with aortic insufficiency. In children the most common combination is aortic and mitral insufficiency. In adults, mitral insufficiency with thick- ening of the aortic valves and slight narrowing is perhaps the most common. 656 DISEASES OF THE CIRCULATORY SYSTEM. The diagnosis rests upon the character of the murmurs and the state of the chambers as regards hypertrophy and dilatation. Prognosis in Valvular Disease.—The question is entirely one of efficient compensation. So long as this is maintained the patient may suffer no inconvenience, and even with the most serious forms of valve lesion the function of the heart may be little, if at all, disturbed. Practitioners who are not adepts in auscultation and feel unable to estimate the value of the various heart murmurs should remember that the best judgment of the conditions may be gathered from inspection and palpation. With an apex beat in the normal situation and regular in rhythm the auscultatory phenomena may be practically disregarded. As Sir Andrew Clark states, a murmur per se is of little or no moment in determining the prognosis in any given case. There is a large group of patients who present no other symptoms than a systolic murmur heard over the body of the heart, or over the apex, in whom the left ventricle is not hypertrophied, the heart rhythm is normal, and who may not have had rheumatism. Indeed, the condition is accidentally discovered, often during examination for life insurance. I know cases of this kind which have persisted unchanged for more than fifteen years Among the condi- tions influencing prognosis are: (a) Age.—Children under ten are had subjects. Compensation is well effected, and they are free from many of the influences which disturb compensation in adults. The coronary arteries also are healthy, and nutrition of the heart-muscle can be readily maintained. Yet, in spite of this, the outlook in cardiac lesions developing in very young children is usually bad. One reason is that the valve lesion itself is apt to be rapidly progressive, and the limit of cardiac reserve force is in such cases early reached. There seems to he proportionately a greater degree of hypertrophy and dilatation. Among other causes of the risks of this period are to be mentioned insufficient food in the poorer classes, the recurrence of rheumatic attacks, and the existence of pericardial adhesions The outlook in a child who can be carefully supervised and prevented from damaging himself by overexertion is naturally better than in one who is constantly overtasking his muscles. The valvular lesions which develop at, or subsequent to, the period of puberty are more likely to he permanently and efficiently compensated. Sudden death from heart- disease is very rare in children. (b) Sex.—Women bear valve lesions, as a rule, better than men, owing partly to the fact that they live quieter lives, partly to the less common involvement of the coronary arteries, and to the greater frequency of mit- ral lesions. Pregnancy and parturition are disturbing factors, but are, I think, less serious than some writers would have us believe. (c) Valve affected.—The relative prognosis of the different valve lesions is very difficult to estimate. Each case must, therefore, be judged on its own merits. Aortic insufficiency is unquestionably the most serious; yet CHRONIC VALVULAR DISEASE. 657 for years it may be perfectly compensated. Favorable circumstances in any case are the moderate grade of hypertrophy and dilatation, the absence of all symptoms of cardiac distress, and the absence of extensive arterio- sclerosis and of angina. The prognosis rests in reality with the condition of the coronary arteries. Rheumatic lesions of the valves, inducing insuf- ficiency, are less apt to be associated with endarteritis at the root of the aorta; and in such cases the coronary arteries may escape for years. I know a physician, now about thirty-nine years of age, who, when sixteen, had his first attack of rheumatism, which involved the aortic segments. He has had two subsequent attacks of rheumatism, but with care has been able to live a comfortable and fairly active life. On the other hand, when the aortic insufficiency is only a part of an extensive arterio-sclerosis at the root of the aorta, the coronary arteries are almost invariably involved, and the outlook in such cases is much more serious. Sudden death is not un- common, either from acute dilatation during some exertion, or, more fre- quently, from blocking of one of the branches of the coronary arteries. The liability of this form to be associated with angina pectoris also adds to its severity. Aortic stenosis is a rare lesion, most commonly met with in middle-aged or elderly men, and is, as a rule, well compensated. In many cases it does not appear to limit the duration of life. In mitral lesions the outlook on the whole is much more favorable than in aortic insufficiency. Mitral insufficiency, when well compensated, carries with it, perhaps, a better prognosis than mitral stenosis; but it must be borne in mind that the cases which last the longest are those in which the valve orifice is more or less narrowed, as well as incompetent. There is, in reality, no valve lesion so rapidly fatal and so poorly com- pensated as that in which the mitral segments are gradually curled and puckered until they form a narrow strip around a wide mitral ring—a con- dition specially seen in children. There are many cases of mitral insuffi- ciency in which the defect is thoroughly balanced for thirty or even forty years, without distress or inconvenience. Even with great hypertrophy and the apex beat almost in the mid-axillary line, there may be little or no distress, and the compensation may be most effective. W omen may pass safely through repeated pregnancies, though here they are liable to acci- dents associated with the severe strain. I have had under my care for many years a patient who had her first attack of rheumatism at the age of fifteen, when she already had a well-marked mitral murmur. AV hen she first came under my observation, eighteen years ago, she had signs of hypertrophy of the left ventricle with a loud systolic murmur. She has had no cardiac disturbance whatever. She has lived a very active life, has been unusually vigorous, has borne eleven children, and has passed through three subsequent attacks of rheumatism. In mitral stenosis the prognosis is usually regarded as less favorable. My own experience has led me, however, to place this lesion almost on a level, particularly in women, with the mitral insufficiency. It is found 658 DISEASES OF THE CIRCULATORY SYSTEM. very often in persons in perfect health, who have had neither palpitation nor signs of heart-failure, and who have lived laborious lives. The figures given, too, by Broadbent indicate that the date of death in mitral stenosis is comparatively advanced. These patients, too, pass through repeated pregnancies with safety. There are of course those too common accidents, the result of cerebral embolism, which are more liable to occur in this than in other forms. Hard and fast lines cannot be drawn in the question of prognosis in valvular disease. Every case must be judged separately, and all the cir- cumstances carefully balanced. There is no question which requires greater experience and more mature judgment, and even the most ex- perienced are sometimes at fault. The following brief summary of the conditions which justify a favora- ble prognosis embodies the large and varied clinical experience of Sir Andrew Clark : Good general health; just habits of living; no excep- tional liability to rheumatic or catarrhal affections; origin of the valvular lesion independently of degeneration; existence of the valvular lesion without change for over three years; sound ventricles, of moderate fre- quency and genera] regularity of action; sound arteries, with a normal amount of blood and tension in the smaller vessels; free course of blood through the cervical veins; and, lastly, freedom from pulmonary, hepatic, and renal congestion. Treatment of Valvular Lesions.—For this purpose the valvu- lar lesion may be divided into the period of progressive development, with establishment and maintenance of hypertrophy, and the period of dis- turbed compensation. (a) Stage of Compensation.—Medicinal treatment at this period is not necessary and is often hurtful. A very common error is to administer cardiac drugs, such as digitalis, on the discovery of a murmur or of hyper- trophy. If the lesion has been found accidentally, it may be best not to tell the patient, but rather an intimate friend. Often it is necessary, however, to be perfectly frank in order that the patient may take certain preventive measures. lie should lead a quiet, regulated, orderly life, free from excitement and worry. An ordinary wholesome diet should be taken, tobacco should be interdicted, and stimulants not allowed. Exer- cise should be regulated entirely by the feelings of the patient. So long as no cardiac distress or palpitation follows, moderate exercise will prove very beneficial. The skin should be kept active by a daily bath. Hot baths should be avoided and the Turkish bath should be interdicted. In the case of full-blooded, somewhat corpulent individuals an occasional saline purge should be taken. Patients with valvular lesions should not go into very high altitudes. The act of coition has serious risks, particu- larly in aortic insufficiency. Knowing that the causes which most surely and powerfully disturb the compensation are overexertion, mental worry, and malnutrition, the physician should give suitable instructions in each CHRONIC VALVULAR DISEASE. 659 case. As it is always better to have the co-operation of an intelligent patient, he should, as a rule, be told of the condition, but in this matter the physician must be guided by circumstances, and there are cases in which reticence is the wiser policy. (b) Stage of Broken Compensation.—The break may be immediate and final, as when sudden death results from acute dilatation or from blocking of a branch of the coronary artery. Among the first indications are short- ness of breath on exertion or attacks of nocturnal dyspnoea. These are often associated with impaired nutrition, particularly with anaemia, and a course of iron or change of air may suffice to relieve the symptoms. Irregularity of the action of the heart cannot always be termed an in- dication of failing compensation, particularly in instances of mitral disease. It has greater significance in aortic lesions. Serious failure of compensa- tion is indicated by signs of dilatation of the heart, the gallop rhythm, or various forms of arrhythmia, with or without the existence of dropsy. Under these circumstances the following measures are to be carried out: (1) Rest.—Disturbed compensation maybe completely restored by rest of the body. Both in Montreal and in Philadelphia it was a favorite dem- onstration in practical therapeutics to show the influence of complete rest and quiet on the cardiac dilatation. In many cases with oedema of the ankles, moderate dilatation of the heart, and irregularity of the pulse, the rest in bed, a few doses of the compound tincture of cardamoms, and a saline purge suffice, within a week or ten days, to restore the compensa- tion. One patient, in Ward 11 of the Montreal General Hospital, with aortic insufficiency recovered from four successive attacks of failing com- pensation by these measures alone. (2) The relief of the embarrassed circulation. (a) By Venesection.—In cases of dilatation, from whatever cause, whether in mitral or aortic lesions or distention of the right ventricle in emphysema, when signs of venous engorgement are marked and when there is orthopncea with cyanosis, the abstraction of from twenty to thirty ounces of blood is indicated. This is the occasion in which timely vene- section may save the patient’s life. It is a condition in which I have had most satisfactory results from venesection. It is done much better early than late. I have on several occasions regretted its postponement, par- ticularly in instances of acute dilatation and cyanosis in connection with emphysema.* (b) By Depletion through the Bowels.—This is particularly valuable when dropsy is present. Of the various purges the salines are to be pre- ferred, and may be given by Matthew Hay’s method. Half an hour to an hour before breakfast from half an ounce to an ounce and a half of Epsom salts may be given in a concentrated form. This usually produces * For illustrative cases from my wards see paper by H. A. Lafleur, Medical News, July, 1891. 660 DISEASES OF THE CIRCULATORY SYSTEM. from three to five liquid evacuations. The compound jalap powder in half-drachm doses, or elaterium, may be employed for the same purpose. Even when the pulse is very feeble these liydragogue cathartics are well borne, and they deplete the portal system rapidly and efficiently. (c) The Use of Remedies which stimulate the Heart's Action.—Of these, by far the most important is digitalis, which was introduced into practice by Withering. The indication for its use is dilatation; the contra-indication is a perfectly balanced compensatory hyq>ertrophy, such as we see in all forms of valvular disease. Broken compensation, no mat- ter what the valve lesion may be, is the signal for its use. It acts upon the heart, slowing and at the same time increasing the force of the pulsa- tions. It acts on the peripheral arteries, raising their tension, so that a steady and equable flow of blood is maintained in the capillaries, which, after all, is the prime aim and object of the circulation. ' The beneficial effects are best seen in cases of mitral disease with small, irregular pulse and cardiac dropsy. Its effects are not less striking in the dilatation of the left ventricle, in the failing compensation of aortic insufficiency or of arterio-sclerosis. On theoretical grounds it has been urged that its use is not so advantageous in aortic insufficiency, since it prolongs the diastole and leads to greater distention. This need not be considered, and digi- talis is just as serviceable in this as in any other condition associated with progressive dilatation; larger doses are often required. It may be given as the tincture or the infusion. In cases of cardiac dropsy, from whatever cause, fifteen minims of the tincture or half an ounce of the infusion may be given every three hours for two days, after which the dose may be reduced. Some prefer the tincture, others the infusion ; it is a matter of indifference if the drug is good. The urine of a patient taking digi- talis should be carefully estimated each day. As a rule, when its action is beneficial, there is within twenty-four hours an increase in the amount; often the flow is very great. Under its use the dyspnoea is relieved, the dropsy gradually disappears, the pulse becomes firmer, fuller in volume, and sometimes, if it has been very intermittent, regular. Ill effects sometimes follow digitalis. There is no such thing as a cumulative action of the drug manifested by sudden symptoms. Toxic effects are seen in the production of nausea and vomiting. The pulse be- comes irregular and small, and there may be two beats of the heart to one of the pulse, which, as pointed out by Broadbent, is found particularly in cases of mitral stenosis when they are under the influence of this drug. The urine is reduced in amount. These symptoms subside on the with- drawal ot the digitalis, and are rarely serious. There are patients who take digitalis uninterruptedly for years, and feel palpitation and distress if the drug is omitted. In mitral disease, even when it does good it does not always steady the pulse. There are many cases in which the irregularity is not affected by the digitalis. When the compensation has been re- established the drug may be omitted. When there is dyspnoea on exer- CHRONIC VALVULAR DISEASE. 661 tion and cardiac distress, from five to ten minims three times a day may be advantageously given for prolonged periods, but the effects should be carefully watched. In cardiac dropsy digitalis should be used at the out- set with a free hand. Small doses should not be given, but from the first half-ounce doses of the infusion every three hours, or from fifteen to twenty minims of the tincture. There are no substitutes for digitalis. Of other remedies strophanthus alone is of service. Given in doses of from five to eight minims of the tincture, it acts like digitalis. It cer- tainly will sometimes steady the intermittent heart of mitral valve disease when digitalis fails to do so, but it is not to be compared with this drug when dropsy is present. Convallaria, citrate of caffeine, and adonis ver- nalis and sparteine are warmly recommended as substitutes for digitalis, but their inferiority is so manifest that their use is rarely indicated. There are two valuable adjuncts in the treatment of valvular disease— iron and strychnia. When anaemia is a marked feature iron should be given in full doses. In some instances of failing compensation iron is the only medicine needed to restore the balance. Arsenic is occasionally an excellent substitute, and one or, other of them should be administered in all instances of heart-trouble when pallor is present. Strychnia is a heart tonic of very great value. It may be given in combination with the digi- talis in one or two drop doses of the one per cent solution. Treatment of Special Symptoms, (a) Dropsy.—The increased arterial tension and activity of the capillary circulation under the influ- ence of digitalis hastens the interstitial lymph flow and favors resorption of the fluid. The hydragogue cathartics, by rapidly depleting the blood, promote the absorption of the fluid from the lymph spaces and the lymph sacs. These two measures usually suffice to rid the patient of the dropsy. In some cases, however, it cannot be relieved, and then Southey’s tubes may be used or the legs punctured. If done with care, after a thorough washing of the parts, and if antiseptic precautions are taken, scarification is a very serviceable measure, and should be resorted to more frequently than it is. Canton-flannel bandages may be applied on the oedematous legs. (b) Dyspnoea.—The patients are usually unable to lie down. A com- fortable bed-rest should therefore be provided—if possible, one with lateral projections, so that in sleeping the head can be supported as it falls over. The shortness of breath is associated with dilatation, chronic bronchitis, or hydrothorax. The chest should be carefully examined in all these cases, as hydrothorax of one side or of both is a common cause of short- ness of breath. There are cases of mitral regurgitation with recurring hydrothorax as the sole dropsical symptom, which is relieved, week by week or month by month, by tapping. For the nocturnal dyspnoea, par- ticularly when combined with restlessness, morphia is invaluable and may be given without hesitation. The value of the calming influence of opium in all conditions of cardiac insufficiency is not enough recognized. There 662 DISEASES OF THE CIRCULATORY SYSTEM. are instances of cardiac dyspnoea unassociated with dropsy, particularly in mitral-valve disease, in which nitroglycerin is of great service, if given in the one per cent solution in increasing doses. It is especially serviceable in the cases in which the pulse tension is high. (c) Palpitation and Cardiac Distress.—In instances of great hyper- trophy and in the throbbing which is so distressing in some cases of aortic insufficiency, aconite is of service in doses of from one to three minims every two or three hours. An ice-bag over the heart or Leiter’s coil is also of service in allaying the rapid action and the throbbing. For the pains, which are often so marked in aortic lesions, iodide of potassium in ten grain doses, three times a day, or the nitroglycerin may be tried. Small blisters are sometimes advantageous. It must be remembered that an important? cause of palpitation and cardiac distress is flatulent disten- tion of the colon, against which suitable measures must be directed. (d) Gastric Symptoms.—The cases of cardiac insufficiency which do badly and fail to respond to digitalis are most often those in which nausea and vomiting are prominent features. The liver is often greatly enlarged in these cases; there is more or less stasis in the hepatic vessels, and but little can be expected of drugs until the venous engorgement is relieved. If the vomiting persists, it is best to stop the food and give small bits of ice, small quantities of milk and lime water, and effervescing drinks, such as Apollinaris water and champagne. Creosote, hydrocyanic acid, and the oxalate of cerium are sometimes useful; but, as a rule, the condition is obstinate and always serious. (ie) Cough and Ilcemoptysis.—The former is almost a necessary con- comitant of cardiac insufficiency, owing to engorgement of the vessels and more or less bronchitis. It is allayed by measures directed rather to the heart than to the lungs. Hasmoptysis in chronic valvular disease is sometimes a salutary symptom. An army surgeon, who was invalided during the late civil war on account of haemoptysis, supposed to be due to tuberculosis, has since that time had, in association with mitral insuffi- ciency and enlarged heart, many attacks of haemoptysis. He assures me that his condition is invariably better after the attack. It is rarely fatal, except in some cases of acute dilatation, and seldom calls for special treat- ment. (/) Sleeplessness.—One of the most distressing features of valvular lesions, even in the stage of compensation, is disturbed sleep. Patients may wake suddenly with throbbing of the heart, often in an attack of nightmare. Subsequently, when the compensation has failed, it is also a worrying symptom. The sleep is broken, restless, and frequently dis- turbed by frightful dreams. Sometimes a dose of the spirits of chloro • form or of ether, with half a drachm of spirits of camphor, given in a little hot whisky, will give a quiet night. The compound spirits of ether, Hoffman’s anodyne, though very unpleasant to take, is frequently a great boon in the intermediate period when compensation has partially failed CIIRONIC VALVLFLAR DISEASE. 663 and the patients suffer from restless and sleepless nights. Paraldehyde and amylene hydrate are sometimes serviceable. Urethan, sulphonal, and chloralamide are rarely efficacious, and it is best, after a few trials, particularly if the paraldehyde does not answer, to give morphia. It may be given in combination with atropine. (g) Renal Symptoms.—With ruptured compensation and lowering of the tension in the aorta, the urinary secretion is greatly diminished, and the amount may sink to five or six ounces in the day. Digitalis, and strophanthus when efficient, usually increase the flow. A brisk purge may be followed by augmented secretion. The combination in pill form of digitalis, squill, and the black oxide of mercury, will sometimes prove effective when the infusion or tincture of digitalis alone has failed. Calo- mel acts well in some cases, given in grs. iij every six hours for three or four days. The diet in chronic valve diseases is often very difficult to regulate. With the dilatation and venous engorgement come nausea and often a great distaste for food. The amount of liquid should be restricted, and milk, beef-juice, or egg albumen given every three hours. When the serious symptoms have passed, eggs, scraped meat, fish, and fowl may be allowed. Starchy foods, and all articles likely to cause flatulency, should be forbidden. Stimulants are usually necessary, either whisky or brandy. III. HYPERTROPHY AND DILATATION. Hypertrophy is an enlargement of the heart due to an increased thick- ness, total or partial, in the muscular walls. Dilatation is an increase in size of one or more of the chambers with or without thickening of the walls. The conditions usually coexist, and could be more correctly de- scribed together under the term enlargement of the heart. Simple hyper- trophy, in which the cavities remain of a normal size and the walls are increased, occurs, but simple dilatation, in which the cavities are increased and the walls remain of a normal diameter, probably does not, as it is always associated with thinning or with thickening of the coats. Com- monly we have the forms of simple hypertrophy, hypertrophy with dilata- tion, and dilatation with thinning of the coats. Hypertrophy of the Heart. There are two forms—the simple hypertrophy, in which the cavity or cavities are of normal size; and hypertrophy with dilatation (eccentric hypertrophy), in which the cavities are enlarged and the walls increased in thickness. The condition formerly spoken of as concentric hyper- trophy, in which there is diminution in the size of the cavity with thick- ening of the walls, is, as a rule, a post-mortem change. 664 DISEASES OF THE CIRCULATORY SYSTEM. The enlargement may affect the entire organ, one side, or only one chamber. Naturally, as the left ventricle does the chief work in forcing the blood through the systemic arteries, the change is most frequently found in it. Etiology.—Hypertrophy of the heart follows the law governing muscles, that within certain limits, if the nutrition is kept up, increased work is followed by increased size—i. e., hypertrophy. Hypertrophy of the left ventricle alone, or with general enlargement of the heart, is brought about by— Conditions affecting the heart itself: (1) Disease of the aortic valve; (2) mitral insufficiency; (3) pericardial adhesions; (4) sclerotic myo- carditis ; (5) disturbed innervation, with overaction, as in exophthalmic goitre, in long-continued nervous palpitation, and as a result of the action of certain articles, such as tea, alcohol, and tobacco. In all of these conditions the work of the heart is increased. In the case of the valve lesions the increase is due to the increased intraventricular pressure; in the case of the adherent pericardium and myocarditis, to direct interference with the symmetrical and orderly contraction of the chambers. Conditions acting upon the blood-vessels : (1) General arterio-sclerosis, with or without renal disease; (2) all states of increased arterial tension induced by the contraction of the smaller arteries under the influence of certain toxic substances, which act, as Bright suggested, by affecting “ the minute capillary circulation, render greater action necessary to send the blood through the distant subdivisions of the vascular system ”; (3) pro- longed muscular exertion, which enormously increases the blood-pressure in the arteries; (4) narrowing of the aorta, as in the congenital stenosis. Hypertrophy of the right ventricle is met with under the following conditions— (1) Lesions of the mitral valve, either incompetence or stenosis, which act by increasing the resistance in the pulmonary vessels. (2) Pulmonary lesions, obliteration of any number of blood-vessels within the lungs, such as occurs in emphysema or cirrhosis, is followed by hypertrophy of the right ventricle. (3) Valvular lesions on the right side occasionally cause hypertrophy in the adult, not infrequently in the foetus. (4) Chronic valvular disease of the left heart and pericardial adhesions are sooner or later associated with hypertrophy of the right ventricle. In the auricles simple hypertrophy is never seen; it is always dilata- tion with hypertrophy. In the left auricle the condition develops in lesions at the mitral orifice, particularly stenosis. The right auricle hypertrophies when there is greatly increased blood-pressure in the lesser circulation, whether due to mitral stenosis or pulmonary lesions. Narrowing of the tricuspid orifice is a less frequent cause. Morbid Anatomy.—The heart of an average-sized man weighs about nine ounces (280 grammes); that of a woman, about eight ounces (250 grammes). In cases of general hypertrophy the heart may weigh HYPERTROPHY AND DILATATION. 665 from sixteen to twenty ounces. Weights above twenty-five ounces are rare. So far as I know, the heaviest heart on record is one described by Beverly Robinson, weighing fifty-three ounces. Dulles has reported one weighing forty-eight ounces. The measurement of the thickness of the walls is, next to weighing, the best means of determining the hypertrophy. In extreme dilatation the walls, though actually thickened, may look thin. When rigor mortis is present, the cavity may be small and the walls may appear greatly thickened. The measurements should not be made until the heart has been soaked in water and thoroughly relaxed. In the left ventricle a thickness of ten lines, or from twenty to twenty-five millimetres, indicates hypertrophy. The right ventricle is thinner than the left, and has an average diameter of from four to seven millimetres. In hyper- trophy it may measure from thirteen to twenty millimetres. The left auricle has a normal thickness of about three millimetres, which may be doubled in hypertrophy. The wall of the right auricle is thinner than that of the left, rarely exceeding two millimetres in diameter. The appen- dices of the auricles often present marked increase in thickness and the musculi pectinati are greatly developed. The shape of the heart is altered in hypertrophy; with great enlarge- ment of the ventricles, the apex is broadened, and the conical shape is lost. In the enormous enlargement of aortic insufficiency this rotundity of the apex is very marked. When the right ventricle is chiefly affected it occu- pies the largest share of the apex. In mitral stenosis the contrast is very striking between the large, broad right ventricle, reaching to the apex, and the small left chamber. The hypertrophied muscle has a deep red color, is firm, and is cut with increasing resistance. The right ventricle, as Rokitansky noted, may have a peculiar hard, leathery consistence. In simple hypertrophy of the left ventricle the papillary muscles and the columns carnese may be enlarged, but the former are often much flattened in dilated hypertrophy. The muscular trabeculae are more developed, as a rule, in the right ventricle than in the left. The increase in size of the heart is probably due to a definite numerical increase, resulting from development of new fibres. Symptoms.—Hypertrophy is a conservative process, secondary to some valvular or arterial lesion, and is not necessarily accompanied by symptoms. So admirable is the adjusting power of the heart that, for example, an advancing stenosis of aortic or mitral orifice may for years be perfectly equalized by a progressive hypertrophy, and the subject of the affection be happily unconscious of the existence of heart-trouble. Hyper- trophy is in almost all cases an unmixed good; the symptoms which arise are usually to be attributed to its failure, or, as we say, to disturbance of compensation. Among the most common symptoms are unpleasant feelings about the heart—a sense of fulness and discomfort, rarely amounting to pain. This 666 DISEASES OF THE CIRCULATORY SYSTEM. may be very noticeable when the patient is recumbent on the left side. Actual pain is rare, except in the irritable heart from tobacco or in neur- asthenics. Palpitation may not occur, nor do patients always have sen- sations from the violent shocks of a greatly hypertrophied organ. There are instances in which very uneasy feelings arise from a moderately exag- gerated pulsation. The general condition has much to do with this. In health we are not conscious of the heart’s pulsations, but one of the first indications of exhaustion from excesses or overstudy is the consciousness of the heart’s action, not necessarily with palpitation. Headaches, flush- ings of the face, noises in the ears, and flashes of light may be present. Certain untoward effects of long-continued hypertrophy of the left ventricle must be mentioned, chief among which is the production of arterio-sclerosis. Particularly is this the case when the hypertrophy re- sults from increased peripheral resistance. The heightened blood-pressure (expressed by the word strain) in the arteries gradually induces an endar- teritis and a stiff, inelastic state of those vessels most exposed to it—viz., the aorta and its primary divisions. In overcoming the peripheral ob- struction the hypertrophy “ ruins the arteries as a sequential result ” (Fothergill). Prolonged muscular exertion also acts injuriously in this way. Another danger is rupture of the blood-vessels, particularly those of the brain. In general arterial degeneration associated with contracted kidneys and hypertrophied left heart apoplexy is common. Indeed, in the majority of cases of cerebral haemorrhage there is sclerosis of the smaller vessels, often with the development of miliary aneurisms, and the rupture may be caused by the forcible action of the heart. Physical Signs.—Inspection may show bulging of the praecordia, pro- ducing in children marked asymmetry of the chest. It may occur with- out pericardial adhesions, which Schroetter thinks are invariably associated with this condition. The intercostal spaces are widened, and the area of visible impulse is much increased. On palpation the impulse is forcible and heaving, and with each systole the hand or the ear applied over the heart may be visibly raised. A slow, heaving impulse is one of the best signs of simple hypertrophy. With large dilated hypertrophy the forcible impulse is often more sudden and abrupt. A second, weaker impulse can sometimes be felt, due perhaps to a rebound from the aortic valves (Gowers). The beat may be felt in the sixth, seventh, or eighth interspace from one to three inches outside the nipple. This downward dislocation of the apex is an important sign in hypertrophy of the left ventricle. In moder- ate grades, such as are seen in chronic Bright’s disease, the impulse may be in the sixth interspace in the nipple line, or a little outside of it. Percussion reveals increased dulness, which in the parasternal line may begin at the third rib or in the second interspace, and transversely may extend from half an inch to two inches beyond the nipple line and an equal distance beyond the middle line of the sternum. The dull area HYPERTROPHY AND DILATATION. 667 is more ovoid than in health. When carefully delimited the colossal hypertrophy of aortic valve disease may give an area of dulness from seven to eight inches in transverse extent. In moderate grades a transverse dulness of four inches is not uncommon. On auscultation the sounds, when the valves are healthy, may present no special changes, but the first sound is often prolonged and dull. When there is dilatation as well, it may be very clear and sharp. Redu- plication is common in the hypertrophy of renal disease. A peculiar clink —the tintement metallique of Bouillaud—may be heard just to the right of the apex beat. The second sound is clear and loud, sometimes ringing in character or reduplicated. With valvular lesions, the sounds, of course, are much altered, and are replaced or accompanied by murmurs. In simple hypertrophy not dependent on valvular lesions, the pulse is usually regular, full, strong, and of high tension. It may be in- creased in rapidity, but is often normal. In eccentric hypertrophy the pulse is full, but softer, and usually more rapid. One of the earliest signs of failure and dilatation is irregularity and intermittence of the pulse. Hypertrophy of the right ventricle in the adult very rarely follows valvular disease on the right side, but results from increased resistance in the pulmonary circulation, as in cirrhosis of the lung and emphysema, or in stenosis of the mitral orifice. With perfect compensation, which fully maintains the equilibrium of the circulation, there are no symptoms. Extra exertion, as the ascent of stairs or running, may cause shortness of breath, but in many ways hypertrophy of the right ventricle is the most enduring and salutary form in the whole cycle of cardiac affections. For long periods of years the effects of mitral stenosis may be counterbalanced, and only sudden death by accident or an acute disease reveal the existence of an unsuspected lesion. In tk hypertrophy secondary to emphysema or cirrhosis of the lungs, there may be sensations of distress in the cardiac region, with cough and shortness of breath ; but as long as the dilatation is moderate the symptoms are not marked. With great dilatation and tricuspid leakage come venous engorgement, oedema, and pulmonary troubles. The increased pressure in the lesser circulation leads to sclerosis of the pulmonary arteries and the constant engorgement of the capillaries leads ultimately to a deposition of pigment and increase in the fibrous elements in the lung—the brown induration. Extreme pulmonary con- gestion and apoplexy are more often associated with dilatation. Ilgemop- tysis may result from rupture of vessels during sudden exertion. Physical Signs.—Bulging of the lower part of the sternum and left cartilages occurs. The apex beat is forced to the left, but is not so often displaced downward. The most marked impulse may be in the angle between the ensiform cartilage and the seventh rib or beneath the carti- lages of the sixth and seventh ribs. The pulsation is rather diffuse, not punctuate, particularly if there is much dilatation. In thin-walled chests there may be pulsation in the third and fourth right interspaces. 668 DISEASES OF THE CIRCULATORY SYSTEM. The cardiac dulness is increased transversely and toward the right; it may extend an inch or more beyond the border of the sternum. On auscultation the first sound at the lower part of the sternum is louder and fuller than normal, but the differences are not very marked unless there is much dilatation, when the sound is clearer and sharper. Accentuation and reduplication of the second sound are heard in the pulmonary artery on account of the increased tension. The pulse at the wrist is usually small. Pulsation occurs in the jugulars when there is tricuspid incompetence. Hypertrophy of the auricles always occurs with dilatation. It is most common in the left chamber, which hypertrophies in mitral stenosis and incompetency and naturally assists in restoring the balance of the circu- lation. There are no distinctive physical signs, and we usually can infer its presence only by the existence of mitral stenosis and a presystolic mur- mur. Increased dulness may be determined to the left of the sternum, and there may be a presystolic wave in the second left interspace. Hypertrophy and dilatation of the right auricle are met with (associ- ated with a similar condition in the right ventricle and incompetency of the tricuspid) in emphysema, cirrhosis of the lung, chronic bronchitis, and mitral disease. In comparison with the left auricle the greater de- velopment and hypertrophy of the appendix and its musculi peotinati is very striking. The latter may be distributed over the anterior wall of the sinus to a greater extent than in health. There are increased dulness in the third and fourth interspaces, pulsation sometimes presystolic in rhythm, signs of venous engorgement, jugular pulsation, and other evi- dences of dilatation of the right heart. Diagnosis. —Among conditions to be distinguished are : (1) Neurotic palpitation, from whatever cause, even when very forci- ble, has not the heaving impulse of genuine hypertrophy. Enlargement of the organ may, however, follow prolonged overaetion, as in the smoker’s heart, the irritable heart of neurasthenics, and in exophthalmic goitre, but it is usually slight. (2) The increased area of dulness may be due to a variety of causes, some of which may closely simulate hypertrophy, such as pericardial effu- sion, aneurism, mediastinal growths, or displacement of the heart from pressure, or the existence of malformation of the chest. With the exer- cise of ordinary care, however, the diagnosis can usually be made. There are two opposite conditions which frequently give trouble. With the left lung contracted from pleurisy, phthisis, or cirrhosis, a large surface of the heart is exposed ; the pulsation may be extensive and forcible, and may at first sight resemble hypertrophy. In this condition there is dislocation upward and to the left. The existence of pulmonary or pleuritic disease and the fixation of the lung on deep inspiration will suffice to prevent mistakes. A less extensive exposure of the heart may occur without any disease in very narrow-chested persons with ill-developed lungs; here, though the area of dulness may be much increased, the normal position HYPERTROPHY AND DILATATION. 669 of the apex, the absence of forcible, heaving impulse, and of any obvious cause of hypertrophy will afford satisfactory criteria for a diagnosis. The reverse condition exists in some cases in which emphysema masks moder- ate cardiac hypertrophy. The area of dulness may be normal, or even diminished, and the pulse and character of the sounds will help in the diagnosis; but it is sometimes a difficult matter. Prognosis.—The course of any case of cardiac hypertrophy may be divided into three stages : (a) The period of development, which varies with the nature of the primary lesion. For example, in rupture of an aortic valve, during a sud- den exertion, it may require months before the hypertrophy becomes fully developed ; or, indeed, it may never do so, and death may follow from an uncompensated dilatation. On the other hand, in sclerotic affections of the valves, with stenosis or incompetency, the hypertrophy develops step by step with the lesion, and may continue to counterbalance the progress- ive and increasing impairment of the valve. (b) The period of full compensation—the latent stage—during which the heart’s vigor meets the requirements of the circulation. This period may last an indefinite time, and a patient may never be made aware by any symptoms that he has a valvular lesion. (c) The period of broken compensation, which may come on suddenly during very severe exertion. Death may result from acute dilatation; but more commonly it takes place slowly and results from degeneration and weakening of the heart-muscle. The breaking or rupture of cardiac compensation may be induced by many causes, among which the most important are: (1) Failure of the general nutrition. In many instances of heart-disease, exposure, poor food, and alcohol combine to bring about disturbance of a well-balanced heart lesion. Acute illnesses, particularly the fevers, may induce general debility and with it weakening of the heart-muscle. (2) Disturbance of the local nutrition of the heart, owing to gradual sclerosis of the coronary arteries, is a common cause. (3) Very severe muscular exertion, which may disturb a compensation, perfect for years, and induce death in a few days (Traube). (4) Mental emotions. Severe grief or fright may bring on failure of compensation. The prognosis is largely, as already stated, a matter of maintained compensation. Once established, the hypertrophy rarely, if ever, disap- pears, inasmuch as the cause usually persists. Occasionally, perhaps, the hypertrophy associated with neurotic palpitation from tobacco, or other causes, or the hypertrophy following muscular over-exertion, may dis- appear. 670 DISEASES OF THE CIRCULATORY SYSTEM. Dilatation of the Heart. Two varieties are recognized, dilatation with thickening and dilata- tion with thinning. The former is the most common, and corresponds to the dilated or eccentric hypertrophy. Etiology.—Two important causes combine to produce dilatation— increased pressure within the cavities and impaired resistance, due to weakening of the muscular wall—which may act singly, but are often combined. A weakened wall may yield to a normal distending force, or a normal wall may yield under a heightened blood-pressure. (1) Heightened endocardiac pressure results either from an increased quantity of blood to be moved or an obstacle to be overcome, and is the most frequent cause. It does not necessarily bring about dilatation; sim- ple hypertrophy may follow, as in the early period of aortic stenosis, and in the hypertrophy of the left ventricle in Bright’s disease. A majority of the important causes of increased endocardiac pressure have already been discussed under hypertrophy. One or two may be con- sidered more in detail. The size of the cardiac chambers varies in health. With slow action of the heart the dilatation is complete and fuller than it is with rapid action. Physiologically, the limits of dilatation are reached when the chamber does not empty itself during the systole. This may occur as an acute, transient condition in severe exertion—during, for example, the ascent of a mountain. There may be great dilatation of the right heart, as shown by the increased epigastric pulsation, and even increase in the cardiac dulness. The safety-valve action of the tricuspid valves may here come into play, relieving the lungs by permitting regurgitation into the auricle. With rest the condition is removed, but if it has been ex- treme, the heart may suffer a strain from which it may recover slowly, or, indeed, the individual may never be able again to undertake severe exer- tion. In the process of training, the getting wind, as it is called, is largely a gradual increase in the capability of the heart, particularly of the right chambers. A degree of exertion can be safely maintained in full training which would be quite impossible under other circumstances, because, by a gradual process of what we may call physical education, the heart has strengthened its reserve force—widened enormously its limits of physiological work. Endurance in prolonged contests is measured by the capabilities of the heart, and its essence consists in being able to meet the continuous tendency to overstep the limits of dilatation. We have no positive knowledge of the nature of the changes in the heart which occur in this process, but it must be in the direction of increased muscular and nervous energy. The large heart of athletes may be due to the prolonged use of their muscles, but no man becomes a great runner or oarsman who has not naturally a capable if not a large heart. Master McGrath, the celebrated greyhound, and Eclipse, the HYPERTROPHY AND DILATATION. 671 race-horse, both famous for endurance rather than speed, had very large hearts. Excessive dilatation during severe muscular effort results in heart- strain. A man, perhaps in poor condition, calls upon his heart for extra work during the ascent of a high mountain, and is at once seized with pain about the heart and a sense of distress in the epigastrium. He breathes rapidly for some time, is “ puffed,” as we say, but the symptoms pass off after a night’s quiet. An attempt to repeat the exercise is fol- lowed by another attack, or, indeed, an attack of cardiac dyspnoea may come on while he is at rest. For months such a man may be unfitted for severe exertion, or he may be permanently incapacitated. In some way he has overstrained his heart and become “ broken-winded.” Exactly what has taken place in these hearts we cannot say, but their reserve force is lost, and with it the power of meeting the demands exacted in maintain- ing the circulation during severe exertion. The “ heart-shock ” of Latham includes cases of this nature—sudden cardiac breakdown during exertion, not due to rupture of a valve. It seems probable that sudden death in men during long-continued efforts, as in a race, is sometimes due to over- distention and paralysis of the heart. Examples of dilatation occur in all forms of valve lesions. In aortic incompetency blood enters the left ventricle during diastole from the unguarded aorta and from the left auricle, and the quantity of blood at the termination of diastole subjects the walls to an extreme degree of pressure, under which they inevitably yield. In time they augment in thickness, and present the typical eccentric hypertrophy of this condition. In mitral insufficiency blood which should have been driven into the aorta is forced into and dilates the auricle from which it came, and then in the diastole of the ventricle a large amount is returned from the auri- cle, and with increased force. In mitral stenosis the left auricle is the seat of greatly increased tension during diastole, and dilates as well as hypertrophies; the distention, too, may be enormous. Dilatation of the right ventricle is produced by a number of conditions, which were con- sidered under hypertrophy. All circumstances, such as mitral stenosis, emphysema, etc., which permanently increase the tension of the blood in the pulmonary vessels, cause its dilatation. (2) Impaired nutrition of the heart-walls may lead to a diminution of the resisting power so that dilatation readily occurs. The loss of tone due to parenchymatous degeneration or myocarditis in fevers may lead to a fatal condition of acute dilatation. It is a recog- nized cause of death in scarlatinal dropsy (Goodhart), and may occur in rheumatic fever, typhus, typhoid, erysipelas, etc. The changes in the heart-muscle which accompany acute endocarditis or pericarditis may lead to dilatation, especially in the latter disease. In anaemia, leukaemia, and chlorosis the dilatation may be considerable. In sclerosis of the walls, the yielding is always where this process is most advanced, as at the left apex. DISEASES OF THE CIRCULATORY SYSTEM. Under any of these circumstances the walls may yield with normal blood- pressure. Pericardial adhesions are a cause of dilatation, and we generally find in cases with extensive and firm union considerable hypertrophy and dila- tation. There is usually here some impairment as well of the superficial layers of muscle. Morbid Anatomy.—The condition usually exists with hypertrophy in two or more chambers. It is more common on the right than on the left side. The most extreme dilatation is in cases of aortic incompetency, in which all the cavities may be enormously distended. In mitral stenosis the left auricle is often trebled in capacity, and the right chambers also are very capacious. The auricles may contain from eighteen to twenty ounces of blood. In chronic lesions of the lungs the right chambers are chiefly involved. In great distention of one ventricle the septum may bulge toward the other side. The auriculo-ventricular rings are often dilated, and there may be an increase in the circumference of an inch and a half or even two inches. Thus, the tricuspid orifice, the circumference of which is about four and a half inches, may freely admit a graduated heart- cone of above six inches; and the mitral orifice, which normally is about three and a half inches, may admit the cone to five and a half inches or even more. Great dilatation is always accompanied with relative incom- petency of the valves, so that free regurgitation into the auricles is per- mitted. The orifices of the venae cavae and of the pulmonary veins may be greatly dilated. The endocardium is often opaque, particularly that of the auricles. The muscle substance varies according to the presence or absence of de- generations. The microscope may show marked fatty or parenchymatous change, but in some instances no special alteration may be noticeable. There is much truth in Niemeyer’s assertion “ that it is not possible by means of the microscope to recognize all the alterations of the muscular fibrillae which diminish the functional power of the heart.” Of the changes in the ganglia of the heart we know very little. As centres of control they probably have more to do with cardiac atony and breakdown than we generally admit. Degeneration of them has been noted by Put- jakin, Ott, and others. Symptoms and Physical Signs.—Dilatation causes weakness of the cardiac walls, diminishes the vigor of their contractions, and is there- fore the reverse of hypertrophy. So long as compensation is maintained the enlargement of a cavity may be considerable. The limit is reached when the hypertrophied walls in the systole can no longer expel all the contents, part of which remain, so that at each diastole the chamber is abnormally full. Thus, in aortic incompetency blood enters the left ven- tricle from the aorta as well as the auricle; dilatation ensues, and also hypertrophy as a direct effect of the increased pressure and increased amount of blood to be moved. But if from any cause the hypertrophy IIYPERTROPHY AND DILATATION. 673 weakens and the ventricle during systole fails to empty itself completely, a still larger amount is in it at the end of each diastole, and the dilatation becomes greater. The amount remaining after systole prevents the blood from entering freely from the auricle. Incompetency of the auriculo- ventricular valves follows, with dilatation of the auricle and impeded blood-flow in the pulmonary veins. Dilatation and hypertrophy of the right heart may compensate for a time, but when this fails the venous system becomes engorged and dropsy may result. The consideration of the symptoms of chronic valvular lesions is largely that of dilatation and its effects. Acute dilatation, such as we see in fevers or in sudden failure of a hypertrophied heart, is accompanied by three chief symptoms—weak, usually rapid, impulse, dyspnoea, and signs of obstructed venous circula- tion. Cardiac pain may be present, but is often absent. The physical signs of dilatation are those of a weak and enlarged organ. The impulse is diffuse, often undulatory, and is felt over a wide area, and an apex beat or a point of maximum intensity may not exist. When it does exist, it may be visible and yet cannot be felt—a valuable observation made by Walshe. An extensive area of impulse with a quick, weak maximum apex beat may be present. When the right heart is chiefly dilated the left may be pushed over so as to occupy a much less ex- tensive area in front of the heart, and the true apex beat cannot be felt; but the chief impulse is just below, or to the right of, the xiphoid carti- lage, and there is a wavy pulsation in the fourth, fifth, and sixth inter- spaces to the left of the sternum. In extreme dilatation of the right auricle a pulsation may sometimes be seen in the third right interspace close to the sternum, and with free tricuspid regurgitation this may be systolic in character. Whether the pulsation frequently seen in the sec- ond left interspace is ever due to a dilated left auricle has not been deter- mined- I have sometimes thought it was presystolic in rhythm, though it may be distinctly systolic. Post mortem, it is rare in the most extreme distention to see the auricular appendix so far forward as to warrant the belief that it could beat against the second interspace. The area of dul- ness is increased, but an emphysematous lung or the fully distended organ in a state of brown induration may cover over the heart and greatly limit the extent. The directions of increase were considered in connection with hypertrophy. The first sound is shorter, sharper, more valvular in character, and more like the second. As the dilatation becomes excessive it gets weaker. Keduplication is not common, but occasionally differences may be heard in the first sound over the right and left hearts. The sounds are fre- quently obscured by murmurs, which are produced by incompetency of the valves due to the great dilatation, or are associated with the chronic valve disease on which the condition depends. The aortic second sound is replaced by a murmur in aortic regurgitation. The pulmonary sound is accentuated in mitral regurgitation and pulmonary congestion, but 674 DISEASES OF THE CIRCULATORY SYSTEM. with extreme dilatation it may be much weakened. The heart’s action is irregular and intermittent, and the pulse is small, weak, and quick. On auscultation both the sounds may be free from murmur. Often there is the condition known as embryocardia or foetal heart-rhythm, in which the first and second sounds are very alike, and the long pause is shortened. In other instances there is the typical and characteristic gallop rhythm, rarely found apart from conditions of dilatation. With the various valvular lesions the corresponding murmurs may be heard. Murmurs, however, which have been present may disappear, as in the case of mitral stenosis. In other instances a loud systolic murmur may be heard at the apex, and when the case first comes under observation it may be impossible to say whether this is due to organic mitral lesion. The murmur may be confined to the apex region, or propagated well to the back. It is extremely common in the dilatation which follows the hypertrophy of the left ventricle in arterio-sclerosis. Under treatment, with the gradual disappearance of the dilatation, a murmur of this kind, even though most intense, may completely disappear, showing that it has been due to a relative insufficiency, not to a valvular lesion. All varieties of arrhythmia may occur in dilatation of the heart. The pulse, as a rule, is small, weak, quick, and often irregular. Dilatation and Hypertrophy due to Overexertion and Alcohol.—There is a group of cases of dilatation and hypertrophy dependent upon pro- longed overexertion, which rarely comes under observation until compen- sation has failed, and which then may be very difficult to distinguish from the similar conditions produced by valvular disease. The patients are able-bodied men at the middle period of life, and complain first of pal- pitation or irregularity of the action of the heart, shortness of breath, and subsequently the usual symptoms of cardiac insufficiency develop. On inquiring into the history of these patients none of the usual etiological factors causing valve disease are present, but they have always been en- gaged in laborious occupations and have usually been in the habit of taking stimulants freely. This is the affection which has been specially studied by McLean, Clifford Albutt, Seitz, and others, and in its earlier condition by Da Costa, in what he termed the irritable heart It is met with very frequently in soldiers. These cases may return to hospital three or four times with cardiac insufficiency, sometimes with slight ana- sarca, haemoptysis, and signs of pulmonary engorgement. The condition is by no means infrequent. Bollinger has called attention to the common occurrence of dilatation and hypertrophy in beer-drinkers, particularly in the workers in the German breweries, who drink twenty or more litres in the day. Strumpell, at his Erlangen clinic, told me that this condition was very common in the draymen and workers in the breweries of that town, very few of whom pass the forty-fifth year without indications of hypertrophy and dilatation of the heart. On post-mortem examination the valves may be quite healthy, the aorta smooth, and no extensive arterio- AFFECTIONS OF THE MYOCARDIUM. 675 sclerosis or renal disease. The heart weighs from eighteen to twenty-five ounces; the chambers are dilated. The condition has been met with also in animals, and Houghton states that the heart of the celebrated grey- hound Master McGrath weighed 9'57 ounces, just threefold in excess of the normal proportion of heart-weight to body-weight. Idiopathic Dilatation,—And, lastly, there are other cases in which dilatation of the heart occurs without discoverable cause. In some in- stances there has been a history of sudden exercise or of mental emotion, but in other cases the condition seems to have come on spontaneously. In some the condition is acute and the patient has dyspnoea, slight cyano- sis, cough, and great cardiac distress. Death may occur in a few days, or dropsy may supervene and the case may become chronic. Delafield has reported an interesting series of cases of this group. Treatment.—The treatment of hypertrophy and dilatation has al- ready been considered under the section on valvular lesions. I would only here emphasize the fact that with signs of dilatation, as indicated by gallop rhythm, urgent dyspnoea, and slight lividity, venesection is in many cases the only means by which the life of the patient may be saved, and from twenty-five to thirty ounces of blood should be abstracted with- out delay. Subsequently stimulants, such as ammonia and digitalis, may be administered, but they are accessories only to the bleeding in the criti- cal condition of acute dilatation, which is so frequently met with in cardiac lesions. IV. AFFECTIONS OF THE MYOCARDIUM. 1. Lesions due to Disease of the Coronary Arteries.—A knowledge of the changes produced in the myocardium by disease of the coronary vessels gives a key to the understanding of many problems in cardiac pathol- ogy. The terminal branches of the coronary vessels are end arteries. The blocking of one of these vessels by a thrombus or an embolus leads to a condition which is known as— (ia) Ancemic necrosis, or white infarct. This is most commonly seen in the left ventricle and in the septum, in the territory of distribution of the anterior coronary artery. The affected area has a yellowish- white color, sometimes a turbid, parboiled aspect, at others a grayish- red tint. It may be somewhat wedge-shaped, more often it is irregular in contour and projects above the surface. Microscopically the changes are very characteristic. The nuclei disappear from the muscle fibres, the condition of fragmentation is present, and the fibres present a ho- mogeneous, hyaline appearance. In some instances there is complete transformation, and even to the naked eye a firm white patch of hyaline degeneration may appear in the centre of the area. Sudden death not infrequently follows the blocking of one of the branches of the coronary 676 DISEASES OF THE CIRCULATORY SYSTEM. artery and the production of this ansemic necrosis. In medico-legal cases it is a point of primary importance to remember that this is one of the common causes of sudden death. This condition should be care- fully sought for, inasmuch as it may be the sole lesion, except a general, sometimes slight arterio-sclerosis. Rupture of the heart may be asso- ciated with aneemic necrosis. (Z>) The second important effect of coronary-artery disease upon the myocardium is seen in the production of fibrous myocarditis. This may result from the gradual transformation of areas of anaemic necrosis. More commonly it is caused by the narrowing of a coronary branch in a process of obliterative endarteritis. The sclerosis is most frequently seen at the apex of the left ventricle and in the septum, but it may occur in any portion. In the septum and walls there are often streaks and patches which are only seen in carefully made systematic sections. Hypertrophy of the heart is commonly associated with this degeneration. It is the invariable precursor of aneurism of the heart. Complete obliteration of one coronary artery, if produced suddenly, is usually fatal. When induced slowly, either by arterio-sclerosis at the ori- fice of the artery at the root of the aorta or by an obliterating endarteritis in the course of the vessel, the circulation may be carried on through the other vessel. Sudden death is not uncommon, owing to thrombosis of a vessel which has become narrowed by sclerosis. In the most extreme grade one coronary artery may be entirely blocked, with the production of extensive fibroid disease, and a main branch of the other also may be occluded. A large, powerfully built imbecile, aged thirty-five, at the Elwyn Institution, Pennsylvania, who had for years enjoyed doing the heavy work about the place, died suddenly, without any preliminary symptoms. The heart, which is in my collection, weighed over twenty ounces; the anterior coronary artery was practically occluded by oblit- erating endarteritis, and of the posterior artery one main branch was occluded. (c) Septic Infarcts.—In pyaemia the smaller branches of the coronary arteries may be blocked with septic emboli and cause infarcts in the myo- cardium in the form of abscesses, varying in size from a pea to a pin’s head. These may not cause any disturbance, but when large they may perforate into the ventricle or into the pericardium, forming what has been called acute ulcer of the heart. 2. Acute Interstitial Myocarditis.—In the fevers and in pericarditis the intermuscular connective tissue is swollen and infiltrated with round cells and nuclei, the vessels are dilated, there are minute extravasations, and the muscle fibres may be granular or fatty, with indistinct strife and nuclei. These instances have been met with in typhoid fever, small- pox, and diphtheria. The muscle substance is pale, soft, and easily torn, and the condition has been described either as inflammatory or degener- ative. AFFECTIONS OF THE MYOCARDIUM. 677 3. Parenchymatous Degeneration.—This is usually met with in fevers, or in connection with endocarditis or pericarditis. It is characterized by a pale, turbid state of the cardiac muscle, which is general, not local- ized. Turbidity and softness are the special features. It is the soft- ened heart of Laennec and Louis. Stokes speaks of an instance in which “ so great was the softening of the organ that when the heart was grasped by the great vessels and held with the apex pointing upward, it fell down over the hand, covering it like a cap of a large mushroom.” Histologically, there is a degeneration of the muscle fibres, which are infiltrated to a various extent with granules which resist the action of ether. Sometimes this granular change in the fibres is extreme, and no trace of the striae can be detected. It is probably the effect of a toxic agent, and is seen in its most exquisite form in the lumbar muscles in cases of toxic haemoglobinuria in the horse. It is met with in cases of typhoid, typhus, small-pox, and other infectious diseases, particularly when the course is protracted. There is no definite relation between it and the high temperature. A form of myocarditis has been described, characterized by fragmenta- tion of the fibres owing to softening of the cement substance. According to von Recklinghausen this is a post-mortem change. 4. Fatty Heart.—Under this term are embraced fatty degeneration and fatty overgrowth. (a) Fatty degeneration is a very common condition, and mild grades are met with in many diseases. It is found in the failing nutrition of old age, of wasting diseases, and of cachectic states; in prolonged infec- tious fevers, in which it may follow or accompany the parenchymatous change; associated with acute and chronic anasmias. Certain poisons, such as phosphorus, produce an intense fatty degeneration. Local causes : Peri- carditis is usually associated with fatty or parenchymatous changes in the superficial layers of the myocardium. Disease of the coronary arteries is a common and important cause. Lastly, in the hypertrophied ventricular wall in chronic heart-disease fatty change is by no means infrequent. This degeneration may be limited to the heart or it may be more or less general in the solid viscera. The diaphragm may also be involved, even when the other muscles show no special changes. There appears to be a special proneness to fatty degeneration in the heart-muscle, which may perhaps be connected with its incessant activity. So great is its need of an abundant oxygen supply that it feels at once any deficiency, and is in consequence the first muscle to show nutritional changes. Anatomically the condition may be local or general. The left ven- tricle is most frequently affected. If the process is advanced and general the heart looks large and is flabby and relaxed. It has a light yellowish- brown tint, or, as it is called, a faded-leaf color. Its consistence is re- duced and the substance tears easily. In the left ventricle the papillary columns and the muscle beneath the endocardium show a streaked or DISEASES OF TI1E CIRCULATORY SYSTEM. patchy appearance. Microscopically, the fibres are seen to be occupied by minute globules distributed in rows along the line of the primitive fibres (Welch). In advanced grades the fibres seem completely occupied by the minute globules. (b) Fatty Overgrowth.—This is usually a simple excess of the normal subpericardial fat, to which the term cor adiposum was given by the older writers. In other instances the fat infiltrates the muscular sub- stance and, separating the strands, may reach even to the endocardium. In corpulent persons there is always much pericardial fat. It forms part of the general obesity, and occasionally leads to dangerous or even fatal impairment of the contractile power of the heart. Of 122 cases analyzed by Forchheimer there were 88 males and 34 females. Over eighty per cent occurred between the fortieth and seventieth years. The entire heart may be enveloped in a thick sheeting of fat through which not a trace of muscle substance can be seen. On section, the fat infiltrates the muscle, separating the fibres, and in extreme cases—particu- larly in the right ventricle—reaches the endocardium. In some places there may be even complete substitution of fat for the muscle substance. In rare instances the fat may be in the papillary muscles. The heart is usual- ly much relaxed and the chambers are dilated. Microscopically the mus- cle fibres may show, in addition to the atrophy, marked fatty degeneration. 5. Other Degenerations of the Myocardium, (a) Brown Atrophy.— This is a common change in the lieart-muscle, particularly in chronic valvular lesions and in the senile heart. When advanced, the color of the muscles is a dark red-brown, and the consistence is usually increased. The fibres present an accumulation of yellow-brown pigment chiefly about the nuclei. The cement substance is often unusually distinct, but seems more fragile than in healthy muscle. (h) Amyloid degeneration of the heart is occasionally seen. It occurs in the intermuscular connective tissue and in the blood-vessels, not in the fibres. (c) The hyaline transformation of Zenker is sometimes met with in prolonged fevers. The affected fibres are swollen, homogeneous, trans- lucent, and the striae are very faint or entirely absent. (d) Calcareous degeneration may occur in the myocardium, and the muscle fibres may be infiltrated and yet retain their appearance as figured and described by Coats in his Text-book of Pathology. Symptoms of Myocardial Disease. —These are notoriously un- certain. A man with advanced fibroid myocarditis may drop dead sud- denly, while doing heavy work, without having complained of cardiac dis- tress. On the other hand, a patient may present enfeebled, irregular action and signs of dilatation; he may have shortness of breath, oedema, and the general symptoms believed to be characteristic of cases of fibroid and fatty heart, and the post-mortem show little or no change in the myocardium. Cardio-sclerosis or fibroid heart is in some cases characterized by a feeble, irregular, slow pulse, with dyspnoea on exertion and occasional at- AFFECTIONS OF THE MYOCARDIUM. 679 tacks of angina. Irregularity is present in many, but not in all cases. The pulse may be very slow, even 30 or 40 per minute. Ultimately the cases come under observation with the symptoms of cardiac insufficiency. The arrhythmia, which may have been present, becomes aggravated and, according to Riegel, may not only precede, but also persist after the car- diac insufficiency has passed away. Fatty degeneration of the heart presents the same difficulties. Extreme fatty changes, as in pernicious anaemia, may be consistent with full, regu- lar pulse and a regularly acting heart. In some of these cases the fat does not appear to interfere seriously with the function of the organ. The truth is it may exist in an extreme grade without producing symptoms, so long as great dilatation of the chambers does not occur. The cardiac irregularity, the dyspnoea, palpitation, and small pulse are in reality not symptoms of the fatty degeneration, but of dilatation which has supervened. The fatty arcus senilis is of no moment in the diagnosis of fatty heart. The heart- sounds may be weak and the action irregular. When dilatation occurs, there is often the gallop rhythm, shortening of the long pause, and a sys- tolic murmur at the apex. Shortness of breath on exertion is an early feature in many cases, and anginal attacks may occur. There is some- times a tendency to syncope, and in both fibroid and fatty heart there are attacks in which the patient feels cold and depressed and the pulse sinks to 40 or 30, or even, as in one case which I saw, to 26. The patient may wake from sleep in the early morning with an attack of severe cardiac asthma. These “ spells ” may be associated with nausea and may alter- nate with others in which there are anginal symptoms. These are the cases, too, in which for weeks there may be mental symptoms. The pa- tient has delusions and may even become maniacal. Toward the close, the type of breathing known as Cheyne-Stokes may occur. It was de- scribed in the following terms by John Cheyne, speaking of a case of fatty heart (Dublin Hospital Reports, vol. ii, p. 221, 1818) : “For several days his breathing was irregular; it would entirely cease for a quarter of a minute, then it would become perceptible, though very low, then by degrees it became heaving and quick, and then it would gradually cease again: this revolution in the state of his breathing lasted about a minute, during which there were about thirty acts of respiration.” It is seen much more frequently in arterio-sclerosis and uraemic states than in fatty heart. Fatty overgrowth of the heart is a condition certain to exist in very obese persons. It produces no symptoms until the muscular fibre is so weakened that dilatation occurs. These patients may for years present a feeble but regular pulse; the heart-sounds are weak and muffled, and a murmur may be heard at the apex. Attacks of cardiac asthma are not uncommon, and the patient may suffer from bronchitis. Dizziness and pseudo-apoplectic seizures may occur. Sudden death may result from syncope or from rupture of the heart. The physical examination is often difficult because of the great increase in the fat, and it may be impossible to define the area of dulness. 680 DISEASES OF THE CIRCULATORY SYSTEM. For practical purposes we may group the cases of myocardial disease as follows: (1) Those in which sudden death occurs with or without previous indications of heart-trouble. Sclerosis of the coronary arteries exists —in some instances with recent thrombus and white infarcts; in others, extensive fibroid disease; in others again, fatty degeneration. Many patients never complain of cardiac distress, but, as in the case of Chal- mers, the celebrated Scottish divine, enjoy unusual vigor of mind and body. (2) Cases in which there are cardiac arrhythmia, shortness of breath on exertion, attacks of cardiac asthma, sometimes anginal attacks, collapse symptoms with sweats and extremely slow pulse, and occasionally marked mental symptoms. These are the cases in which the condition may be strongly suspected and, in some instances, diagnosed. It is rarely possible to make a distinction between the fatty and fibroid heart. (3) Cases in which there are cardiac insufficiency and symptoms of dila- tation of the heart. Dropsy is often present, and with a loud murmur at the apex it may be difficult, unless the case has been seen from the outset, to determine whether or not a valvular lesion is present. Prognosis.—The outlook in affections of the myocardium is ex- tremely grave. Patients recover, however, in a surprising way from the most serious attacks, particularly those of the second group. Treatment.—Many cases never come under treatment; the first are the final symptoms. Cases with signs of well-marked cardiac insufficiency, as manifested by dyspnoea, weak, irregular, rapid heart, and oedema, may be treated on the plan laid down for the treatment of broken compensation in valvular dis- ease. Digitalis may be given even if fatty degeneration is suspected, and is often very beneficial. Much more difficult is the management of those cases in which there is marked cardiac arrhythmia, with a feeble, irregular, very slow pulse, and syncope or angina. Dropsy is not, as a rule, present; the heart- sounds may be perfectly clear, and there are no signs of dilatation. Di- gitalis, under these circumstances, is not advisable, particularly when the pulse is infrequent. Complete rest in bed, a carefully regulated diet, and the use of the aromatic spirits of ammonia, sulphuric ether, and stimulants are indicated. For the restlessness and distressing feelings of anxiety mor- phia is invaluable. From an eightieth to a sixtieth of a grain of strychnia may be given three times a day. If, as is sometimes the case, the pulse is hard and firm, nitroglycerin may be cautiously administered, beginning with one minim of the one per cent solution three times a day and in- creased gradually. In certain cases of weak heart, particularly when it is due to fatty over- growth, the plans recommended by Oertel and by Schott are advanta- geous. They are invaluable methods in those forms of heart-weakness AFFECTIONS OF THE MYOCARDIUM. 681 due to intemperance in eating and drinking and defective bodily exer- cise. The Oertel plan consists of three parts: First, the reduction in the amount of liquid. This is an important factor in reducing the fat in these patients. It also slightly increases the density of the blood. Oertel allows daily about thirty-six ounces of liquid, which includes the amount taken with the solid food. Free perspiration is promoted by bathing (if advisable, the Turkish bath), or even by the use of pilocarpine. The second important point in his treatment is the diet, which should consist largely of proteids. Morning.—Cup of coffee or tea, with a little milk, about six ounces altogether. Bread, three ounces. Noon.—Three to four ounces of soup, seven to eight ounces of roast beef, veal, game, or poultry, salad or a light vegetable, a little fish; one ounce of bread or farinaceous pudding; three to six ounces of fruit for dessert. No liquids at this meal, as a rule, but in hot weather six ounces of light wine may be taken. Afternoon.—Six ounces of coffee or tea, with as much water. As an indulgence an ounce of bread. Evening.—One or two soft-boiled eggs, an ounce of bread, perhaps a small slice of cheese, salad, and fruit; six to eight ounces of wine with four or five ounces of water (Yeo). The most important element of all is graduated exercise, not on the level, but up hills of various grades. The distance walked each day is marked off and is gradually lengthened. In this way the heart is sys- tematically exercised and strengthened. At the Bad Nauheim, under Schott, good results are obtained by a combination of stimulating C02 baths and a system of “ resistance gym- nastics ” in which the patient makes certain definite movements of each limb in succession, which are resisted by the attendant. Cases of fatty overgrowth of the heart are those most suitable. The plan of treatment reduces the obesity, and the patients are, for a time at least, much more comfortable and are able to go about and do their work without cardiac distress or great shortness of breath. Aneurism of the Heart. {a) Aneurism of a Valve results from acute endocarditis, which pro- duces softening or erosion and may lead either to perforation of the seg- ment or to gradual dilatation of a limited area under the influence of the blood-pressure. The aneurisms are usually spheroidal and project from the ventricular face of a sigmoid valve. They are much less common on the mitral segments. They frequently rupture and produce extensive destruction and incompetency of the valves. (b) Aneurism of the Walls.—This comparatively rare condition results from the weakening of the walls by chronic myocarditis, or occasionally 682 DISEASES OF THE CIRCULATORY SYSTEM. it follows mural endocarditis, which more commonly, however, leads to perforation. Aneurism has followed a stab-wound of the heart. The left ventricle near the apex is usually the seat, at the situation in which the fibrous degeneration is most common. Fifty-nine of the 90 cases collected by Legg were situated here. In the early stages the ante- rior wall of the ventricle, near the septum, sometimes involving the septum itself, is slightly dilated, the endocardium opaque, and the muscular tissue sclerotic. In a more advanced stage the dilatation is pronounced and layers of thrombi occupy the sac. Ultimately a large rounded tumor may project from the ventricle and may attain a size equal to that of the heart Occasionally the aneurism is sacculated and communicates with the ven- tricle through a very small orifice. The sac may be double, as in a case reported by Janeway. In the museum of Guy’s Hospital there is a speci- men showing the wall of the ventricle covered with aneurismal bulgings. Kupture occurred in 7 of the 90 cases collected by Legg. The symptoms produced by aneurism of the heart are indefinite. Oc- casionally there is marked bulging in the apex region and the tumor may perforate the chest wall. When the sac is large and produces pressure upon the heart itself, there may be a marked disproportion between the strong cardiac impulse and the feeble pulsation in the peripheral arteries. Rupture of the Heart. This rare event is usually associated with fatty infiltration or degenera- tion of the heart-muscles. In some instances, acute softening in conse- quence of embolism of a branch of the coronary artery, suppurative myo- carditis, or a gummatous growth has been the cause. Of 100 cases col- lected by Quain, fatty degeneration was noted in 77. Two thirds of the patients were over sixty years of age.. The rent may occur in any of the chambers, but is found most fre- quently in the left ventricle on the anterior wall, not far from the septum. The accident usually takes place during exertion. There may be no pre- liminary symptoms, but without any warning the patient may fall and die in a few moments. Sudden death occurred in seventy-one per cent of Quain’s cases. In other instances there may be in the cardiac region a sense of anguish and suffocation, and life may be prolonged for several hours. In a Montreal case which I examined the patient walked up a steep hill after the onset of the symptoms, and lived for thirteen hours. A case is on record in which the patient lived for eleven days. New Growths and Parasites. Tubercle and syphilis have already been considered. Primary cancer or sarcoma is extremely rare. Secondary tumors may be single or mul- tiple, and are usually unattended with symptoms, even when the disease AFFECTIONS OF THE MYOCARDIUM. 683 is most extensive. In one case I found in the wall of the right ventricle a mass which involved the anterior segment of the tricuspid valve and partly blocked the orifice. The surface was eroded and there were nu- merous cancerous emboli in the pulmonary artery. In another instance the heart was greatly enlarged, owing to the presence of innumerable masses of colloid cancer the size of cherries. The mediastinal sarcoma may penetrate the heart, though it is remarkable how extensive the dis- ease of the mediastinal glands may be without involvement of the heart or vessels. Cysts in the heart are rare. They are found in different parts, and are filled either with a brownish or a clear fluid. Blood-cysts occasionally occur. The parasites will be discussed under the appropriate section, but it may be mentioned here that both the cysticercus celluloses and the echino- coccus cysts occur occasionally in the heart. Wounds and Foreign Bodies. Wounds of the heart are usually fatal, although there are many in- stances in which recovery has taken place. Bullets have been found en- cysted inside the ventricle. A majority of the cases of gunshot wounds, however, are necessarily fatal. Puncture of the heart by a sharp-point- ed body, such as a needle or a stiletto, does not always prove fatal. Peabody has reported a case in which a pin was found embedded in the left ventricle. Suicide has been attempted by passing a needle or pin into the heart. It is not, however, necessarily fatal. Moxon mentioned a case, at the Clinical Society of London, in which a medical student, while on a spree, passed a pin into his heart. The pericardium was opened, and the head of the pin was found outside of the right ventricle. It was grasped and an attempt made to remove it, but it was withdrawn into the heart and, it is said, caused the patient no further trouble. Hysterical girls sometimes swallow pins and needles, which, passing through the oesophagus and stomach, are found in various parts of the body. A re- markable case is reported by Allen J. Smith of a girl from whom several dozen needles and pins were removed, usually from subcutaneous abscesses. Several years later she developed symptoms of chronic heart-disease. At the post-mortem needles were found in the tissues of the adherent peri- cardium, and between thirty and forty were embedded in the thickened pleural membranes of the left side. Puncture of the heart has been recommended as a therapeutic pro- cedure to stimulate it to action, as in chloroform narcosis, and experi- mental evidence has been brought forward by B. A. Watson in favor of the operation. He advises abstraction of blood in combination with the puncture—cardiocentesis. The proceeding is not without risk. Haemor- rhage may take place from the puncture, though it is not often extensive. 684 DISEASES OF TEE CIRCULATORY SYSTEM. Sloan has recently urged its use in all cases of asphyxia and in suffo- cation by drowning and from coal-gas. The successful case which he re- ports illustrates forcibly its stimulating action. V. NEUROSES OF THE HEART. Palpitation. In health we are unconscious of the action of the heart. In some peo- ple one of the first indications of debility or overwork is the consciousness of the cardiac pulsations, which may, however, be perfectly regular and orderly. This is not palpitation. The term is properly limited to irregu- lar or forcible action of the heart perceptible to the individual. Etiology.—The expression “ perceptible to the individual ” covers the essential element in palpitation of the heart. The most extreme dis- turbance of rhythm, a condition even of what is termed delirium cordis, may be unattended with subjective sensations of distress, and there may be no consciousness of disturbed action. On the other hand, there are cases in which complaint is made of the most distressing palpitation and sensations of throbbing, in which the physical examination reveals a regu- larly acting heart, the sensations being entirely subjective. Vie meet with this symptom in a large group of cases in which there is increased excita- bility of the nervous system. Palpitation may be a marked feature at the time of puberty, at the climacteric, and occasionally during menstruation. It is a very common symptom in hysteria and neurasthenia, particularly in the form of the latter which is associated with dyspepsia. Emotions, such as fright, are common causes of palpitation. It may occur as a sequence of the acute fevers. Females are more liable to the affection than males. In a second group the palpitation results from the action upon the heart of certain substances, such as tobacco, coffee, tea, and alcohol. And, lastly, palpitation may be associated with organic disease of the heart, either of the myocardium or of the valves. As a rule, however, it is a purely nervous phenomenon—seldom associated with organic disease—in which the most violent action and the most extreme irregularity may exist without that subjective element of consciousness of the disturbance which constitutes the essential feature of palpitation. The irritable heart described by Da Costa, which was so common among the young soldiers during the civil war, is a neurosis of this kind. The chief symptoms were palpitation with great frequency of the pulse on ex- ertion, a variable amount of cardiac pain, and dyspnoea. The factors at work in producing this condition appeared to be the mental excitement, the unwonted muscular exertion associated with the drill, and diarrhoea. NEUROSES OF THE HEART. 685 The condition is not infrequent in civil life among young men, and it leads in some cases to hypertrophy of the heart. Symptoms.—In the mildest form, such as occurs during a dys- peptic attack, there is slight fluttering of the heart and a sense of what patients sometimes call “goneness.” In more severe attacks the heart beats violently, its pulsations against the chest wall are visible, the rapidity of the action is much increased, the arteries throb forcibly, and there is a sense of great distress. In some instances the heart’s action is not at all quickened. The most striking cases are in neurasthenic women, in whom the mere entrance of a person into the room will cause the most violent action of the heart and throbbing of the peripheral arteries. The pulse may be rapidly increased until it reaches 150 or 160. A diffuse flushing of the skin may appear at the same time. After such attacks, there may be the passage of a large quantity of pale urine. In many cases of palpi- tation, particularly in young men, the condition is at once relieved by exertion. A patient with extreme irregularity of the heart may, after ■walking quickly one hundred yards or running up-stairs, return with the pulse perfectly regular. This is not infrequently seen, too, in the irregu- lar action of the heart in mitral-valve disease. The physical examination of the heart is usually negative. The sounds, the shock of which may be very palpable, are on auscultation clear, ringing, and metallic, but not associated with murmurs. The second sound at the base may be greatly accentuated. A murmur may sometimes be heard over the pulmonary artery or even at the apex in cases of rapid action in neurasthenia or in severe anaemia. The attacks may be transient, lasting only for a few minutes, or may persist for an hour or more. In some in- stances any attempt at exertion renews the attack. The progtiosis is usually good, though it may be extremely difficult to remove the conditions underlying the palpitation. Arrhythmia. An intermission occurs when one or more beats of the heart are dropped. Irregularity is the condition when the beats are unequal in vol- ume and force, or follow each other at unequal distances. Allorrhythmia is a term which is also used to express deviations from the normal heart rhythm. The following varieties of arrhythmical action may be recognized : (1) The paradoxical pulse of Kussmaul, in which the beats during inspiration are more frequent but less full than during expiration. This is found in weak heart, in chronic pericarditis, and when fibrous bands encircle the root of the aorta; but it may also occur normally from the influence of the respirations upon the heart. It is sometimes to be felt in sleeping children. (2) Intermittence, in which there is simply an intermission or drop- 686 DISEASES OF THE CIRCULATORY SYSTEM. ping of a cardiac beat. The term deficience is more correctly applied to those instances in which the absence of the heart-sound proves that the systole is really omitted. The systole may be so weak as not to produce a pulsation, and yet at the same time a feeble first sound may be heard. (3) The alternate heart-beat, in which strong and weak pulsations alternate regularly and which is expressed in the peripheral arteries by alternate full and feeble pulse-beats. (4) The bigeminal and trigeminal pulsations occur when two or three beats follow each other in rapid succession, each group being separated from the following by a longer interval. This is not very uncommon in mitral disease and as an effect of digitalis. In the bigeminal pulse the first beat of the pair is usually the stronger. Indeed, in the condition known as heart bigeminisin the second systole is so feeble that the pulse wave does not reach the peripheral arteries and the two systoles are repre- sented by only a single pulse-beat at the wrist. (5) Delirium cordis, in which these various factors are combined and the heart’s action is wholly irregular. (6) Foetal heart rhythm—embryocardia—described by Stokes, is a very common condition in which the long pause is shortened and the characters of the sounds are “ almost completely identical.” The resem- blance to the foetal heart-beat is very striking. In the later stages of fevers and in extreme dilatation this form of heart rhythm is very fre- quently heard. (7) Gallop rhythm, in which the sounds resemble the footfall of a horse at canter, usually results from the reduplication of the second sound in a rapidly acting heart. It is expressed by the words '* rat- ta-tat.” Sometimes it seems as if the first sound was split; more com- monly it is the second. It is most frequently heard in interstitial ne- phritis and arterio-sclerosis, but it is said to be met with also in healthy persons. The causes of these various disturbances of rhythm are thus classified by G. Baumgarten : * (1) Those due to central—cerebral—causes, either organic disease, as in haemorrhage, or concussion; more commonly psychical influences. (2) Keflex influences, such as produce the cardiac irregularity in dys- pepsia and diseases of the liver, lungs, and kidneys. (3) Toxic influences. Tobacco, coffee, and tea are common causes of arrhythmia. Various drugs, such as digitalis, belladonna, and aconite, may also induce it. (4) Changes in the heart itself, (a) In the cardiac ganglia. Fatty, pigmentary, and sclerotic changes have been described in cases of this sort and may have an important influence in producing disturbances in the rhythm; but as yet we do not know their exact significance. They * Transactions of the Association of American Physicians, vol. iii. NEUROSES OF THE HEART. may be present in cases which have not presented arrhythmia. (3) Mural changes are common in conditions of this kind. Simple dilatation, fatty degeneration, and sclerosis are most commonly present, the two latter usually associated with sclerosis of the coronary arteries. The significance of arrhythmia is not always easy to determine. Sim- ple irregular action of the heart may persist for years. The late Chan- cellor Ferrier, of McGill University, a man of unusual bodily and mental vigor, who died at the age of eighty-seven, had an extremely irregular pulse for almost fifty years of his life. One or two other instances have come under my notice of persons in good health, without arterial or car- diac disease, in whom the heart’s action was persistently irregular. The bigeminal and trigeminal pulsations are found more frequently in mitral than in other conditions. The delirium cordis is met with in the dilata- tion associated with valvular lesions, particularly toward the latter stages. Fcetal heart rhythm is rarely found apart from dilatation. Kapid Heart—Tachycardia. The rapid action may be perfectly natural. There are individuals whose normal heart action is at 100 or even more per minute. It may be caused by the various conditions which induce palpitation; but the two are not necessarily associated. Emotional causes, violent exercise, and fevers all produce great increase in the rapidity of the heart’s action. The extremely rapid action which follows fright may persist for days, or even weeks. Traube reports an instance in which, after violent exercise, the rapid action of the heart continued. Cases are not uncommon at the menopause. There are cases again in which the condition can hardly be termed a neurosis, since it depends upon definite changes in the pneumogastrics or in the medulla. Cases have been reported in which tumor or clot in or about the medulla or pressure upon the vagi has been associated with heart hurry. Some of the cases of frequent action of the heart in women have been thought to be due to reflex irritation from ovarian or uterine disease. Paroxysmal tachycardia is a remarkable affection, characterized by spells of heart hurry, during which the action is greatly increased, the pulse reaching 200 and over. The cases are not common. The condition has been thoroughly studied by Nothnagel. The attack may be quite short and persist only for an hour or so. A patient at the Philadelphia Infirmary for Nervous Diseases was attacked every week or two; the pulse would rise to 220 or 230, and there were such feelings of distress and un- easiness that the patient always had to lie down. There may be, however, no subjective disturbance, and in another case the patient was able to walk about during the paroxysm and had no dyspnoea. One of the most remarkable cases is reported by H. C. AYood< A physician in his eighty- DISEASES OF THE CIRCULATORY SYSTEM. seventh year has had attacks at intervals since his thirty-seventh year. The onset is abrupt and the pulse rapidly rises to 200 a minute. For more than twenty years the taking of ice-water or strong coffee would arrest the attacks. Bouveret has analyzed a number of cases of this essential or idiopathic form; he finds that a permanent cure is rare, and that the pa- tients suffer for ten or more years. Four instances terminated fatally from heart-failure. Wood suggests that these cardiac paroxysms are caused by discharging lesions affecting the centres of the accelerator nerves. Franqois Franck has shown that the acceleration of the heart’s action is due to the shortening of the diastole, and during the systole so little blood is expelled from the heart that the average amount in the minute is not increased. Moreover, the accelerators appear to have no trophic relation to the heart, and stimulation of them is not accompanied either by in- creased arterial pressure or by augmentation of the work done by the heart. Slow Heart—Brachycardia (Bradycardia). Slow action of the heart is sometimes normal and may be a family peculiarity. Napoleon is stated to have had a pulse of only 40 per minute. In any case of slow pulse it is important first to make sure that the number of heart, and arterial beats correspond. In many instances this is not the case, and with a radial pulse at 40 the cardiac pulsations may be 80, half the beats not reaching the wrist. The heart contractions, not the pulse wave, should be taken into account. A most exhaustive study of this condition has been made recently by Riegel, whose division is here followed: (a) Physiological brachycardia. In the puerperal state the pulse may beat from 44 to 60 per minute, or may even be as low as 34. It is seen in premature labor as well as at term. The explanation of its occurrence at this period is not clear. Slowness of the pulse is associated with hunger.' Brachycardia depending on individual peculiarity is extremely rare. (b) Pathological brachycardia, which is met with under the following conditions: (1) In convalescence from acute fevers. This is extremely common, particularly after pneumonia, typhoid fever, acute rheumatism, and diphtheria. It is most frequently seen in young persons and in cases which have run a normal course. Traube’s explanation that it is due to exhaustion is probably the correct one. (2) In diseases of the digestive system, such as chronic dyspepsia, ulcer or cancer of the stomach, and jaundice. The largest number of Riegel’s cases were of this group. (3) In diseases of the respiratory system. Here it is by no means so common, but is seen not infrequently in emphysema. (4) In diseases of the circu- latory system. Excluding all cases of irregularity of the heart, brachy- cardia is not common in diseases of the valves. It is most frequently seen in fatty and fibroid changes in the heart, but is not constant in them. (5) In diseases of the urinary organs. It occurs occasionally in nephritis and NEUROSES OF THE HEART. 689 may be a feature of uraemia. (6) From the action of toxic agents. It occurs in uraemia, poisoning by lead, alcohol, and follows the use of to- bacco, coffee, and digitalis. (7) In constitutional disorders, such as anae- mia, chlorosis, and diabetes. (8) In diseases of the nervous system. Apoplexy, epilepsy, the cerebral tumors, affections of the medulla, and diseases and injuries of the cervical cord may be associated with very slow pulse. In general paresis, mania, and melancholia it is not infrequent. (9) It occurs occasionally in affections of the skin and sexual organs, and in sunstroke, or in prolonged exhaustion from any cause. It is seen most frequently in the convalescence from acute fevers, then in disorders of the digestive system. The significance of this symptom is variable. It is only in diseases of the heart or brain that it is ominous. It may be due to direct irritation of the vagi, to diminished excitability of the cardiac ganglia, to reflex influences acting upon the vagus centre, or to weakness of the heart-muscle itself. The pulse-beat rarely sinks be- low 20. Prentiss, at the Association of American Physicians at Wash- ington, showed a patient with attacks of unconsciousness, who had, par- ticularly during the attacks, but also in the intervals, a pulse as low as 12 per minute. Such cases are extremely rare. Cases are on record in which the pulse has fallen to 8 or 9 beats in the minute. At the dis- cussion which followed the exhibition of Prentice’s patient, both Jacobi and Kinnicutt referred to similar cases associated with epileptic seizures, in one of which the pulse fell as low as 7 in the minute. Treatment of Palpitation and Arrhythmia.—An important element in many cases is to get the patient’s mind quieted, and he can be assured that there is no actual danger. The mental element is oftentimes very strong. In palpitation, before using medicines, it is well to try the effect of hygienic measures. As a rule, moderate exercise may be taken with advantage. Regular hours should be kept, and at least ten hours out of the twenty-four should be spent in the recumbent posture. A tepid bath may be taken in the morning, or, if the patient is weakly and nerv- ous, in the evening, followed by a thorough rubbing. Hot baths and the Turkish bath should be avoided. The dietetic management is most im- portant. It is best to prohibit absolutely alcohol, tea, and coffee. The diet should be light and the patient should avoid taking large meals. Articles of food known to cause flatulency should not be used. If a smoker, the patient should give up tobacco. Sexual excitement is par- ticularly pernicious, and the patient should be warned specially on this point. For the distressing attacks of palpitation which occur with neur- asthenia, particularly in women, a rigid Weir-Mitchell course is the most satisfactory. It is in these cases that we find the most distressing throb- bing in the abdomen, which is apt to come on after meals, and is very much aggravated by flatulency. The cases of palpitation due to excesses or to errors in diet and dyspepsia are readily remedied by hygienic meas- ures. 690 DISEASES OF THE CIRCULATORY SYSTEM. A course of iron is often useful. Strychnia is particularly valuable, and is perhaps best administered as the tincture of nux vomica in large doses. Very little good is obtained from the smaller quantities. It should be given freely, 20 minims three times a day. If there is great rapidity of action, aconite may be tried or veratrum viride. There are cases associated with sleeplessness and restlessness which are greatly benefited by bromide of potassium. Digitalis is very rarely indicated, but in obstinate cases it may be tried with the nux vomica. Cases of heart hurry are often extremely obstinate, as may be judged from the case of the physician reported by II. C. Wood, in whom the con- dition persisted in spite of all measures for fifty years. The bromides are sometimes useful; the general condition of neurasthenia should be treated, and during the paroxysm an ice-bag may be placed upon the heart, or Leiter’s coil, through which ice-water may be passed. Electricity, in the form of galvanism, is sometimes serviceable, and for its mental effect the Franklinic current. For the condition of slow pulse but little can be done. A great majority of the cases are not dangerous. Angina Pectoeis. Stenocardia, or the breast-pang described by Heberden, is not an inde- pendent affection, but a symptom associated with a number of morbid conditions of the heart and vessels, more particularly with sclerosis of the root of the aorta and changes in the coronary arteries. True angina, which is a rare disease, is characterized by paroxysms of agonizing pain in the region of the heart, extending into the arms and neck. In violent attacks there is a sensation of impending death. Etiology and Pathology.—It is a disease of adult life and occurs almost exclusively in men. Arterio-sclerosis, hypertrophy of the heart, increased arterial tension, or aortic insufficiency are often present, while anatomical changes in the aorta, arteries, and myocardium are almost constant. No instance of true angina has come under my observation in which there were not signs of cardio-vascular changes. The immediate exciting cause of an attack is most frequently sudden exertion or emo- tional excitement. The paroxysm may come on in the daytime, but in some of the worst cases, they occur at night. The nature of the affection is doubtful. The following views have been entertained. (1) That it is a neuralgia of the cardiac nerves. In the true form the agonizing cramp-like character of the pain, the suddenness of the onset, and the associated features, are unlike any neuralgic affection. The pain, however, is undoubtedly in the cardiac plexus and radiates, to adjacent nerves. It is interesting to note in connection with the almost constant sclerosis of the coronary arteries in angina that Thoma has found marked sclerosis of the temporal artery in migraine and Dana has met with local thickening of the arteries in some cases of neuralgia (2) Ileb- NEUROSES OF THE HEART. 691 erden believed that it was a cramp of the heart-muscle itself. Cramp of certain muscular territories would better explain the attack. (3) That it is due to the extreme tension of the ventricular walls, in consequence of an rfcute dilatation associated, in the majority of cases, with affection of the coronary arteries. Traube, who supported this view, held that the agonizing pain resulted from the great stretching and tension of the nerves in the muscular substance. A modified form of this view is that there is a spasm of the coronary arteries with great increase of the intra- cardiac pressure. (4) The theory of Allan Burns, revived by Potain and others, that the condition is one of transient ischaemia of the heart muscle in conse- quence of disease, or spasm, of the coronary arteries. The condition known as intermittent claudication illustrates what may take place. In man (and in the horse), in consequence of thrombosis of the abdominal aorta or iliacs, transient paraplegia and spasm may follow exertion. The collateral circulation, ample when the limbs are at rest, is insufficient after the muscles are actively used, and a state of relative ischaemia is induced with loss of power, which disappears in a short time. This “ intermittent claudication ” theory has been applied to explain the angina paroxysm. A heart the coronary arteries of which are sclerotic or calcified, is in an anal- ogous state, and any extra exertion is likely to be followed by a relative ischaemia and spasm. In Allan Burns’s work on The Heart (1809) the theory is discussed at length, but he does not think that spasm is a neces- sary accompaniment of the ischaemia. In fatal cases of angina the coronary arteries are almost invariably diseased either in their main divisions, or there is chronic endarteritis with great narrowing of the orifices at the root of the aorta. Experimentally, occlusion of the coronary arteries produces slowing of the heart’s action, gradual dilatation, and death within a very few minutes. Cohnheim has shown that in the dog ligation of one of the large coronary branches pro- duces within a minute a condition of arrhythmia, and within two minutes the heart ceases in diastole. These experiments, however, do not throw much light upon the etiology of angina pectoris. Extreme sclerosis of the coronary arteries is common, and a large majority of the cases present no symptoms of angina. Even in the cases of sudden death due to block- ing of an artery, particularly the anterior branch of the coronary artery, there is usually no great pain either before or during the attack. The lesions of the nerves described by Lancereaux, Hadden, and others cannot yet be correlated satisfactorily with the symptoms of true angina. Vari- ous forms have been recognized, but the differences, in the majority of instances, are not sufficiently marked to permit a separation. Reference may be made, however, to the angina pectoris vaso-motoria described by Nothnagel. In this the attack may come on after exposure to cold. There is general spasm of the peripheral arteries with a sense of stiffness and deadness in the extremities, and pallor, cyanosis, and lowering of 692 DISEASES OF THE CIRCULATORY SYSTEM. the temperature. The arteries are small and contracted. There is some- times a feeling of faintness or even a loss of consciousness. With this there is a sense of pressure, tension, or even agonizing pain in the car- diac region. The pulse, however, is regular, and there are no signs of disease of the heart. The condition is supposed to depend upon a wide- spread spasm of the peripheral arteries. Tobacco angina is a rare but well-recognized form, in which the paroxysm may be typical and of great intensity; more commonly we meet with attacks of heart-pain with irreg- ular action. Symptoms.—Usually during exertion or intense mental emotion the patient is seized with an agonizing pain in the region of the heart and a sense of constriction, as if the heart had been seized in a vise. The pains radiate up the neck and down the arm and, there may be numbness of the fingers or in the cardiac region. The face is usually pallid and may as- sume an ashy-gray tint, and not infrequently a profuse sweat breaks out over the surface. Dyspnoea is not usually present. The paroxysm lasts from several seconds to a minute or two, during which, in severe attacks, the patient feels as if death were imminent. As pointed out by Latham, there are two elements in the paroxysm, the pain—dolor pectoris—and the indescribable feeling of anguish and sense of imminent dissolution— angor animi. There are great restlessness and anxiety, and the patient may drop dead at the height of the attack or faint and pass away in syn- cope. The condition of the heart during the attack is variable; the pul- sations may be uniform and regular. The pulse tension, however, is usu- ally increased, but it is surprising, even in cases of extreme severity, how slightly the character of the pulse may be altered. After the attack there may be eructations, or the passage of a large quantity of clear urine. The patient usually feels exhausted, and for a day or two may be badly shaken ; in other instances in an hour or two the patient feels himself again. The attacks may recur at intervals of a few weeks, or perhaps not for many years. There are individuals who have well-marked anginal attacks for years, and, except during the paroxysms, suffer but slight inconvenience. With reference to the radiation of pain in angina the studies of Mac- kenzie and of Head are of great interest. Head concludes that (1) in dis- eases of the heart, and more particularly in aortic disease, the pain is re- ferred along the first, second, third, and fourth dorsal areas; (2) in angina pectoris the pain may be referred in addition along the fifth, sixth, and seventh, and even the eighth and ninth dorsal areas, and is always ac- companied by pain in certain cervical areas (see page 828). Diagnosis.—There are many grades of true angina. A man may have slight prascordial pain, a sense of distress and uneasiness, and radia- tion of the pains to the arm and neck. Such attacks following slight ex- ertion, an indiscretion in diet, or a disturbing emotion may alternate with attacks of much greater severity, or they may occur in connection with a pulse of increased tension and signs of general arterio-sclerosis. In the NEUROSES OF THE HEART. 693 milder grades the diagnosis cannot rest upon the symptoms of the attack itself, since they may be simulated by the pseudo-angina; but the diag- nosis should be based upon the examination of the circulatory system. In true angina, even in the milder forms, signs of arterio-sclerosis are usually present. In a case presenting attacks of praecordial pain or pains in the cervical or brachial plexuses, if the aortic second sound is clear, not ringing, the pulse tension low, and the peripheral arteries soft, the diag- nosis of true angina should not be made. After all, the chief difficulty, however, arises in the cases of the hysterical or pseudo-angina. This is a common affection in women, but may occur also in neuras- thenic men. It is in this form particularly that we see vaso-motor phe- nomena. The patient may complain of great coldness of the hands or feet, or a general feeling of deadness and stiffness, often with pain in the back of the head and neck. The attacks recur frequently, and sometimes become worse at each monthly period. They may come on with great severity at the menopause. Worry and disturbing emotions of all kinds may at any time precipitate an attack. Huchard has given in concise form the following points in diagnosis between the true and hysterical angina: TRUE ANGINA. PSEUDO-ANGINA. Most common between the ages of forty and fifty years. At every age, even six years. Most common in men. Attacks brought on by exertion. Most common in women. At- tacks spontaneous. Attacks rarely periodical or noc- turnal. Often periodical and nocturnal. Not associated with other symp- toms. Associated with nervous symp- toms. Yaso-motor form rare. Agoniz- ing pain and sensation of compres- sion by a vise. Yaso-motor form common. Pain less severe; sensation of dis- tention. Pain of short duration. Atti- tude : silence, immobility. Pain lasts one or two hours. Agitation and activity. Lesions: sclerosis of coronary artery. Neuralgia of nerves and cardio- plexus. Prognosis grave, often fatal. Never fatal. Arterial medication. Antineuralgic medication. There are cases in women which are sometimes very puzzling; for instance, when the patient presents a combination of marked hysterical manifestations and attacks of angina and has aortic insufficiency. In such instances the patient should receive the benefit of the doubt and be treated for true angina. 694 DISEASES OF THE CIRCULATORY SYSTEM. Prognosis.—Cardiac pain without evidence of arterio-sclerosis or valve disease is not of much moment. True angina is almost invariably associated with marked cardio-vascular lesions in which the prognosis is always grave. With judicious treatment the attacks, however, may be long deferred, and a few instances recover completely. The prognosis is naturally more serious with aortic insufficiency and advanced arterio- sclerosis. Patients who have had well-marked attacks may live for many years, but much depends upon the care with which they regulate their daily life. Treatment.—Patients subject to this affection should live a quiet life, avoiding particularly excitement and sudden muscular exertion. During the attack nitrite of amyl should be inhaled, as advised by Lauder Brunton. From two to five drops may be placed upon cotton-wool in a tumbler or upon the handkerchief. This is frequently of great service in the attack, relieving the agonizing pain and distress. Subjects of the dis- ease should carry the perles of the nitrite of amyl with them, and use them on the first indication of an attack. In some instances the nitrite of amyl is quite powerless, though given freely. If within a minute or two relief is not obtained in this way, chloroform should at once be given. A few in- halations act promptly and give great relief. Should the pains continue, a hypodermic of morphia may be administered. In severe and repeated paroxysms a patient may display remarkable resistance to the action of this drug. In the intervals, nitroglycerin may be given in full doses, as recom- mended by Murrell, or the nitrate of sodium (Matthew Hay). The nitro- glycerin should be used for a long time and in increasing doses, beginning with one minim three times a day of the one per cent solution, and in- creasing the dose one minim every five or six days until the patient com- plains of flushing or headache. Huchard recommends the iodides, believing that their prolonged use influences the arterio-sclerosis. Twenty grains three times a day may be given for several years, omitting the medicine for about ten days in each month. In some instances this treatment is certainly beneficial. Two men, both with arterio-sclerosis, ringing, accentuated aortic sound, and attacks of true angina, have under its use remained practically free from attacks—one case for nearly three, and the other for fully eight years. This treatment is, however, not always satisfactory, and I have had several cases in which the condition has not been at all relieved by it. For the pseudo-angina, the treatment must be directed to the general nervous condition. Electricity is sometimes very beneficial, particularly the Franklinic form. CONGENITAL AFFECTIONS OF THE HEART. 695 VI. CONGENITAL AFFECTIONS OF THE HEART. These have only a limited clinical interest, as in a large propor- tion of the cases the anomaly is not compatible with life, and in others nothing can be done to remedy the defect or even to relieve the symp- toms. The congenital affections result from interruption of the normal course of development or from inflammatory processes—endocarditis; sometimes from a combination of both. (a) Of general anomalies of development the following conditions may be mentioned : Acardia, absence of the heart, which has been met with in the monstrosity known by the same name; double heart, which has occasionally been found in extreme grades of foetal deformity; dextro- cardia, in which the heart is on the right side, either alone or as part of a general transposition of the viscera; ectopia cordis, a condition asso- ciated with fission of the chest wall and of the abdomen. The heart may be situated in the cervical, pectoral, or abdominal regions. Except in the abdominal variety the condition is very rarely compatible with extra- uterine life. (h) Anomalies of the Cardiac Septa.—The septa of both auricles and ventricles may be defective, in which case the heart consists of but two chambers, the cor biloculare or reptilian heart. In the septum of the auri- cles there is a very common defect, owing to the fact that the membrane closing the foramen ovale has failed at one point to become attached to the ring, and leaves a valvular slit which may be large enough to admit the 696 DISEASES OF THE CIRCULATORY SYSTEM. handle of a scalpel. Neither this nor the small cribriform perforations of the membrane are of any significance. The foramen ovale may be patent without a trace of membrane clos- ing it. In some instances this exists with other serious defects, such as stenosis of the pulmonary artery, or imperfection of the ventricular sep- tum. In others the patent foramen ovale is the only anomaly, and in many instances it does not appear to have caused any embarrassment, as the condition has been found in persons who have died of various affections. The ventricular septum may be absent, the condition known as trilocular heart. Much more frequently there is a small defect in the upper portion of the septum, either in the situation of the membranous portion known as the “ undefended space ” or in the region situated just anterior to this. The anomaly is very frequently associated with narrowing of the pul- monary orifice or of the conus arteriosus of the right ventricle. (c) Anomalies and Lesions of the Valves.—Numerical anomalies of the valves are not uncommon. The semilunar segments at the arterial orifices are not infrequently increased or diminished in number. Supernumer- ary segments are more frequent in the pulmonary artery than in the aorta. Four, or sometimes five, valves have been found. The segments may be of equal size, but, as a rule, the supernumerary valve is small. Instead of three there may be only two semilunar valves, or, as it is termed, the bicuspid condition. In my experience, this is most frequent in the aortic valve. Of twenty-one instances only two occurred at the pulmonary orifice. Two of the valves have united, and from the ventricu- lar face show either no trace of division or else a slight depression indicat- ing where the union had occurred. From the aortic side there is usually to be seen some trace of division into two sinuses of Valsalva. There has been a discussion as to the origin of this condition, whether it is really an anomaly or whether it is not due to endocarditis, foetal or post-natal. The combined segment is usually thickened, but the fact that this anomaly is met with in the foetus without a trace of sclerosis or endocarditis shows that it may, in some cases at least, result from a developmental error. Clinically this is a very important congenital defect, owing to the liability of the combined valve to sclerotic changes. Except two foetal specimens all of my cases showed thickening and deformity, and in fifteen of those which I have reported death resulted directly or indirectly from the lesion. The little fenestrations at the margins of the sigmoid valves have no significance; they occur in a considerable proportion of all bodies. Anomalies of the auriculo-ventricular valves are not often met with. Foetal endocarditis may occur either at the arterial or auriculo-ven- tricular orifices. It is nearly always of the chronic or sclerotic variety. Very rarely indeed is it of the warty or verrucose form. There are little nodular bodies, sometimes six or eight in number, on the mitral and tri- cuspid segments—the nodules of Albini—which represent the remains of CONGENITAL AFFECTIONS OF THE HEART. 697 foetal structures, and must not be mistaken for endocardial outgrowths. The little rounded, bead-like haemorrhages of a deep purple color, which are very common on the heart valves of children, are also not to be mis- taken for the products of endocarditis. In foetal endocarditis the segments are usually thickened at the edges, shrunken, and smooth. In the mitral and tricuspid valves the cusps are found united and the chordae tendineae are thickened and shortened. In the semilunar valves all trace of the segments has disappeared, leaving a stiff membranous diaphragm perfo- rated by an oval or rounded orifice. It is sometimes very difficult to say whether this condition has resulted from foetal endocarditis or whether it is an error in development. In very many instances the processes are combined ; an anomalous valve becomes the seat of chronic sclerotic changes, and, according to Bauchfuss, endocarditis is more common on the right side of the heart only because the valves are here most often the seat of developmental errors. Lesions at the Pulmonary Orifice.—Stenosis of this orifice is one of the commonest and most important of congenital heart affections. A slow endocarditis causes gradual union of the segments and narrowing of the orifice to such a degree that it only admits the smallest-sized probe. In some of the cases the smooth membranous condition of the combined segments is such that it would appear to be the result of faulty develop- ment. In some instances vegetations develop. The condition is com- patible with life for many years, and in a considerable proportion of the cases of heart-disease above the tenth year this lesion is present. With it there may be defect of the ventricular septum. Obliteration or atresia of the pulmonary orifice is less frequent but a more serious condition than stenosis. It is associated with defect of the ventricular septum or patency of the foramen ovale and persistence of the ductus arteriosus with hyper- trophy of the right heart. Stenosis of the conus arteriosus of the right ventricle exists in a considerable proportion of the cases of obstruction at the pulmonary orifice. At the outset a developmental error, it may be combined with sclerotic changes. The ventricular septum is imperfect, the foramen ovale is usually open, and the ductus arteriosus patent. These three lesions at the pulmonary orifice constitute the most important group of all congenital cardiac affections. Of 181 instances of various congenital anomalies collected by Peacock 119 cases came under this cate- gory, and, according to this author, in eighty-six per cent of the patients living beyond the twelfth year the lesion is at this orifice. Congenital lesions of the aortic orifice are not very frequent. Eauch- fuss has collected 24 cases of stenosis and atresia, and stenosis of the left conus arteriosus may also occur, a condition which is not incompatible with prolonged life. Ten of the sixteen cases tabulated by Dilg were over thirty years of age. Symptoms of Congenital Heart-disease.—Cyanosis occurs in over ninety per cent of the cases, and forms so distinctive a feature that the terms “ blue disease ” and “ morbus cseruleus ” are practically 698 DISEASES OF THE CIRCULATORY SYSTEM. synonyms for congenital heart-disease. The lividity in a majority of cases appears early, within the first week of life, and may be general or confined to the lips, nose, and ears, and to the fingers and toes. In some instances there is in addition a general dusky suffusion, and in the most extreme grades the skin is almost purple. It may vary a good deal and may only be intense on exertion. The external temperature is low. Dyspnoea on exertion and cough are common symptoms. A great increase in the number of the red corpuscles has been noted by Gibson and by Yaquez. In a case of Gibson there were above eight millions of red corpuscles to the cubic millimetre. The children rarely thrive, and often display a lethargy of both mind and body. The fingers and toes are clubbed in a grade rarely met with in any other affection. The cause of the cyanosis has been much discussed. Morgagni referred it to the general conges- tion of the venous system due to obstruction, and this view was supported in a paper, one of the ablest that has been written on the subject, by Moreton Stille. Morrison’s recent analysis of 75 cases of congenital heart-disease shows that closure of the pulmonary orifice and patency of the foramen ovale and the ventricular septum are the lesions most fre- quently associated with cyanosis, and he concludes that the deficient aera- tion of the blood owing to diminished lung function is the most important factor. Another view, advocated by William Hunter, was that the dis- coloration was due to the admixture in the heart of venous and arterial blood; but lesions may exist which permit of very free mixture without producing cyanosis. Diagnosis.—In the case of children, cyanosis, with or without en- largement of the heart, and the existence of a murmur are sufficient, as a rule, to determine the presence of a congenital heart-lesion. The cyano- sis gives us no clew to the precise nature of the trouble, as it is a symptom common to many lesions and it may be absent in certain conditions. The murmur is usually systolic in character. It is, however, not always pres- ent, and there are instances on record of complicated congenital lesions in which the examination showed normal heart-sounds. In two or three instances foetal endocarditis has been diagnosed in gravida by the pres- ence of a rough systolic murmur, and the condition has been corroborated subsequent to the birth of the child. Hypertrophy is present in a major- ity of the cases of congenital defect. It is remarkable in how many instances of congenital heart-disease the fatal event is caused by abscess of the brain. It is impossible in a work of this sort to enter upon elab- orate details in differential diagnosis between the various congenital heart- lesions. I here abstract the conclusions of Ilochsinger: “(1) In childhood, loud, rough, musical heart-murmurs, with normal or only slight increase in the heart-dulness, occur only in congenital heart- disease. The acquired endocardial defects with loud heart-murmurs in young children are almost always associated with great increase in the heart-dulness. “ (2) In young children heart-murmurs with great increase in the DEGENERATIONS. 699 cardiac dulness and feeble apex beat suggest congenital changes. The increased dulness is chiefly of the right heart, whereas the left is only slightly altered. On the other hand, in the acquired endocarditis in chil- dren, the left heart is chiefly atfected and the apex beat is visible; the dilatation of the right heart comes late and does not materially change the increased strength of the apex beat. “ (3) The entire absence of murmurs at the apex, with their evident presence in the region of the auricles and over the pulmonary orifice, is always an important element in differential diagnosis, and points rather to septum defect or pulmonary stenosis than to endocarditis. “ (4) An abnormally weak second pulmonic sound associated with a distinct systolic murmur is a symptom which in early childhood is only to be explained by the assumption of a congenital pulmonary stenosis, and possesses therefore an importance from a point of differential diagnosis which is not to be underestimated. “ (5) Absence of a palpable thrill, despite loud murmurs which are heard over the whole praecordial region, is rare except with congenital defects in the septum, and it speaks therefore against an acquired cardiac affection. “ (6) Loud, especially vibratory, systolic murmurs, with the point of maximum intensity over the upper third of the sternum, associated with a lack of marked symptoms of hypertrophy of the left ventricle, are very important for the diagnosis of a persistence of the ductus Botalli, and can- not be explained by the assumption of an endocarditis of the aortic valve.” Treatment.—The child should be warmly clad and guarded from all circumstances liable to excite bronchitis. In the attacks of urgent dysp- noea with lividity blood should be freely let. Saline cathartics are also useful. Digitalis must be used with care, and it is sometimes beneficial in the later stages. When the compensation fails, the indications for treat- ment are those of valvular disease in adults. III. DISEASES OF THE ARTERIES. I. DEGENERATIONS. Fatty degeneration of the intima is extremely common, and is seen in the form of yellowish-white spots in the aorta and larger vessels. Calcifica- tion of the arterial wall follows fatty degeneration, atheromatous changes, and sclerosis. It occurs in either the intima or the media. In the latter it produces what is sometimes known as annular calcification, which oc- curs particularly in the middle coat of medium-sized vessels and may con- vert them into firm tubes. Calcification of the intima is a common terminal process of arterio-sclerosis. 700 DISEASES OF THE CIRCULATORY SYSTEM. Hyaline degeneration may attack either the larger or the smaller vessels. In the former the intima is converted into a smooth, homogeneous substance, and it is commonly an initial stage of arterio-sclerosis. In the smaller arteries and capillaries the hyaline degeneration is often seen, particularly in the glomeruli of the kidney. Its exact production is still a matter of some doubt. “ It appears to arise principally by homogeneous coagulation of an albuminous fluid, either within the vessels or infiltrating the cells and the hyaline transformation of proliferating cells and of leu- cocytes.” II. ARTERIO-SCLEROSIS (Arterio-capillary Fibrosis). The conception of arterio-sclerosis as an independent affection—a gen- eral disease of the vascular system—is due to Gull and Sutton. Definition.—A condition of thickening, diffuse or circumscribed, of the intima, consequent upon primary changes in the media and adventitia. The process leads, in the larger arteries, to what is known as atheroma or endarteritis deformans. Etiology.—(1) As an involution process arterio-sclerosis is an ac- companiment of old age, and is the expression of the natural wear and tear to which the tubes are subjected. Longevity is a vascular question, and has been well expressed in the axiom that “ a man is only as old as his arteries.” To a majority of men death comes primarily or secondarily through this portal. The onset of what may be called physiological arterio-sclerosis depends, in the first place, upon the quality of arterial tis- sue (vital rubber) which the individual has inherited, and secondly upon the amount of wear and tear to which he has subjected it. That the former plays the most important role is shown in the cases in which arterio-sclerosis sets in early in life in individuals in whom none of the recognized etiological factors can be found. Thus, for instance, a man of twenty-eight or twenty-nine may have arteries of a man of sixty, and a man of forty may present vessels as much degenerated as they should be at eighty. Entire families sometimes show this tendency to early arterio- sclerosis—a tendency which cannot be explained in any other way than that in the make-up of the machine bad material was used for the tubing. More commonly the arterio-sclerosis results from the bad use of good vessels, and among the circumstances which tend to produce this condi- tion are the following: (2) Chronic Intoxications.—Alcohol, lead, gout, and syphilis play an important role in the causation of arterio-sclerosis, although the precise mode of their action is not yet very clear. They may act, as Traube sug- gests, by increasing the peripheral resistance in the smaller vessels and in this way raising the blood tension, or possibly, as Bright taught, they alter ARTERIO-SCLEROSIS. 701 the quality of the blood and render more difficult its passage through the capillaries. The poison of syphilis and of gout may act directly on the arteries, producing degenerative changes in the media and adventitia. (3) Overeating.—Many authors attribute an important part of the etiology of arterio-sclerosis to the overfilling of the blood-vessels which occurs when unnecessarily large quantities of food and drink are taken. Particularly is this the case in stout persons who take very little exercise. (4) Ovenvork of the muscles, which acts by increasing the peripheral resistance and by raising the blood-pressure. (5) Renal Disease.—The relation between the arterial and kidney lesions has been much discussed, some regarding the arterial degenera- tion as secondary, others as primary. There are certainly two groups of cases, one in which the arterio-sclerosis is the first change, and the other in which it appears to be secondary to a primary affection of the kidneys. The former occurs, I believe, with much greater frequency than has been supposed. Morbid Anatomy.—Thoma divides the cases into 'primary arterio- sclerosis, in which there are local changes in the arteries leading to dilata- tion and a compensatory increase of the connective tissue of the intima; secondary arterio-sclerosis, due to changes in the arteries which follow increased resistance to the blood-flow in the peripheral vessels. This in- creased tension leads to dilatation and to slowing of the blood-stream and a secondary compensatory development of the intima. In a recent study of 41 autopsies upon arterio-sclerotic cases from my wards, Councilman * follows the useful division into nodular, senile, and diffuse forms. {a) Nodular Form.—In the circumscribed or nodular variety the ma- croscopic changes are very characteristic. The aorta presents, in the early stages, from the ring to bifurcation, numerous flat projections, yellowish or yellowish white in color, hemispherical in outline, and situated par- ticularly about the orifices of the branches. In the early stage these patches are scattered and do not involve the entire intima. In more ad- vanced grades the patches undergo atheromatous changes. The material constituting the button undergoes softening and breaks up into granu- lar material, consisting of molecular debris—the so-called atheromatous abscess. In the circumscribed or nodular arterio-sclerosis the primary alteration consists in a degeneration or a local infiltration in the media and adven- titia, chiefly about the vasa vasorum. The affection is really a mesarteritis and a periarteritis. These changes lead to the weakening of the wall in the affected area, at which spot the proliferative changes commence in the intima, particularly in the subendothelial structures, with gradual thick- * Transactions of the Association of American Physicians, vol. vi. DISEASES OF THE CIRCULATORY SYSTEM. ening and the formation of an atheromatous button or a patch of nodular arterio-sclerosis. The researches of Thoma have shoAvn that this is really a compensatory process, and that before its degeneration the nodular but- ton, which post mortem projects beyond the lumen, during life fills up and obliterates what would otherwise be a depression of the wall in conse- quence of the weakening of the media. A similar process goes on in the smaller vessels, and in any one of the smaller branches it can be readily seen on section that each patch of endarteritis corresponds to a defect in the media and often to changes in the adventitia. The condition is one which may lead to rapid dilatation or to the production of an aneurism, particularly in the early stage, before the weakened spot is thickened and strengthened by the intimal changes. (b) Senile Arterio-sclerosis.—The larger arteries are dilated and tort- uous, the walls thin hut stiff, and often converted into rigid tubes. The subendothelial tissue undergoes degeneration and in spots breaks down, forming the so-called atheromatous abscesses, the contents of which con- sist of a molecular debris. They may open into the lumen, when they are known as atheromatous ulcers. The greater portion of the intima may be occupied by rough calcareous plates, with here and there fissures and losses of substance, upon which not infrequently white thrombi are deposited. Microscopically there is extreme degeneration of the coats, particularly of the media. Senile atrophy of the liver and kidneys usually accompanies these changes. Senile changes are common in other organs. The heart may be small and is not necessarily hypertrophied. In 7 of 14 cases of Councilman’s series there was no enlargement. Brown atrophy is common. (c) Diffuse Arterio-sclerosis.—The process is wide-spread throughout the aorta and its branches, in the former usually, but not necessarily, asso- ciated with the nodular form. The subjects of this variety are usually middle-aged men, but it may occur early. Of the 27 in Councilman’s series belonging to this group the majority were between the ages of forty and fifty-five. The youngest was a negro of twenty-three and the oldest a man of sixty. The affection is very prevalent among negroes; less than fifty per cent were in whites, whereas the ratio of colored to white patients in the wards is one to seven. The affection is met with in strongly built, muscular men and, as Councilman remarks, they rarely present on the autopsy table signs of general anasarca or, if oedema exists, it has come on during the last few days of life. The aorta and its branches are more or less dilated, the branches some- times more than the trunk. The intima may be smooth and show very slight changes to the naked eye; more commonly there are scattered ele- vated areas of an opaque white color, some of which may have undergone atheromatous changes as in the senile form. Microscopically the media shows necrotic and hyaline changes, involving in the larger arteries both muscular and elastic elements, and the intima presents a great increase ARTERIO-SCLEROSIS. 703 in the subendothelial connective tissue, which is particularly marked oppo- site areas of advanced degeneration in the media. The small arteries— those of the kidneys, for example—show “ a thickening of the wall, due to the formation of a homogeneous hyaline tissue within the muscular coat. This tissue contains but few cells, is faintly striated, and stains a light brown in the osmic acid used in the hardening solution. In many of the smallest vessels nothing can be seen of the elastic lamina, in others only fragments can be made out, in others it is preserved. . . . The muscular fibres of the media show marked atrophic changes. Fatty degeneration of the cells can be made out both in fresh sections and after hardening in Fleming’s solution. The nuclei are thin and atrophic and vacuoles are sometimes seen in them. In some arteries the muscle-fibres have almost disappeared and the media is changed into a homogeneous tissue, similar to that in the thickened intima” (Councilman). The degeneration of the media is most marked in the smaller arteries. The capillaries are thickened, particularly those of the glomeruli of the kidneys, which are often obliterated and involved in extensive hyaline degeneration. It is in this group of cases that the heart shows the most important changes. The average weight in the cases referred to was over 450 grammes, and there were two cases in which without valvular disease the weight was over 800 grammes. Fibrous myocarditis is often present, particularly when the coronary arteries are involved. The semilunar valves are sometimes opaque and sclerotic, and may be incompetent. The kidneys may show extensive sclerosis, but in many cases the changes are so slight that macroscopically they might be overlooked. They may be increased in size. The capsule is usually adherent, the surface a little rough, and very often presents atrophic areas at a lower level of a deep- red color. Increased consistence is always present. Sclerosis of the pulmonary artery is met with in all conditions which for a long time increase the tension in the lesser circulation, particularly in mitral-valve disease and in emphysema. Sometimes the sclerosis reaches a high grade and is accompanied with aneurismal dilatation of the primary and secondary branches, more rarely with insufficiency of the pulmonary valve. In a remarkable case of a young man of twenty-four, reported by Romberg from Curschmann’s clinic, the pulmonary arteries were involved in most extensive arterio-sclerosis ; the main branches were dilated, and the smaller branches were the seat of the most extreme sclerotic changes. On the other hand, the aorta and its branches were normal. The heart was greatly hypertrophied, and the clinical symptoms were those of a congeni- tal heart affection. In many cases of arterio-sclerosis the condition is not confined to the arteries, but extends not only to the capillaries but also to the veins, and may properly be termed angio-sclerosis. Sclerosis of the veins—phlebo-sclerosis—is not at all an uncommon accompaniment of arterio-sclerosis, and is a condition to which of late a good deal of attention has been paid. It is seen in conditions of height- 704 DISEASES OF THE CIRCULATORY SYSTEM. ened blood-pressure, as in the portal system in cirrhosis of the liver and in the pulmonary veins in mitral stenosis. The affected vessels are usually dilated, and the intima shows, as in the arteries, a compensatory thicken- ing, which is particularly marked in those regions in which the media is thinned. The new-formed tissue in the endophlebitis may undergo hya- line degeneration, and is sometimes extensively calcified. In a case of fibroid obliteration of the portal vein of long standing, I found the intima of the greatly dilated gastric, splenic, and mesenteric extensively calcified. Without existing arterio-sclerosis the peripheral veins may be sclerotic usually in conditions of debility, but occasionally in young persons. Symptoms.—Increased Tension.— The pressure with which the blood flows in the arteries depends upon the degree of peripheral resistance and the force of the ventricular contraction. A high-tension pulse may exist with very little arterio-sclerosis; but, as a rule, when the condition has been persistent, the sclerosis and high tension are found together. The pulse wave is slow in its ascent, enduring, subsides slowly, and in the intervals of the beats the vessel remains full and firm. It may be very difficult to obliterate the pulse, and the firmest pressure on the radial or the tem- poral may not be sufficient to annihilate the pulse wave beyond the point of pressure. This is not always a sign of high tension. The anastomotic or recurrent pulse may be felt even when the tension is low, as in the early stage of typhoid fever. Pressure on the ulnar at once obliterates it.* The sphygmographic tracing shows a sloping, short up-stroke, no percussion wave, and a slow, gradual descent, in which the dicrotic wave is very slightly marked. It may be difficult to estimate how much of the hardness and firmness is due to the tension of the blood within the vessel, and how much to the thickening of the wall. If, for example, when the radial is compressed with the index-finger the artery can be felt beyond the point of compression, its walls are sclerosed. Hypertrophy of the Heart.—In consequence of the peripheral resist- ance and increased work the left ventricle increases in size', and some of the purest examples of simple hypertrophy occur in this condition. The chamber may be little, if at all, dilated. The apex beat is dislocated in advanced cases an inch or more beyond the nipple line. The impulse is heaving and forcible. The aortic second sound is clear, ringing, and accentuated. The combination of increased arterial tension, a palpable thickening of the arteries, hypertrophy of the left ventricle, and accentuation of the aortic second sound are signs pathognomonic of arterio-sclerosis. From this period of establishment the course of the disease may be very varied. For years the patient may maintain good health, and be in a condition analogous to a person with a well-compensated valvular lesion. There may be no renal symptoms, or there may be the passage of a larger * The student is referred to Ewart On the Pulse, and to his larger Heart Studies. ARTERIO-SCLEROSIS. 705 amount of urine than normal, with transient albuminuria, and now and then hyaline tube-casts. The subsequent history is extraordinarily diverse, depending upon the vascular territory in which the sclerosis is most ad- vanced, or upon the accidents which are so liable to happen, and the symptoms may be cardiac, cerebral, renal, etc. (1) Cardiac.—The involvement of the coronary arteries may lead to the various symptoms already referred to under that section—thrombosis with sudden death, fibroid degeneration of the heart, aneurism of the heart, rupture, and angina pectoris. Angina pectoris is not uncommon, and in the true variety is almost always associated with arterio-sclerosis. A second important group of cardiac symptoms results from the dilatation which ultimately may follow the hypertrophy. The patient then presents all the symptoms of cardiac insufficiency—dyspnoea, scanty urine, and very often serous effusions. If the case has come under observation for the first time the clinical picture is that of chronic valvular disease, and the exist- ence of a loud blowing murmur at the apex may throw the practitioner off his guard. Many cases terminate in this way. (2) The cerebral symptoms of arterio-sclerosis are varied and important, and embrace those of many degenerative processes, acute and chronic (which follow sclerosis of the smaller branches), and cerebral hsemorrhage. Transient hemiplegia, monoplegia, or aphasia may occur in advanced arterio-sclerosis. Recovery may be perfect. It is difficult to say upon what these attacks depend. Spasm of the arteries has been suggested, but the condition of the smaller arteries is not very favorable to this view. Peabody has recently called attention to these cases, which are more com- mon than indicated in the literature. Vertigo occurs frequently, and may be either simple, or is associated with slow pulse and syncopal or epileptiform attacks (Grasset, Church). (3) Renal symptoms supervene in a large number of the cases. A sclerosis, patchy or diffuse, is present in a majority of the cases at the time of autopsy, and the condition is practically that of contracted kidneys. It is seen in a typical manner in the senile form, and not infrequently devel- ops early in life as a direct sequence of the diffuse variety. It is often difficult to decide clinically (and the question is one upon which good ob- servers might not agree in a given case) whether the arterial or the renal disease has been primary. (4) Among other events in arterio-sclerosis may be mentioned gan- grene of the extremities, due either directly to endarteritis or to the dis- lodgment of thrombi. Respiratory symptoms are not uncommon, particu- larly bronchitis and the symptoms associated with emphysema. Treatment.—In the late stages the conditions must be treated as they arise in connection with the various viscera. In the early stages, be- fore any local symptoms are manifest, the patient should be enjoined to live a quiet, well-regulated life, avoiding excesses in food and drink. It is usually best to explain frankly the condition of affairs, and so gain his intelligent co-operation. Special attention should be paid to the state of 706 DISEASES OF THE CIRCULATORY SYSTEM. the bowels and urine, and the secretion of the skin should be kept active by daily baths. Alcohol in all forms should be prohibited, and the food should be restricted to plain, wholesome articles. The use of mineral waters or a residence every year at one of the mineral springs is usually serviceable. If there has been a syphilitic history an occasional course of iodide of potassium is indicated, and whenever the pulse tension is high nitroglycerine may be used. In cases which come under observation for the first time with dyspnoea, slight lividity, and signs of cardiac insufficiency, venesection is indicated. In some instances, with very high tension, striking relief is afforded by the abstraction of twenty ounces of blood. III. ANEURISM. The following forms of aneurism are usually recognized : (a) The true, in which the sac is formed of one or more of the arterial coats. This may be fusiform, cylindrical, or cirsoid (in which the dilatation is in an artery and its branches), or it may be circumscribed or sacculated. Aneurisms are usually fusiform, resulting from uniform dilatation of the vessel, or saccular. (b) The false aneurism, in which there is rupture of all the coats, and the blood is free (or circumscribed) in the tissues. (c) The dissecting aneurism, which results from injury or laceration of the internal coat. The blood dissects between the layers; hence the name, dissecting aneurism. This occurs usually in the aorta, persisting for years. (d) Arterio-venous aneurism results when a communication is estab- lished between an artery and a vein. A sac may intervene, in which case it is called a varicose aneurism; but in many cases the communication is direct and the chief change is in the vein, which is dilated, tortuous, and pulsating, and is termed an aneurismal varix. Etiology and Pathology. —Aneurisms arise : (a) By the gradual diffuse distention of the arterial coats, which have been weakened by arterio-sclerosis, particularly in its early stages, before compensatory en- darteritis develops. The arch of the aorta is often dilated in this way so as to form an irregular aneurism. (b) In consequence of circumscribed loss of resisting power in the media and adventitia, and due often to laceration of the media. This is the most common cause of sacculated aneurism. The laceration is fre- quently found in the ascending portion of the arch and occurs early in the process of arterio-sclerosis, before the compensatory thickening has taken place. Occasionally one meets with remarkable specimens illustrat- ing the important part played by this process. The intima may also be torn. In a case of Daland’s there was just above the aortic valves ANEURISM. 707 an old transverse tear of the intima, extending almost the entire circum- ference of the vessel. Sclerosis of the media and adventitia had taken place and the process was evidently of some standing. An inch or more above it was a fresh transverse rent which had produced a dissecting an- eurism. These arterio-sclerotic aneurisms, as they are called, are found also in the smaller vessels. (c) Embolic Aneurism.—When an embolus has lodged in a vessel and permanently plugged it, aneurismal dilatation may follow on the proximal side. The embolus itself may, if a calcified fragment from a valve, lacer- ate the wall, or if infected may produce inflammation and softening. (d) Mycotic Aneurism.—The importance of this form has been spe- cially considered by Eppinger in his exhaustive monograph. The occur- rence of multiple aneurisms in malignant endocarditis has been observed by several writers. Probably the first case in which the mycotic nature was recognized was one which occurred at the Montreal General Hospital and is reported in full in my lectures on malignant endocarditis. In addi- tion to the ulceration of the valves there were four aneurisms of the arch, of which one was large and saccular, and three were not bigger than cherries. An extensive growth of micrococci was present. A form of parasitic aneurism which occurs with great frequency in the mesenteric arteries of the horse is due to the development of the strongylus armatus. Thoma has described a “ traction ” aneurism of the concavity of the arch at the point of insertion of the remnant of the ductus Botalli (Vir- chow’s Archiv, Bd. 122). And, lastly, there are cases in which without any definite cause there is a tendency to the development of aneurisms in various parts of the body. A remarkable instance of it in our profession was afforded by the brilliant Thomas King Chambers, who first had an aneurism in the left popliteal artery, eleven years subsequently an aneurism in the right leg which was cured by pressure, and finally aneurism of both carotid arteries. Aneurism of the Thoracic Aorta. The causes which favor the development of arterio-sclerosis prevail in aortic aneurism, particularly alcohol, syphilis, and overwork. The great- est danger probably is in strong muscular men with commencing degen- erative processes in the arteries (a consequence of syphilis or alcohol or a result of hereditary weakness of the arterial tissues), who during a sudden muscular exertion are liable to lacerate the media, the intima not yet being strengthened by compensatory thickening over a spot of mesarteritis. Aneurisms of the thoracic aorta vary greatly in size and shape. A major- ity of them are saccular. They may be small and situated just above the aortic ring. Others form large tumors which project externally and occupy a large portion of the upper thorax. Small sacs from the descending por- tion of the arch may compress the trachea or the bronchi. In the tho- 708 DISEASES OF THE CIRCULATORY SYSTEM. racic portion the sac may erode the vertebrae or grow into the pleural cavity and compress the lung. In some instances it grows through the ribs and appears in the back. Symptoms.—The chief influence of an aneurism is manifested in what are known as pressure effects. In the absence of these the aneurisms attain a large size without producing symptoms or seriously interfering with the circulation. Indeed, a useful clinical subdivision as given by Bramwell is into three groups—aneurisms which are entirely latent and give no physical signs; aneurisms which present signs of intrathoracic pressure, but it is difficult or impossible to determine the nature of the lesion producing the pressure; and, lastly, aneurisms which produce dis- tinct tumors with well-marked pressure symptoms and external signs. It is perhaps best to consider aneurisms of the aorta according to the situation of the tumor. [a) Aneurisms of the Ascending Portion of the Arch.—When just above the sinuses of Valsalva they are often small and latent. The first symptom may be rupture, which usually takes place into the pericardium and causes instant death. Above the sinuses, along the convex border of the ascending part, aneurism frequently develops, and may grow to a large size, either passing out into the right pleura or forward, pointing at the second or third interspace, eroding the ribs and sternum, and produc- ing large external tumors. In this situation the sac is liable indeed to compress the superior vena cava, causing engorgement of the vessels of the head and arm, sometimes compressing only the subclavian vein, and causing enlargement and cedema of the right arm. Perforation may take place into the superior vena cava, of which accident Pepper and Griffith have collected twenty-nine cases. Large aneurisms in this situation may cause much dislocation of the heart, pushing it down and to the left, and sometimes compressing the inferior vena cava, and causing swelling of the feet and ascites. The right recurrent laryngeal nerve is often in- volved in these tumors. Death commonly follows from rupture into the pleura, or into the superior cava; less commonly from rupture externally, sometimes from heart-failure. (h) Aneurisms of the Transverse Arch.—These may grow forward, erode the sternum, and produce large tumors. More commonly they are small and produce no external tumor, but cause marked pressure signs in their growth backward toward the spine, involving the trachea and the oesophagus, producing cough, which is often of a paroxysmal character, and dysphagia. The left recurrent laryngeal is often involved in its course round the arch. A small aneurism from the lower or posterior wall of the arch may compress a bronchus, inducing bronchorrhcea, gradual bronchiectasy, and suppuration in the lung—a process which by no means infrequently causes death in aneurism, and a condition which at the Montreal General Hospital we were in the habit of terming aneu- rismal phthisis. Occasionally enormous aneurisms develop in this situa- ANEURISM. 709 tion, and grow into both pleurae, extending between the manubrium and the vertebrae, and may persist for years. The sac may be evident at the sternal notch. The innominate, less commonly the left carotid and sub- clavian, may be involved in the sac, and the radial or carotid pulse may be absent or retarded. Pressure on the sympathetic may at first cause dilatation and subsequently contraction of the pupil. Sometimes the thoracic duct is compressed. (c) Aneurisms of the Descending Portion.—Pressure signs are not so marked. The pain is often intense, owing to erosion of the vertebrae. Dysphagia may occur. Compression of the lung or compression of cer- tain bronchi may induce bronchieetasy, retention of secretions, and fever. A tumor may appear externally in the region of the scapula, and here attain an enormous size. Occasionally the aneurisms in this region are small and latent, and prove fatal by rupture into the oesophagus. I have reported a case of sudden death, in which the heart and arch of the aorta were normal and the stomach was distended with blood, which could not be accounted for until the oesophagus was slit open, when it was found that a small aneurism in the thoracic aorta, smaller than a walnut, had ruptured into the gullet. The sac may erode the vertebrae and open the spinal canal, producing compression of the cord. Death not infrequently occurs from rupture into the pleura. Diagnosis and Physical Signs.—Inspection.—In many instances this is negative. On either side of the sternum there may be abnormal pulsation, due to dislocation of the heart or to deformity of the thorax. The aneurismal pulsation is usually above the level of the third rib and most commonly to the right of the sternum, either in the first or second interspace. It may be only a diffuse heaving impulse without any exter- nal tumor. Often the impulse is noticed only when the chest is looked at obliquely in a favorable light. When the innominate is involved the throbbing may pass into the neck or be apparent at the sternal notch. Posteriorly, when pulsation occurs, it is most commonly found in the left scapular region. An external tumor is present in many cases, projecting either through the upper part of the sternum or to the right, sometimes involving the sternum and costal cartilages on both sides, forming a tumor the size of a cocoa-nut or even larger. The skin is thin, often blood- stained, or it may have ruptured, exposing the laminae of the sac. The apex beat may be much dislocated, particularly when the sac is large. It is more commonly a dislocation from pressure than from enlargement of the heart itself. Palpation.—The area and degree of pulsation are best determined by palpation. When the aneurism is deep-seated and not apparent exter- nally, the bimanual method should be used, one hand upon the spine and the other on the sternum. When the sac has perforated the chest wall the impulse is, as a rule, forcible, slow, heaving, and expansile. The re- sistance may be very great if there are thick laminae beneath the skin; 710 DISEASES OF THE CIRCULATORY SYSTEM. more rarely the sac is soft and fluctuating. The hand upon the sac, or on the region in which it is in contact with the chest wall, feels in many cases a diastolic shock, often of great intensity, which forms one of the valuable physical signs of aneurism. A systolic thrill is sometimes pres- ent, not so often in saccular aneurisms as in the dilatation of the arch. The pulsation may sometimes be felt in the suprasternal notch. Percussion.—The small and deep-seated aneurisms are in this respect negative. In the larger tumors, as soon as the sac reaches the chest wall, there is produced an area of abnormal dulness, the position of which de- pends upon the part of the aorta affected. Aneurisms of the ascending arch grow forward and to the right, jmoducing dulness on one side of the manubrium ; those from the transverse arch produce dulness in the mid- dle line, extending toward the left of the sternum, while aneurisms of the descending portion most commonly produce dulness in the left inter- scapular and scapular regions. The percussion note is flat and gives a feeling of increased resistance. Auscultation.—Adventitious sounds are not always to be heard. Even in a large sac there may be no murmur. Much depends upon the thick- ness of the lamina? of fibrin. An important sign, particularly if heard over a dull region, is a ringing, accentuated second sound, a phenomenon rarely missed in large aneurisms of the aortic arch. A systolic murmur may be present; sometimes a double murmur, in which case the diastolic hruit is usually due to associated aortic insufficiency. The systolic mur- mur alone is of little moment in the diagnosis of an aneurismal sac. With the single stethoscope the shock of the impulse with the first sound is sometimes very marked. Among other physical signs of importance are slowing of the pulse in the arteries beyond the aneurism, or in those involved in the sac. There may, for instance, be a marked difference between the right and left radial, both in volume and time. A physical sign of large thoracic aneurism which I have not seen referred to is obliteration of the pulse in the ab- dominal aorta and its branches. My attention was called to this in a patient who was stated to have aortic insufficiency. There was a Avell- marked diastolic murmur, hut in the femorals and in the aorta I was surprised to find no trace of pulsation, and not the slightest throbbing in the abdominal aorta or in the peripheral arteries of the leg. The circula- tion was, however, unimpaired in them and there was no dilatation of the veins. Attracted by this, I then made a careful examination of the pa- tient’s back, when the circumstance was discovered, which neither the patient himself nor any of his physicians had noticed, that he had a very large area of pulsation in the left scapular region. The sac probably was large enough to act as a reservoir annihilating the ventricular systole, and converting the intermittent into a continuous stream. The tracheal tugging, a valuable sign in deep-seated aneurisms, was described by Surgeon-Major Oliver, and has been specially studied by my ANEURISM. 711 colleagues Ross and MacDonnell * at the Montreal General Hospital. Oliver gives the following directions: “ Place the patient in the erect position, and direct him to close his mouth and elevate his chin to almost the full extent; then grasp the cricoid cartilage between the finger and thumb, and use steady and gentle upward pressure on it, when, if dilata- tion or aneurism exists, the pulsation of the aorta will be distinctly felt transmitted through the trachea to the hand.” On several occasions I have known this to be a sign of great value in the diagnosis of deep- seated aneurisms. I have never felt it in tumors, or in the extreme dynamic dilatation of aortic insufficiency. Occasionally a systolic murmur may he heard in the trachea, as pointed out by David Drummond, or even at the patient’s mouth, when opened. This is either the sound conveyed from the sac, or is produced by the air as it is driven out of the wind-pipe during the systole. An important hut variable feature in thoracic aneurism is pain, which is particularly marked in deep-seated tumors. It is usually paroxysmal, sharp, and lancinating, often very severe when the tumor is eroding the vertebrae, or perforating the chest wall. In the latter case, after perfora- tion the pain may cease. Anginal attacks are not uncommon, particularly in aneurisms at the root of the aorta. Frequently the pain radiates down the left arm or up the neck, sometimes along the upper intercostal nerves. Cough results either from the direct pressure on the wind-pipe, or is as- sociated with bronchitis. The expectoration in these instances is abundant, thin, and watery ; subsequently it becomes thick and turbid. Paroxysmal cough of a peculiar brazen, ringing character is a characteristic symptom in some cases, particularly when there is pressure on the recurrent laryn- geal nerves. Dyspnoea, which is common in cases of aneurism of the transverse portion, is not necessarily associated with pressure on the recurrent laryn- geal nerves, but may be due directly to compression of the trachea or the left bronchus. It may occur with marked stridor. Loss of voice and hoarseness are consequences of pressure on the recurrent laryngeal, usually the left, inducing either a spasm in the muscles of the left vocal cord or paralysis. Paralysis of an abductor on one side may be present without any symptoms. It is more particularly, as Semon states, when the paralytic contractures supervene that the attention is called to laryngeal symptoms. Hcemorrhage in thoracic aneurism may come from (a) the soft granula- tions in the trachea at the point of compression, in which case the sputa are blood-tinged, but large quantities of blood are not lost; (b) from rupture of the sac into the trachea or bronchi; (c) from perforation into the lung or erosion of the lung tissue. The bleeding may be profuse, rapidly prov- ing fatal, and is a common cause of death. It may persist for weeks or * London Lancet, 1891. DISEASES OF THE CIRCULATORY SYSTEM. months, in which case it is simply haemorrhagic weeping through the sac, which is exposed in the trachea. In some instances, even after a very profuse haemorrhage, the patient recovers and may live for years. A patient with well-marked thoracic aneurism, whom I showed to my class at the University of Pennsylvania and who had had several brisk haemor- rhages, died four years after, having in the meantime enjoyed average health. Difficulty of swallowing is a comparatively rare symptom, and may be due either to spasm or to direct compression. The sound should never be passed in these cases, as the oesophagus may be almost eroded and a perforation may be made. Among other signs and symptoms venous compression, which has already been mentioned, may involve one subclavian or the superior vena cava. A curious phenomenon in intrathoracic aneurism is the clubbing of the fingers and incurving of the nails of one hand, of which two ex- amples have been under my care, in both without any special distention or signs of venous engorgement. Tumors of the arch may involve the pulmonary artery, producing compression, or in some instances adhesion of the pulmonary segments and insufficiency of the valve; or the sac may rupture into the artery, an accident which happened in two of my cases, producing instantaneous death. Pressure on the sympathetic is particularly liable to occur in growths from the ascending portion of the arch. Either the upper dorsal or the lower cervical ganglion is involved. The symptoms are variable. If the nerve is simply irritated there is stimulation of the vaso-dilator fibres and dilatation of the pupil. With this may be associated pallor of the same side of the face. On the other hand, destruction of the cilio-spinal branches causes paralysis of the dilator fibres, in consequence of which the iris contracts, the vessels on the side of the head dilate, causing con- gestion, and in some instances unilateral sweating. It is much more com- mon to see the pupillary symptoms alone than in combination either with pallor, redness, or sweating. The clinical picture of aneurism of the aorta is extremely varied. Many cases present characteristic symptoms and no physical signs, while others have well-marked physical signs and no symptoms. As Broadbent remarks, the aneurism of physical signs springs from the ascending por- tion of the aorta; the aneurism of symptoms grows from the transverse arch. Aneurism of the aorta may be confounded with: (a) The violent throbbing impulse of the arch in aortic insufficiency. I have already re- ferred to a case of this kind in which the diagnosis of aneurism was made by several good observers. In a case recently under observation dulness and pulsation existed in the second right interspace with a well-marked systolic and a loud diastolic murmur, which was heard far out in the right mammary region. The question arose whether aneurism was present in ANEURISM. 713 addition to the aortic insufficiency. The post-mortem showed the mar- gin of the right lung retracted and adherent to the pericardium, leaving exposed the aorta, which must have been greatly distended during each systole. (b) Simple Dynamic Pulsation.—No instance of this, which is com- mon in the abdominal aorta, has ever come under my notice. One which came under the care of William Murray and Bramwell presented, without any pain or pressure symptoms, pulsation and dulness over the aorta. The condition gradually disappeared and was thought to be neurotic. (c) Dislocation of the heart in curvature of the spine may cause great displacement of the aorta, so that it has been known to pulsate forcibly to the right of the sternum. (d) Solid Tumors.—When the tumor projects externally and pulsates the difficulty may be considerable. In tumor the heaving, expansile pul- sation is absent, and there is not that sense of force and power which is so striking in the throbbing of a perforated aneurism. There is not to be felt as in aortic aneurism the shock of the heart-sounds, particularly the diastolic shock. Auscultatory sounds are less definite, as large aneurisms may occur without murmur; and, on the other hand, murmurs may be heard over tumors. The greatest difficulty is in the deep-seated thoracic tumors, and here the diagnosis may be impossible. I have already re- ferred to the case which was regarded by Skoda as aneurism and by Op- polzer as tumor. The physical signs may be indefinite. The ringing aortic second sound is of great importance and is rarely, if ever, heard over tumor. Tracheal tugging is here a valuable sign. Pressure phe- nomena are less common in tumor, whereas pain is more frequent. The general appearance of the patient in aneurism is much better than in tumor. There may be signs of enlargement of the glands in the axilla or in the neck. Healthy, strong males who have worked hard and have had syphilis are the most common subjects of aneurism. Occasionally cancer of the oesophagus may simulate aneurism, producing pressure on the left bronchus, and in one instance at the Philadelphia Hospital, with a husky, brazen cough, the symptoms were very suggestive. (e) Pulsating Pleurisy.—In cases of empyema necessitatis, if the pro- jecting tumor is in the neighborhood of the heart and pulsates, the condi- tion may readily be mistaken for aneurism. The absence of the heaving, firm distention and of the diastolic shock would, together with the his- tory and the existence of pleural effusion, determine the nature of the case. If necessary, puncture may be made with a fine hypodermic needle. In a majority of the cases of pulsating pleurisy the throbbing is diffuse and widespread, moving the whole side. Prognosis.—The outlook in thoracic aneurism is always grave. Life may be prolonged for some years, but the patients are in constant jeopardy. Spontaneous cure is not very infrequent in the small sacculated tumors of the ascending and thoracic portions. The cavity becomes filled with lam- 714 DISEASES OF THE CIRCULATORY SYSTEM. inae of firm fibrin, which become more and more dense and hard, the sac shrinks considerably, and finally lime salts are deposited in the old fibrin. The laminae of fibrin may be on a level with the lumen of the ves- sel, causing complete obliteration of the sac. The cases which rupture ex- ternally, as a rule run a rapid course, although to this there are exceptions; the sac may contract, become firm and hard, and the patient may live for five, or even, as in a case mentioned by Balfour, for ten years. The cases which have lasted longest in my experience have been those in which a saccular aneurism has projected from the ascending arch. One patient in Montreal had been known to have aneurism for eleven years. The aneu- rism may be enormous, occupying a large area of the chest, and yet life be prolonged for many years, as in the case mentioned as under the care of Skoda and Oppolzer. One of the most remarkable instances is the case of dissecting aneurism reported by Graham. The patient was invalided after the Crimean War with aneurism of the aorta, and for years was under the observation of J. H. Richardson, of Toronto, under whose care he died in 1885. The autopsy showed a healed aneurism of the arch, with a dis- secting aneurism passing the whole length of the aorta, which formed a double tube. Treatment.—In a large proportion of the cases this can only be pal- liative. Still in every case measures should be taken which are known to promote clotting and consolidation within the sac. In any large series of cured aneurisms a considerable majority of the patients have not been known to be subjects of the disease, but the obliterated sac has been found accidentally at the post mortem. The most satisfactory plan in early cases, when it can be carried out thoroughly, is that advised by the late Mr. Tufnell, of Dublin, the essen- tials of which are rest and a restricted diet. Rest is essential and should, as far as possible, be absolute. The reduction of the daily number of heart-beats when a patient is recumbent and makes no exertion whatever amounts to many thousands, and is one of the principal advantages of this plan. Mental quiet should also be enjoined. The diet advised by Tufnell is extremely rigid—for breakfast, two ounces of bread and butter and two ounces of milk; for dinner, two or three ounces of meat and three or four ounces of milk or claret; for supper, two ounces of bread and two ounces of milk. This low diet diminishes the blood-volume and is thought also to render the blood more fibrinous. It reduces greatly the blood-pressure within the sac, in this manner favoring coagu- lation. This treatment should be pursued for several months, but, except in persons of a good deal of mental stamina, it is impossible to carry it out for more than a few weeks at a time. It is a form of treatment adapted only for the saccular form of aneurism, and in cases of large sacs communicating with the aorta by a comparatively small orifice the chances of consolidation are fairly good. Unquestionably rest and the restriction of the liquids are the important parts of the treatment, and a greater ANEURISM. 715 variety and quantity of food may be allowed with advantage. If this plan cannot be thoroughly carried out, the patient should at any rate be ad- vised to live a very quiet life, moving about with deliberation and avoiding all sudden mental or bodily excitement. The bowels should be kept regu- lar, and constipation and straining should be carefully avoided. Of medi- cines, iodide of potassium, as advised by Balfour, is of great value. It may be given in doses of from ten to fifteen or twenty grains three times a day. Larger doses are not necessary. The mode of action is not well understood. It may act by increasing the secretions and so inspissating the blood, by lowering the blood-pressure, or, as Balfour thinks, by causing thickening and contraction of the sac. The most striking effect of the iodide in my experience has been the relief of the pain. The evidence is not conclusive that the syphilitic cases are more benefited than the non- syphilitic. All these measures have little value unless the sac is of a suit- able form and size. The large tumors with wide mouths communicating with the ascending portion of the aorta may be treated on the most ap- proved plans for months without the slightest influence other than reduc- tion in the intensity of the throbbing. A patient with a tumor project- ing into the right pleura remained on the most rigid Tufnell treatment for more than one hundred days, during which time he also took iodide of potassium faithfully. The pulsations were greatly reduced and the area of dulness diminished, and we congratulated ourselves that the sac was probably consolidating. Sudden death followed rupture into the pleura, and the sac contained only fluid blood, not a shred of fibrin. In cases in which the tumor is large, or in which there seems to be very little prospect of consolidation, it is perhaps better to advise a man to go on quietly with his occupation, avoiding excitement and worry. Our profession has of- fered many examples of good work thoroughly and conscientiously carried out by men with aneurism of the aorta, who wisely, I think, preferred, as did the late Hilton Fagge, to die in harness. Other measures to induce coagulation in the sac are electricity, which has occasionally proved suc- cessful ; the insertion of horse-hair, thin wire, or needles; the injection of an astringent liquid, such as perchloride of iron, into the sac. In a few cases only these have been followed by cure. The fine silver wire pushed through a hypodermic needle is probably the most satisfactory method, and may be combined with electrolysis, the method known as Loreta’s. Kerr and Rosenstein, of San Francisco, have recently reported cases in wrhich cure was effected in this way. Other Symptoms requiring Treatment.—Pressure on veins causing en- gorgement, particularly of the head and arms, is sometimes promptly re- lieved by free venesection, and at any time during the course of a thoracic aneurism, if attacks of dyspnoea with lividity supervene, bleeding may be resorted to with great benefit. It has the advantage also of promptly checking the pain, for which symptom, as already mentioned, the iodide of potassium often gives relief. In the final stages morphia is, as a 716 DISEASES OE THE CIRCULATORY SYSTEM. rule, necessary. Dyspnoea, if associated with cyanosis, is best relieved by bleeding. Chloroform inhalations may be necessary. The question sometimes comes up with reference to tracheotomy in these cases of urgent dyspnoea. If it can be shown by laryngoscopic examination that it is due to bilateral abductor paralysis the trachea may be opened, but this is ex- tremely rare, and in nearly every instance the urgent dyspnoea is caused by pressure about the bifurcation. When the sac appears externally and grows large an ice-cap may be applied upon it, or a belladonna plaster to allay the pain. In some instances an elastic support may be used with advantage, and I saw a physician with an enormous external aneurism in the right mammary region who for many months had obtained great relief by the clastic support, passing over the shoulder and under the arm of the opposite side. Digitalis, ergot, aconite, and veratrum viride are rarely, if ever, of service in thoracic aneurism. Aneurism of the Abdominal Aorta. The sac is most common in the neighborhood of the coeliac axis. It is rare in comparison with thoracic aneurism. The tumor may be fusi- form or sacculated, and it is sometimes multiple. Projecting backward, it erodes the vertebras and may cause numbness and tingling in the legs and finally paraplegia, or it may pass into the thorax and burst into the pleura. More commonly the sac is on the anterior wall and projects for- ward as a definite tumor, which may be either in the middle line or a. little to the left. The tumor may be large and evident, or when high up beneath the pillar of the diaphragm it may attain considerable size with- out being very apparent on palpation. The symptoms are chiefly pain, very often of a cardialgic nature* passing round the sides or localized in the back, and gastric symptoms, particularly vomiting. Retardation of the pulse in the femoral is a very common symptom. Diagnosis and Physical Signs.—Inspection may show marked pulsation in the epigastric region, sometimes a definite tumor. A thrill is not uncommon. The pulsation is forcible, expansile, and sometimes double when the sac is large and in contact with the pericardium. On pal- pation a definite tumor can be felt. If large, there is some degree of dul- ness on percussion which usually merges with that of the left lobe of the liver. On auscultation, a systolic murmur is, as a rule, audible, and is sometimes best heard at the back. A diastolic murmur is occasionally present, usually very soft in quality. One of the commonest of clinical errors is to mistake a throbbing aorta for an aneurism. It is to be remem- bered that no pulsation, however forcible, or the presence of a thrill or a systolic murmur justifies the diagnosis of abdominal aneurism unless there is a definite tumor which can be grasped and whicli has an expansile pulsa- ANEURISM. 717 tion. Attention to this rule will save many errors. The throbbing aorta —the “ preternatural pulsation in the epigastrium,” as Allan Burns calls it—is met with in all neurasthenic conditions, particularly in women. In angemia, particularly some instances of traumatic anaemia, the throb- bing may be very great. In the case of a large, stout man with severe haemorrhages from a duodenal ulcer the throbbing of the abdominal aorta not only shook violently the whole abdomen, but communicated a pulsa- tion to the bed, the shock of which was distinctly perceptible to any one sitting upon it. Very frequently a tumor of the pylorus, of the pancreas, or of the left lobe of the liver is lifted with each impulse of the aorta and may be confounded with aneurism. The absence of the forcible expansile impulse and the examination in the knee-elbow position, in which the tumor, as a rule, falls forward, and the pulsation is not then communi- cated, suffice for differentiation. The tumor of abdominal aneurism, though usually fixed, may be very freely movable. The outlook in abdominal aneurism is bad. A few cases heal spon- taneously. Death may result from (a) complete obliteration of the lumen by clots ; (5) compression paraplegia ; (c) rupture either into the pleura, retroperitoneal tissues, peritonaeum or the intestines, very commonly the duodenum ; (d) by embolism of the superior mesenteric artery, producing infarction of the intestines. The treatment is such as already advised in thoracic aneurism. When the aneurism is low down pressure has been successfully applied in a case by Murray, of Newcastle. It must be kept up for many hours under chlo- roform. The plan is not without risk, as patients have died from bruising and injury of the sac. Aneurism of the Branches of the Abdominal Aorta. The cceliac axis is itself not infrequently involved in aneurism of the first portion of the abdominal aorta. Of its branches, the splenic artery is occasionally the seat of aneurism. This rarely causes tumor large enough to he felt; sometimes, however,the tumor is'of large size. I have reported a case in a man, aged thirty, who had an illness of several months’ dura- tion, severe epigastric pain and vomiting, which led his physicians in New York to diagnose gastric ulcer. There was a deep-seated tumor in the left hypochondriac region, the dulness of which merged with that of the spleen. There was no pulsation, but it was thought on one occasion that a bruit was heard. The chief symptoms while under observation were vomiting, severe epigastric pain, occasional haematemesis, and finally severe haemor- rhage from the bowels. An aneurism of the splenic artery the size of a cocoa-nut was situated between the stomach above and the transverse colon below, and extended to the left as far as the level of the navel. The sac contained densely laminated fibrin. It had perforated the colon. I have twice seen small aneurisms on the splenic artery. Of thirty-nine instances 718 DISEASES OF THE CIRCULATORY SYSTEM. of aneurism on the branches of the abdominal aorta collected by Lebert, ten were of the splenic artery. Aneurism of the hepatic artery is very rare, and there are only ten or twelve cases on record. The syinpt&ms are extremely indefinite; the con- dition could rarely be diagnosed. In the case reported by Ross and myself, a man aged twenty-one had the symptoms of pyamiia. The liver was greatly enlarged, weighed nearly 5,000 grammes, and presented innu- merable small abscesses. An oval aneurism, half the size of a small lemon, involved the right and part of the left branches. A few cases of aneurism of the superior mesenteric artery are on record. The diagnosis is scarcely possible. Plugging of the branches or of the main stem may cause the symptoms of infarction of the bowels which have al- ready been considered. Small aneurisms of the renal artery are not very uncommon. Large tumors are rare. The sac may rupture and give rise to extensive retro- peritoneal haemorrhage. Arterio-venous Aneurism. In this form there is abnormal communication between an artery and a vein. When a tumor lies between the two it is known as varicose aneu- rism ; when there is a direct communication without tumor the vein is chiefly distended and the condition is known as aneurismal varix. An aneurism of the ascending portion of the arch may open directly into the vena cava. Twenty-nine cases of this lesion have been analyzed by Pepper and Griffith. Cyanosis, oedema, and great distention of the veins of the upper part of the body are the most frequent symptoms, and develop, as a rule, with suddenness. Of the physical signs a thrill is pres- ent in some cases. A continuous murmur with systolic intensification is of great diagnostic value. In a recent case, after the existence for some time of pressure symptoms, intense cyanosis developed with engorgement of the veins of the head and arms. Over the aortic region there was a loud continuous murmur with systolic intensification. A majority of the cases of arterio-venous aneurism and of aneurismal varix result from the accidental opening of an artery and vein as in vene- section, and are met with at the bend of the elbow or sometimes in the temporal region. The condition may persist for years without causing any trouble. Pulsation, a loud thrill, and a continuous humming mur- mur are usually present. Congenital Aneurism. In consequence of failure of proper development of the elastic coat in many places in the arterial system, multiple aneurisms may develop. In the well-known case described by Kussmaul and Maier, upon many of the ANEURISM. 719 medium-sized arteries there were nodular prominences, which consisted of thickening of the intima and infiltration of the adventitia and of the media, with a nuclear growth which in places looked quite sarcomatous. They called it a case of periarteritis nodosa, and Eppinger holds that it belongs to the category which he makes of congenital aneurism. As many as sixty-three aneurismal tumors have been found in one case. In the smaller branches, such as the coronary and the mesenteric arteries or in the pulmonary arteries, there may be numerous elongated or saccular aneurisms varying in size from a cherry to a hazel-nut. These are true aneurismal dilatations, and, according to Eppinger’s careful study, consist of the intima and the adventitia, the elastic lamina having disappeared. The condition has been met with in children. Some of the cases, how- ever, have been in adults; but the term as applied by Eppinger ex- presses, and probably correctly, the deep-seated fundamental error in development which must be at the basis of this condition. The coronary arteries is a favorite situation; a case has been reported by Gee in a boy of seven. SECTION VI. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. I. ANAEMIA. may be defined as a reduction in the amount of the blood as a Avhole or of its corpuscles, or of certain of its more important constitu- ents, such as albumen and haemoglobin. The condition may be general or local. The former alone Ave are here considering. It is interesting to note, however, that the pallor, particularly of the face, which is one of the most striking symptoms of anaemia, is just as characteristic of local anaemia due to fright or to nausea. There are persons persistently pale without actual anaemia in whom the condition may be due to inherited peculiarities. Our knowledge is not yet sufficiently advanced to classify satisfactorily the various forms of anaemia. The following provisional grouping may be made: (1) Secondary or symptomatic anaemia; (2) primary, essential, or cytogenic anaemia. Secondary Anemia. Under this division comes a large proportion of all cases. The follow- ing are the most important groups, based on the etiology : (1) Anaemia from haemorrhage, either traumatic or spontaneous. The loss of blood may be rapid, as in lesions of large vessels, in injury or in rupture of aneurisms, or in cases of ulcer of the stomach or duodenum, or post-partum haemorrhage. If the loss is excessive, death results from lowering of the arterial pressure. In sudden profuse haemorrhage the loss of three or four pounds of blood may prove fatal. In the rupture of an aneurism into the pleura the loss of blood may amount to seven pounds and a half, the largest quantity I have known to be shed into one cavity. In a case of haematemesis the patient lost over ten pounds by measure- ment in one Aveek and yet recovered from the immediate effects. Even after very severe haemorrhage the number of red blood-corpuscles is not reduced so greatly as in forms of idiopathic anaemia. Thus in a case just ANAEMIA. 721 mentioned, at the termination of the week of bleeding there were nearly 1,390,000 red blood-corpuscles to the cubic millimetre. The process of regeneration goes on with great rapidity, and in some “ bleeders ” a week or ten days suffice to re-establish the normal amount. The watery and saline constituents of the blood are readily restored by absorption from the gastro-intestinal tract. The albuminous elements also are quickly re- newed, but it may take weeks or months for the corpuscles to reach the MEAN NORM. NUMBER OF WHITE CORPU8CLE8 Chart XV.—Illustrates the rapidity with which anfemia is produced in purpura h£emorrhagica and the gradual recovery.* BLACK,.RED CORPUSCLES., RED, HAEMAGLOBIN, BLUE, COLORLESS CORPUSCLE8. normal standard. The accompanying chart illustrates the rapid fall and gradual restitution in a case of severe purpura haemorrhagica. The microscopical characters of the blood after severe haemorrhage may not be greatly changed. The red corpuscles show, usually, rather more marked differences in size than normally, while the average size may be a trifle reduced; there may be a moderate poikilocytosis. The * On September 27th the patient returned from the country, where she had spent the summer. The blood-count was then : Red corpuscles, 5,350,000; white corpuscles, 5,500 ; haemoglobin, ninety-four per cent. 722 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. corpuscles are paler than normally. Nucleated red corpuscles appear, almost always, soon after the haemorrhage ; they are, however, not numer- ous. These are small bodies of about the same size as a normal red cor- puscle with a small, round, deeply staining nucleus. Free nuclei may be found. The colorless corpuscles are, at first, increased in number. There is a moderate leucocytosis, the differential count showing an increase in the multinuclear neutrophiles with a diminution in the small monounclear elements. During recovery the leucocytosis diminishes. The reduction in haemoglobin is always jiroportionately greater than that in the corpuscles. In some instances a rapidly fatal anaemia may follow a single severe haemorrhage, or repeated small haemorrhages as in purpura. Here the appearances of the red corpuscles are much the same, except in the total absence of nucleated red corpuscles. The leucocytes in these cases are usually reduced in number; the poly- nuclear elements are present in a relatively diminished proportion, while the small mononuclear forms are numerous. The autopsy, in these cases, reveals usually a total absence of any regenerative activity on the part of the bone-marrow. (2) Anaemia is frequently produced by long-continned drain on the albuminous materials of the blood, as in chronic suppuration and Bright’s disease. Prolonged lactation acts in the same way. Rapidly growing tumors may cause a profound anaemia, as in gastric cancer. The charac- ters of the blood here may be much the same as in the acute cases. Usu- ally, though, the poikilocytosis is much more marked ; in several cases it may be excessive. The presence, however, of the very large corpuscles, such as one sees in pernicious angemia, is not noted, the average size ap- pearing to be rather smaller than normal. Nucleated red corpuscles are usually scanty. In long-continued chronic secondary angemias occasional larger nucleated red corpuscles may be seen, bodies with larger palely staining nuclei; in some of these cells karyo- kinetic figures occur. Nucleated red corpuscles with fragmentary nuclei may also be seen. The leucocytes may be increased in number, though in some severe chronic cases there may be a diminution. (3) Anaemia from Inanition.—This may be brought about by defect- ive food supply, or by conditions which interfere with the proper recep- tion and preparation of the food, as in cancer of the oesophagus and chronic dyspepsia. The reduction of the blood mass may be extreme, but the plasma suffers proportionately more than the corpuscles, which, even in the wasting of cancer of the oesophagus, may not be reduced more than one half or three fourths. In some instances the reduction in the plasma may be so great that the corpuscles show an apparent increase. (4) Toxic ancemia, induced by the action of certain poisons on the blood, such as lead, mercury, and arsenic, among inorganic substances, ANiEMlA. 723 a,nd the virus of syphilis and malaria among organic poisons. They act either by directly destroying the red blood-corpuscles, as in malaria, or by increasing the rate of ordinary consumption. The anaemia of pyrexia may in part be due to a toxic action, but is also caused in part by the disturbance of digestion and interference with the function of the blood- making organs. Primary or Essential Anaemia. 1. Chlorosis.—An essential anaemia met with chiefly in young girls, characterized by a marked relative diminution of the haemoglobin. Etiology.—Cases are rarely seen in men. Blondes are more fre- quently affected than brunettes. The age of onset is usually between the fourteenth and the seventeenth years. Recurrences throughout the third decade are, however, not uncommon. Chlorosis is extremely rare in young children. Hereditary influences probably play a part. Virchow pointed out that in many cases there was a defective development of the circulatory sys- tem, either congenital or resulting in a failure of the normal state of growth. In some instances a compensatory hypertrophy of the heart has been found. The disease is most common among the ill-fed, overworked girls of large towns, who are confined all day in close, badly lighted rooms, or have to do much stair-climbing. Cases are frequent, however, under the most favorable conditions of life. Lack of proper exercise and fresh air and improper food are important factors. Emotional and nervous dis- turbances may be prominent—so prominent that certain writers have regarded the disease as a neurosis. Menstrual disturbances are not un- common, but are probably a sequence, not a cause, of chlorosis. Sir Andrew Clark believed that constipation plays an important role, and that the condition is in reality a coprcemia due to the absorption of poisons— leucomaines and ptomaines—from the large bowel. Morbid Anatomy.—Fortunately, the disease is rarely fatal. The fat is well retained. Hypoplasia of the aorta and larger arteries has been found in some cases, and the vessels have had a remarkable degree of elas- ticity. The heart is usually dilated and the left ventricle hypertrophied. Hypoplasia of the uterus and defective development of the genitalia have also been found. Symptoms.—The blood examination : Johann Duncan in 1867 first called attention to the fact that the essential feature was not a quali- tative but a quantitative change in the haemoglobin. This has been abundantly confirmed. The red blood-corpuscles may show only a mod- erate grade of reduction, but the corpuscles themselves are very poor in haemoglobin. Thus in sixty-three consecutive cases examined at my clinic by Thayer, the average number per cubic millimetre of the red blood-cor- puscles was 4,096,544, or over eighty per cent, whereas the percentage of 724 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. haemoglobin for the total number was 42’3 per cent. The accompanying chart illustrates well these striking differences. There may, however, be well-marked actual anaemia. The least blood-count in the series of cases referred to above was 1,932,000. There may be all the physical charac- MEAN NORM- NUMBER OF WHITE CORPUSCLES BLACK, RED CORPUSCLES. RED, HAEMAGLOBIN. BLUE, COLORLESSTCDRPUSCLES. Chart XVI.—Chlorosis. teristics and symptoms of a profound anaemia with blood-corpuscles nearly at the normal standard. Thus in one instance the globular richness was over eighty-five per cent with the haemoglobin about thirty-five. These characteristics are distinctive, I believe, and not found in the same grade in any other form of anaemia. The importance of the reduction in the haemoglobin depends upon the fact that it is the iron-containing element of the blood with which in respiration the oxygen enters into combination. This marked diminution in the iron has also been determined by chemical analysis of the blood. The microscopical characteristics of the blood are ANAEMIA. 725 as follows: In severe cases the corpuscles may be extremely irregular in size and shape—poikilocytosis—which may occasionally be as marked as in some cases of pernicious anaemia. The large forms of red blood-cells are not as common, and the average size is stated to be below normal. The color of the corpuscles is noticeably pale and the deficiency may be seen either in individual corpuscles or in the blood mixture prepared for counting. The leucocytes may show a slight increase; the average of the sixty-three cases above referred to was 8,467 per cubic millimetre. Though there is no especial difference between the blood of any case of chlorosis and one of ordinary secondary anaemia, yet the relatively great diminution in haemoglobin and the absence of special factors serve to distinguish the former. The general symptoms of chlorosis are those of an anaemia of moderate grade. The subcutaneous fat is well retained or even increased in amount. The complexion is peculiar; neither the blanched aspect of haemorrhage nor the muddy pallor of grave anaemia, but a curious yellow-green tinge which has given the name to the disease, and to its popular designation, the green sickness. In cases of moderate grade the color may be decep- tive, as the cheeks have a reddish tint, particularly on exertion (chlorosis rubra). The subjects complain of breathlessness and palpitation, and there may be a tendency to fainting. The palpitation and breathlessness often lead to the suspicion of heart or lung disease. The eyes have a pe- culiar brilliancy and the sclerotics are of a sky-blue color. Occasionally the skin shows areas of pigmentation, particularly about the joints. Digestive symptoms are common. The appetite is capricious and the patients often have a longing for unusual articles, particularly acids. In some instances they eat all sorts of indigestible things, such as chalk or oven earth. Superacidity of the gastric juice is commonly associated with chlorosis. In nineteen out of twenty-one cases in Riegel’s clinic this con- dition was found to exist. In the other two instances the acidity was normal or a trifle increased. Constipation is a common symptom, and, as already mentioned, has been regarded as an important element in caus- ing the disease. Enteroptosis with palpable right kidney is frequently seen. Contourier has noted the common association of dilatation of the stomach with chlorosis, and states that in some cases this may be an etio- logical factor, while in others it may be a result. The circulatory symptoms are important. Palpitation of the heart oc- curs on exertion, and may be the most distressing symptom of which the patient complains. Percussion may show slight increase in the transverse dulness. A systolic murmur is heard at the apex or at the base; more commonly at the latter, but in extreme cases at both. A diastolic murmur is rarely heard. The systolic murmur is usually loudest in the second left intercostal space, where there is sometimes a distinct pulsation. The exact mode of production is still in dispute. Balfour holds that it is pro- duced at the mitral orifice by relative insufficiency of the valves in the 726 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. dilated condition of the ventricle. On the right side of the neck over the jugular vein a continuous murmur is heard, the bruit de diable, or hum- ming-top murmur. The pulse is usually full and soft. Pulsation in the peripheral veins is sometimes seen. There is a tendency to thrombosis in the veins; most commonly in the femoral, but in other instances in the longitudinal sinus, or the thrombosis may be multiple. Except in the sinuses, the condition is rarely serious. Tuckwell has reported an instance in which there was embolism of the right axillary artery with the loss of a thumb and part of the fingers. Brayton Ball has recently called attention to the impor- tance of this feature of chlorosis. As in all forms of essential anaemia, fever is not uncommon. Especial attention has of late been directed to this by French writers.* Chlorotic patients suffer frequently from headache and neuralgia, which may be paroxysmal. Hysterical manifestations are not infrequent. Menstrual disturbances are very common—amenorrhcea or dysmenorrhoea. With the improvement in the blood condition this function is usually restored. Diagnosis.—The green sickness, as it is sometimes called, is in many instances recognized at a glance. The well-nourished condition of the girl, the peculiar complexion, which is most marked in brunettes, and the white sclerotics are very characteristic. A special danger exists in mis- taking the anaemia of the early stage of pulmonary tuberculosis for chlo- rosis. The palpitation of the heart and shortness of breath frequently suggest heart-disease, and the oedema of the feet and general pallor cause the cases to be mistaken for Bright’s disease. In the great majority of cases the characters of the blood readily separate chlorosis from other forms of anaemia. 2. Idiopathic or Progressive Pernicious Anaemia.—The disease was first clearly described by Addison, who called it idiopathic anaemia. Chan- ning and Gusserow described the cases occurring post partum, but to Bier- mer we owe a revival of interest in the subject. Etiology.—The existence of a separate disease worthy of the term progressive pernicious anaemia has been doubted, but there are unques- tionably cases in which, as Addison says, there exist none of the usual causes or concomitants of anaemia. Clinically there are several different groups which present the characters of a progressive and pernicious anae- mia and are etiologically different. Thus, a fatal anaemia may be due to the presence of parasites, or may follow haemorrhage, or be associated with chronic atrophy of the stomach; but when we have excluded all these causes there remains a group which, in the words of Addison, is characterized by a “ general anaemia occurring without any discoverable cause whatever, cases in which there had been no previous loss of blood, * Trazit, Paris Thesis, 1888. ANAA1IA. 727 no exhausting diarrhoea, no chlorosis, no purpura, no renal, splenic, mias- matic, glandular, strumous, or malignant disease.” Idiopathic anaemia is widely dfstributed. It is of frequent occurrence in the Swiss Cantons, and it is not uncommon in this country. It affects middle-aged persons, but instances in children have been described. Grif- fith mentions about ten cases occurring under twelve years of age. The youngest patient I have seen was a girl of twenty. Males are more fre- quently affected than females. Of my 27 cases, 10 were females and 17 were males. Of 110 cases collected by Coupland, 56 were in men and 54 in women. With the following conditions may be associated a profound anaemia not to be distinguished clinically from Addison’s idiopathic form : (a) Pregnancy and Parturition.—The symptoms may develop during pregnancy, as in 19 of 29 cases of this group in Eichhorst’s table. More commonly, in my experience, the condition has been post partum; thus, of my 27 cases, 5 followed delivery. (b) Atrophy of the Stomach.—This condition, early recognized by Flint and Fenwick, may certainly cause a progressive pernicious anaemia. By modern methods it may now be possible to exclude this extreme gastric atrophy. (c) Parasites.—The most severe form may be due to the presence of parasites, and the accounts of cases depending upon the anchylostoma and the bothriocephalus describe a progressive and often pernicious anaemia. After the exclusion of these forms there remains a large proportion, numbering eighteen cases in my series, which correspond to Addison’s description. The etiology of these cases is still dark. The researches of Quincke and his student Peters showed that there was an enormous in- crease in the iron in the liver, and he suggested that the affection was probably due to increased haemolysis. This has been strongly supported by the extensive observations of Hunter, who has also shown that the urine excreted is darker in color and contains pathological urobilin. The lemon tint of the skin or the actual jaundice is attributed, on this view, to the changes in the liver cells produced by the excessive amount of pig- ment, but in the light grades it is unquestionably haematogenous. To explain the haemolysis, it has been thought that in the condition of faulty gastro-intestinal digestion, which is so commonly associated with these cases, poisonous materials are developed, which when absorbed cause de- struction of the corpuscles. Certainly the evidence for haemolysis is very strong, but we are still far away from a full knowledge of the conditions under which it is produced. Stockman suggests that repeated small capillary haemorrhages—chiefly internal—play an important role in the causation of the disease, which also explains, he holds, the existence of a great excess of iron in the liver. On the other hand, F. P. Henry, Stephen Mackenzie, Rindfleisch, and other authorities incline to the belief that the essence of the disease is in 728 DISEASES OF TITE BLOOD AND DUCTLESS GLANDS. defective hasmogenesis, in consequence of which the red blood-corpuscles are abnormally vulnerable. A point noted by Copeman, that the haemo- globin crystallizes from the blood-corpuscles with great readiness, can scarcely be regarded as favoring the view of imperfect haemogenesis, since this is a feature specially characteristic of the blood of the young. Morbid Anatomy.-—The body is rarely emaciated. A lemon tint of the skin is present in a majority of the cases. The muscles often are intensely red in color, like horse-flesh, while the fat is light yellow. Haemorrhages are common on the skin and serous surfaces. The heart is usually large, flabby, and empty. In one instance I obtained only two drachms of blood from the right heart, and between three and four from the left. The muscle substance of the heart is intensely fatty, and of a pale, light-yellow color. In no affection do we see more extreme fatty degeneration. The lungs show no special changes. The stomach in many instances is normal, but in some cases of fatal anaemia the mucosa has been extensively atrophied. In the case described by Henry and myself the mucous membrane had a smooth, cuticular appearance, and there was complete atrophy of the secreting tubules. The liver may be enlarged and fatty. In most of my autopsies it was normal in size, but usu- ally fatty. The iron is in excess, and in striking contrast to cases of secondary anaemia. It is deposited in the outer and middle zones of the lobules, and in two specimens which I examined seemed to have such a distribution that the bile capillaries were distinctly outlined. This Hunter states is a special and characteristic lesion, possibly peculiar to pernicious anaemia. A. J. Scott examined for me the livers in forty-five consecutive autopsies without finding (except in pernicious anaemia) this special distribution of pigment. The spleen shows no important changes. In one of Palmer Howard’s cases the organ weighed only an ounce,and five drachms. The iron pig- ment is usually in excess. The lymph-glands may be of a deep red color. The amount of iron pigment is increased in the kidneys, chiefly in the convoluted tubules. The bone marrow, as pointed out by II. C. Wood, is usually red, lymphoid in character, showing great numbers of nucleated red corpuscles, especially the larger forms called by Ehrlich gigantoblasts. Changes in the ganglion cells of the sympathetic have been reported on several occasions. Lichtheim has found sclerosis in the posterior columns of the cord. Burr has recently (University Med. Magazine, 1895) de- scribed a series of cases. The subject is referred to again under diseases of the spinal cord. Symptoms.—The patient may have been in previous good health, but in many cases there is a history of gastro-intestinal disturbance, mental shock, or worry. The description given by Addison presents the chief features of the disease in a masterly way. “It makes its approach in so slow and insidious a manner that the patient can hardly fix a date to the earliest feeling of that languor which is shortly to become so extreme. ANAEMIA. 729 The countenance gets pale, the whites of the eyes become pearly, the general frame flabby rather than wasted, the pulse perhaps large, but remarkably soft and compressible, and occasionally with a slight jerk, especially under the slightest excitement. There is an increasing indis- position to exertion, with an uncomfortable feeling of faintness or breath- lessness in attempting it; the heart is readily made to palpitate ; the whole surface of the body presents a blanched, smooth, and waxy appearance; the lips, gums, and tongue seem bloodless, the flabbiness of the solids increases, the appetite fails, extreme languor and faintness supervene, breathlessness and palpitations are produced by the most trifling exertion or emotion; some slight oedema is probably perceived about the ankles; the debility becomes extreme—the patient can no longer rise from bed; the mind occasionally wanders; he falls into a prostrate and half-torpid state, and at length expires; nevertheless, to the very last, and after a sickness of several months’ duration, the bulkiness of the general frame and the amount of obesity often present a most striking contrast to the failure and exhaustion observable in every other respect.” The Blood.—The corpuscles may fall to one fifth or less of the normal number. They may sink to 500,000 per cubic millimetre, and in a case of Quincke’s the number was reduced to 143,000 per cubic millimetre. The haemoglobin is relatively increased, so that the individual globular richness is plus, a condition exactly the opposite to that which occurs in chlorosis and the secondary anaemia, in which the corpuscular richness in coloring matter is minus. The relative increase in the haemoglobin is probably associated with the average increase in the size of the red blood- corpuscles. The accompanying chart illustrates these points. Microscop- ically the red blood-corpuscles present a great variation in size, and there •can be seen large giant forms, megalocytes, which are often ovoid in form, measuring eight, eleven, or even fifteen micromillimetres in diameter—a circumstance which Henry regards as indicating a reversion to a lower type. Laache thinks these pathognomonic, and they certainly form a constant feature. There are also small round cells, microcytes, from two to six micromillimetres in diameter, and of a deep red color. The corpus- cles show a remarkable irregularity in form, elongated and rodlike or pyri- form ; one end of a corpuscle may retain its shape while the other is nar- row and extended. To this condition of irregularity Quincke gave the name poikilocytosis. Nucleated red blood-corpuscles are almost always present, as pointed out by Ehrlich. Besides the ordinary form, which is of the same size as the common corpuscle and which has a small, deeply stained nucleus (normo- blasts), there are very large forms with palely staining nuclei (giganto- blasts), which resemble somewhat the larger megalocytes. Ehrlich re- gards the presence of these as almost distinctive of progressive pernicious anaemia. Though these large forms are most characteristic, occasionally forms closely similar to them may be found in the graver secondary an- 730 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. aemias—i. e., anchylostomiasis—and in leukaemia. Karyokinetic figures may be seen in these bodies. Red corpuscles with fragmenting nuclei are common in pernicious anaemia. The leucocytes are generally nor- mal or diminished in number; and in the graver cases a marked increase MEAN NORM. NUMBER OF WHITE CORPUSCLES BLACK, RED CORPUSCLES RED, HAEMOGLOBIN. BLUE, COLORLESS CORPUSCLES. Chart XVII.—Pernicious anaemia. in the small mononuclear forms, Avith a diminution in the polynuclear leucocytes, is often noted. The blood-plates are either absent or very scanty. The cardio-vascular symptoms are important and are noted in the de- scription given above. Haemic murmurs are constantly present. The larger arteries pulsate visibly and the throbbing in them may be distress- ing to the patient. The pulse is full and frequently suggests the water- ANAEMIA. 731 hammer beat of aortic insufficiency. The capillary pulse is frequently to be seen. The superficial veins are often prominent, and in two cases I have seen well-marked pulsation in them. Haemorrhages may occur, either in the skin or from the mucous surfaces. Retinal haemorrhages are com- mon. There are rarely symptoms in the respiratory organs. Gastro-intestinal symptoms, such as dyspepsia, nausea, and vomiting, may be present throughout the disease. Diarrhoea is not infrequent. The urine is usually of a low specific gravity and sometimes pale, but in other instances it is of a deep sherry color, shown by Hunter and Mott to be due to great excess of urobilin. Fever is a variable symptom. For weeks at a time the temperature may be normal, and then irregular pyrexia may develop. Nervous symptoms may occur, numbness and tingling, and oc- casionally symptoms resembling those of tabes. Lepine reports a case of extensive paralysis. Diagnosis.—From chlorosis the disease is readily distinguished. I have not seen a case in which the two diseases could have been con- founded. Two points in the blood examination are of especial impor- tance, namely, the relative increase in the haemoglobin and the presence of the large forms of nucleated red blood-corpuscles, the gigantoblasts of Ehr- lich. Poikilocytosis may occur in any severe anaemia. The separation of the different clinical forms above referred to can usually be made. The profound secondary anaemia of cancer of the stomach may sometimes be puzzling, but the skin is rarely, if ever, lemon-tinted, and the blood has the characteristics of a secondary, not a primary, anaemia. Prognosis.—In the true Addisonian cases the outlook is bad, though of late years on the arsenic treatment the proportion of recovery is increased. My personal experience is as follows: Of the 27 cases 4 are now under ob- servation, 2 of these having recovered with arsenic. Of the remaining 23 the following statement maybe made: Four of the 5 post-partum cases recovered, and when I left Montreal 3 of these cases had remained in good health for several years. Of the remaining 18 cases 2 were lost sight of ; 1 had improved very much. The remaining 16 are dead. Six of these fatal cases recovered from the first attack; one had an interval of nearly three years, and another nearly two years, before the return. I know of no instance in a male in which the recovery has lasted for five years. In Pye-Smith’s article in Guy’s Hospital Reports, he mentions twenty cases of recovery. Hale White, in a recent article, states that one of these cases, treated by arsenic in 1880, remained alive and well January, 1891. One of my patients made an apparently complete recovery and resumed active business and political duties. So characteristic are recurrences in this affection that Stephen Mackenzie, in his recent lectures, considered them under a separate heading of relapsing pernicious anaemia. The ex- amination of the blood may give us some help. The presence of numer- ous normoblasts appears in some instances to be indicative of an active regeneration in the marrow. Cases in which a majority of the nucleated 732 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. red corpuscles are gigantoblasts are generally more malignant. A marked relative increase in the small mononuclear leucocytes appears to be also an unfavorable sign. Treatment of Anaemia.—Secondary Anaemia.—The traumatic cases do best, and with plenty of good food and fresh air the blood is readily restored. The extraordinary rapidity with which the normal percentage of red blood-corpuscles is reached without any medication whatever is an important lesson. The cause of the haemorrhage should be sought and the necessary indications met. The large group depending on the drain on the albuminous materials of the blood, as in Bright’s disease, suppuration, and fever, is difficult to treat successfully, and so long as the cause keeps up it is impossible to restore the normal blood con- dition. The anaemia of inanition requires plenty of nourishing food. When dependent on organic changes in the gastro-intestinal mucosa not much can be expected from either food or medicine. In the toxic cases due to mercury and lead, the poison must be eliminated and a nutritious diet given with full doses of iron. In a great majority of these cases there is deficient blood formation, and the indications are briefly three : plenty of food, an open-air life, and iron. As a rule it makes but little difference what form of the drug is administered. The treatment of chlorosis affords one of the most brilliant instances— of which we have but three or four—of the specific action of a remedy. Apart from the action of quinine in malarial fever, and of mercury and iodide of potassium in syphilis, there is no other remedy the beneficial effects of which we can trace with the accuracy of a scientific experiment. It is a minor matter how the iron cures chlorosis. In a week we give to a case as much iron as is contained in the entire blood, as even in the worst case of chlorosis there is rarely more than a deficit of two grammes of this metal. Iron is present in the faeces of chlorotic patients before they are placed upon any treatment, so that the disease does not result from any deficiency of available iron in the food. Bunge believes that it is the sulphur which interferes with the digestion and assimilation of this natural iron. The sulphides are produced in the process of fermentation and decomposition in the fseces, and interfere with the assimilation of the normal iron con- tained in the food. By the administration of an inorganic preparation of iron with which these sulphides unite the natural organic combinations in the food are spared. In studying a number of charts of chlorosis, it is seen that there is an increase in the red blood-corpuscles under the influ- ence of the iron, and in some instances the globular richness rises above normal. The increase in the liamioglobin is slower and the maximum percentage may not be reached for a long time. I have for years in the treatment of chlorosis used with the greatest success Blaud’s pills, made and given according to the formula in Niemeyer’s text-book, in which each pill contains 2 grs. of the sulphate of iron. During the first week one pill is given three times a day ; in the second week, two pills; in the third LEUKEMIA. 733 week, three pills, three times a day. This dose should be continued for four or five weeks at least before reduction. An important feature in the treatment of chlorosis is to persist in the use of the iron for at least three months, and, if necessary, subsequently to resume it in smaller doses, as re- currences are so common. The diet should consist of good, easily digested food. Special care should be directed to the bowels, and if constipation is present a saline purge should be given each morning. Such stress does Sir Andrew Clark lay on the importance of constipation in chlorosis, that he states that if limited to the choice of one drug in the treatment of the disease he would choose a purgative. The good influence of alkaline waters in association with the treatment by iron has been noted by von Jaksch. In many instances the dyspeptic symptoms may be relieved by alkalies and a treatment directed toward a moderate hyperacidity. Dilute hydrochloric acid, manganese, phosphorus, and oxygen have been recom- mended. Treatment of Pernicious Anaemia.—Since the introduction by Byrom Bramwell of arsenic in this affection a large number of cases have been temporarily, a few permanently, cured by it. It should be given as Fowler’s solution in increasing doses. It is usually well borne, and patients, as a rule, take up to twenty minims three times a day without any disturbance. I usually begin with three minims and increase to five at the end of the first week, to ten at the end of the second week, to fifteen at the end of the third week, and, if necessary, increase to twenty or twenty-five. In a case in which the recovery persisted for nearly three years the dose was gradually increased to thirty minims. These patients seem to bear the arsenic extremely well. It is sometimes better borne as arsenious acid in pill form. Vomiting and diarrhoea are rare; occasionally puffiness of the face is produced, and in some cases pigmentation of the skin. Rest in bed and a light but nutritious diet (giving the food in small amounts and at fixed intervals) are the first indications. I always prefer to begin the treatment of a case of pernicious anasmia, whatever the grade may be, with rest in bed as one of the essential elements. The beneficial effect of massage has been shown by J. K. Mitchell. I have abandoned the use of rectal injections of dried blood. Iron rarely acts well in this form, but in a case in which the arsenic disagrees it may be tried. Bone marrow has been recommended. It is best given as a glycerin extract. I have not seen any benefit follow its administration. II. LEUK/EMIA. Definition.—An affection characterized by persistent increase in the white blood-corpuscles, associated with changes, either alone or together, in the spleen, lymphatic glands, or bone marrow. The disease was described almost simultaneously by Virchow and by DISEASES OF THE BLOOD AND DUCTLESS GLANDS. Bennett, who gave to it the name leucocythaemia. It is ordinarily seen in two main types, though combinations and variations may occur: (1) Spleno-medullary leukaemia, in which the changes are especially localized in the spleen and the bone marrow, while the blood shows a great increase in elements which are derived especially from the latter tissue. (2) Lymphatic leukaemia, in which the changes are chiefly localized in the lymphatic apparatus, the blood showing an especial increase in those elements derived from the lymph glands. Etiology.—We know nothing of the conditions under which the dis- ease develops. It is not uncommon on this continent. Of 26 cases of which I have notes, 11 occurred in Montreal, 2 in Philadelphia, and 13 in hos- pital and private work in Baltimore. It does not seem more frequent in the southern parts of the country. The disease is most common in the middle period of life. The young- est of my patients was a child of eight months, and cases are on record of the disease as early as the eighth or tenth week. It may occur as late as the seventieth year. Males are more prone to the affection than females. Of my cases 17 were in males and 9 in females. Birch-IIirschfeld states that of 200 cases collected from the literature, 135 were males and 65 females. A tendency to haemorrhage has been noted in many cases, and some of the patients have suffered repeatedly from nose-bleeding. In women the disease is most common at the climacteric. There are instances in which it has developed during pregnancy. The case described by J. Chalmers Cameron, of Montreal, is in this respect remarkable, as the pa- tient passed through three pregnancies, bearing on each occasion non- leukgemic children. The case is interesting, too, as showing the heredi- tary character of the affection, as the grandmother and mother, as well as a brother, suffered from symptoms strongly suggestive of leukaemia. One of the patient’s children had leukaemia before the mother showed any signs, and a second died of the disease. At the last report this patient had gradually recovered from the third confinement, and the red blood- corpuscles had risen to 4,000,000 per cubic millimetre, and the ratio of white to red 1 to 200. Sanger has reported a case in which a healthy mother bore a leukaemic child. Malaria is believed by some to be an etiological factor. Of 150 cases analyzed by Gowers, there was a history of malaria in 30; in my series there was a history in at least 9. Syphilis appears in some cases to have been closely associated with leukaemia. The disease has followed injury or a blow. The lower animals are subject to the affection, and cases have been described in horses, dogs, oxen, cats, swine, and mice. Morbid Anatomy.—The wasting may be extreme, and dropsy is sometimes present. There is in many cases a remarkable condition of LEUKAEMIA. 735 polysemia; the heart and veins are distended with large blood-clots. In Case XI of my series the weight of blood in the heart chambers alone was 620 grammes. There may be remarkable distention of the portal, cerebral, pulmonary, and subcutaneous veins. The blood is usually clotted, and the enormous increase in the leucocytes gives a pus-like appearance to the coagula, so that it has happened more than once, as in Virchow’s memorable case; that on opening the right auricle the observer at first thought he had cut into an abscess. The coagula have a peculiar greenish color, somewhat like the fat of a turtle. The alkalinity of the blood is diminished. The fibrin is increased. The character of the corpuscles will be described under the symptoms. Charcot’s octohedral crystals may separate from the blood after death. The specific gravity of the blood is somewhat lowered. There may be pericardial ecchymoses. The spleen in the great majority of cases is enlarged. Strong adhe- sions may unite it to the abdominal wall, the diaphragm, or the stomach. The capsule may be thickened. The vessels at the hilus are enlarged; the weight may range from two to eighteen pounds. The organ is in a condition of chronic hyperplasia. It cuts with resistance, has a uniformly reddish-brown color, and the Malpighian bodies are invisible. Grayish- white, circumscribed, lymphoid tumors may occur throughout the organ, contrasting strongly with the reddish-brown matrix. In the early stage the swollen spleen pulp is softer, and it is stated that rupture has occurred from the intense hyperasmia. In association with these changes in the spleen the bone marrow is involved, the lieno-medullary form of the Germans. The marrow may be involved alone, forming a pure myelogenous leukaemia. Instead of a fatty tissue, the medulla of the long bones may resemble the consistent matter which forms the core of an abscess, or it may be dark brown in color. In Ponfick’s case there were haemorrhagic infarctions. There may be much expansion of the shell of bone, and localized swellings which are tender and may even yield to firm pressure. Histologically, there are found in the medulla large numbers of nucleated red corpuscles in all stages of develop- ment, numerous cells with eosinophilic granules, and also many large cells with single large nuclei—the cellules medullaires of Cornil—the mye- locytes which are found in the blood. Polynuclear leucocytes are also present, as well as a certain number of small mononuclear elements. Enlargement of the lymphatic glands may occur, either in conjunction with splenic enlargement or alone. In only one of my cases was the en- largement notable. In the cases of lymphatic leukaemia the cervical, axil- lary, mesenteric, and inguinal groups may be much enlarged, but the glands are usually soft, isolated, and movable. They may vary consider- ably in size during'the course of the disease. The tonsils and the lymph follicles of the tongue, pharynx, and mouth may be enlarged. Numerous mitoses may be found in the small cells of the lymphatic tissue. In some instances there are leukasinic enlargements in the solitary and 736 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. agminated glands of Peyer. In a case of Willcocks there were growths on the surface of the stomach and gastro-splenic omentum. The thymus is rarely involved, though it has been enlarged in some of the cases of acute lymphatic leukaemia. The liver may be enlarged, and in a case described by Welch it weighed over thirteen pounds. The enlargement is usually due to a diffuse leukaemic infiltration. The columns of liver cells are widely separated by leucocytes, which are partly within and partly outside the lobular capillaries. There may be definite leukaemic growths. There are rarely changes of importance in the lungs. The kidneys are often enlarged and pale, the capillaries may be distended with leu- cocytes, and leukaemic tumors may occur. The skin may be involved, as in a case described by Kaposi. Leukaemic tumors in the organs are not common. They were present in only one of the twelve autopsies in my series. In 159 cases collected by Gowers there were only thirteen instances of leukaemic nodules in the liver and ten in the kidneys. These new growths probably develop from leucocytes which leave the capillaries. Bizzozero has shown that the cells which compose them are in active fission. Symptoms.—The onset is insidious, and, as a rule, the patient seeks advice for progressive enlargement of the abdomen and shortness of breath, or for the enlarged glands or the pallor, palpitation, and other symptoms of anaemia. Bleeding at the nose is common. Gastro-intestinal symptoms may precede the onset. Occasionally the first symptoms are of a very serious nature. In one of the cases of my series the boy played lacrosse two days before the onset of the final haematemesis; and in an- other case a girl, who had, it was supposed, only a slight chlorosis, died of fatal haemorrhage from the stomach before any suspicion had been aroused as to the true condition. Anaemia is not a necessary accompaniment of the disease; the subjects may look very healthy and well. As has been stated, the disease is most commonly seen in two main types, though combinations may occur. (1) Spleno-medullary Leukaemia. This is much the commonest type of the disease. The gradual in- crease in the volume of the spleen is the most prominent symptom in a majority of the cases. Pain and tenderness are common, though the pro- gressive enlargement may be painless. A creaking fremitus may be felt on palpation. The enlarged organ extends downward to the right, and may be felt just at the costal edge, or when large it may extend as far over as the navel. In many cases it occupies fully one half of the abdo- men, reaching to the pubes below and extending beyond the middle line. As a rule, the edge, in some the notch or notches, can be felt distinctly. Its size varies greatly from time to time. It may be perceptibly larger after meals. A hsemorrliage or free diarrhoea may reduce the size. The LEUKAEMIA. 737 pressure of the enlarged organ may cause distress after eating; in one case it caused fatal obstruction of the bowels. A murmur may sometimes be heard over the spleen, and Gerhardt has described a pulsation in it. The pulse is usually rapid, soft, compressible, but often full in volume. There are rarely any cardiac symptoms. The apex beat may be lifted an interspace by the enlarged spleen. Toward the close, as a consequence of the feeble circulation, oedema may occur in the feet or there may be gen- eral anasarca. Hsemorrhage is a common symptom and may be either late or early. Epistaxis is the most frequent form. Ilgemoptysis and hsematuria are rare. Bleeding from the gums may be present. Ilsema- temesis proved fatal in two of my cases, and in a third a large cerebral haemorrhage rapidly killed. The leuksemic retinitis is a part of the haem- orrhagic manifestations. There are very few pulmonary symptoms. The shortness of breath is due, as a rule, to the anaemia. Toward the end there may be oedema of the lungs, or pneumonia may carry off the patient. The gastro-intestinal symptoms are rarely absent. Nausea and vomiting are early features in some cases. Diarrhoea may be very troublesome, even fatal. Intestinal haemorrhage is not common. There may be a dysenteric process in the colon. Jaundice rarely occurs, though in one case of my series there were recurrent attacks. Ascites may be a prominent symptom, probably due to the presence of the splenic tumor. A leuksemic peritonitis also may be present, due to new growths in the membranes. The nervous system is not often involved. Headache, dizziness, and fainting spells are due to anaemia. The patients are usually tranquil and resigned. Sudden coma may follow cerebral haemorrhage. The special senses are often affected. There is a peculiar retinitis, due chiefly to the extravasation of blood, but there may be aggregations of leucocytes, forming small leukasmic growths. Optic neuritis is rare. Deafness has frequently been observed ; it may appear early and possibly is due to haemorrhage. The urine presents no constant changes. The uric acid excreted is always in excess, and possibly, as Salkowski suggests, stands in direct relation to the splenic tumor, or to the abundant leucocytes. Priapism is a curious symptom which has been present in a large number of cases. It may, as in one of Edes’ cases, be the first symptom. Peabody reports a case in which it persisted for six weeks. The cause is not known. Slight fever is present in a majority of cases. Periods of pyrexia may alternate with prolonged intervals of freedom. The temperature may range from 102° to 103°. Blood.—In all forms of the disease the diagnosis must be made by the examination of the blood, as it alone offers distinctive features. In the normal blood there may be distinguished the following varieties of color- less elements: (a) Small mononuclear leucocytes—small cells about the 738 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. size of a red blood-corpuscle, and probably derived from the lymphatic glands, which have a single large, round, deeply staining nucleus, sur- rounded by a narrow rim of non-granular protoplasm (lymphocytes) ; also cells a trifle larger than these, with similar small round nuclei, but a larger amount of clear, pale protoplasm, (b) Large mononuclear leuco- cytes—cells several times as large as the red blood-corpuscle, with an oval or elliptical nucleus and a relatively larger amount of ungranulated pro- toplasm. (c) Transitional forms—cells which resemble the last variety, but have indentations and irregularities in the nucleus. (d) Poly- nuclear leucocytes—these are about the same size or a little smaller than the last variety. The nucleus is a long, deeply staining body which is bent and twisted on itself into irregular shapes. The protoplasm of these cells is filled with granules, which are stained not by acid or basic color- ing matters alone, but only by a combined fluid. The granules are there- fore termed neutrophilic, and the name “ neutrophiles ” is given to these cells. (e) Cells about the same size as the last, but containing large, highly refractile, fat-like granules, which have an affinity for acid coloring matters. On account of their affinity for eosin Ehrlich terms them eosino- philes. In normal blood these cells occur in a fairly definite proportion to each other; the small mononuclear fifteen to twenty-five per cent, the polynuclear sixty-five to eighty per cent, the mononuclear and transitional forms about six per cent, and the eosinophiles two to four per cent or less. The most striking change in the more common form, the lieno- myelogenic, is the increase in the colorless corpuscles. The average num- ber of white per .cubic millimetre is estimated at about 6,000-7,000 ; thus the proportion of white to red is 1 to 500-1,000. In leukaemia the pro- portion may be 1 to 10, or 1 to 5, or the ratio may reach 1 to 1. There are instances on record in which the number of leucocytes has exceeded that of the red corpuscles. The character of the cells in splenic myelogenous leukaemia is as follows : The small mononuclear forms are little if at all increased ; rela- tively they are greatly diminished. The eosinophiles are present in normal or increased relative proportion, so that there is a great total increase, and their presence is a striking feature in the stained blood- slide. The polynuclear neutrophiles may be in normal proportion ; more frequently they are relatively diminished, and in the latter stages they may form but a small proportion of the colorless elements. Marked dif- ferences in size between individual polynuclear leucocytes may be noted ; the same is true of the eosinophiles. The most characteristic features of the blood in this form of leukaemia is the presence of cells which do not occur in normal blood. They appear to be derived from the marrow, and are called by Ehrlich myelocytes. They are considerably larger than the large mononuclear leucocytes, and are similar to them in appearance, but differ from them in the fact that the protoplasm is filled with the fine neutrophilic granules. Muller has recently found many large mononu- LEUKAEMIA. 739 clear elements with karyokinetic figures in leukaemic blood and in the marrow. These probably correspond to the myelocytes of Ehrlich as well as to the “ cellules medullaires ” of Cornil. MEAN NORM. NUMBER OF WHITE CORPUSCLES BLACK, RED CORPUSCLES. RED, HAEMOGLOBIN BLUE, COLORLESS CORPUSCLES. Chart XVIII.—Leukaemia. Nucleated red blood-corpuscles are present in considerable num- bers. These are usually “ normoblasts,” but cells with larger paler nuclei, some showing evidences of mitosis, may be seen. Red cells with fragmented nuclei are common, while true gigantoblasts may be found. 740 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. There is, as a rule, only a moderate reduction in the number of red blood- corpuscles, rarely under two million per cubic millimetre. The hemo- globin is usually reduced in a somewhat greater proportion. The accom- panying blood chart is from a case of leukasmia with an enormously enlarged spleen. Among other points about leuksemic blood may be mentioned the feebleness of the amoeboid movement, as noted by Cafavy, which may be accounted for by the large number of mononuclear ele- ments present, the polynuclear alone possessing this power. The blood- plates exist in variable numbers; they may be remarkably abundant. The fibrin network between the corpuscles is usually thick and dense. In blood-slides which are kept for a short time, Charcot’s octohedral crystals separate, and in the blood of leukasmia the haemoglobin shows a remark- able tendency to crystallize. 2. Lymphatic Leukaemia. This form of leukaemia is rare. As mentioned, in but 4 of my series of 26 cases were the glands enlarged. The superficial groups are usually most involved, and even when affected it is rare to see such large bunches as in Hodgkin’s disease. External lymph tumors are rare. Lymphatic leukaemia is often more rapid and fatal in its course, though chronic cases may occur. It is more common in young subjects. The histological characters of the blood in lymphatic leukaemia differ materially from those in the spleno-medullary form. The increase in the colorless elements is never so great as in the preceding form ; a propor- tion of one to ten would be extreme. This increase takes place solely in the lymphocytes, all other forms of leucocytes being present in greatly diminished relative proportion. In one of my cases over 98 per cent of all the leucocytes were lymphocytes. Eosinophiles and nucleated red corpuscles are rare. Myelocytes are not present. The pure myelogenous cases without associated enlargement of the spleen are rare. The most extreme hyperplasia of the bone marrow may exist without any tenderness. Occasionally the sternum, ribs, and flat bones show great irregularity and deformity, owing to definite tumor-like expansions. Combined forms of leukaemia may occur though they are not common. One such instance occurred at the Johns Hopkins Hospital. Here the spleen, marrow, and lymphatic glands all showed marked changes. The blood in this instance showed, besides a large proportion of lymphocytes and myelocytes, a considerable number of large mononuclear leucocytes. Diagnosis.—The recognition of leukaemia can be determined only by microscopical examination of the blood. The clinical features may be identical with those of ordinary splenic anaemia, or with Hodgkin’s disease. An interesting question arises whether real increase in the leucocytes is the only criterion of the existence of the disease. Thus, for instance, in the case whose chart is given on page 739, the patient came under obser- vation in September, 1890, with 2,000,000 red blood-corpuscles per cubic LEUKAEMIA. 741 millimetre, thirty per cent of haemoglobin, and 500,000 white blood-cor- puscles per cubic millimetre—a proportion of one to four. As shown by the chart, throughout September, October, November, and December, this ratio was maintained. Early in January, under treatment with arsenic, the white corpuscles began to decrease, and gradually, as shown in the chart, the normal ratio was reached. At this time could it be said that the case was one of leukaemia without increase in the number of leuco- cytes? The blood examination by Ehrlich’s method, as made by Thayer, showed that nucleated red corpuscles in large numbers as well as the char- acteristic myelocytes, elements which are but rarely found in normal blood, were still present in numbers sufficient, at any rate, to suggest, if the pa- tient had come under observation for the first time, that leukaemia might occur. By Ehrlich’s method of blood examination a condition of leu- cocytosis can readily be distinguished from that of leukaemia, for in all ordinary leucocytoses the increase takes place solely in the polynuclear neutrophilic leucocytes. The remarkable “ green cancer ” or chloroma is, according to Dock, “ a lymphomatous process similar in its classical features to leukaemia and pseudo-leukaemia.” Prognosis.—Recovery occasionally occurs. A great majority of the cases prove fatal within two or three years. Unfavorable signs are a tend- ency to haemorrhage, persistent diarrhoea, early dropsy, and high fever. Remarkable variations are displayed in the course, and a transient im- provement may take place for weeks or even months. The pure lym- phatic form seems to be of particular malignancy, some cases proving fatal in from six to eight weeks; but there are exceptions, and I have recently seen a case in which the diagnosis was made ten years ago by W. H. Draper. The patient has had enlarged glands ever since, and, though not anaemic, the leucocytes were 242,000 per cubic millimetre, above ninety per cent of them lymphocytes. Treatment.—Fresh air, good diet, and abstention from mental worry and care, are the important general indications. The indicatio morbi can- not be met. There are certain remedies which have an influence upon the disease. Of these, arsenic, given in large doses, is the best. I have re- peatedly seen improvement under its use. On the other hand, there are curious remissions in the disease which render therapeutical deductions very fallacious. I have seen such marked improvement without special treatment that the patient, from a bed-ridden, wretched condition, recov- ered strength enough to enable him to attend to light duties. Quinine may be given in cases with a malarial history. Iron may be of value in some cases, as may also inhalations of oxygen. Excision of the leukaemic spleen has been performed twenty-four times, with one recovery—the case of Eranzolini. Fussell gives the statistics of 105 cases of splenectomy with 48 deaths. Of the cases of simple hyper- trophy, 28 in number, 9 recovered. Of 16 cases of floating spleen, 15 recovered. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. III. HODGKIN’S DISEASE. Definition.—An affection characterized by progressive hyperplasia of the lymph glands, with anaemia, and occasionally the development of secondary lymphoid growths in liver, spleen, and other organs. The dis- ease has also the names pseudo-leukcemia, general lymphadenoma, and adenie. Hodgkin, the well-known morbid anatomist of Guy’s Hospital, first described cases in detail, and by the labors of Wilks, Virchow, Billroth, and Cohnheim the disease attained definite recognition. Etiology.—A majority of the cases are in young persons. In Gowers’ table of 100 cases, 30 were under twenty years, 34 between twenty and forty, and 36 above forty. Three fourths of the cases are in males. In a few instances heredity has been adduced as a possible cause, and antece- dent disease, such as syphilis, but this is doubtful. More important is local irritation, upon which Trousseau lays sqtecial stress, and gives instances in which chronic irritation of the skin, chronic nasal catarrh, or the irrita- tion of a decayed tooth gave rise to local gland swellings, which preceded a general development of the disease. In a large majority of the cases the disease comes on insidiously, without any recognizable cause. Morbid Anatomy.—The Lymph Glands.—In a few cases the en- larged glands are hard and firm, but in a majority the growth is soft and elastic. In the early stage the individual glands are isolated, not larger than almonds or walnuts, and readily separated and movable. When ad- vanced the glands fuse together, and a group, as in the neck, may form a large tumor, the size of an orange or even of a cocoa-nut. About such masses the capsular tissues are hard and dense, forming a firm investment. A growth may perforate the capsule and invade contiguous parts, such as the muscles, skin, or the solid organs. On section, the tumor has a gray- ish-white appearance; it is smooth, and of variable consistence, either firm and dry or soft and juicy. Suppuration is most frequently seen when the growth reaches the skin. In the deep glands the formation of pus is rare. Caseation is not common; occasionally there are areas of necrosis very like it- The superficial glands are most often attacked, particularly the cervical groups, and the glands may be traced as continuous chains along the trachea and the carotids, uniting the axillary and mediastinal glands. The axillary group is involved next in order of frequency, and the masses may pass beneath the pectorals and beneath the scapulae. The inguinal glands occasionally form very large masses. Of the internal groups, those of the thorax are most often affected, either the chain in the posterior mediastinum or the bronchial group, or those of the anterior mediastinum. The trachea and the aorta with its branches may be com- pletely surrounded by the growths, and be but little compressed. From the anterior mediastinum the masses may perforate the sternum and ap- pear as an external tumor. HODGKIN’S DISEASE. 743 Of the abdominal groups, the retroperitoneal is most frequently in- volved and may form a continuous chain from the diaphragm to the inguinal canals, and extend into the pelvis. The glands may compress the ureters, involve the sacral or lumbar nerves, or compress the iliac veins. Occasionally they adhere to the uterus and broad ligament so as to simu- late fibroids. I saw, some years ago, one of the most distinguished gynae- cologists of Germany perform laparotomy in a case of this kind, in which the diagnosis of myomatous tumors of the uterus had been made. Occa- sionally the mesenteric or hepatic lymph glands may form large abdominal tumors. Histologically the chief change is an increase in the cells, with or without thickening of the reticulum. In the early stage there is simple hyperplasia and the relations of the lymph paths are maintained, but when the glands are greatly enlarged the normal arrangement is disturbed. The reticulum varies extremely ; in the softer growths it is expanded and can scarcely be found ; in the harder structures the network of fibres is very distinct, and there is probably an increased development of the adenoid tissue. Spleen.—In seventy-five per cent of the cases collected by Gowers this organ was hypertrophied, and in fifty-six of these cases it presented lym- phoid growths. The enlargement is rarely great, and does not approximate to the large leukaemic spleen. The lymphoid tumors form grayish-white bodies ranging in size from a pea to a walnut, and may resemble lymph glands in appearance and consistence. Histologically, they consist of lymph corpuscles in a fibrous reticulum. The marrow of the long bones may be converted into a rich lymphoid tissue ; in a few instances the pyoid form, such as is more common in leu- kaemia, has been found. The tonsils may be involved and the follicles at the root of the tongue. Occasionally secondary growths are seen in the intestines. The liver is often enlarged and may present scattered lymphoid tumors. The kidneys are occasionally involved and are the seat of growths similar to those of the spleen and liver. The lungs are occasionally directly at- tacked from the bronchial glands at the root, and secondary nodules may be found throughout their substance. Pleural effusions are not uncommon. Involvement of the nervous system is rare, but paraplegia may be induced by invasion of the spinal canal. The skin may be the seat of adenoid growths, as in a case reported by Greenfield. Symptoms.—Enlargement of the glands of the neck, axilla, or groins is usually the first symptom noticed. In a few cases the anaemia and constitutional symptoms attract attention before the glandular in- volvement is evident. When the trouble begins in the deeper groups, pressure effects may be first noticed ; thus, paroxysmal dyspnoea with pain in the chest may result from enlargement of the bronchial glands before any physical signs can be detected. CEdema of the feet and shooting DISEASES OF THE BLOOD AND DUCTLESS GLANDS. pains in the nerves were the first symptoms in one case which I dis- sected for Eoss, and in another case at the Montreal General Hospital there was paraplegia from pressure on the cord. Such instances, however, are exceptional, and in the majority of cases the swelling of the superficial glands is the earliest symptom. Epistaxis has occasionally been noted, but not so frequently as in leukaemia. With progressive enlargement of the glands the patient becomes anaemic. Usually, the cervical group is first affected, and it may be impossible to decide whether the enlargement is syphilitic, tuberculous, or lymphad- enomatous. One side is first affected as a rule, and it may be months or even, as in one of my cases, three years before the affection extends to other groups Ultimately huge tumors may develop, which obliterate the neck and extend upon the shoulders and over the clavicles and sternum. The trachea is surrounded, great dyspnoea is produced, and not infre- quently tracheotomy is necessary. In the later stages, the skin becomes involved and ulcerates. The axillary group may form large tumors, which compress the brachial or axillary veins and cause swelling of the arms. The inguinal glands may form large or even pendulous tumors. In the thoracic glands, as mentioned, the various groups may be in- volved and produce pressure upon the veins or upon the trachea. In a case recently under observation the superior cava was completely obliter- ated and a very extensive collateral circulation was established by means of the mammary and epigastric veins. The skin over the sternum was a mass of fluctuating veins, some of which contained phleboliths. In the abdomen the mesenteric glands may be enlarged, or more commonly the retroperitoneal group. When the patient is thin there may be no diffi- culty in detecting these, but in stout persons the diagnosis may be impos- sible. In connection with the affections of the abdominal glands there may be bronzing of the skin, which was well marked in Case IV of my series. A remarkable feature is the variations in the rate of growth and in the size of the glands. They may reduce rapidly and almost disappear from a region, and before death the tumors may diminish very much. The spleen may be enlarged and readily palpable. The thyroid also may be involved, and in a few instances the thymus has been affected. Though present in a majority of the cases, there may be enormous enlargement of the lymph glands without marked anaemia. In one of my cases the blood- corpuscles did not sink below 4,000,000 per cubic millimetre, and in only one instance have I counted the blood below 2,000,000. The red blood- corpuscles rarely show extreme poikilocytosis. The white corpuscles may be moderately increased and the lymphocytes abundant, though usually there is little characteristic in the blood. Occasionally the leucocytes are greatly increased and the characters of the blood become those of a lym- phatic leukaemia. Nucleated red blood-corpuscles may be present, but not in such numbers as in leukaemia. Of cardiac symptoms, palpitation is common. Haemic murmurs are HODGKIN’S DISEASE. 745 often heard over the heart. Shortness of breath may be due to the anaemia, to pressure upon the trachea, or, in some instances, to pleuritic effusion associated with mediastinal growths. Fever is observed in nearly all cases; even in the early stages there is slight elevation. It may be of an irregu- lar hectic type, or continuous, with evening exacerbation. Very remarka- ble are the cases with ague-like paroxysms, which may persist for weeks or months. They were present in Case I of my series. Pel, of Amster- dam, has given a thorough description of these attacks, and Ebstein has described a case under the remarkable title of “ Chronic Recurrent Fever, a New Infectious Disease.” In his case during nine months the attacks were present for periods of from twelve to fourteen days and alternated with apyrexia for ten or eleven days. The digestive symptoms are usually not marked. It is not uncommon to find albumen in the urine. Headache, giddiness, and noises in the ear may be associated with the anaemia. Delirium and coma may be present. Deafness may be produced by growth of the adenoid tissue in the phar- ynx close to the Eustachian tubes. Inequality of the pupils may be pres- ent, owing to pressure of the glands on the cervical sympathetic. The skin may show definite secondary lymphatic tumors, bronzing may occur, and occasionally a most intense and troublesome prurigo. Diagnosis.—A tuberculous adenitis may at first be very difficult to differentiate. The chief points of distinction are as follows: Tuber- eulous adenitis is more common in the young and involves the submaxil- lary group of glands more frequently than those of the anterior and pos- terior cervical triangles, which are usually affected first in Hodgkin’s disease. The enlargement may last for years in a group without extend- ing. The bunches are often, when small, welded together and, most im- portant of all, tend to suppurate—a feature rarely seen in true lymphade- noma, except when it has attained very large size. Strict limitation to one side of the neck or to the axilla is suggestive of tuberculous disease rather than lymphadenoma. There is an acute tuberculous adenitis, which may involve the lymph glands of the neck, producing enormous enlargement. A man, aged twenty- four, was admitted to the General Hospital, Montreal, with great swelling of the cervical glands on both sides, tonsillitis, and sloughing pharyngitis, with irregular fever and diarrhoea. The case was at first regarded as one of Hodgkin’s disease. The occurrence of rigors and intermittent pyrexia is in favor of lymphadenoma. There are cases in which it may for a time be impossible to make a diagnosis. When the glands are only mod- erately enlarged on one side of the neck or axilla, they should be removed, and the diagnosis can then be thoroughly established. Prognosis.—Recovery is very rare. The course of the disease is ex- tremely variable. Early and rapid growth in the mediastinal groups may produce pressure effects and cause death before the development is ex- treme. In some cases the enlargements spread rapidly and group after DISEASES OF THE BLOOD AND DUCTLESS GLANDS. group becomes involved in a few months. These acute cases may run a course in three or four months. Chronic cases may last for three or four years. Periods of quiescence are not uncommon. The tumors may not only cease to grow, but gradually diminish and even disappear, without special treatment. LTsually a cachexia develops, the ansemia progresses, and there are dropsical symptoms. The mode of death is usually by asthenia ; less commonly by pressure from a tumor ; and occasionally by coma. Treatment.—When small and localized the glands should be removed. Local applications are of doubtful benefit. I have never seen special im- provement follow the persistent use of iodine or the various ointments. Arsenic has a positive value in the disease. It should be given in in- creasing doses, and stopped when unpleasant effects are manifested. The results have in many instances been striking. Due allowance must be made for the fluctuations in the size of the growths which occur sponta- neously. Ill effects from the administration of Fowler’s solution, even for months at a time, are rare, but I have had a case in which neuritis followed the use of § iv 3 j lUxviij within a period of less than three months. Recoveries have been reported under this treatment. Person- ally, no instance of recovery has come under my notice in the cases of which I have notes. Phosphorus is recommended by Gowers and Broad- bent, and should be used if the arsenic is not well borne. Quinine, iron, and cod-liver oil are useful as tonics. Every possible means must be taken to support the patient’s strength. IV. ADDISON’S DISEASE. Definition.—A constitutional affection characterized by asthenia,, depressed circulation, irritability of the stomach, and pigmentation of the skin. Tuberculosis of the adrenals is the common anatomical change. Eecent observations indicate that the symptoms may be due to loss of function of the suprarenal bodies. The recognition of the disease is due to Addison, of Guy’s Hospital, whose monograph on The Constitutional and Local Effects of Disease of the Suprarenal Capsules was published in 1855. Etiology.—Males are more frequently attacked than females. In Greenhow’s analysis of 183 cases 119 were males and 64 females. A ma- jority of the cases occur between the twentieth and the fortieth year. A congenital case has been described in which the skin had a yellow-gray tint. The child lived for eight weeks, and post mortem the adrenals were found to be large and cystic. Injury such as a blow upon the abdomen or back, and caries of the spine, have in many cases preceded the attack. The disease is rare in America. Nine cases have come under my personal observation, either clinically or anatomically, eight in men. ADDISON’S DISEASE. Morbid Anatomy and Pathology.—There is rarely emaciation or anaemia. Eolleston * thus summarizes the condition of the suprarenal bodies in Addison’s disease : “ 1. The fibro-caseous lesion due to tuberculosis—far the commonest condition found. 2. Simple atrophy. 3. Chronic interstitial inflamma- tion leading to atrophy. 4. Malignant disease invading the capsules, including Addison’s case of malignant nodule compressing the suprarenal vein. 5. Blood extravasated into the suprarenal bodies. 6. No lesion of the suprarenal bodies themselves, but pressure or inflammation involving the semilunar ganglia. “ The first is the only common cause of Addison’s disease. The others, with the exception of simple atrophy, may be considered as very rare.” Among other anatomical features the condition of the abdominal sym- pathetic has been specially studied. The nerve-cells of the semilunar ganglia have been described as degenerated and deeply pigmented, and the nerves sclerotic. The ganglia are not uncommonly entangled in the cicatricial tissue about the adrenals. The spleen has occasionally been found enlarged; the thymus may persist and be larger than normal. It is difficult to explain satisfactorily all the symptoms of this remark- able disease. The two chief theories which have been advanced are briefly as follows: (a) That the disease depended upon the loss of function of the adrenals. This was the view of Addison. The balance of experimental evidence is in favor of the view that the adrenals are functional glands, which furnish an internal secretion essential to the normal metabolism. Schafer and Oliver have shown that the human adrenals contain a very powerful extract, which is not to be obtained in cases of Addison’s dis- ease ; they have also studied the toxic effects on animals of the extracts of the glands. In the cases in which the adrenals have been found involved without the symptoms of Addison’s disease, accessory glands may have been present; while in the rare cases in which the symptoms of the dis- ease have been present with healthy adrenals the semilunar ganglia and adjacent tissues have been involved in dense adhesions, which may have interfered readily with the vessels or lymphatics of the glands. On this view Addison’s disease is due to an inadequate supply of the adrenal secre- tion, just as myxoedema is caused by loss of function of the thyroid gland. “ Whether the deficiency in this internal secretion leads to a toxic condi- tion of the blood or to a general atony and apathy is a question which must remain open ” (Eolleston). (£) That it is an affection of the ab- dominal sympathetic system, induced most commonly by disease of the adrenals, but also by other chronic disorders which involve the solar plexus and its ganglia. According to this view, it is an affection of the * Goulstonian Lectures, Royal College of Physicians, British Medical Journal, 1895, i, to which the student is referred for an exhaustive consideration of the entire question. 748 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. nervous system, and the pigmentation has its origin in changes induced through the trophic nerves. The pronounced debility is the outcome of disturbed tissue metabolism, and the circulatory, respiratory, and digestive symptoms are due to implication of the pneumogastric. The changes found in the abdominal sympathetic are held to support this view, and its advocates urge the occurrence of pigmentation of the skin in tuberculosis of the peritonaeum, cancer of the pancreas, or aneurism of the abdominal aorta. Opposed to it are the facts that the lesions described in the sym- pathetic system are indefinite, and identical changes occur without the symptoms of Addison’s disease. Symptoms.—In the words of Addison, the characteristic symptoms are “ anaemia, general languor or debility, remarkable feebleness of the heart’s action, irritability of the stomach, and a peculiar change of color in the skin.” The pigmentation is the symptom which, as a rule, first attracts at- tention. The grades of coloration range from a light yellow to a deep brown, or even black. In typical cases it is diffuse, but always deeper on the exposed parts and in the regions where the normal pigmentation is most intense. At first it may be confined to the face and hands. Occa- sionally it is absent. Patches of atrophy of pigment, leucoderma, may oc- cur. The pigmentation is found on the mucous membranes of the mouth, conjunctivae, and vagina. A patchy pigmentation of the serous membranes has often been found. The anaemia, upon which Addison laid stress, is of a moderate grade. It was not present in a marked degree in any of my cases. Gastric disturbances are common; nausea and vomiting may be early and prominent symptoms; diarrhoea, too, is frequent, and may come on without cause. The pulse is small and rapid, and the heart’s action feeble. Sometimes there is a special liability to syncope. One of the most pronounced features of the disease is the profound asthenia, which is out of all proportion to the general condition. The patient complains of a lack of energy, both mental and bodily; the least exertion is an effort, and may be followed by giddiness or noises in the ears. Headache is a frequent symptom. With the advancement of the disease the prostra- tion becomes more marked, the patient remains in bed, the voice gets weak, the intelligence dulled, and death occurs either by syncope or grad- ual asthenia. Occasionally there are convulsions. The urine is usually normal. Polyuria has been described. The urinary pigments have been found increased. Diagnosis.—Pigmentation of the skin is not confined to Addison’s disease. The following are the conditions which may give rise to an in- crease in the pigment: (1) Abdominal growths—tubercle, cancer, or lymphoma. In tubercu- losis of the peritonaeum pigmentation is not uncommon. (2) Pregnancy, in which the discoloration is usually limited to the face, ADDISON’S DISEASE. 749 the so-called masque des femmes enceinte. Uterine disease is a common cause of a patchy melasma. (3) Hepatic disease, which may induce definite pigmentation, as in the diabetic cirrhosis. More commonly in overworked persons of constipated habit and with sluggish livers there is a patchy staining about the face and forehead. (4) The vagabond’s discoloration, caused by the irritation of lice and dirt, which may reach a very high grade, and has sometimes been mistaken for Addison’s disease. (5) In rare instances there is deep discoloration of the skin in mela- notic cancer, so deep and general that it has been confounded with melasma suprarenale. (6) In certain cases of exophthalmic goitre abnormal pigmentation occurs, as noted by Drummond and others. In any case of unusual pigmentation these various conditions must be sought for, and the diagnosis of Addison’s disease is scarcely jus- tifiable without the asthenia. In many instances it is difficult early in the disease to arrive at a definite conclusion. The occurrence of fainting fits, of nausea, and gastric irritability are important indica- tions. Prognosis.—The disease is usually fatal. The cases in which the bronzing is slight or does not occur run a more rapid course. There are occasionally acute cases which, with great weakness, vomiting, and diar- rhoea, prove fatal in a few weeks. In a few cases the disease is much prolonged, even to six or ten years. In rare instances recovery has taken place, and periods of improvement, lasting many months, may occur. Treatment.—The causal indications cannot be met. When there is profound asthenia the patient should be confined to bed, as fatal syncope may at any time occur. In three of my cases death was sudden. When anaemia is present iron may be given in full doses. Arsenic and strychnia are useful tonics. For the diarrhoea large doses of bismuth should be given ; for the irritability of the stomach, creosote, hydrocyanic acid, ice, and champagne. The diet should be light and nutritious. Many patients thrive best on a strict milk diet. An extract of the gland has been given—in two cases of Oliver’s with benefit, in one case of Grainger Stewart’s without any noticeable benefit. In a case at present under treatment in my wards the patient says that he feels much stronger, and in six weeks has gained fifteen pounds in weight. The equivalent of about two glands a day should be given. The glands may be eaten cooked, or a glycerine extract or a dried extract may be made. 750 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. V. DISEASES OF THE THYROID GLAND. Goitre. Definition.—Hypertrophy of the thyroid gland, occurring sporad- ically or endemically. In this country sporadic cases are common. The endemic centres re- ferred to in Barton’s monograph (1810) and in Hirsch’s Geographical Pathology no longer exist. The disease is very prevalent about the eastern end of Lake Ontario, and in parts of Michigan (Dock). Endemically it is found particularly in the mountainous regions of Switzerland and in parts of Italy. No satisfactory explanation has been given of the existence of the disease in this form. Anatomically the following varieties may be distinguished : (a) Paren- chymatous, in which the enlargement is general and the follicles, usually newly formed, contain a gelatinous colloid material, (b) Vascular, in which the enlargement is chiefly due to dilatation of the blood-vessels without the new formation of glandular tissue. (c) Cystic goitre, in which the enlarged gland is occupied by large cysts, the walls of which often undergo calcification. Symptoms.—The enlargement may be uniform throughout the entire gland, or affect only one lobe, or the isthmus alone. When small, a goitre causes no inconvenience. In its growth it may compress the trachea, causing dyspnoea, or may pass beneath the sternum and compress the veins. These, however, are exceptional circumstances, and in a large proportion of all cases no serious symptoms are noted. The affection usually comes under the care of the surgeon. Sudden death occasionally occurs in large bronchoceles. In some instances it may be difficult to de- termine the cause, and it has been thought to be associated with pressure on the vagi. I have reported an instance in which it resulted from •haemor- rhage into the gland and into the adjacent tissues. The blood passed into the cellular tissues of the neck and under the sternum, covering the aorta and pericardium. In regions in which goitre prevails the drinking-water should be boiled. Change of locality is sometimes followed by cure. The medicinal treatment is very unsatisfactory. Iodine and various counter- irritants externally, iodide of potash, ergot, and many other drugs are rec- ommended by writers. The thyroid extract has been used with success by Bruns in nine of twelve cases. Tumors of the Thyroid. These are very varied, (a) Adenomata, either simple or malignant. The latter may form extensive metastases. A case is reported by Hay- ward in which growths resembling thyroid tissue occurred in the lungs and various bones of the body. (&) Cancer, of which several forms have been DISEASES OF THE THYROID GLAND. 751 described, (c) Sarcoma. All of these have a surgical rather than a medical interest. It may be mentioned that the aberrant or accessory thyroid gland may form large tumors in the mediastinum or in the pleura. I have reported two cases of this kind,* and an instance is on record in which an enor- mous cystic accessory thyroid occupied the entire right pleura. Thyroid abscess is rare. In Havel’s monograph on Strumitis (1892) cases are given after nearly every one of the specific diseases, and he re- ports eighteen cases from Kocher’s clinic, nearly all secondary or metastatic. Exophthalmic Goitre (Graves's Disease; Basedoiv's Disease). Definition.—A disease characterized by exophthalmos, enlargement of the thyroid, and functional disturbance of the vascular system. It is very possibly caused by disturbed function of the thyroid gland (hyper- thyroidism). Etiology.—The disease is rare in men. The age of onset is usually from the twentieth to the thirtieth year. It is sometimes seen in several members of the same family. Worry, fright, and depressing emotions precede the development of the disease in a number of cases. The disease is regarded by some as a pure neurosis, in favor of which is urged the onset after a profound emotion, the absence of lesions, and the cure which has followed in a few cases operations upon the nose. Others believe that it is caused by a central lesion in the medulla oblongata. In support of this there is a certain amount of experimental evidence, and in a few autopsies changes have been found in the medulla. Of late years the view has been urged, particularly by Moebius and by Greenfield, that exophthalmic goitre is primarily a disease of the thyroid gland (hyper- thyrea), in antithesis to myxcedema (athyrea). The clinical contrast be- tween these two diseases is most suggestive—the increased excitability of the nervous system, the flushed, moist skin, the vascular erythism in the one ; the dull apathy, the low temperature, slow pulse, and dry skin of the other. The changes in the gland in exophthalmic goitre are, as shown by Greenfield, those of an organ in active evolution—viz., increased prolifera- tion with the production of newly formed tubular spaces, and absorption of the colloid material which is replaced by a more mucinous fluid (Brad- shaw Lecture, 1893). The thyroid extract given in excess produces symp- toms not unlike those of Basedow’s disease—tachycardia, tremor, head- ache, sweating, and prostration. Beclere has recently reported a case in which exophthalmos developed after an overdose. Use of the thyroid extract usually aggravates the symptoms of exophthalmic goitre. The most successful line of treatment has been that directed to diminish the bulk of the goitre. These are some of the considerations which favor the view that the symptoms are due to disturbed function of the thyroid gland, * Medical News, 1890. DISEASES OF THE BLOOD AND DUCTLESS GLANDS. 752 probably to a hypersection of certain materials, which induce a sort of chronic intoxication. Symptoms.—Acute and chronic forms may be recognized. In the acute form the disease may develop with great rapidity. In a patient of J. II. Lloyd’s, of Philadelphia, a woman, aged thirty-nine, who had been considered perfectly healthy, but whose friends had noticed that for some time her eyes looked rather large, was suddenly seized with in- tense vomiting and diarrhoea, rapid action of the heart, and great throb- bing of the arteries. The eyes were prominent and staring and the thyroid gland was found much enlarged and soft. The gastro-intestinal symptoms continued, the pulse became more rapid, the vomiting was in- cessant, and the patient died on the third day of the illness. Only the abdominal and thoracic organs could be examined and no changes -were found. Two rapidly fatal cases occurred at the Philadelphia Hospital, one of which, under F. P. Henry’s care, had marked cerebral symptoms. More frequently the onset is gradual and the disease is chronic. The three characteristic symptoms vary a good deal in their onset. Cardiac and vascular symptoms are usually first to develop and the patient com- plains of palpitation with breathlessness, and on examination the im- pulse is found to be increased in force, the apex beat is in normal posi- tion, the carotids throb, and the abdominal aorta pulsates visibly. This is one of the conditions in which the capillary pulse and the pulsation in the veins of the hands are occasionally seen. The pulse-rate at first may not be more than 95 or 100, but when the disease is established may reach 140 or 160. Any emotional excitement sets the heart beating with great intensity, and on exposure of the skin of the upper part of the chest a transient hyperaemia is seen. Soft murmurs are not uncommon at the base of the heart. In the long-standing cases the heart may be hyper- trophied and the sounds very intense. In rare instances they may be heard some distance from the patient; according to Graves, as far as four feet. Exophthalmos usually follows the vascular disturbance. It is readily recognized by the protrusion of the balls, and partly by the fact that the lids do not completely cover the sclerotics, so that a rim of white is seen above and below the cornea. The protrusion may become very great and the eye may even be dislocated from the socket. The vision is normal. Graefe noted that when the eyeball is moved downward the upper lid does not follow it as in health. This is known as Graefe’s sign. It seems to be rare; it was not present in one of seventeen cases examined at my clinic (Oppenheimer). The palpebral aperture is wider than in health, owing to spasm or retraction of the upper lid (Stellwag’s sign). The patient winks less frequently than in health. Moebius has called atten- tion to the lack of convergence of the two eyes. Changes in the pupils and in the optic nerves are rare. Pulsation of the retinal arteries is common. DISEASES OF THE THYROID GLAND. 753 The enlargement of the thyroid commonly develops with the exoph- thalmos. It may be general or in only one lobe, and is rarely so large as in ordinary goitre. The vessels are usually much dilated, and the whole gland may be seen to pulsate. A thrill may be felt on palpation and on auscultation a loud systolic murmur, or more commonly a bruit de diable. Tremor must be regarded as a cardinal symptom. It is involuntary, fine, about eight to the second. It is of great importance in the diagnosis of the early cases. Among other symptoms which may develop are anaemia, emaciation, and slight fever. Attacks of vomiting and diarrhoea may occur. The latter may be very severe and distressing, recurring at inter- vals. The greatest complaint is of the forcible throbbing in the ar- teries, often accompanied with unpleasant flushes of heat and pro- fuse perspirations. Skin symptoms are not infrequent—pigmentation, which may be intense and simulate Addison’s disease, patches of leuco- derma, or atrophy of pigment, and urticaria. Patches of solid oedema have been seen. Occasionally myxcedema has been present. In the very acute case above referred to urticaria was a prominent symptom. Irritability of temper, change in disposition, and great mental depression have been described. An important complication is acute mania, in which the patient may die in a few days. Weakness of the muscles is not uncom- mon, particularly a feeling of “giving way” of the legs. If the patient holds the head down and is asked to look up without raising the head, the forehead remains smooth and is not wrinkled, as in a normal individ- ual (Joifroy). A feature of interest noted by Charcot is the great diminu- tion in the electrical resistance, which may be due to the saturation of the skin with moisture owing to the vaso-motor dilatation (Ilirt). Bryson has noted the fact that the chest expansion may be greatly diminished. The emaciation may be extreme. Glycosuria and albuminuria are not infrequent complications. The course of the disease is usually chronic, lasting several years. After persisting for six months or a year the symptoms may disappear. There are remarkable instances in which the symptoms have come on with great intensity, following fright, and have disappeared again in a few days. A certain proportion of the cases recover, but when the disease is well de- veloped recovery is rare. Treatment.—Medicinal measures are notoriously uncertain. The combination of digitalis and iron may be tried, and, when there is anaemia, often does good. I have never seen any advantage from the use of aco- nite or veratrum viride. The tincture of strophanthus will sometimes reduce the rapidity of the heart’s action. Ergot is warmly recommended by some writers. Belladonna gives relief occasionally, and should be ad- ministered until the dryness of the throat is obtained. No measures are so successful as rest in bed with an ice-bag or Leiter’s tube applied occa- sionally over the heart, or, what is sometimes more agreeable, over the lower part of the neck and manubrium sterni. I have known the pulse 754 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. to be reduced in this way from 140 to 90. Electricity has been much lauded and instances of cure have been reported. In many cases tem- porary improvement certainly follows the use of the galvanic current, the cathode being placed at the back of the neck and the anode along the course of the sympathetic or over the heart. The use of the thyroid ex- tract has not been successful. Operative treatment has recently been tried, with the following results: “ Out of sixty-eight operations on record, eighteen completely recovered ; in twenty-six there was more or less im- provement ; nine showed no change ; in five death was almost immediate ; and in four death occurred within twenty-four hours” (Oppenheimer). Myxcedema (Atliyrea). Definition.—A constitutional affection, due to the loss of function of the thyroid gland. The disease, which was described by Sir William Gull as a cretinoid change, and later by Ord, is characterized clinically by a myxcedematous condition of the subcutaneous tissues and mental failure, and anatomically by atrophy of the thyroid gland. Clinical Forms.—Three groups of cases may be recognized: (a) Congenital form, or sporadic cretinism. In these cases there is congenital absence of the thyroid, and the child is a dwarf, having a thick neck, short arms and legs, and prominent abdomen. The face is large, the lips are thick, the tongue is large and usually protrudes. The mental condition is that of imbecility or idiocy. Since the introduction of thyroid treat- ment the recognition of this condition is all-important. I was only able in 1893 to collect eleven or twelve cases in this country (American Journal of Medical Sciences, November, 1893). The diagnosis of spo- radic cretinism, though easy in advanced and typical cases, is often, I find, not clearly made: I judge this from the number of descriptive cases sent to me as instances of this condition, but which in reality have been cases of various forms of idiocy. The important criteria are the physiog- nomy, the shape of the head, the stunted growth, and the condition of the connective tissues. The mental deficiency is less characteristic, presenting nothing not seen in instances of ordinary idiocy. The appearance of the thyroid is uncertain. There are cretins with and cretins without goitre, while in others the gland seems entirely absent. The most satisfactory diagnostic feature is the condition of the skin and connective tissues. (b) Myxcedema Proper.—In this, women are very much more frequently affected than men—in a ratio of one to six. The disease may affect several members of a family, and it may be transmitted through the mother. In some instances there has been first the appearance of exophthalmic goitre. Though occurring most commonly in women, it seems to have no special relation to the catamenia or to pregnancy, but in one instance the symptoms of myxcedema disappeared during pregnancy. Myxcedema and exophthalmic goitre may occur in sisters. It is not so common in this DISEASES OF THE THYROID GLAND. 755 country as in England. The symptoms of this form, as given by Ord,* are marked increase in the general bulk of the body, a firm, inelastic swelling of the skin, which does not pit on pressure; dryness and rough- ness, whicn tend, with the swelling, to obliterate in the face the lines of expression; imperfect nutrition of the hair; local tumefaction of the skin and subcutaneous tissues, particularly in the supraclavicular region. The physiognomy is altered in a remarkable way: the features are coarse and broad, the lips thick, the nostrils broad and thick, and the mouth is en- larged. Over the cheeks, sometimes the nose, there is a reddish patch. There is a striking slowness of thought and of movement. The memory becomes defective, the patients grow irritable and suspicious, and there may be headache. In some instances there are delusions and hallucina- tions, leading to a final condition of dementia. The gait is heavy and slow. The temperature may be below normal. The functions of the heart, lungs, and abdominal organs are normal. Haemorrhage sometimes occurs. Albuminuria is sometimes present, more rarely glycosuria. Death is usually due to some intercurrent disease, most frequently tuberculosis (Greenfield). The thyroid gland is diminished in size and may become completely atrophied and converted into a fibrous mass. The subcutane- ous fat is abundant, and in one or two instances a great increase in the mucin has been found. The course of the disease is slow but progressive, and extends over ten or fifteen years. I have recently had under observation a case to which the term acute myxcedema might be applied. A young man, aged twenty, presented a gradual enlargement of the face, particularly of the lips and cheeks and nose, without actual oedema. The backs of the hands were also swollen, but did not pit. The condition came on with enlargement of the thyroid, and, after persisting for between three and four months, gradually disappeared. (c) Operative Myxcedema ; Cachexia strumipriva.—Horsley, in a series of interesting experiments, showed that complete removal of the thyroid in monkeys was followed by the production of a condition similar to that of myxcedema and often associated with spasms or tetanoid contractures, and followed by apathy and coma. When the monkeys were kept warm myx- cedema was averted, and, instead of an acute myxcedema, the animals devel- oped a condition which closely resembled cretinism. An identical con- dition may follow extirpation of the thyroid in man. Kocher, of Bern, found that after complete extirpation a cachectic condition followed in many cases, the symptoms of which are practically identical with those of myxcedema. The disease follows only a certain number of total and a much smaller proportion of partial removals of the thyroid gland. Of 408 cases, in 69 the operative myxcedema developed. It has been thought that if a small fragment of the thyroid remains, or if there are accessory ♦Report on Myxoedema, Clinical Society’s Transactions, 1888. 48 756 DISEASES OF THE BLOOD AND DUCTLESS GLANDS. glands, which in animals are very common, these symptoms do not de- velop. It is possible that in men, in the cases of complete removal, the accessory fragments subserve the function of the gland. Operative myx- oedema is very rare in this country; the only case of which I know is a patient of McGraw’s, of Detroit. It is evident that the thyroid gland supplies some essential secretion of first importance to normal metabolism. What this is or how it acts is at present beyond our knowledge. The diagnosis of the disease is easy, as a rule. The general aspect of the patient—the subcutaneous swelling and the pallor—suggests Bright’s disease, which may be strengthened by the discovery of tube-casts and of albumin in the urine ; but the solid character of the swelling, the exceed- ing dryness of the skin, the yellowish-white color, the low temperature, the loss of hair, and the dull, listless mental state should suffice to differ- entiate the two conditions. Treatment.—The patients suffer in cold and improve greatly in warm weather. They should therefore be kept at an even temperature, and should, if possible, move to a warm climate during the winter months. Repeated warm baths with shampooing are useful. Our art has made no more brilliant advance than in the cure of these disorders due to disturbed function of the thyroid gland. That we can to-day rescue children other- wise doomed to helpless idiocy—that we can restore to life the hopeless victims of myxoedema—is a triumph of experimental medicine to which we are indebted very largely to Victor Horsley and to his pupil Murray. Transplantation of the gland was first tried ; then Murray used an extract subcutaneously. Hector Mackenzie in London and Ilowitz in Copenhagen introduced the method of feeding. We now know that the gland, taken either fresh, or as the watery or glycerine extract, or dried and powdered, is equally efficacious in a majority of all the cases of myxoedema in infants or adults. Many preparations are now on the market, but it makes little difference how the gland is administered. The dried powdered gland and the glycerine extract are most convenient. It is well to begin with the powdered gland, one grain three times a day, of the Parke-Davis prepara- tion, or one of Burroughs and Welcome tablets. It may be increased gradually until the patient takes ten or fifteen grains in the day. In many cases there are no unpleasant symptoms; in others there are irritation of the skin, restlessness, rapid pulse, and delirium; in rare instances tonic spasms, the condition to which the term thyroidism is applied. The re- sults, as a rule, are most astounding—unparalleled by anything in the whole range of curative measures. Within six weeks a poor, feeble-minded, toad-like caricature of humanity may be restored to mental and bodily health. Loss of weight is one of the first and most striking effects; one of my patients lost over thirty pounds within six weeks.. The skin becomes moist, the urine is increased, the perspiration returns, the temperature rises, the pulse-rate quickens and the mental torpor lessens. Ill effects DISEASES OF THE THYROID GLAND. 757 are rare. Two or three cases with old heart lesions have died during or after the treatment; in one instance a temporary condition of Graves dis- ease was induced. The treatment, as Murray suggests, must be carried out in two stages— one, early, in which full doses are given until the cure is effected; the other, the permanent use of small doses sufficient to preserve the normal metabolism. The literature of thyroid therapy and a list of all the cases of myxcedema and cretinism treated to December 31, 1894, are given by Heinsheimer.* * Die Schilddriisenbehandlung, Miinchen, 1895. SECTION VII. DISEASES OF THE KIDNEYS. I. ANOMALIES IN FORM AND POSITION. Anomalies in Form.—These rarely come within the scope of the phy- sician. Atrophy or congenital absence of one kidney is associated with great enlargement of the other organ. Fused kidneys may have a horse- shoe shape, or both organs may form a large mass, which is often dis- placed, being either in an iliac fossa or in the middle line of the abdomen, or even in the pelvis. Under these circumstances it may be mistaken for a new growth. In Polk’s case the organ was removed under the belief that it was a floating kidney.* The patient lived eleven days, had com- plete anuria, and it was found post mortem that a single unsymmetrical kidney, as this form is called, had been removed. Movable Kidney {Floating Kidney; Palpable Kidney; Ren mobilis; Nephroptosis). The kidney is held in position by its fatty capsule, by the peritonaeum which passes in front of it, and by the blood-vessels. The lower edge of the left kidney is nearly two inches from the iliac crest, a little below the level of the second lumbar spine ; that of the right is usually from one half to three quarters of an inch lower. Normally the kidney is firmly fixed, but under certain circumstances one or another organ, more rarely both, becomes movable. In rare cases the kidney is surrounded, to a greater or less extent, by the peritonaeum, and is anchored at the hilus by a mesonephron. Some would limit the term floating kidney to this condition. Movable kidney is almost always acquired. It is most common in women. Of the 667 cases collected in the literature by Kuttner, 584 were in women and only 83 in men. It is more common on the right than on the left side. Of 727 cases analyzed by this author, it occurred on the right in 553 cases, on the left in 81, and on both sides in 93. The * New York Medical Journal, 1883. ANOMALIES IN FORM AND POSITION. 759 greater frequency of the condition in women may be attributed to com- pression of the lower thoracic zone by tight lacing, and, more important still, to the relaxation of the abdominal walls which follows repeated pregnancies. This does not account for all the cases, as movable kidney is by no means uncommon in nulliparas. Drummond believes that in a majority of the cases there is a congenitally relaxed condition of the peri- toneal attachments. Wasting of the fat about the kidney may be a cause in some instances. Trauma and the lifting of heavy weights are occasionally factors in its production. The kidney is sometimes dragged down by tumors. The greater frequency on the right side is probably associated with the position of the kidney just beneath the liver, and the depression to which the organ is subjected with each descent of the diaphragm in inspiration. And, lastly, movable kidney is met with in many cases which present that combination of neurasthenia with gastro-intestinal disturbance which has been described by Glenard * as enteroptosis. To determine the presence of a movable kidney the patient should be placed in the dorsal position, with the head moderately low and the ab- dominal walls relaxed'. The left hand is placed in the lumbar region behind the eleventh and twelfth ribs; the right hand in the hypochon- driac region, in the nipple line, just under the edge of the liver. Bimanual palpation may detect the presence of a firm, rounded body just below the edge of the ribs. If nothing can be felt the patient should be asked to draw a deep breath, when, if the organ is palpable, it is touched by the fingers of the right hand. Various grades of mobility may be recognized. It may be possible barely to feel the lower edge on deep palpation—palpa- ble kidney—or the organ may be so far displaced that on drawing the deepest breath the fingers of the right hand may be in a thin person slipped above the upper end of the organ, which can be readily held down, but cannot be pushed below the level of the navel—movable kidney. In a third group of cases the organ is freely movable, and may even be felt just above Poupart’s ligament, or may be in the middle line of the abdomen, or can even be pushed over beyond this point. To this the term floating kidney is appropriate, whether the organ has a mesonephron or not. And, lastly, a dislocated kidney may become fixed in an abnormal posi- tion. A woman, aged twenty-nine, with four children, had nervous symp- toms with abdominal pain, and had been much worried by the discovery of a tumor, just to the right of the middle line, close to the navel. It was not movable, but the distinctly reniform shape and the depression at the left margin indicated that it was doubtless a dislocated kidney which had become fixed. Since writing the above the tumor has disappeared. It was probably a gall-bladder ! * Revue de Medecine, 1887; Pourcelot, Paris Thesis, 1889. 760 DISEASES OF THE KIDNEYS. The movable kidney is not painful on pressure, except when it is grasped very firmly, when there is a dull pain, or sometimes a sickening sensation. Examination of the patient from behind may show a distinct flattening in the lumbar region on the side in which the kidney is mobile. Symptoms.—In a large majority of cases the condition gives no trouble, and it is well, if detected accidentally, not to let the patient know of its presence. In other instances there is pain in the lumbar region or a sense of dragging and discomfort, or there may be intercostal neuralgia. In a large group the symptoms are those of neurasthenia with dyspeptic disturbance. In women the hysterical symptoms may be marked, and in men various grades of hypochondriasis. The gastric disturbance is usu- ally a form of nervous dyspepsia. Dilatation of the stomach has been ob- served, owing, as suggested by Bartels, to pressure of the dislocated kidney upon the duodenum. This view has been supported by Oser, Landau, and Ewald. On the other hand, Litten holds that the dilatation of the stom- ach is the cause of the mobility of the kidney, and he found in 40 cases of depression and dilatation of the stomach 22 instances of dislocation of the kidney on the right side. My own experience coincides with that of Drummond, who has very exceptionally found the two conditions to co- exist. While not denying the possibility of causal relationship between the two, it seems probable, considering the frequency of floating kidney, that the complication is only a coincidence. The association, however, with a depressed stomach is certainly not uncommon in women. Consti- pation is not infrequent. Some writers have described pressure upon the gall-ducts, with jaundice, but it is not very likely to occur. Under the name enteroptosis, Glenard has described a special symp- tom group characterized by nervous dyspepsia, prolapse of the abdominal organs, particularly the transverse colon, with looseness of the mesenteric and peritoneal attachments, so that there is a falling down of the viscera (splanchnoptosis). Dilatation of the stomach and mobility of the kidney are very commonly associated with this state. Glenard held that he could feel the prolapsed transverse colon as a narrow band, but Ewald states correctly that this is the pancreas, which in many of these cases can be distinctly palpated. According to Glenard, the kink in the colon causes the constipation, while the depression of the stomach and intestines leads to vascular disturbance and impairment of the motor and secretory functions. DietVs Crises.—In floating kidney there are attacks characterized by severe abdominal pain, chills, nausea, vomiting, fever, and collapse. Scarcely any mention is made of such symptoms, which were first de- scribed by Dietl in 1864, and a more wide-spread knowledge of their occurrence in connection with this condition is desirable. My atten- tion was called to them in 1880 by Palmer Howard in the case of a stout lady, who suffered repeatedly with the most severe attacks of abdominal pain and vomiting, which constantly required morphia. A ANOMALIES IN FORM AND POSITION. 761 tumor was discovered a little to the right of the navel, and the diag- nosis of probable neoplasm was concurred in by Flint (Sr.) and Gaillard Thomas. The patient lost weight rapidly, became emaciated, and in the spring of 1881 again went to New York, where she saw Van Buren, who diagnosed a floating kidney and said that these paroxysms were asso- ciated with it in a gouty person. He cut off all stimulants, reassured the lady that she had no cancer, and from that time she rapidly recovered, and the attacks have been few and far between. In this patient any over- indulgence in eating or in drinking is still liable to be followed by a very severe attack. These attacks may also be mistaken for renal colic, and the operation of nephrotomy has been performed. In other instances the attacks of pain may be thought to be due to in- testinal disease or to recurring appendicitis. The cause of these parox- ysmal attacks is not quite clear. Dietl thought they were due to strangu- lation of the kidney or to twists or kinks in the renal vessels due to the extreme mobility. During the attacks the urine is sometimes high-colored and contains an excess of uric acid or of the oxalates. It is stated, too, that blood or pus may be present. The kidney may be tender, swollen, and less freely movable. Intermittent hydronephrosis has sometimes been associated with movable kidney. The diagnosis is rarely doubtful, as the shape of the organ is usually distinctive and the mobility marked. Tumors of the gall-bladder, ovarian growths, and tumors of the bowels may in rare instances be confounded with it. Treatment.—The kidney has been extirpated in many instances, but the operation is not without risk, and there have been several fatal •cases. Stitching of the kidney—nephrorrhaphy—as recommended by Hahn, is the most suitable procedure, and statistics recently published by Keen show that relief is afforded in many cases by the procedure. It does not, however, always succeed. The treatment by trusses and bandages is not satisfactory, though great relief is sometimes obtained. As a rule, bandages, with pads press- ing to the right of the navel, are not well borne, as the kidney is often sensitive. In some instances, however, the greatest relief is experi- enced by this procedure. An air-pad beneath the bandage, as recom- mended by Newman, is probably the best. In other cases a broad bandage well padded in the lower abdominal zone pushes up the intestines and makes them act as a support. In the attacks of severe colic morphia is required. When dependent, as seems sometimes the case, upon an excess of uric acid or the oxalates, the diet must be carefully regulated. 762 DISEASES OF THE KIDNEYS. II. CIRCULATORY DISTURBANCES. Normally the secretion of urine is accomplished by the maintenance of a certain blood-pressure within the glomeruli and by the activity of the renal epithelium. Bowman’s views on this question have been gen- erally accepted, and the watery elements are held to be filtered from the glomeruli; the amount depending on the rapidity and the pressure of the blood current; the quality, whether normal or abnormal, depending upon the integrity of the capillary and glomerular epithelium ; while the greater portion of the solid ingredients are excreted by the epithelium of the con- voluted tubules. The integrity of the epithelium covering the capillary tufts within Bowman’s capsule is essential to the production of a normal urine. If under any circumstances their nutrition fails, as when, for example, the rapidity of the blood-current is lowered, so that they are deprived of the necessary amount of oxygen, the material which filters through is no longer normal (i. e., water), but contains serum albumen. Cohnheim has shown that the renal epithelium is extremely sensitive to circulatory changes, and that compression of the renal artery for only as few minutes causes serious disturbance. The circulation of the kidney is remarkably influenced by reflex stimuli coming from the skin. Exposure to cold causes heightened blood-pressure within the kidneys and increased secretion of urine. So- also in the chills of malaria, after which a large amount of pale urine may be passed. Congestion of the Kidneys.—(1) Active Congestion; Hypercemia.— Acute congestion of the kidney is met with in the early stage of nephritis, whether due to cold or to the action of poisons and severe irritants. Turpentine, cubebs, cantharides, and copaiba are all stated to cause ex- treme hyperaemia of the organ. The most typical congestion of the kidney which we see post mortem is that in the early stage of acute Bright’s disease, when the organ may be large, soft, of a dark color, and on section blood drips from it freely. It has been held that in all the acute fevers the kidneys are congested, and that this explained the scanty, high-colored, and often albuminous, urine. On the other hand, by Roy’s oncometer, Walter Mendelson has shown that the kidney in acute fever is in a state of extreme anasmia, small, pale, and bloodless; and that this anaemia, increasing with the pyrexia and interfering with the nutrition of the glomerular epithelium, accounts for the scanty, dark-colored urine of fever and for the presence of albumin. In the prolonged fevers, however, it is probable that relaxa- tion of the arteries again takes place. Certainly it is rare to find post mortem such a condition of the kidney as is described by Mendelson. On the contrary, the kidney of fever is commonly swollen, the blood-vessels are congested, and the cortex frequently shows traces of cloudy swelling. However, the circulatory disturbances in acute fevers are probably less im- ANOMALIES OF THE URINARY SECRETION. 763 portant than the irritative effects of either the specific agents of the dis- ease or the products produced in their growth, or in the altered metabo- lism of the tissues. The urine is diminished in amount, and may contain albumin and tube-casts. (2) Passive Congestion; Mechanical Hypercemia.—This is found in cases of chronic disease of the heart or lung, with impeded circulation, and as a result of pressure upon the renal veins by tumors, the pregnant uterus, or ascitic fluid. In the cardiac kidney, as it is called, the cyanotic induration associated with chronic heart-disease, the organs are enlarged and firm, the capsule strips off, as a rule, readily, the cortex is of a deep red color, and the pyramids of a purple red. The section is coarse-look- ing, the substance is very firm, and resists cutting and tearing. The in- terstitial tissue is increased, and there is a small-celled infiltration be- tween the tubules. Here and there the Malpighian tufts have become sclerosed. The blood-vessels are usually thickened, and there may be more or less granular, fatty, or hyaline changes in the epithelium of the tubules. The condition is indeed a diffuse nephritis. The urine is usu- ally reduced, is of high specific gravity, and contains more or less albu- min. Hyaline tube-casts and blood-corpuscles are not uncommon. In uncomplicated cases of the cyanotic induration urgemia is rare. On the other hand, in the cardiac cases with extensive arterio-sclerosis, the kidneys are more involved and the renal function is likely to be disturbed. 111. ANOMALIES OF THE URINARY SECRETION. 1. Anuria. Total suppression of urine occurs under the following conditions : (1) As an event in the intense congestion of acute nephritis. For a time no urine may be formed; more often the amount is greatly re- duced. (2) More commonly complete anuria is seen in subjects of renal stone, fragments of which block both ureters. Curiously enough, there may be no discomfort, and cases are on record in which six or eight days have passed before the function was restored. Cabot reports an instance of re- covery after the suppression had lasted for nearly eight days. This obstruc- tive suppression is the most common, and the recent experiences of sur- geons show that, as in Cabot’s case, operative interference is very hopeful. (3) Cases occur occasionally in which the suppression is prerenal. The following are among the more important conditions with which this form of anuria may be associated (Hensley): Fevers and inflammations; acute poisoning by phosphorus, lead, and turpentine ; in the collapse after severe injuries or after operations, or, indeed, after the passing of a catheter; in the collapse stage of cholera and yellow fever; and, lastly, there is an DISEASES OF THE KIDNEYS, hysterical anuria, of which Charcot reports a case in which the suppres- sion lasted for eleven days. A patient may live for from ten days to two weeks with complete sup- pression. In Polk’s case, in which the only kidney was removed, the patient lived eleven days. It is remarkable that in many instances there are no toxic features. In the treatment of suppression of urine, in the obstructive cases, sur- gical interference should be resorted to. In the non-obstructive cases, par- ticularly when due to extreme congestion of the kidney, cupping over the loins, hot applications, free purging, and sweating with pilocarpine and hot air are indicated. When the secretion is once started diuretin often acts well. 2. Hematuria. The following division may be made of the causes of haematuria : (1) General Diseases.—The malignant forms of the acute specific fevers, such as small-pox, malaria, yellow fever, etc.; scurvy, purpura, and haemo- philia. Occasionally in leukaemia haematuria occurs. (2) Renal Causes.—Acute congestion and inflammation, as in Bright’s disease, or the effect of toxic agents, such as turpentine, carbolic acid, and cantharides. When the carbolic spray was in use many surgeons suffered from haematuria in consequence of this poison. Renal infarction, as in ulcerative endocarditis. New growths, in which the bleeding is usually profuse. Tubercle rarely causes haematuria, though at the onset, when the papillae are involved, there may be bleeding. Stone in the kidney is a frequent cause. Parasites: The Filaria sanguinis hominis and the Bil- harzia cause a form of haematuria met with in the tropics. The echino- coccus is rarely associated with haemorrhage. (3) Affections of the Urinary Passages.—Stone in the ureter, malig- nant disease or ulceration of the bladder, the presence of a calculus, para- sites, and, very rarely, ruptured veins in the bladder. Bleeding from the urethra occasionally occurs in gonorrhoea and as a result of the lodgment of a calculus. (4) Traumatism.—Injuries may produce bleeding from any part of the urinary passages. By a fall or blow on the back the kidney may be ruptured, and this may be followed by very free bleeding; less commonly the blood comes from injury of the bladder or of the prostate. Blood from the urethra is frequently due to injury by the passage of a catheter, or sometimes to falls or blows. And, lastly, there are cases in which haematuria occurs for a long time without discoverable cause, particularly in young persons. The health may not be seriously impaired. Gull has characterized, in a happy way, a case of this kind as one of renal epistaxis. Of special interest is the malarial haematuria which prevails in certain districts and has already been considered in the section on paludism. ANOMALIES OF THE URINARY SECRETION. 765 The diagnosis of haematuria is usually easy. The color of the urine varies from a light smoky to a bright red, or it may have a dark porter color. Examined with the microscope, the blood-corpuscles are readily recognized, either plainly visible and retaining their color, in which case they are usually crenated, or simply as shadows. In ammoniacal urine or urines of low specific gravity the haemoglobin is rapidly dissolved from the corpuscles, but in normal urine they remain for many hours un- changed. Other tests are rarely necessary. The guaiacum test consists of the addition to the urine, in a test-tube, of a drop or two of the tincture of guaiacum and two minims of ozonic ether. A blue color forms at the line of contact of the two fluids and diffuses itself through the ether. The spectroscopical examination of the urine may show either the sin- gle hand of reduced haemoglobin or the double band of oxyhaemoglobin between the lines D and E. It is important to distinguish between blood coming from the bladder and from the kidneys, though this is not always easy. From the bladder the blood may be found only with the last portions of urine, or only at the termination of micturition. In haemorrhage from the kidneys the blood and urine are intimately mixed. Clots are more commonly found in the blood from the kidneys, and may form moulds of the pelvis or of the ureter. When the seat of the bleeding is in the bladder, on washing out this organ, the water is more or less blood-tinged ; but if the source of the bleeding is higher, the water comes away clear. In many instances it is difficult to settle the question by the examination of the urine alone, and the symp- toms and the physical signs must also be taken into account. 3. HiEMOGLOBINURIA. This condition is characterized by the presence of blood-pigment in the urine. The blood-cells are either absent or in insignificant numbers. The coloring matter is not haematin, as indicated by the old name, hcema- tinuria, nor in reality always haemoglobin, but it is most frequently methae- moglobin. The urine has a red or brownish-red, sometimes quite black color, and usually deposits a very heavy brownish sediment. When the haemoglobin occurs only in small quantities, it may give a lake or smoky color to the urine. Microscopical examination shows the presence of granular pigment, sometimes fragments of blood-disks, epithelium, and very often darkly pigmented urates. The urine is also albuminous. The number of red blood-corpuscles bears no proportion whatever to the in- tensity of the color of the urine. Examined spectroscopically, there are either the two absorption bands of oxyhaemoglobin, which is rare, or, more commonly, there are the three absorption bands of methaemoglobin, of which the one in the red near C is characteristic. Two clinical groups may be distinguished. 766 DISEASES OF THE KIDNEYS. (1) Toxic Hsemoglobinuria.—This is caused by poisons which produce rapid dissolution of the blood-corpuscles, such as chlorate of potash in large doses, pyrogallic acid, carbolic acid, arseniuretted hydrogen, carbon mon- oxide, naphthol, and muscarine; also the poisons of scarlet fever, yellow fever, typhoid fever, malaria, and syphilis. It has also followed severe burns. Exposure to excessive cold and violent muscular exertion are stated to produce haemoglobinuria. A most remarkable toxic form occurs in horses, coming on with great suddenness and associated with paresis of the hind legs. Death may occur in a few hours or a few days. Horses are attacked only after being stalled for some days and then taken out and driven, particularly in cold weather. The affection is common in horses in this country. The form of haemoglobinuria from cold and exertion is extremely rare. No instance of it, even in association with frost-bites, came under my observation in Canada. Blood transfused from one mam- mal into another causes dissolution of the corpuscles with the production of haemoglobinuria; and, lastly, there is the epidemic haemoglobinuria of the new-born, associated with jaundice, cyanosis, and nervous symptoms. (2) Paroxysmal Hsemoglobmuria.—This rare disease is characterized by the occasional passage of bloody urine, in which the coloring matter only is present. It is more frequent in males than in females, and occurs chiefly in adults. It seems specially associated with cold and exertion, and has often been brought on, in a susceptible person, by the use of a cold foot-bath. Paroxysmal haemoglobinuria has been found, too, in per- sons subject to the various forms of Raynaud’s disease. Many regard the relation between these two affections as extremely close; some hold that they are manifestations of one and the same disorder. Druitt, the author of the well-known Surgical Yade-mecum, has given a graphic description of his sufferings, which lasted for many years, and were accompanied with local asphyxia and local syncope. The connection, however, is not very common. In only one of the cases of Raynaud’s disease which I have seen was paroxysmal hsemoglobinuria present, and in it epileptic attacks occurred at the same time. The relation of the disease to malaria is not so close as has been thought by many writers. No doubt it has been frequently confounded with a malarial hsematuria. The attacks may come on suddenly after exposure to cold or as a result of mental or bodily exhaustion. They may be preceded by chills and pyrexia. In other instances the temperature is subnormal. There may be vomiting and diarrhoea. Pain in the lumbar region is not uncommon. The hsemo- globinuria rarely persists for more than a day or two—sometimes, indeed, not for a day. There are instances in which, even in the course of a sin- gle day, there have been two or three paroxysms, and in the intervals clear urine has been passed. Jaundice has been present in a number of cases. According to Ralfe, paroxysmal hsemoglobinuria may alternate with gen- eral symptoms of the same character, but associated only with the passage of albumin and an increased quantity of urea in the urine. In such cases ANOMALIES OF THE URINARY SECRETION. 767 he supposes that the toxic agent, whatever its nature, has destroyed only a limited number of the corpuscles, the coloring matter of which is readily dealt with by the spleen and liver, while the globulin is excreted in the urine. The cases are rarely if ever fatal. The essential pathology of the disease is unknown, and it is difficult to form a theory which will meet all the facts—particularly the relation with Raynaud’s disease, which is rightly regarded as a vaso-inotor disorder. Increased haemolysis and dissolution of the haemoglobin in the blood-serum (haemoglobinaemia) precedes, in each instance, the appearance of the color- ing matter in the urine. A full discussion of the subject is to be found in F. Chvostek’s recent monograph. Treatment.—In all forms of haematuria rest is essential. In that produced by renal calculi the recumbent posture may suffice to check the bleeding. Full doses of acetate of lead and opium should be tried, then ergot, gallic and tannic acid, and the dilute sulphuric acid. The oil of turpentine, which is sometimes recommended, is a risky remedy in haematuria. Extr. hamamelis virgin, and extr. hydrastis canad. are also recommended. Cold may be applied to the loins or dry cups in the lumbar region. The treatment of hasmoglobinuria is unsatisfactory. Amyl nitrite will sometimes cut short or prevent an attack (Chvostek). During the par- oxysm the patient should be kept warm and given hot drinks. Quinine is recommended in large doses, on the supposition—as yet unwarranted— that the disease is specially connected with malaria. If there is a syphilitic history, iodide of potassium in full doses may be tried. In a warm cli- mate the attacks are much less frequent. 4. Albuminuria. The presence of albumin in the urine, formerly regarded as indicative of Bright’s disease, is now recognized as occurring under many circum- stances without the existence of serious organic change in the kidney. Two groups of cases may be recognized—those in which the kidneys show no coarse lesions, and those in which there are evident anatomical changes. Albuminuria without Coarse Renal Lesions.—(a) Functional, so- called Physiological Albuminuria.—In a normal condition of the kidney only the water and the salts are allowed to pass from the blood. When albuminous substances transude there is probably disturbance in the nu- trition of the epithelium of the capillaries of the tuft, or of the cells sur- rounding the glomerulus. This statement is still, however, in dispute, and Senator, Grainger Stewart, and others hold that there is a physiologi- cal albuminuria which may follow muscular work, the ingestion of food rich in albumen, violent emotions, cold bathing, and dyspepsia. The dif- ferences of opinion on this point are striking, and observers of equal 768 DISEASES OF THE KIDNEYS. thoroughness and reliability have arrived at directly opposite conclusions. The presence of albumin in the urine, in any form and under any cir- cumstance, may be regarded as indicative of change in the renal or glom- erular epithelium, a change, however, which may be transient, slight, and unimportant, depending upon variations in the circulation or upon the irritating effects of substances taken with the food or temporarily present, as in febrile states. Albuminuria of adolescence and cyclic albuminuria, in which the albu- min is present only at certain times during the day, are interesting forms. A majority of the cases occur in young persons—boys more commonly than girls—and the condition is often discovered accidentally. The urine, as a rule, contains only a very small quantity of albumin, but in some instances large quantities are present. The most striking feature is the variability. It may be absent in the morning and only present after exer- tion, or it may be greatly increased after taking food, particularly pro- teids. The quantity of urine may be but little if at all increased, the spe- cific gravity is usually normal, and the color may be high. Occasionally hyaline casts may be found, and in some instances there has been transient glycosuria. As a rule, the pulse is not of high tension and the second aortic sound is not accentuated. Various forms of this affection have been recognized by writers, such as. neurotic, dietetic, cyclic, intermittent, and paroxysmal—names which indicate the characters of the different varieties. A large proportion of the cases get well after the condition has persisted for a variable period. This in itself is an evidence that the changes, whatever their nature, were transient and slight. In these instances the albumin exists in small quan- tity, tube-casts are rarely present, and the arterial tension is not increased. In a second group the albumin is more persistent, the amount is larger, though it may vary from day to day, and the pulse tension is increased. In such instances the persistent albuminuria probably indicates actual organic change in the kidney. (b) Febrile Albuminuria. — Pyrexia, by whatever cause produced, may cause slight albuminuria. The presence of the albumin is due to slight changes in the glomeruli induced by the fever, such as cloudy swell- ing, which cannot be regarded as an organic lesion. It is extremely common, occurring in pneumonia, diphtheria, typhoid fever, and even in the fever of acute tonsillitis. The amount of albumin is slight, and it usually disappears from the urine with the cessation of the fever. (c) Hcemic Changes.—Purpura, scurvy, chronic poisoning by lead or mercury, syphilis, leukaemia, and profound anaemia may be associated with slight albuminuria. Abnormal ingredients in the blood, such as bile- pigment and sugar, may cause the passage of small amounts of albu- min. The transient albuminuria of pregnancy may belong to this haemic group, although in a majority of such cases there are changes in the renal ANOMALIES OF THE URINARY SECRETION. 769 tissue. Albumin may be found sometimes after the inhalation of ether or chloroform. (d) Albuminuria occurs in certain affections of the nervous system. This so-called neurotic albuminuria is seen after an epileptic seizure and in apoplexy, tetanus, exophthalmic goitre, and injuries of the head. Albuminuria with Definite Lesions of the Urinary Organs.—(a) Con- gestion of the kidney, either active, such as follows exposure to cold and is associated with the early stages of nephritis, or passive, due to obstructed outflow in disease of the heart or lungs, or to pressure on the renal veins by the pregnant uterus or tumors. (Z>) Organic disease of the kidneys—acute and chronic Bright’s disease, amyloid and fatty degeneration, suppurative nephritis, and tumors. () Strabismus.—The axes of the eyes do not correspond. Thus, pa- ralysis of the internal rectus causes a divergent squint; of the external rectus, a convergent squint. At first this is only evident when the eyes are moved in the direction of the action of the weak muscle, but may become constant by the contraction of the opposing muscle. The deviation of the axis of the affected eye from parallelism with the other is called the pri- mary deviation. (c) Secondary Deviation.—If, while the patient is looking at an ob- ject, the sound eye is covered, so that he fixes the object looked at with the affected eye only, the sound eye is moved still further in the same di- 852 DISEASES OF THE NERVOUS SYSTEM. rection—e. g., outward—with paralysis of the opposite internal rectus. This is known as secondary deviation. It depends upon the fact that, if two muscles are acting together, when one is weak and an effort is made to contract it, the increased effort—innervation—acts powerfully upon the other muscle, causing an increased contraction. (d) Erroneous Projection.—“We judge of the relation of external objects to each other by the relation of their images on the retina; but we judge of their relation to our own body by the position of the eyeball as indicated to us by the innervation we give to the ocular muscles ” (Gowers). With the eyes at rest in the mid-position, an object at which we are looking is directly opposite our face. Turning the eyes to one side, we recognize that object in the middle of the field or to the side of this former position. We estimate the degree by the amount of move- ment of the eyes, and when the object moves and we follow it we judge of its position by the amount of movement of the eyeballs. When one ocular muscle is weak, the increased innervation gives the impression of a greater movement of the eye than has really taken place. The mind, at the same time, receives the idea that the object is further on one side than it really is, and in an attempt to touch it the finger may go beyond it. As the equilibrium of the body is in a large part maintained by a knowledge of the relation of external objects to it obtained by the action of the eye muscles, this erroneous projection resulting from paralysis dis- turbs the harmony of these visual impressions and may lead to giddiness —ocular vertigo. (e) Double Vision.—This is one of the most disturbing features of paralysis of the eye muscles. The visual axes do not correspond, so that there is a double image—diplopia. That seen by the sound eye is termed the true image; that by the paralyzed eye, the false. In simple or homon- ymous diplopia the false image is “ on the same side of the other as the eye by which it is seen.” In crossed diplopia it is on the other side. In con- vergent squint the diplopia is simple; in divergent it is crossed. Ophthalmoplegia.—Under this term is described a chronic progressive paralysis of the ocular muscles. Two forms are recognized—ophthalmo- plegia externa and ophthalmoplegia interna. The conditions may occur separately or together and are described by Gowers under nuclear ocular palsy. Ophthalmoplegia externa.—The condition is one of more or less com- plete palsy of the external muscles of the eyeball, due usually to a slow degeneration in the nuclei of the nerves, but sometimes to pressure of tumors or to basilar meningitis. It is often but not necessarily associated with ophthalmoplegia interna. Siemerling. in the recent monograph in which he has analyzed the material (eight cases) left by the late Prof. Westphal, states that sixty-two cases are on record. In only eleven of these could syphilis be positively determined. The levator muscles of the eyelids and the superior recti are first involved, and gradually the other DISEASES OF TPIE CRANIAL NERVES. 853 muscles, so that the eyeballs are fixed and the eyelids droop. There is sometimes slight protrusion of the eyeballs. The disease is essentially chronic and may last for many years. It is found particularly in association with general paralysis, locomotor ataxia, and in progressive muscular atrophy. Mental disorders were present in eleven of the sixty-two cases. With it may be associated atrophy of the optic nerve and affections of other cranial nerves. Occasionally, as noted by Bristowe, it may be func- tional. Ophthalmoplegia interna.—Jonathan Hutchinson applied this term to a progressive paralysis of the internal ocular muscles, causing loss of pupil- lary action and the power of accommodation. When the internal and external muscles are involved the affection is known as total ophthalmo- plegia, and in a majority of the cases the two conditions are associated. In some instances the internal form may depend upon disease of the ciliary ganglion. While, as a rule, ophthalmoplegia is a chronic process, there is an acute form associated with hsemorrhagic softening of the nuclei of the ocular muscles. There is usually marked cerebral disturbance. It was to this form that Wernicke gave the name polio-encephalitis superior. Treatment of Ocular Palsies.—It is important to ascertain, if possible, the cause. The forms associated with locomotor ataxia are obstinate, and resist treatment. Occasionally, however, a palsy, complete or partial, may pass away spontaneously. The group of cases associated with chronic degenerative changes, as in progressive paresis and bulbar paralysis, is little affected by treatment. On the other hand, in syphilitic cases, mercury and iodide of potassium are indicated and are often bene- ficial. Arsenic and strychnia, the latter hypodermically, may be employed. In any case in which the onset is acute, with pain, hot fomentations and counter-irritation or leeches applied to the temple give relief. The direct treatment by electricity has been extensively employed, but probably with- out any special effect. The diplopia may be relieved by the use of prisms, or it may be necessary to cover the affected eye with an opaque glass. Fifth Nerve. Paralysis may result from: (a) Disease of the pons, particularly haem- orrhage or patches of sclerosis, (b) Injury or disease at the base of the brain. Fracture rarely involves the nerve; on the other hand, menin- gitis, acute or chronic, and caries of the bone are not uncommon causes. (c) The branches may be affected as they pass out—the first division by tumors pressing on the cavernous sinus or by aneurism; the second and third divisions by growths which invade the spheno-maxillary fossa. (d) Primary neuritis, which is rare. Symptoms.—(a) Sensory Portion.—Paralysis of the fifth nerve causes loss of sensation in the parts supplied, including the half of the 854 DISEASES OP THE NERVOUS SYSTEM. face, the corresponding side of the head, the conjunctiva, the mucosa of the lips, tongue, hard and soft palate, and of the nose of the same side. The anaesthesia may be preceded by tingling or pain. The muscles of the face are also insensible and the movements may be slower. The sense of smell is interfered with. There is disturbance of the sense of taste. There are, in addition, trophic changes; the salivary, lachrymal, and buc- cal secretions may be lessened, abrasions of the mucous membranes heal slowly, and the teeth may become loose. The eye inflames, the cornese become cloudy and may ulcerate. It was formerly held that these symp- toms only occurred when the Gasserian ganglion was affected, but of late years this has been completely removed for obstinate neuralgia without pro- ducing any trophic disturbance. Herpes may develop in the region supplied by the nerve, usually the upper branch, and is associated with much pain, which may be peculiarly enduring, lasting for months or years (Gowers). (h) Motor Portion.—The inability to use the muscles of mastica- tion on the affected side is the distinguishing feature of paralysis of this portion of the nerve. It is recognized by placing the finger on the mas- seter and temporal muscles, and, when the patient closes the jaw, the feebleness of their contraction is noted. If paralyzed, the external ptery- goid cannot move the jaw toward the unaffected side ; and when depressed, the jaw deviates to the paralyzed side. The motor paralysis of the fifth nerve is almost invariably a result of involvement of the nerve after it has left the nucleus. Cases, however, have been associated with cortical lesions. Hirt concludes, from his case, that the motor centre for the trigeminus is in the neighborhood of the lower third of the ascending frontal convolution. Spasm of the Muscles of Mastication.—Trismus, the masticatory spasm of Bomberg, may be tonic or clonic, and is either an associated phenome- non in general convulsions or, more rarely, an independent affection. In the tonic form the jaws are kept close together—lock-jaw—or can be separated only for a short space. The muscles of mastication can be seen in contraction and felt to be hard and the spasm is often painful. This tonic contraction is an early symptom in tetanus, and is sometimes seen in tetany. A form of this tonic spasm occurs in hysteria. Occasionally tris- mus follows exposure to cold, and is said to be due to reflex irritation from the teeth, the mouth, or caries of the jaw. It may also be a symptom of organic disease due to irritation near the motor nucleus of the fifth nerve. Clonic spasm of the muscles supplied by the fifth occurs in the form of rapidly repeated contractions, as in “ chattering teeth.” This is rare apart from general conditions, though cases are on record, usually in women late in life, in whom this isolated clonic spasm of the muscles of the jaw has been found. In another form of clonic spasm sometimes seen in chorea, there are forcible single contractions. Gowers mentions an instance of its occurrence as an isolated affection. (c) Gustatory.—Loss of the sense of taste in the anterior two thirds of DISEASES OF THE CRANIAL NERVES. 855 the tongue, as a rule, follows paralysis of the fifth nerve. The gustatory fibres pass from the chorda tympani to the lingual branch of the fifth. Disease of the fifth nerve is, however, not always associated with loss of taste in the anterior part of the tongue, in which case either the taste fibres escape, or the disease is w'ithin the pons where these fibres are separate from those of sensation. The diagnosis of disease of the trifacial nerve is rarely difficult. It must be remembered that the preliminary pain and hyperaesthesia are sometimes mistaken for neuralgia. The loss of sensation and the palsy of the muscles of mastication are readily determined. Treatment.—When the pain is severe morphia may be required and local applications are useful. If there is a suspicion of syphilis, appropri- ate treatment should be given. Faradization is sometimes beneficial. Facial Nerve. Paralysis (Bell's Palsy).—The facial or seventh may be paralyzed by (1) lesions of the cortex—supranuclear palsy; (2) lesions of the nucleus itself; or (3) involvement of the nerve trunk in its tortuous course within the pons and through the wall of the skull. I. Supranuclear Paralysis, due to lesion of the cortex or of the facial fibres in the corona radiata or internal capsule, is, as a rule, associated with hemiplegia. It may be caused by tumors, abscess, chronic inflamma- tion, or softening in the region of the internal capsule. It is distinguished from the peripheral form by two well-marked characters—the persistence of the normal electrical excitability of both nerves and muscles and the absence of involvement of the upper branches of the nerve, so that the or- bicularis palpebrarum and frontalis muscle are spared. In rare instances these muscles are paralyzed. A third difference is that in this form the voluntary movements are more impaired than the emotional. There are instances of cortical facial paralysis—monoplegia facialis—associated with lesions in the centre for the face muscles in the lower Rolandic region. Isolated paralysis, due to involvement of the nerve fibres in their path to the nucleus, is uncommon. In the great majority of cases supranuclear facial paralysis is part of a hemiplegia. Paralysis is on the same side as that of the arm and leg because the facial muscles bear precisely the same relation to the cortex as the spinal muscles. The nuclei of origin on either side of the middle line in the medulla are united by decussating fibres with the cortical centre on the opposite side (see Fig. 9). II. The nuclear paralysis caused by lesions of the nerve centre in the medulla is not common alone; but is seen occasionally in tumors, chronic softening, and haemorrhage. In rare instances of anterior polio-myelitis the facial nucleus is affected. In diphtheria this centre may also be involved. The symptoms are practically similar to those of an affection of the nerve fibre itself—infranuclear paralysis. 856 DISEASES OF THE NERVOUS SYSTEM. III. Involvement of the Nerve Trunk.—Paralysis may result from: (a) Involvement of the nerve as it passes through the pons—that is, between its nucleus in the floor of the fourth ventricle and the point of emergence in the postero-lateral aspect of the pons. The specially inter- esting feature in connection with involvement of this part is the production of what is called alternating or cross paralysis, the face being involved on the same side as the lesion, and the arm and leg on the opposite side, since the motor path is involved above the point of decussation in the medulla (Fig. 9). This occurs only when the lesion is in the lower section of the pons. A lesion in the upper division involves the fibres not of the out- going nerve on the same side, but of the fibres from the hemispheres before they have crossed to the nucleus of the opposite side. In this case there would of course be, as in hemiplegia, paralysis of the face and limbs on the side opposite to the lesion. The palsy, too, would resemble the cerebral form, involving only the lower fibres of the facial nerve. (b) The nerve may be involved at its point of emergence by tumors, gummata, meningitis, or occasionally may be injured in fracture of the base. (c) In passing through the Fallopian canal the nerve may be involved in disease of the ear, particularly by caries of the bone in otitis media. This is a common cause in children. (d) As the nerve emerges from the styloid foramen it is exposed to injuries and blows which not infrequently cause paralysis. The fibres may be cut in the removal of tumors in this region, or the paralysis may be caused by pressure of the forceps in an instrumental delivery. (e) Exposure to cold • is the most common cause of facial paralysis, inducing a neuritis of the nerve within the Fallopian canal. (/) Syphilis is notan infrequent cause, and the paralysis may develop early with the secondary symptoms. Facial diplegia is a rare condition occasionally found in affections at the base of the brain, lesions in the pons, simultaneous involvement of the nerves in ear disease, and in diphtheritic paralysis. Disease of the nuclei or symmetrical involvement of the cortex might also produce it. Symptoms.—In the peripheral facial paralysis all the branches of the nerve are involved. The face on the affected side is immobile and can neither be moved at Avill nor participate in any emotional movements. The skin is smooth and the wrinkles are effaced, a point particularly noticeable on the forehead of elderly persons. The eye cannot be closed, the lower lid droops, and the eye waters. On the affected side the angle of the mouth is lowered, and in drinking the lips are not kept in close apposition to the glass, so that the liquid is apt to run out. In smiling or laughing the contrast is most striking, as the affected side does not move, which gives a curious unequal appearance to the two sides of the face. The eye cannot be closed and the forehead cannot be wrinkled. On asking a patient to show his upper teeth, the angle of the mouth is not raised. In DISEASES OF THE CRANIAL NERVES. 857 all these movements the face is drawn to the sound side by the action of the muscles. Speaking may be slightly interfered with, owing to the im- perfection in the formation of the labial sounds. Whistling cannot be performed. In chewing the food, owing to the paralysis of the buccinator, particles collect on the affected side. The paralysis of the nasal muscles is seen on asking the patient to sniff. Owing to the fact that the lips are drawn to the sound side, the tongue, when protruded, looks as if it were pushed to the paralyzed side; but on taking its position from the incisor teeth, it will be found to be in the middle line. The reflex movements are lost in this peripheral form. It is usually stated that the palate is paralyzed on the same side and that the uvula deviates. Both Gowers and Hughlings Jackson deny the existence of this involvement in the great majority of cases, and Horsley and Beevor have shown that these parts are innervated by the accessory nerve to the vagus. When the nerve is involved within the canal between the genu and the origin of the chorda tympani, the sense of taste may be lost in the anterior part of the tongue on the affected side. When the nerve is damaged outside the skull the sense of taste is unaffected. Hearing is often impaired in facial paralysis, most commonly by preceding ear dis- ease. The paralysis of the stapedius muscle may lead to increased sen- sitiveness to musical notes. Herpes is sometimes associated with facial paralysis. Pain is not common, but there may be neuralgia about the ear. The face on the affected side may be swollen. The electrical reactions, which are those of a peripheral palsy, have considerable importance from a prognostic standpoint. Erb’s rules are as follows: If there is no change, either faradic or galvanic, the prognosis is good and recovery takes place in from fourteen to twenty days. If the faradic and galvanic excitability of the nerve is only lessened and that of the muscle increased to the galvanic current and the contraction formula altered (the contraction sluggish AnC>CC), the outlook is relatively good and recovery will probably take place in from four to six weeks ; oc- casionally in from eight to ten. When the reaction of degeneration is present—that is, if the faradic and galvanic excitability of the nerves and the faradic excitability of the muscles are lost and the galvanic excita- bility of the muscle is quantitatively increased and qualitatively changed, and if the mechanical excitability is altered—the prognosis is relatively unfavorable and the recovery may not occur for two, six, eight, or even fif- teen months. The course of facial paralysis is usually favorable. The onset in the form following cold is very rapid, developing perhaps within twenty-four hours, but rarely is the paralysis permanent. On the other hand, in the paralysis from injury, as by a blow on the mastoid process, the paralysis may remain. When permanent the muscles are entirely toneless. In some instances contracture develops as the voluntary power returns, and the natu- ral folds and the wrinkles on the affected side may be deepened, so that on 858 DISEASES OF THE NERVOUS SYSTEM. looking at the face one at first may have the impression that the affected side is the sound one. This is corrected at once on asking the patient to smile, when it is seen which side of the face has the most active move- ment. The diagnosis of facial paralysis is usually easy. The distinction be- tween peripheral and central is based on facts already mentioned. Treatment.—In the cases which result from cold and are probably due to neuritis within the bony canal, hot applications first should be made; subsequently the thermo-cautery may be used lightly at intervals of a day or two over the mastoid process, or small blisters applied. If the ear is diseased, free discharge for the secretion should be ob- tained. The continuous current may be employed to keep up the nu- trition of the muscles. The positive pole should be placed behind the ear, the negative one along the zygomatic and other muscles. The ap- plication can be made daily for a quarter of an hour and the patient can readily be taught to make it himself before the looking-glass. Massage of the muscles of the face is also useful. A course of iodide of potassium may be given even when there is no indication of syphilis. Spasm.—The spasm may be limited to a few or involve all the muscles innervated by the facial nerve and may be unilateral or bilateral. It is known also by the name of mimic spasm or of convulsive tic, Several different affections are usually considered under the name of facial or mimic spasm, but we shall here speak only of the simple spasm of the facial muscles, either primary or following paralysis, and shall not in- clude the cases of habit spasm in children, or the tic convulsif of the French. Gowers recognizes two classes—one in which there is an organic lesion, and an idiopathic form. It is thought to be due also to reflex causes, such as the irritation from carious teeth or the presence of intestinal worms. The disease usually occurs in adults, whereas the habit spasm and the tic convulsif of the French, often confounded with it, are most common in children. True mimic spasm occasionally comes on in childhood and per- sists. In the case of a school-mate, the affection was marked as early as the eleventh or twelfth year and still continues. When the result of or ganic disease there has usually been a lesion of the centre in the cortex, as in the case reported by Berkeley, or pressure on the nerve at the base of the brain by aneurism or tumor. Symptoms.—The spasm may involve only the muscles around the eye—blepharospasm—in which case there is constant, rapid, quick action of the orbicularis palpebrarum, which, in association with photophobia, may be tonic in character. More commonly the spasm affects the lateral facial muscles with those of the eye and there is constant twitching of the side of the face with partial closure of the eye. The frontalis is rarely in* DISEASES OF THE CRANIAL NERVES. 859 volved. In aggravated cases the depressors of the angle of the mouth, the levator menti, and the platysma myoides are affected. This spasm is con- fined to one side of the face in a majority of cases, though it may extend and become bilateral. It is increased by emotional causes and involuntary movements of the face. As a rule, it is painless, but there may be tender points on the course of the fifth nerve, particularly the supraorbital branch. Tonic spasm of the facial muscle may follow paralysis, and is said to result occasionally from cold. The outlook in facial spasm is always dubious. A majority of the cases persist for years and are incurable. Treatment.—Sources of irritation should be looked for and re- moved. When a painful spot is present over the fifth nerve, blistering or the application of the thermo-cautery may relieve it. Hypodermic injections of strychnia may be tried, but are of doubtful benefit. Weir Mitchell recommends the freezing of the cheek for a few minutes daily or every second day with the spray, and this, in some instances, is bene- ficial. Often the relief is transient; the cases return, and at every clinic may be seen half a dozen or more of such patients who have run the gamut of all measures without material improvement. Operative interference may be resorted to in severe cases, although not much can be expected of it. Auditory Nerve. The eighth, known also as portio mollis of the seventh pair, enters the internal auditory meatus, and divides into the cochlear and vestibular branches. The cortical centre for hearing is in the temporo-sphenoidal lobe. Primary disease of the auditory nerve in its centre or intracranial course is uncommon. More frequently the terminal branches are affected within the labyrinth. (a) Affection of the Cortical Centre.—In the monkey, experiments indicate that the first temporal gyri represent the centre for hearing. In man the cases of disease indicate that it has the same situation, as de- struction of this gyrus on the left side results in wrord-deafness, which may be defined as an inability to understand the meaning of words, though they may still be heard as sounds. The central fibres of the auditory nerve between the cortical centre and the nucleus in the fourth ventricle may be involved and produce deafness. This has resulted from the presence of a tumor in the corpora quadrigemina, and may be associated with a lesion of the internal capsule. (5) Lesions of the nerve at the base of the brain may result from the pressure of tumors, meningitis (particularly the cerebro-spinal form),ha3m- orrhage, or traumatism. A primary degeneration of the nerve may occur in locomotor ataxia. Nuclear disease is rare. By far the most interest- ing form results from epidemic cerebro-spinal meningitis, in which the 860 DISEASES OF TOE NERVOUS SYSTEM. nerve is frequently involved, causing permanent deafness. In young children the condition results in deaf-mutism. (c) In a majority of the cases associated with auditory-nerve symptoms the lesion is in the labyrinth, either primary or the result of extension of disease of the middle ear. Three groups of symptoms may be produced— hyperaesthesia and irritation, diminished function or nervous deafness, and vertigo. (1) Hyperaesthesia and Irritation.—This may be due to altered func- tion of the centre as well as of the nerve ending. True hyperaesthesia— hyperacusis—is a condition in which sounds, sometimes even those inaudi- ble to other persons, are heard with great intensity. It occurs in hysteria and occasionally in cerebral disease. As already mentioned, in paralysis of the stapedius low notes may be heard with intensity. In dysaesthesia, or dysacusis, ordinary sounds cause an unpleasant sensation, as commonly happens in connection with headache, when ordinary noises are badly borne. Tinnitus aurium is a term employed to designate certain subjective sensations of ringing, roaring, ticking, and whirring noises in the ear. It is a very common and often a distressing symptom. It is associated with many forms of ear disease and may result from pressure of wax on the drum. It is rare in organic disease of the central connections of the nerve. Sudden intense stimulation of the nerve may cause it. A form not uncommonly met with in medical practice is that in which the patient hears a continual bruit in the ear, and the noise has a systolic intensification, usually on one side. I have twice been consulted by physicians for this condition under the belief that they had an internal aneurism. It occurs in condi- tions of anaemia and neurasthenia. Subjective noises in the ear may pre- cede an epileptic seizure and are sometimes present in migraine. In whatever form tinnitus exists, though slight and often regarded as trivial, it occasions great annoyance and often mental distress, and has even driven patients to suicide. The diagnosis is readily made; but it is often extremely difficult to de- termine upon what condition the tinnitus depends. The relief of con- stitutional states, such as anaemia, neurasthenia, or gout, may result in cure. ' A careful local examination of the ear should always be made. One of the most worrying forms is the constant clicking, sometimes audi- ble many feet away from the patient, and due probably to clonic spasm of the muscles connected with the Eustachian tube or of the levator palati. The condition may persist for years unchanged, and then disappear sud- denly. The pulsating forms of tinnitus, in which the sound is like that of a systolic bruit, are almost invariably subjective, and nothing is audible with the stethoscope. It is to be remembered that in children there is a systolic brain murmur, best heard over the ear, and in some instances is heard in the adult. (&) Diminished Function or Nervous Deafness.—In testing for nervous DISEASES OP THE CRANIAL NERVES. 861 deafness, if the tuning-fork cannot be heard when placed near the meatus, but the vibrations are audible by placing the foot of the tuning-fork against the temporal bone, the conclusion may be drawn that the deafness is not due to involvement of the nerve. The vibrations are conveyed through the temporal bone to the cochlea and vestibule. The watch may be used for the same purpose, and if the meatus is closed and the watch is heard better in contact with the mastoid process than when opposite the open meatus, the deafness is probably not nervous. Practically, disturbance of the function of the auditory nerve is not a very frequent symptom in brain-disease, but in all cases the function of the nerve should be carefully tested (3) Auditory Vertigo—Meniere’s Disease.—In 1861 Meniere, a French physician, described an affection characterized by noises in the ear, ver- tigo (which might be associated with loss of consciousness), vomiting, and, in many cases, progressive loss of hearing. The term is now used to in- clude all cases of sudden vertigo accompanied by noises in the ear and deafness. The frequency of vertigo with ear symptoms is striking. Thus, of 106 cases noted by Gowers, in which there was definite vertigo, in 94 ear symptoms were present, either tinnitus or deafness or both. Symptoms.—The attack usually sets in suddenly with a buzzing noise in the ears and the patient feels as if he was reeling or staggering. He may feel himself to be reeling, or the objects about him may seem to be turning, or the phenomena may be combined. The attack is often so abrupt that the patient falls, though, as a rule, he has time to steady him- self by grasping some neighboring object. There may be slight but transient loss of consciousness. In a few minutes, or even less, the ver- tigo passes off and the patient becomes pale and nauseated, a clammy sweat breaks out on the face, and vomiting may follow. The deafness, which is always of a nervous character, may be in only one ear and is never complete. As a rule, the patients have no affec- tion of the middle ear. The tinnitus is described as either a roaring or a throbbing sound. Ocular symptoms may be present; thus, jerk- ing of the eyeballs or nystagmus may develop during the attack, or diplopia. Labyrinthine vertigo is paroxysmal, coming on at irregular intervals. Sometimes weeks or months may elapse between the attacks; in other cases there may be several attacks in a day. The disease rarely occurs in young persons, is most frequent after the fortieth year, and is more com- mon in men than in women. The pathology of the disease has been much discussed. There are two theories concerning its origin—one, that it is due to affection of the labyrinth itself, which causes a disturbance of equilibrium, such as is proved by experiment to be associated with lesion of the semicircular canals; the other that it is really a trouble involving the centres presiding over hearing and equilibration. DISEASES OF THE NERVOUS SYSTEM. It has also been held to be a vaso-motor neurosis of the vessels of the labyrinth. The condition of the labyrinth in these cases is variable. Acute disease with heemorrhage has been described, or slow progressive degeneration of the nerves. Giddiness and vomiting may, however, be produced by irritation in other parts of the ear; thus, there are instances in which pressure on the drum or irritation of the external meatus is fol- lowed by an attack of giddiness and vomiting. Diagnosis.—The combination of tinnitus with giddiness, with or without gastric disturbance, is sufficient to establish a diagnosis. There are other forms of vertigo from which it must be distinguished. The form known as gastric vertigo, which is associated with dyspepsia and oc- curs most commonly in persons of middle age, is, as a rule, readily distin- guished by the absence of tinnitus or evidences of disturbance in the func- tion of the auditory nerve. This variety of vertigo is much less common than Trousseau’s description would lead us to believe. The cardio-vascular vertigo, one of the most common forms, occurs in cases of valvular disease, particularly aortic insufficiency, and as frequently in arterio-sclerosis. There is a remarkable form of vertigo described by Gerlier, which is characterized by attacks of paretic weakness of the extremities, falling of the eyelids, remarkable depression, but with retention of consciousness. It attacks only men, and has occurred in epidemic form among laborers in the canton of Geneva. Aural vertigo must be carefully distinguished from attacks of petit mal, or, indeed, of definite epilepsy. It is rare in petit mat to have noises in the ear or actual giddiness, but in the aura preceding an epileptic attack the patient may feel giddy. Giddiness and transient loss of consciousness may be associated with organic disease of the brain, more particularly with tumor. Vomiting also may be present. A careful investigation of the symptoms will usually lead to a correct diagnosis. The outlook in Meniere’s disease is uncertain. While many cases re- cover completely, in others deafness results and the attacks recur at shorter intervals. In aggravated cases the patient constantly suffers from vertigo and may even be confined to his bed. Treatment.—Bromide of potassium, in twenty-grain doses three times a day, is sometimes beneficial. If there is a history of syphilis, the iodide should be administered. The salicylates are recommended, and Charcot advises quinine to cinchonism. In cases in which there is increase in the arterial tension nitroglycerine may be given, at first in very small doses, but increasing gradually. It is not specially valuable in Meniere’s disease, but in the cases of giddiness in middle-aged men and women asso- ciated with arterio-sclerosis it sometimes acts very satisfactorily. DISEASES OF THE CRANIAL NERVES. 863 Glosso-pharyngeal Nerve. This nerve contains both motor and sensory fibres and is also a nerve of the special sense of taste to the tongue. It supplies, by its motor branches, the stylo-pharyngeus and the middle constrictor of the pharynx. The sensory fibres are distributed to the upper part of the pharynx. Symptoms.—Of nuclear disturbance we know very little. The pharyngeal symptoms of bulbar paralysis are probably associated with in- volvement of the nuclei of this nerve. Lesion of the nerve trunk itself is rare, but it may be Compressed by tumors or involved in meningitis. Dis- turbance of the sense of taste may result from loss of function of this nerve, in which case it is chiefly in the posterior part of the tongue and soft palate. Gowers, however, states that there is no case on record in which loss of taste in these regions has been produced by disease of the roots of the glosso-pharyngeal; whereas, on the other hand, disease of the root of the fifth nerve may cause loss of taste on the back as well as the front of the tongue, as if the taste fibres of the glosso-pharyngeal came from the fifth. The general disturbances of the sense of taste may here be briefly re- ferred to. Loss of the sense of taste—ageusia—may be caused by dis- turbance of the peripheral end organs, as in affections of the mucosa of the tongue. This is very common in the dry tongue of fever or the furred tongue of dyspepsia, under which circumstances, as the saying is, every- thing tastes alike. Strong irritants too, such as pepper, tobacco, or vinegar, may dull or diminish the sense of taste. Complete loss may be due to in- volvement of the nerves either in their course or in the centres. Dis- turbance in the sense of taste is most commonly seen in involvement of the fifth nerve, and it may be that this nerve alone subserves the function. Perversion of the sense of taste—parageusis—is rarely found, except as an hysterical manifestation and in the insane. Increased sensitiveness is still more rare. There are occasional subjective sensations of taste, occur- ring as an aura in epilepsy or as part of the hallucinations in the insane. To test the sense of taste the patient’s eyes should be closed and small quantities of various substances applied. The sensation should be per- ceived before the tongue is withdrawn. The following are the most suit- able tests : For bitter, quinine; for sweetness, a strong solution of sugar or saccharin; for acidity, vinegar; and for the saline test, common salt. One of the most important tests is the feeble galvanic current, which gives the well-known metallic taste. PNEUMOGASTRIC NERVE. The vagus nerve has an important and extensive distribution, supply- ing the pharynx, larynx, lungs, heart, oesophagus, and stomach. The nerve may be involved at its nucleus with the spinal accessory and the hypoglossal, forming what is known as bulbar paralysis. It may be com- 864 DISEASES OF THE NERVOUS SYSTEM. pressed by tumors or aneurism, or in the exudation of meningitis, simple or syphilitic. In its course in the neck the trunk may be involved by tumors or in wounds. It has been tied in ligature of the carotid, and has been cut in the removal of deep-seated tumors. The trunk may be at- tacked by neuritis. The affections of the vagus are best considered in connection with the distribution of the separate nerves. (a) Pharyngeal Branches.—In combination with the glosso-pharyngeal the branches from the vagus form the pharyngeal plexus, from which the muscles and mucosa of the pharynx are supplied. In paralysis due to involvement of this either in the nuclei, as in bulbar paralysis, or in the course of the nerve, as in diphtheritic neuritis, there is difficulty in swal- lowing and the food is not passed on into the oesophagus. If the nerve on one side only is involved, the deglutition is not much impaired. In these cases the particles of food frequently pass into the larynx, and, when the soft palate is involved, into the posterior nares. Spasm of the pharynx is always a functional disorder, usually occur- ring in hysterical and nervous people. Gowers mentions a case of a gen- tleman who could not eat unless alone, on account of the inability to swallow in the presence of others from spasm of the pharynx. This spasm is a well-marked feature in hydrophobia, and I have seen it in a case of pseudo-hydrophobia. (b) Laryngeal Branches.—The superior laryngeal nerve supplies the mucous membrane of the larynx above the cords and the crico-thyroid muscle. The inferior or recurrent laryngeal curves around the arch of the aorta on the left side and the subclavian artery on the right, passes along the trachea and supplies the mucosa below the cords and all the muscles of the larynx except the crico-thyroid and the epiglottidean. Experiments have shown that these motor nerves of the pneumogastric are all derived from the spinal accessory. The remarkable course of the recurrent laryngeal nerves renders them liable to pressure by tumors within the thorax, par- ticularly by aneurism. The following are the most important forms of paralysis: (1) Bilateral Paralysis of the Abductors.—In this condition, the pos- terior crico-arytenoids are involved and the glottis is not opened during inspiration. The cords may be close together in the position of phonation, and during inspiration may be brought even nearer together by the pressure of air, so that there is only a narrow chink through which the air whistles with a noisy stridor. This dangerous form of laryngeal paralysis occurs occasionally as a result of cold, or may follow a laryngeal catarrh. The posterior muscles have been found degenerated when the others were healthy. The condition may be produced by pressure upon both vagi, or upon both recurrent nerves. As a central affection it occurs in tabes and bulbar paralysis, but may occur also in hysteria. The characteristic symptoms are inspiratory stridor with unimpaired phonation. Possibly, DISEASES OF THE CRANIAL NERVES. as Gowers suggests, many cases of so-called hysterical spasm of the glottis are in reality abductor paralysis. (2) Unilateral Abductor Paralysis.—This frequently results from the pressure of tumors or involvement of one recurrent nerve. Aneurism is by far the most common cause, though on the right side the nerve may be involved in thickening of the pleura. The symptoms are hoarseness or roughness of the voice, such as is so common in aneurism. Dyspnoea is not often present. The cord on the affected side does not move in in- spiration. Subsequently the adductors may also become involved, in which case the phonation is still more impaired. (3) Adductor Paralysis.—This results from involvement of the lateral crico-arytenoid and the arytenoid muscle itself. It is common in hysteria, particularly of women, and causes the hysterical aphonia, which may come on suddenly. It may result from catarrh of the larynx or from overuse of the voice. In laryngoscopic examination it is seen, on attempt at phonation, that there is no power to bring the cords together. In this connection the following table from Gowers work will be found valuable to the student: Symptoms. Signs. Lesion. No voice; no cough; stridor only on deep in- spiration. Both cords moder- ately abducted and mo- tionless. Total bilateral palsy. Voice low pitched and hoarse; no cough ; stridor absent or slight on deep breathing. One cord moder- ately abducted and mo- tionless, the other mov- ing freely, and even beyond the middle line in phonation. Total unilateral palsy Voice little changed; cough normal; inspira- tion difficult and long, with loud stridor. Both cords near to- gether, and during in- spiration not separated, but even drawn nearer together. Total abductor palsy. Symptoms incon- clusive ; little affection of voice or cough. One cord near the middle line not moving during inspiration, the other normal. Unilateral abductoi palsy. No voice; perfect cough; no stridor or dyspnoea. Cords normal in po- sition and moving nor- mally in respiration, but not brought to- gether on an attempt at phonation. Adductor palsy. 866 DISEASES OF THE NERVOUS SYSTEM. .Spasm of the Muscles of the Larynx.—In this the adductor muscles are involved. It is not an uncommon affection in children, and has al- ready been referred to as laryngismus stridulus. Paroxysmal attacks of laryngeal spasm are rare in the adult, but cases are described in which the patient, usually a young girl, wakes at night in an attack of intense dysp- noea, which may persist long enough to produce cyanosis. Liveing states that they may replace attacks of migraine. They occur in a characteristic form in locomotor ataxia, forming the so-called laryngeal crises. There is a condition known as spastic aphonia, in which, when the patient attempts to speak, phonation is completely prevented by a spasm. Disturbance of the sensory nerves of the larynx is rare. Anaesthesia may occur in bulbar paralysis and in diphtheritic neuritis— a serious condition, as portions of food may enter the windpipe. It is usually associated with dysphagia and is sometimes present in hysteria. Hyperassthesia of the larynx is rare. (c) Cardiac Branches.—The cardiac plexus is formed by the union of branches of the vagi and of the sympathetic nerves. The vagus fibres sub- serve motor, sensory, and probably trophic functions. (1) Motor.—The fibres which inhibit, control, and regulate the cardiac action pass in the vagi. Irritation may produce slowing of the action. Czer- mak could slow or even arrest the heart’s action for a few beats by pressing a small tumor in his neck against one pneumogastric nerve, and it is said that the same can be produced by forcible bilateral pressure on the ca- rotid canal. There are instances in which persons appear to have had vol- untary control over the action of the heart. The most remarkable in- stance was that of Colonel Townsend, who could slow the action of the heart at will. Retardation of the heart’s action has also followed acci- dental ligature of one vagus. Irritation at the nuclei may also be accom- panied by extreme slowness. The condition of brachycardia may be asso- ciated with a neurosis of this nerve. On the other hand, when there is complete paralysis of the vagi, the inhibitory action may be abolished and the acceleratory influences have full sway. The heart’s action is then greatly increased. This is seen in some instances of diptheritic neuritis and in involvement of the nerve by tumors, or its accidental removal or ligature. Complete loss of function of one vagus may, however, not be followed by any symptoms. (2) Sensory symptoms on the part of the cardiac branches are very varied. Normally, the heart’s action proceeds regularly without the par- ticipation of consciousness, but the unpleasant feelings and sensations of palpitation and pain are conveyed to the brain through this nerve. IIow far the fibres of the pneumogastric are involved in angina it is impossible to say. The various disturbances of sensation are described under the cardiac neuroses. (id) Pulmonary Branches.—We know very little of the pulmonary branches of the vagi. ’ The motor fibres are stated to control the action of DISEASES OF THE CRANIAL NERVES. the bronchial muscles, and it has long been held that asthma may be a neu- rosis of these fibres. The various alterations in the respiratory rhythm are probably due more to changes in the centre than in the nerves them- selves. (e) Gastric and (Esophageal Branches.—The muscular movements of these parts are presided over by the vagi and vomiting is induced through them, usually reflexly, but also by direct irritation, as in meningitis. Spasm of the oesophagus generally occurs with other nervous phenomena. Gas- tralgia may sometimes be due to cramp of the stomach, but is more com- monly a sensory disturbance of this nerve, due to direct irritation of the peripheral ends, or is a neuralgia of the terminal fibres. Hunger is said to be a sensation aroused by the pneumogastric, and some forms of nervous dyspepsia probably depend upon disturbed function of this nerve. The severe gastric crises which occur in locomotor ataxia are due to central irritation of the nuclei. Some describe exophthalmic goitre under lesions of the vagi. Spinal Accessory Nerve. Paralysis.—The smaller or internal part of this nerve joins the vagus and is distributed through it to the laryngeal muscles. The larger external part is distributed to the sterno-mastoid and trapezius muscles. The nuclei of the nerve, particularly of the accessory part, may he in- volved in bulbar paralysis. The nuclei of the external portion, situated as they are in the cervical cord, may be attacked in progressive degenera- tion of the motor nuclei of the cord. The nerve may be involved in the exudation of meningitis, or be compressed by tumors, or in caries. The symptoms of paralysis of the accessory portion which joins the vagus have already been given in the account of the palsy of the laryngeal branches of the pneumogastric. Disease or compression of the external portion is followed by paralysis of the sterno-mastoid and of the trapezius on the same side. In paralysis of one sterno-mastoid, the patient rotates the head with difficulty to the opposite side, hut there is no torticollis, though in some cases the head is held obliquely. As the trapezius is supplied in part from the cervical nerves, it is not completely paralyzed, but the portion which passes from the occipital bone to the acromion is functionless. The paralysis of the muscle is well seen when the patient draws a deep breath or shrugs the shoulders. The middle portion of the trapezius is also weakened, the shoulder droops a little, and the angle of the scapula is rotated inward by the action of the rhomboids and the levator anguli scapulas. Elevation of the arm is impaired, for the trapezius does not fix the scapula as a point from which the deltoid can work. In progressive muscular atrophy we sometimes see bilateral paralysis of these muscles. Thus, if the sterno-mastoids are affected, the head tends to fall back; when the trapezii are involved, it falls forward, a characteristic attitude of the head in many cases of progressive muscular DISEASES OF THE NERVOUS SYSTEM. atrophy. Gowers suggests that lesions of the accessory in difficult labor may account for those cases in which during the first year of life the child has great difficulty in holding up the head. In children this droop- ing of the head is an important symptom in cervical meningitis, the result of caries. The treatment of the condition depends much upon the cause. In the central nuclear atrophy but little can be done. In paralysis from pressure the symptoms may gradually be relieved. The paralyzed muscles should be stimulated by electricity and massage. Accessory Spasm.—(Torticollis; Wryneck.)—The forms of spasm affecting the cervical muscles are best considered here, as the muscles supplied by the accessory are chiefly, though not solely, responsible for the condition. The following forms may be described in this section: (a) Congenital Torticollis.—This condition, also known as fixed torti- collis, depends upon the shortening and atrophy of the sterno-mastoid on one side. It occurs in children and may not be noticed for several years on account of the shortness of the neck, the parents often alleging that it has only recently come on. It affects the right side almost exclusively. A remarkable circumstance in connection with it is the existence of facial asymmetry noted by Wilks, which appears to be an essential part of this congenital form. It occurred in six cases reported by Golding-Bird. In a case recently under my observation, the wryneck was not noticed until her tenth year. The muscle was divided and she seemed quite well; but as she developed the asymmetry of the face became very striking. In con- genital wryneck the sterno-mastoid is shortened, hard and firm, and in a condition of more or less advanced atrophy. This must be distinguished from the local thickening in the sterno-mastoid due to rupture, which may occur at the time of birth and produce an induration or muscle callus. Although the sterno-mastoid is almost always affected, there are rare cases in which the fibrous atrophy affects the trapezius. This form of wryneck in itself is unimportant, since it is readily relieved by tenotomy, but Golding-Bird states that the facial asymmetry persists, or indeed may, as shown by photographs in my case, become more evident With reference to the pathology of the affection, Golding-Bird concludes that the facial asymmetry and the torticollis are integral parts of one affection which has a central origin and is the counterpart in the head and neck of infan- tile paralysis with talipes in the foot. (b) Spasmodic Wryneck.—Two varieties of this spasm occur, the tonic and the clonic, which may alternate in the same case; or, as is most common, they are separate and remain so from the outset. The dis- ease is most frequent in adults and, according to Gowers, most common in females. In this country it is certainly more frequent in males. Of the eight or ten cases which came under my observation in Montreal and Philadelphia, all were males. In females it may be an hysterical manifes- tation. There may be a marked neurotic family history, but it is usually DISEASES OF THE CRANIAL NERVES. 869 impossible to fix upon any definite etiological factor. Some cases have followed cold ; others a blow. The symptoms are well defined. In the tonic form the contracted sterno-mastoid draws the occiput toward the shoulder of the affected side; the chin is raised, and the face rotated to the other shoulder. The sterno- mastoid may be affected alone or in association with the trapezius. When the latter is implicated the head is depressed still more toward the same side. In long-standing cases these muscles are prominent and very rigid. There may be some curvature of the spine, the convexity of which is toward the sound side. The cases in which the spasm is clonic are much more distressing and serious. The spasm is rarely limited to a single muscle. The sterno-mastoid is almost always involved and rotates the head so as to approximate the mastoid process to the inner end of the clavicle, turning the face to the opposite side and raising the chin. When with this the trapezius is affected, the depression of the head toward the same side is more marked. The head is drawn somewhat backward; the shoulder, too, is raised by its action. According to Gowers, the splenius is associated with the sterno-mastoid about half as frequently as the trapezius. Its ac- tion is to incline the head and rotate it slightly toward the same side. Other muscles may be involved, such as the scalenus and platysma myoides; and in rare cases the head may be rotated by the deep cervical muscles, the rectus and obliquus. There are cases in which the spasm is bilateral, causing a backward movement—the retro-collic spasm. This may be either tonic or clonic, and in extreme cases the face is horizontal and looks upward. These clonic contractions may come on without warning, or be pre- ceded for a time by irregular pains or stiffness of the neck. The jerking movements recur every few moments, and it is impossible to keep the head still for more than a minute or two. In time the muscles undergo hyper- trophy and may be distinctly larger on one side than the other. In some cases the pain is considerable; in others there is simply a feeling of fatigue. The spasms cease during sleep. Emotion, excitement, and fatigue increase them. The spasm may extend from the muscles of the neck and involve those of the face or of the arms. The disease varies much in its course. Cases occasionally get well, but the great majority of them persist, and, even if temporarily relieved, the disease frequently recurs. The affection is usually regarded as a functional neurosis, but it is possibly due to disturbance of the cortical centres pre- siding over the muscles. Treatment.—Temporary relief is sometimes obtained; a perma- nent cure is exceptional. Various drugs have been used, but rarely with benefit. Occasionally, large doses of bromide will lessen the in- tensity of the spasm. Morphia, subcutaneously, has been successful in some reported cases, but there is the great danger of establishing the morphia habit. Galvanism may be tried. Counter-irritation is probably 870 DISEASES OF THE NERVOUS SYSTEM. useless. Fixation of the head mechanically can rarely be borne by the patient. These obstinate cases fall ultimately into the hands of the sur- geon, and the operations of stretching, division, and excision of the acces- sory nerve and division of the muscles have been tried. The latter does not check the spasm, and may aggravate the symptoms. Temporary relief may follow, but, as a rule, the condition returns. In the cases of spasm of the deep-seated muscles, Keen has devised an operation for their section. (c) The nodding spasm of children may here be mentioned as involv- ing chiefly the muscles innervated by the accessory nerve. It may be a simple trick, a form of habit spasm, or a phenomenon of epilepsy (E. nu- tans), in which case it is associated with transient loss of consciousness. A similar nodding spasm may occur in older children. In women it some- times occurs as an hysterical manifestation, commonly as part of the so- called salaam convulsion. Hypoglossal Nerve. This is the motor nerve of the tongue and for most of the muscles at- tached to the hyoid bone. Its cortical centre is probably the lower part of the ascending frontal gyrus. Paralysis.—(1) Central Lesion.—The tongue is often paralyzed in hemiplegia, and the paralysis may result from a lesion of the cortex itself, or of the fibres as they pass to the medulla. It does not occur alone and will be considered with hemiplegia. There is this difference, however, be- tween the cortical and other forms, that the muscles on both sides of the tongue may be more or less affected but do not waste, nor are their elec- trical reactions disturbed. (2) Nuclear and infra-nuclear lesions of the hypoglossal result from slow progressive degeneration, as in bulbar paralysis or in locomotor ataxia, and occasionally there is acute softening from obstruction of the vessels. Trauma and lead poisoning have also been assigned as causes. The fibres may he damaged by a tumor, and at the base by meningitis; or the nerve is sometimes involved in its foramen by disease of the skull. The nuclei of both nerves are usually affected together, but may be at- tacked separately. As a result, there is loss of function in the nerve fibres and the tongue undergoes atrophy on the affected side. It is protruded toward the paralyzed side and may show fibrillary twitching. The symptoms of involvement of one hypoglossal, either at its centre or in its course, are those of unilateral paralysis and atrophy of the tongue. When protruded, it is pushed toward the affected side, and there are fi- brillary twitcliings. The atrophy is usually marked and the mucous mem- brane on the affected side is thrown into folds. Articulation is not much impaired in the unilateral affection. When the disease is bilateral, the tongue lies almost motionless in the floor of the mouth; it is atrophied, DISEASES OF THE SPINAL NERVES. 871 and cannot be protruded. Speech and mastication are extremely difficult and deglutition may be impaired. If the seat of the disease is above the nuclei, there may be little or no wasting. The condition is seen in pro- gressive bulbar paralysis and occasionally in progressive muscular atrophy. The diagnosis is readily made and the situation of the lesion can usually be determined, since when supra-nuclear there is associated hemi- plegia and no wasting of the muscles of the tongue. Nuclear disease is only occasionally unilateral; most commonly bilateral and part of a bulbar paralysis. It should be borne in mind that the fibres of the hypoglossal may be involved within the medulla after leaving their nuclei. In such a case there may be paralysis of the tongue on one side and paralysis of the limbs on the opposite side, and the tongue, when protruded, is pushed toward the sound side. Spasm.—This rare affection may be unilateral or bilateral. It is most frequently a part of some other convulsive disorder, such as epilepsy, chorea, or spasm of the facial muscles. In some cases of stuttering, spasm of the tongue precedes the explosive utterance of the words. It may oc- cur in hysteria, and is said to follow reflex irritation in the fifth nerve. The most remarkable cases are those of paroxysmal clonic spasm, in which the tongue is rapidly thrust in and out, as many as forty or fifty times a minute. In the case reported by Gowers the attacks occurred during sleep and continued for a year and a half, The spasm is usually bilateral. Wendt has reported a case in which it was unilateral. The prognosis is usually good. IV. DISEASES OF THE SPINAL NERVES. Cervical Plexus. (1) Occipito cervical Neuralgia.—This involves the nerve territory supplied by the second, the occipitalis major and minor, and the auricu- laris magnus nerves. The pains are chiefly in the back of the head and neck and in the ear. The condition may follow cold and is sometimes associated with stiffness of the neck or torticollis. Unless connected with disease of the bones or due to pressure of tumors, the outlook is usually good. There are tender points midway between the mastoid process and the spine and just above the parietal eminence, and between the sterno- mastoid and the trapezius. The affection may be due to direct pressure, in persons who carry very heavy loads on the neck. (2) Affections of the Phrenic Nerve.—Paralysis may follow a lesion in the anterior horns at the level of the third and fourth cervical nerves, or may be due to compression of the nerve by tumors or aneurism. More rarely paralysis results from neuritis. It may be part of a diphtheritic or lead palsy and is usually bilateral. 872 DISEASES OF THE NERVOUS SYSTEM. When the diaphragm is paralyzed respiration is carried on by the inter- costal and accessory muscles. When the patient is quiet and at rest little may be noticed, but the abdomen retracts in inspiration and is forced out in expiration. On exertion or even on attempting to move there may be dyspnoea. If the paralysis sets in suddenly there may be dypnoea and lividity, which is usually temporary (W. Pasteur). Intercurrent at- tacks of bronchitis seriously aggravate the condition. Difficulty in cough- ing, owing to the impossibility of drawing a full breath, adds greatly to the danger of this complication, as the mucus accumulates in the tubes. When the phrenic nerve is paralyzed on one side the paralysis may be scarcely noticeable, but careful inspection shows that the descent of the diaphragm is much less on the affected side. The diagnosis of paralysis is not always easy, particularly in women, who habitually use this muscle less than men, and in whom the dia- phragmatic breathing is less conspicuous. Immobility of the diaphragm is not uncommon, particularly in diaphragmatic pleurisy, in large effu- sions, and in extensive emphysema. The muscle itself may be degener- ated and its power impaired. Owing to the lessened action of the diaphragm, there is a tendency to accumulation of blood at the bases of the lungs, and there may be im- paired resonance and signs of oedema. As a rule, however, the paralysis is not confined to this muscle, but is part of a general neuritis or an an- terior polio-myelitis, and there are other symptoms of value in determin- ing its presence. The outlook is usually serious. Pasteur states that of fifteen cases following diphtheria, only eight recovered. The treatment is that of the neuritis or polio-myelitis with which it is associated. Hiccough.—Here may, perhaps, best be considered this remarkable symptom, caused by intermittent, sudden contraction of the diaphragm. The mechanism, however, is complex, and while the afferent impressions to the respiratory centre may be peripheral or central, the efferent are distributed through the phrenic nerve to the diaphragm, causing the intermittent spasm, and through the laryngeal branches of the vagus to the glottis, causing sudden closure as the air is rapidly inspired. Obstinate hiccough is one of the most distressing of all symptoms, and may tax to the uttermost the resources of the physician. W. Langford Symes in a recent study groups the cases into: (a) Inflammatory, seen particularly in affections of the abdominal viscera, gastritis, peritonitis, hernia, internal strangulation, appendicitis, suppurative pancreatitis, and in the severe forms of typhoid fever. (b) Irritative, as in the direct stimulus of the diaphragm in the swal- lowing of very hot substances, local disease of the oesophagus near the diaphragm, and in many conditions of gastric and intestinal disorder, more particularly those associated with flatus. (c) Specific, or, perhaps more properly, idiopathic, in which no evident causes are present. In these cases there is usually some constitutional DISEASES OF THE SPINAL NERVES. 873 taint, as gout, diabetes, or chronic Bright’s disease. I have seen several instances of obstinate hiccough in the later stages of chronic interstitial nephritis. (d) Neurotic, cases in which the primary cause is in the nervous sys- tem ; hysteria, epilepsy, shock, or cerebral tumors. Of these cases the hysterical are, perhaps, the most obstinate. The treatment is often very unsatisfactory. Sometimes in the milder forms a sudden reflex irritation will check it at once. Headers of Plato’s Symposium will remember that the physician Eryximachus recommended to Aristophanes, who had hiccough from eating too much, either to hold his breath (which for trivial forms of hiccough is very satisfactory) or to gargle with a little water; but if it still continued, “ tickle your nose with something and sneeze; and if you sneeze once or twice even the most vio- lent hiccough is sure to go.” The attack must have been of some severity, as it is stated subsequently that the hiccough did not disappear until Aristophanes had applied the sneezing., Ice, a teaspoonful of salt and lemon-juice, or salt and vinegar, or a tea- spoonful of raw spirits may be tried. When the hiccough is due to gas- tric irritation, lavage is sometimes promptly curative. In obstinate cases the various antispasmodics have been used in succession. Pilocarpine has been recommended. One has sometimes to resort to hypodermics of mor- phia, or to inhalations of chloroform. The nitrite of amyl and nitro- glycerine have been beneficial in some cases. Galvanism over the phrenic nerve, or pressure on the nerves applied between the heads of the sterno- cleido-mastoid muscles may be used. In the very severe forms all these measures may prove futile. Brachial Plexus. (1) Combined Paralysis,—The plexus may be involved in the supra- clavicular region by compression of the nerve trunks as they leave the spine, or by tumors and other morbid processes in the neck. Below the clavicle lesions are more common and result from injuries following dislo- cation or fracture, sometimes from neuritis. The most common cause of lesion of the brachial plexus is luxation of the humerus, particularly the subcoracoid form. If the dislocation is quickly reduced the symp- toms are quite transient, and disappear in a few days. In severe cases all the branches of the plexus, or only one or two, may be involved. The most serious cases are those in which the dislocation is undetected or unre- duced for some time, when the prolonged pressure on the nerves may cause complete and permanent paralysis of the arm. The muscles waste, the reaction of degeneration is present, and trophic changes in the skin are apt to occur. The medico-legal bearings of these cases are important, and may he thus briefly summarized : Direct injury, as by a fall or blow on the shoulder, resulting in great bruising of the nerves without dislocation, is 874 DISEASES OF THE NERVOUS SYSTEM. occasionally followed by complete paralysis of the arm. A dislocation may be set immediately and yet the lesion of the brachial plexus may be such as to cause permanent paralysis of the nerves. The dislocation may be reduced and the joint in subsequent movements slips out again. It has happened that by the time the surgeon sees the patient again, the damage has become irreparable. Injuries and blows on the neck may cause partial paralysis of the arm, involving the deltoid, supraspinatus, infraspinatus, biceps, brachialis an- ticus, and the supinator. The injury may occur to the child during de- livery. A primary neuritis of the brachial plexus is rare. More commonly the process is an ascending neuritis from a lesion of a peripheral branch, involving first the radial or ulnar nerves, and spreading upward to the plexus, producing gradually complete loss of power in the arm. (2) Lesions of Individual Nerves of the Plexus.—(«) Long Thoracic Nerve (Serratus Palsy).—This occurs chiefly in men. The nerve is injured in the posterior triangle of the neck, usually by direct pressure in the carrying of loads; cold may cause neuritis. It may be involved also in progressive muscular atrophy and in polio-myelitis anterior. When par- alyzed the scapula on the affected side looks winged, which results from the projection of the angle and posterior border. This is particularly noticeable when the arm is moved forward, when the serratus no longer holds the scapula against the thorax. It is a well-defined and readily recognized form of paralysis. The onset is associated with, sometimes preceded by, neuralgic pains. The course is dubious, and many months may elapse before there is any improvement. (b) Circumflex Nerve.—This supplies the deltoid and the teres minor. The nerve is apt to be involved in injuries, in dislocations, bruising by a crutch, or sometimes by extension of inflammation from the joint. Occa- sionally the paralysis arises from a pressure neuritis during an illness. As a consequence of loss of power in the deltoid, the arm cannot be raised. The wasting is usually marked and changes the shape of the shoulder. Sensation may also be impaired in the skin over the muscle. The joint may be relaxed and there may be a distinct space between the head of the humerus and the acromion. In other instances the ligaments are thick- ened, and a condition not unlike ankylosis may be produced, which is readily distinguished on moving the arm. (c) Musculo-spiral Paralysis ; Radial Paralysis.—This is one of the most common of peripheral palsies,, and results from the exposed position of the musculo-spiral nerve. It is often bruised in the use of the crutch, by injuries of the arm, blows, or fractures. It is frequently injured when a person falls asleep with the arm over the back of a chair, or by pressure of the body upon the arm when a person is sleeping on a bench or on the ground. It may be paralyzed by sudden violent contraction of the triceps. It is sometimes involved in a neuritis from cold, but this is uncommon in DISEASES OF THE SPINAL NERVES. 875 comparison with other causes. In the subcutaneous injection of ether the nerve may be accidentally struck and temporarily paralyzed. The paraly- sis of lead poisoning is the result of involvement of certain branches of this nerve. A lesion when high up involves the triceps, the brachialis anticus, and the supinator longus, as well as the extensors of the wrist and fingers. Naturally, in lesions just above the elbow the arm muscles and the supina- tor longus are spared. The most characteristic feature of the paralysis is the wrist-drop and the inability to extend the first phalanges of the fingers and thumb. In the pressure palsies the supinators are usually involved and the movements of supination cannot be accomplished. The sensa- tions may be impaired, or there may be marked tingling, but the loss of sensation is rarely so pronounced as that of motion. The affection is readily recognized, but it is sometimes difficult to say upon what it depends. The sleep and pressure palsies are, as a rule, uni- lateral and involve the supinator longus. The paralysis from lead is bi- lateral and the supinators are unaffected. Bilateral wrist-drop is a very common symptom in many forms of multiple neuritis, particularly the alcoholic; but the mode of onset and the involvement of the legs and arms are features which make the diagnosis easy. The duration and course of the musculo-spiral paralysis are very variable. The pressure pal- sies may disappear in a few days. Recovery is the rule, even when the affection lasts for many weeks. The electrical examination is of impor- tance in the prognosis, and the rules laid down under paralysis of the facial nerve hold good here. The treatment is that of neuritis. (d) Ulnar Nerve.—The motor branches supply the ulnar halves of the deep flexor of the fingers, the muscles of the little finger, the interossei, the adductor and the inner head of the short flexor of the thumb, and the ulnar flexor of the wrist. The sensory branches supply the ulnar side of the hand—two and a half fingers on the back, and one and a half fingers on the front. Paralysis may result from pressure, usually at the elbow- joint, although the nerve is here protected. Possibly the neuritis in the ulnar nerve in some cases of acute illness may be due to this cause. Gowers mentions the case of a lady who twice had ulnar neuritis after confinement. Owing to paralysis of the ulnar flexor of the wrist, the hand moves toward the radial side ; adduction of the thumb is impossible ; the first phalanges cannot be flexed, and the others cannot be extended. In long-standing cases the first phalanges are overextended and the others strongly flexed, producing the claw-hand; hut this is not so marked as in the progressive muscular atrophy. The loss of sensation corresponds to the sensory dis- tribution just mentioned. (e) Median Nerve.—This supplies the flexors of the fingers except the ulnar half of the deep flexors, the abductor and the flexors of the thumb, the two radial lumbricales, the pronators, and the radial flexor of the wrist. 876 DISEASES OF THE NERVOUS SYSTEM. The sensory fibres supply the radial side of the palm and the front of the thumb, the first two fingers and half the third finger, and the dorsal sur- faces of the same three fingers. This nerve is seldom involved alone. Paralysis results from injury and occasionally from neuritis. The signs are inability to pronate the forearm beyond the mid-position. The wrist can only be flexed toward the ulnar side; the thumb cannot be opposed to the tips of fingers. The second phalanges cannot be flexed on the first; the distal phalanges of the first and second fingers cannot be flexed; but in the third and fourth fingers this action can be performed by the ulnar half of the flexor pro- fundus. The loss of sensation is in the region corresponding to the sensory distribution already mentioned. The wasting of the thumb muscles, which is usually marked in this paralysis, gives to it a characteristic appearance. Lumbar and Sacral Plexuses. The lumbar plexus is sometimes involved in growths of the lymph glands, in psoas abscess, and in disease of the bones of the vertebrae. Of its branches the obturator nerve is occasionally injured during parturi- tion When paralyzed the power is lost over the adductors of the thigh and one leg cannot be crossed over the other. Outward rotation is also disturbed. The anterior crural nerve is sometimes involved in wounds or in dislocation of the hip-joint, less commonly during parturition, and sometimes by disease of the bones and in psoas abscess. The special symptoms of affection of this nerve are paralysis of the extensors of the knee with wasting of the muscles, anaesthesia of the antero-lateral parts of thigh and of the inner side of the leg to the big toe. This nerve is some- times involved early in growths about the spine, and there may be pain in its area of distribution. Loss of the power of abducting the thigh results from paralysis of the gluteal nerve, which is distributed to the gluteus, medius, and minimus muscles. The sacral plexus is frequently involved in tumors and inflammations within the pelvis and may be injured during parturition. Neuritis is common, usually an extension from the sciatic nerve. Of the branches, the sciatic nerve, when injured at or near the notch, causes paralysis of the flexors of the legs and the muscles below the knee, but injury below the middle of the thigh involves only the latter muscles. There is also anaesthesia of the outer half of the leg, the sole, and the greater portion of the dorsum of the foot. Wasting of the muscles frequently follows, and there may be trophic disturbances. In paralysis of one sciatic the leg is fixed at the knee by the action of the quadriceps extensor and the patient is able to walk. Paralysis of the small sciatic nerve is rarely seen. The gluteus maximus is involved and there may be difficulty in rising from a seat. There is a strip of anaesthesia along the back of the middle third of the thigh. DISEASES OF THE SPINAL NERVES. 877 External Popliteal Nerve.—Paralysis involves the peronaei, the long ex- tensor of the toes, tibialis anticus, and the extensor brevis digitoruni. The ankle cannot be flexed, resulting in a condition known as foot-drop, and as the toes cannot be raised the whole leg must be lifted, producing the characteristic steppage gait seen in so many forms of peripheral neu- ritis. In long-standing cases the foot is permanently extended and there is wasting of the anterior tibial and peroneal muscles. The loss of sensa- tion is in the outer half of the front of the leg and on the dorsum of the foot. Internal Popliteal Nerve.—When paralyzed plantar flexion of the foot and flexion of the toes are impossible. The foot cannot be adducted, nor can the patient rise on tiptoe. In long-standing cases talipes calcaneus follows and the toes assume a claw-like position from secondary contract- ure, due to overextension of the proximal and flexion of the second and third phalanges. Sciatica. This is, as a rule, a neuritis either of the sciatic nerve or of its cords of origin. It may in some instances be a functional neurosis or neuralgia. it occurs most commonly in adult males. A history of rheumatism or of gout is present in many cases. Exposure to cold, particularly after heavy muscular exertion, or a severe wetting are not uncommon causes. Within the pelvis the nerves may be compressed by large ovarian or uterine tumors, by lymphadenomata, by the foetal head during labor, and occasionally lesions of the hip-joint induce a secondary sciatica. The con- dition of the nerve has been examined in a few cases, and it has often been seen in the operation of stretching. It is, as a rule, swollen, red- dened, and in a condition of interstitial neuritis. The affection may be most intense at the sciatic notch or in the nerve about the middle of the thigh. Of the symptoms, pain is the most constant and troublesome. The onset may be severe, with slight pyrexia, but, as a rule, it is gradual, and for a time there is only slight pain in the back of the thigh, particularly in certain positions or after exertion. Soon the pain becomes more intense, and instead of being limited to the upper portion of the nerve, extends down the thigh, reaching the foot and radiating over the entire distribution of the nerve. The patient can often point out the most sen- sitive spots, usually at the notch or in the middle of the thigh; and on pressure these are exquisitely painful. The pain is described as gnawing or burning, and is usually constant, but in some instances is paroxysmal, and often worse at night. On walking it may be very great; the knee is bent and the patient treads on the toes, so as to relieve the tension on the nerve. In protracted cases there is wasting of the muscles, but the reaction of degeneration can seldom be obtained. In these chronic cases cramp may occur and fibrillar contractions. Herpes may develop, but this is un- 878 DISEASES OF THE NERVOUS SYSTEM. usual. In rare instances the neuritis ascends and involves the spinal cord. The chi ration and course are extremely variable. As a rule it is an obstinate affection, lasting for months, or even, with slight remissions, for years. Relapses are not uncommon, and the disease may be relieved in one nerve only to appear in the other. In the severer forms the patient is bedridden, and such cases prove among the most distressing and trying which the physician is called upon to treat. In the diagnosis it is important, in the first place, to determine whether the disease is primary, or secondary to some affection of the pelvis or of the spinal cord. A careful rectal examination should be made, and, in women, pelvic tumor should be excluded. Lumbago may be confounded with it. Affections of the hip-joint are easily distinguished by the absence of tenderness in the course of the nerve and the sense of pain on movement of the hip-joint or on pressure in the region of the tro- chanter. There are instances of sacro-iliac disease in which the patient complains of pain in the upper part of the thigh, which may sometimes radiate; but careful examination will readily distinguish between the affections. Pressure on the nerve trunks of the cauda equina, as a rule, causes bilateral pain and disturbances of sensation, and, as double sciatica is rare, these circumstances always suggest lesion of the nerve roots. Be- tween the severe lightning pains of tabes and sciatica the differences are usually well defined. Treatment.—The pelvic organs should be carefully and systemati- cally examined. Constitutional conditions, such as rheumatism and gout, should receive appropriate treatment. In a few cases with pronounced rheumatic history, which come on acutely with fever, the salicylates seem to do good. In other instances they are quite useless. If there is a sus- picion of syphilis the iodide of potassium should be employed, and in gouty cases salines. Rest in bed with fixation of the limb by means of a long splint is a most valuable method of treatment in many cases, one upon which Weir Mitchell has specially insisted. I have known it to relieve, and in some instances to cure, obstinate and protracted cases which had resisted all other treatment. Hydrotherapy is sometimes satisfactory, particularly the warm baths or the mud baths. Many cases are relieved by a prolonged residence at one of the thermal springs. Antipyrin, antifebrin, and quinine, are of doubtful benefit. Local applications are more beneficial. The hot iron or the thermo- cautery or blisters relieve the pain temporarily. Deep injections into the nerves give great relief and may be necessary for the pain. It is best to use cocaine at first, in doses of from an eighth to a quarter of a grain. If the pain is unbearable morphia may be used, but it is a dangerous remedy in sciatica and should be withheld as long as possible. The disease is so protracted, so liable to relapse, and the patient’s morale so undermined by DISEASES OF THE SPINAL NERVES. 879 the constant worry and the sleepless nights, that the danger of contract- ing the morphia habit is very great. On no consideration should the patient be permitted to use the hypodermic needle himself. It is remark- able how promptly, in some cases, the injection of distilled water into the nerve will relieve the pain. Acupuncture may also be tried; the needles should be thrust deeply into the most painful spot for a distance of about two inches, and left for from fifteen to twenty minutes. The injection of chloroform into the nerve has also been recommended. Electricity is an uncertain remedy. Sometimes it gives prompt relief; in other cases it may be used for weeks without the slightest benefit. It is most serviceable in the chronic cases in which there is wasting of the legs, and should be combined with massage. The galvanic current should be used; a flat electrode should be placed over the sciatic notch, and a smaller one used along the course of the nerve and its branches. In very obstinate cases nerve-stretching may be employed. It is sometimes suc- cessful ; but in other instances the condition recurs and is as bad as ever. III. DISEASES OF THE SPIHAL COED. I. TOPICAL DIAGNOSIS. We have seen that a lesion involving a definite part of the gray matter of the lower motor segment is accompanied by loss of the power to per- form certain definite movements. A disease, such as anterior polio-mye- litis, which is confined to the gray matter gives as its only symptom a characteristic lower-segment paralysis. The muscles paralyzed reveal the seat of the lesion. In many instances a transverse section of the spinal cord is involved to a greater or less extent; if complete, there is lower-seg- ment paralysis at the level of the lesion. If the muscles so paralyzed are the same on the two sides of the body, the lesion is strictly transverse, for, obviously, if the cord is involved higher on one side than on the other the paralyzed muscles will vary accordingly. Besides the paralysis due to involvement of the lower segment, the muscles whose centres are below the lesion may also be paralyzed by the involvement of the upper segment in the pyramidal tract, and present all the characteristics of such a paraly- sis. The degree of the paralysis depends upon the intensity of the lesion of the pyramidal tract, and varies from a slight weakness in the flexion of the ankle to an absolute paralysis of all the muscles below the lesion. The sphincter muscles of the bladder and rectum are also often paralyzed. Sensory symptoms are usually not as prominent as the motor symp- toms, but ydien the spinal cord is much diseased there is a dulling of sen- sation all over the body below the lesion. The upper border of disturbed sensation often indicates the level of the disease, especially when this is in the dorsal region, where the corresponding motor paralysis is not easy to demonstrate. It is to be noted that the anaesthesia does not reach quite 880 DISEASES OF THE NERVOUS SYSTEM. to the level of the lesion ; thus if the fifth dorsal segment is involved, the anaesthesia will include the area supplied by the sixth segment, but not that supplied by the fifth. This is due to the overlapping of the areas. There is often a narrow zone of hyperaesthesia above the anaesthetic region. When the transverse lesion is complete and the lower part of the cord is cut off from all influence from above, there is complete sensory and motor paralysis, and the deep reflexes instead of being exaggerated are lost. The different reflexes are dependent upon different levels of the cord (see Starr’s table), and their absence or presence may be important localiz- ing symptoms. Unilateral Lesions.—The motor symptoms which follow lesions con- fined to one half of the cross-section of the spinal cord follow the same rules as those given for transverse lesions, except that they are confined to one side of the body—that is, they are on the same side as the lesion. The sensory symptoms are peculiar. On the side corresponding to the disease—the paralyzed side—there is anaesthesia corresponding to the seg- ment of the cord involved ; above this there is a narrow zone of hyperaes- thesia, but below this there is no diminution in the senses of touch, pain, or temperature; indeed, there is often hyperaesthesia. The muscular sense, however, is impaired. On the side opposite to the lesion there may be complete loss of the sense of touch, pain, and temperature, or it may only involve one or two of these, pain and temperature usually being associated. The following table, slightly modified from Gowers, illustrates the dis- tribution of these symptoms in a complete hemi-lesion of the cord : Cord. Zone of cutaneous hyperesthesia. Zone of cutaneous anesthesia. Lower segment paralysis. Lesion. Upper segment paralysis. Hyperesthesia of skin. Muscular sense impaired. Reflex action first lessened and then increased. Temperature raised. Muscular power normal. Loss of sensibility of skin. Muscular sense normal. Reflex action normal. Temperature same as that above- lesion. It is only in exceptional cases that all these features are met with, for they vary with its extent and intensity. This combination of symptoms was first recognized by Brown-Sequard, after whom it has been named. It may follow tumors, stab-wounds, frac- ture and caries of the spine, and it is not infrequently associated with, syringo-myelia and hgemorrhages into the cord. The explanation of the disturbance in sensation is not satisfactory, and cannot be until our knowledge of the paths of sensory conduction is more accurate. These cases have convinced most clinicians that in man the paths for touch, pain, and temperature cross the middle line soon after entering the spinal cord, and proceed toward the brain in the opposite side, while that for muscular sense remains in the posterior columns of AFFECTIONS OF THE MENINGES. 881 the same side. We have seen (page 825) that anatomy lends some sup- port to this view, and this is the explanation that is usually given. The experiments on animals have thrown some doubt on this view, especially those of Mott on monkeys, which seem to indicate that the sensory paths for the most part remain on the same side of the cord. Systemic Degeneration.—The long tracts of the cord sometimes under- go degeneration. This is nearly always secondary to some lesion, either above, causing degeneration in the pyramidal tracts (descending degenera- tion), or below, causing degeneration in the posterior columns, the direct cerebellar and the antero-lateral ascending tracts (ascending degeneration). Lesions affecting the spinal ganglia or posterior spinal roots cause ascend- ing degeneration confined to the posterior columns of the spinal cord. Secondary degeneration in the pyramidal tracts is believed to cause, or at any rate to accompany, the symptoms which give to the upper-segment paralysis its special characteristics. These are increased muscular tension and exaggerated tendon reflexes (the spastic condition). Therefore, when this spastic condition is present we assume that the pyramidal tracts are degenerated, and in certain cases in which there are no other symptoms it is believed by some observers that the disease consists in a primary de- generation of the tracts (primary lateral sclerosis). Ascending secondary degeneration gives no symptoms by which we can determine its presence, but disease involving the posterior columns is often associated with anaesthesia and muscular inco-ordination (ataxia). We not infrequently have ataxia combined with the spastic condition, due to in- volvement of both the posterior and lateral columns (combined sclerosis). II. AFFECTIONS OF THE MENINGES. Diseases' of the Dura Mater. Pachymeningitis.—The dura mater of the cord is separated by a loose connective tissue from the bony canal in which it lies, and an inflamma- tion may involve either its outer or its inner aspect; hence the division into pachymeningitis externa and interna. {a) Pachymeningitis Externa.—This is invariably a secondary inflam- mation and is occasionally met with in an acute form in caries, in syphi- litic affections of the bone, in tumors, or in aneurism. Abscess may pene- trate the spinal canal, or the inflammation may even extend to the peri- dural tissue in long-standing decubitus. The symptoms are usually those of a compression myelitis. The chronic form of external pachymeningitis, also a secondary affec- tion, is much more common. It is a constant accompaniment of tuber- culous disease of the spine and plays a very important part in the produc- tion of the symptoms. The affection may be confined to the part in immediate connection with the local disease, but in some cases the sub- dural space over six or eight vertebrae is occupied by caseous masses. 882 DISEASES OF THE NERVOUS SYSTEM. The cord at the site of the curvature in Pott’s disease may be compressed, with perhaps little or no involvement of the pia mater. The internal sur- face of the dura may be perfectly smooth, perhaps a little adherent to the arachnoid, while the external dura is thickened, rough, and covered with a cheesy substance of a variable degree of consistence. In some instances the dura is completely surrounded by this material; in others it is chiefly on the anterior surface. We can understand the recovery in cases of com- pression paraplegia if we bear in mind that in large part the actual com- pression is produced by this material between the diseased vertebrae and the dura mater. The symptoms are those of myelitis from compression, often with signs of involvement of the nerve roots, such as will be men- tioned in the next section. (b) Pachymeningitis interna, described by Charcot and Joffroy, in- volves chiefly the cervical region (P. cervicalis hypertrophied). The interspace between the cord and the dura is occupied by a firm, concen- trically arranged, fibrinous growth, which is seen to have developed within, not outside of, the dura mater. It is a condition anatomically identical with the haemorrhagic pachymeningitis interna of the brain. The cord is usually compressed ; the central canal may be dilated—hydromyelus— and there are secondary degenerations. The nerve roots are involved in the growth and are damaged and compressed. The extent is variable. It may be limited to one segment, but more commonly involves a con- siderable portion of the cervical enlargement. The disease is chronic, and in some cases presents a characteristic group of symptoms. There are intense neuralgic pains in the course of the nerves whose roots are involved. They are chiefly in the arms and in the cervical region, and vary greatly in intensity. There may be hypersestliesia with numbness and tingling; atrophic changes may develop, and there may be areas of anaes- thesia. Gradually motor disturbances appear; the arms become weak and the muscles atrophied, particularly in certain groups, as the flexors of the hand. The extensors, on the other hand, remain intact, so that the con- dition of claw-hand is gradually produced. The grade of the atrophy depends much upon the extent of involvement of the cervical nerve roots, and in many cases the atrophy of the muscles of the shoulders and arms becomes extreme. The condition is one of cervical paraplegia, with con- tractures, flexion of the wrist, and typical main en griffe. Usually before the arms are greatly atrophied there are the symptoms of what the French writers term the second stage—namely, involvement of the lower extremi- ties and the gradual production of a spastic paraplegia, which may develop several months after the onset of the disease, and is due to secondary changes in the cord. The disease runs a chronic course, lasting, perhaps, two or more years. In a few instances, in which symptoms pointed definitely to this condition, recovery has taken place. The disease is to be distinguished from amyo- trophic lateral sclerosis, syringomyelia, and tumors. From the first it is AFFECTIONS OF THE MENINGES. 883 separated by the marked severity of the initial pains in the neck and arms; from the second by the absence of the sensory changes characteristic of syringomyelia. From certain tumors it is very difficult to distinguish, as, in fact, the fibrinous layers form a tumor around the cord. The condition known as Jicematoma of the dura mater may occur at any part of the cord, or, in its slow, progressive form—pachymeningitis haemorrhagica interna—may be limited to the cervical region and produce the symptoms just mentioned. It is sometimes extensive, and may coexist with a similar condition of the cerebral dura. Cysts may occur filled with haemorrhagic contents. Diseases of the Pia Mater. (a) Acute Spinal Meningitis; Leptomeningitis. Etiology.—Spinal meningitis occurs : (1) In tuberculosis. This is perhaps the most common form in general practice and has already been considered. (2) In specific cerebro-spinal meningitis, which occurs en- demically or epidemically, and has also been considered under its appro- priate section. (3) As a secondary involvement in certain infectious dis- eases, pneumonia, small-pox, scarlet fever, and typhoid fever. This form is very rare Even in pneumonia, in which the cerebral meninges are frequently involved, the spinal meninges are seldom affected, except per- haps in the first two or three inches of the cervical region. (4) From in- jury or the extension of inflammation, as after operation on spina bifida. (5) There are cases in which the meningitis appears to have followed ex- posure to cold and wet. Morbid Anatomy.—The affection may be diffused over the entire cord or localized to the cervical region. In the early stage the vessels of the pia mater are injected. The fluid in the pia-arachnoid space is slightly turbid. In some intense grades, on opening the dura the contour of the cord cannot be seen, as it is completely enveloped in a sero-fibrin- ous or purulent exudate, which here and there causes bulging of the arachnoid. Owing to the position of the body, the exudate is most abundant in the posterior part, or sinks to the lumbar region. In acute cases the pia itself does not look thickened, but in more chronic forms the membrane may be grayish and turbid. In a majority of in- stances, if the inflammation is intense, the exudate is seen in the anterior and posterior median fissures and the cortical portion of the cord is swollen and infiltrated, so the condition can be properly called meningo- myelitis. The affection may be limited to the spinal meninges, but in a majority of instances it is a cerebro-spinal lesion. Symptoms.—These have already been referred to in considering the two commonest varieties, the tuberculous and the epidemic. The disease often sets in with a chill and fever. Pain in the back, stiffness in the neck, pain on pressure along the vertebrae, tremor or spasm of the muscles, and disturbances of sensation are usually present. Girdle sensations are 884 DISEASES OF THE NERVOUS SYSTEM. not common. The reflexes may be increased. Later, paralytic symptoms may develop, but they are uncommon, except in pure spinal meningitis. The diagnosis is often difficult. In a large proportion of the cases supposed to be spinal meningitis the membranes are not inflamed. I have already referred to the identity of the spinal symptoms in certain of the infectious diseases with those of acute leptomeningitis. In the case of a patient with high fever, marked stiffness of the back and neck muscles, or opisthotonus with rigidity and tremor of the muscles, it is not unnatural to make a positive diagnosis of spinal meningitis, but every symptom of the condition may be present without any inflammatory exudate. The truth of Stoke’s dictum, already quoted (p. 26), has been brought home to me on many occasions. On the other hand, there are instances of well-marked leptomeningitis, more particularly the cerebro-spinal form, in which spinal symptoms are trifling or absent. To distinguish between the different forms of spinal meningitis is sometimes extremely difficult. A correct diagnosis is oftenest made in tuberculous cases, since here the prodromes are well defined and the symptoms indicative of involvement of the cerebral meninges well marked. There are cases in which the spinal meninges bear the brunt of the affection. I have already referred to one case in which the meningitis was thought to be due to trauma- tism. The coexistence of disease at the apex of the lungs or of local tuberculous lesions elsewhere, as in a testis, is of great value. The diagnosis of the epidemic form has already been considered. (b) Chronic Leptomeningitis.—As a primary lesion this is extremely rare. It sometimes follows the prolonged use of alcohol. It occurs in connection with syphilis, trauma, and as a complication of various scle- roses of the spinal cord, either systemic or insular. Anatomically the condition is characterized by a thickening and tur- bidity of the pia, often with adhesions to the arachnoid and the dura. The membranes may be stained with blood-pigment. These alterations may occur in localized spots or over extensive areas. The nerve roots may be involved and thickened. The spinal cord itself is rarely affected, though strands of connective tissue may extend into the cortical zone, producing slight sclerosis. The opaque, white, cartilaginous plates which occur so often on the posterior surface of the spinal arachnoid and are sometimes adherent to the pia cause no symptoms and are not to be mis- taken for this chronic meningitis. The symptoms of this form are indefinite. Simple thickening of the meninges may produce no signs during life unless the spinal nerve roots are involved. In any case the diagnosis is somewhat doubtful. There are instances in which pain in the back, stiffness of the dorsal muscles, and pains radiating in the nerves of the trunk or in the extremities have been marked. Ilyperaesthesia and skin eruptions may be present. When the cord is involved paralytic symptoms may develop. The reflexes are increased. The course is always chronic, lasting for many years. The treatment is purely symptomatic. Recovery probably never occurs. AFFECTIONS OF THE MENINGES. 885 Haemorrhage into the Spinal Membranes; HaEmatorriiachis. In meningeal apoplexy, as it is called, the blood may be between the dura mater and the spinal canal—extra-meningeal haemorrhage—or within the dura mater—intra-meningeal haemorrhage. (a) Extra-meningeal Hcemorrhage occurs usually as a result of trauma. The exudation may be extensive without compression of the cord. The blood comes from the large plexuses of veins which surround the dura. The rupture of an aneurism into the spinal canal may produce extensive and rapidly fatal haemorrhage. (b) Intra-menmgeal Hcemorrhage is rather more common, but is rarely extensive from causes acting directly on the spinal meninges themselves. Scattered haemorrhages are not unfrequent in the acute infectious fevers, and I have twice, in malignant small-pox, seen much effusion. Bleeding occurs also in death from convulsive disorders, such as epilepsy, tetanus, and strychnia poisoning. The most extensive haemorrhages occur in cases in which the blood comes from rupture of an aneurism at the base of the brain, either of the basilar or vertebral. In several cases of this kind I have found a large amount of blood in the spinal meninges. In ventricular apoplexy the blood may pass from the fourth ventricle into the spinal meninges. There is a specimen in the medical museum of McGill College of the most extensive intraventricular haemorrhage, in which the blood passed into the fourth ventricle, and descended beneath the spinal arach- noid for a considerable distance. On the other hand, haemorrhage into the spinal meninges may possibly ascend into the brain. The symptoms in moderate grades may be slight and indefinite. In the non-traumatic cases the haemorrhage may either come on suddenly or after a day or two of uneasy sensations along the spine. As a rule, the onset is abrupt, with sharp pain in the back and symptoms of irritation in the course of the nerves. There may be muscular spasms, or paralysis may come on suddenly, either in the legs alone or both in the legs and arms. In some instances the paralysis develops more slowly and is not complete. There is no loss of consciousness, and there are no signs of cerebral dis- turbance. The clinical picture naturally varies Avith the site of the haemor- rhage. If in the lumbar region, the legs alone are involved, the reflexes may be abolished, and the action of the bladder and rectum is impaired. If in the dorsal region, there is more or less complete paraplegia, the reflexes are usually retained, and there are signs of disturbance in the thoracic nerves, such as girdle sensations, pains, and sometimes eruption of herpes. In the cervical region the arms as well as the legs may be involved; there may be difficulty in breathing, stiffness of the muscles of the neck, and occa- sionally pupillary symptoms. The prognosis depends much upon the cause of the haemorrhage. Recovery may take place in the traumatic cases, and in those associated with the infectious diseases. 886 DISEASES OF THE NERVOUS SYSTEM. III. AFFECTIONS OF THE BLOOD-VESSELS. («) Congestion.—Apart from actual myelitis, we rarely see post mor- tem evidences of congestion of the spinal cord, and when we do it is usu- ally limited either to the gray matter or to a definite portion of the organ. There is necessarily, from the posture of the body post mortem, a greater degree of vascularity in the posterior portion of the cord. The white mat- ter is rarely found congested, even when inflamed; in fact, it is remarka- ble how uniformly pale this portion of the cord is. The gray matter often has a reddish-pink tint, but rarely a deep reddish hue, except when mye- litis is present. If we know little anatomically of conditions of conges- tion of the cord, we know less clinically, for there are no features in any way characteristic of it. (b) Anaemia.—So, too, with this state. There may be extreme grades of anaemia of the cord without symptoms. In chlorosis and pernicious anaemia there are rarely symptoms pointing to the cord, and there is no reason to suppose that such sensations as heaviness in the limbs and tin- gling are especially associated with anaemia. There are, however, some very interesting facts with reference to the profound anaemia of the cord which follows ligature of the aorta. In ex- periments made in Welch’s laboratory by Ilerter, it was found that within a few moments after the application of the ligature to the aorta paraplegia came on. Paralysis of of the sphincters developed, but less rapidly. This condition is of interest in connection with the fact of the rapid develop- ment of a paraplegia after profuse haemorrhage, usually from the stomach or uterus. It may come on at once or at the end of a week or ten days, and is probably due to an anatomical change in the nerve elements simi- lar to that produced in Herter’s experiments. In this connection may be mentioned the interesting observations of Lichtheim npon the degeneration of the posterior columns of the cord in pernicious anaemia, of which he has reported three cases. The question is one to which much attention has been paid recently, and the observations of Minick, Nonne, and Burr show that the change is very common; thus, in seven of the cases examined by Burr the cord was normal in only one. The posterior columns may be affected alone, or with the lateral columns. Lichtheim regards it as a form of toxic myelitis, due to the altered condi- tion of the blood. (c) Embolism and Thrombosis.—Blocking of the spinal arteries by em- boli rarely occurs. It may be produced experimentally, and Money found that it was associated with choreiform movements. Thrombosis of the smaller vessels in connection with endarteritis plays an important part in many of the acute and chronic changes in the cord. (d) Endarteritis.—It is remarkable how frequently in persons over fifty the arteries of the spinal cord are found sclerotic. The following forms may be met with : (1) A nodular peri-arteritis or endarteritis associated AFFECTIONS OF THE BLOOD-VESSELS. 887 with syphilis and sometimes with gummata of the meninges; (2) an arter- itis obliterans, with great thickening of the intima and narrowing of the lumen of the vessels, involving chiefly the medium and larger-sized arteries. Miliary aneurisms or aneurisms of the larger vessels are rarely found in the spinal cord. In the classical work of Leyden hut a single instance of the latter is mentioned. (e) Haemorrhage into the Spinal Cord (Hcematomyelia).—The existence of a primary haemorrhage into the cord has been denied on the ground that in all instances it is preceded by a condition of softening. A majority of authors, however, admit the existence of a primary form. About forty- two cases are on record, which are collected in the thesis of Ilayem * and in the article of Berkeley.! It is more common in males than in females, and at the middle period of life. The cases have followed either cold and exposure or overexertion, and, most frequently of all, traumatism. It oc- curs also in tetanus and convulsions. Haemorrhage may be associated with tumors, with syringo-myelia, or with myelitis; it is often difficult to de- termine whether the case is one of primary haemorrhage with myelitis, or myelitis with a secondary haemorrhage. The anatomical condition is very varied. The cord may be enlarged at the site of the haemorrhage, and occasionally the white substance may he lacerated and blood may escape beneath the meninges. The extravasa- tion is chiefly in the gray matter, and may be limited or focal, or very diffuse, extending a considerable distance in the cord. In a case which occurred at the Montreal General Hospital under Wilkins the haemorrhage occupied a position opposite the region of the fifth and sixth cervical nerves and on transverse section the cord was occupied by a dark-red clot measuring twelve by five millimetres, around which the white substance formed a thin, ragged wall. The clot could be traced upward as far as the second cervical, and downward as far as the fourth dorsal. The sudden onset of the symptoms is the most characteristic feature in haematomyelia. The loss of power necessarily varies with the locality affected. If in the cervical region, both arms and legs may be involved; but if in the dorsal or lumbar, there is only paraplegia. There is usually loss of sensation, and at first loss of reflexes. Myelitis frequently develops and becomes extensive, with fever and trophic changes. The condition may rapidly prove fatal; in other instances there is gradual recovery, often with partial paralysis. The diagnosis may be made in some instances, particularly those in which the onset is sudden after injury, but there is great difficulty in dif- ferentiating haemorrhagic myelitis from certain cases of haemorrhage into the spinal meninges. The question of diagnosis has been carefully consid- ered by Hoch J in a recent report of two cases from my clinic. * Paris, 1872. f Brain, 1889. | Johns Hopkins Hospital Reports, vol. ii, fasciculus 6. 888 DISEASES OF THE NERVOUS SYSTEM. (/) Caisson Disease; Diver’s Paralysis.—This remarkable affection, found in divers and in workers in caissons, is characterized by a paraplegia, more rarely a general palsy, which supervenes on returning from the com- pressed atmosphere to the surface. The disease has been carefully studied by the French writers, by Ley- den and Schultze in Germany, and in this country particularly by A. If. Smith. The pressure must be more than that of three atmospheres. The symptoms are especially apt to come on if the change from the high to the ordinary atmospheric pressure is quickly made. They may supervene immediately on leaving the caisson, or they may be delayed for several hours. In the mildest form there are simply pains about the knees and in the legs, often of great severity, and occurring in paroxysms. Abdominal pain and vomiting are not uncommon. The legs may be tender to the touch, and the patient may walk with a stiff gait. Dizziness and headache may accompany these neuralgic symptoms, or may occur alone. More commonly in the severe form there is paralysis both of motion and sen- sation, usually a paraplegia, but it may be general, involving the trunk and arms. Monoplegia and hemiplegia are rare. In the most extreme instances the attacks resemble apoplexy, and the patient rapidly becomes comatose and death occurs in a few hours. In the cases of paraplegia the outlook is usually good, and the paralysis may pass off in a day, or may continue for several weeks or even for months. Identical features are met with in the deep-sea divers. The explanation of this condition is by no means satisfactory. Several careful autopsies have been made. In Leyden’s case death occurred on the fifteenth day, and in the dorsal portion of the cord there were numer- ous foci of haemorrhages and signs of an acute myelitis. In Scliultze’s case death occurred in two and a half months, and a disseminated myelitis was found in the dorsal region. In both cases there were fissures, and appearances as if tissue had been lacerated. In a case examined on the third day (Ziegler’s Beitrage, 1892) this condition of Assuring and lacera- tion was found. It has been suggested that the symptoms are due to the liberation in the spinal cord of bubbles of nitrogen which have been ab- sorbed by the blood under the high pressure, and the condition found at the autopsies just referred to is held to favor this view. A large majority of the cases recover. The severe neuralgic pains often require morphia. Inhalations of oxygen and the use of compressed air have been advised. When paraplegia develops the treatment is simi- lar to that of other forms. In all caisson work care should be exercised that the time in passing through the lock from the high to the ordinary pressure be sufficiently prolonged. According to A. H. Smith, at least five minutes should be allowed for each additional atmosphere of pressure. ACUTE AFFECTIONS OF TIIE SPINAL CORD. 889 IV. ACUTE AFFECTIONS OF THE SPINAL CORD (1) Acute Myelitis, Etiology.—Acute myelitis results from many causes, and may affect the cord in a limited or extended portion—the gray matter chiefly, or the gray and white matter together. It is met with : (a) As an independent affection following exposure to cold, or exertion, and leading to rapid loss of power with the symptoms of an acute ascending paralysis, (b) As a sequel of the infectious diseases, such as small-pox, typhus, and measles. (c) As a result of traumatism, either fracture of the spine or very severe muscular effort. Concussion without fracture may produce it, but this is rare. Acute myelitis, for instance, scarcely ever follows railway accidents. (d) In disease of the bones of the spine, either caries or cancer. This is a more common cause of localized acute transverse myelitis than of the diffuse affection. (e) In disease of the cord itself, such as tumors and syphilis; in the latter, either in association with gummata, in which case it is usually a late manifestation, or it may follow within a year or eighteen months of the primary affection.* Morbid Anatomy.—In localized acute myelitis affecting white and gray matter, as met with after accident or an acute compression, the cord is swollen, the pia injected, the consistence greatly reduced, and on incising the membrane an almost diffluent fluid may escape. In less intense grades, on section at the affected area, all trace of distinction between the gray and white matter is lost, or extremely indistinct. The tissue may be in- jected, or, as is often the case, hgemorrhagic. It is particularly in these forms, due to extension of disease from without or to acute compression, that we find definite involvement of the white matter. In other instances the gray matter is chiefly affected. There may be localized areas through- out the cord in which the gray matter is reduced in consistence and hgemorrhagic, the so-called red softening. There may be definite cavity formations in these foci. In some cases of disseminated or focal myelitis the meninges also are involved and there is a myelo-meningitis. And, lastly, there are instances in which, throughout a long section of the cord, sometimes through the lumbar and the greater part of the dorsal, or in the dorsal and cervical regions, there is a diffuse myelitis of the gray sub- stance. Histologically the nerve fibres are much swollen and irregularly dis- torted, the axis cylinders are beaded, the myelin droplets are abundant, and the laminated bodies known as corpora amylacea may be seen. The granular fatty cells are also numerous and there may be leucocytes and red blood-corpuscles. Changes in the blood-vessels are striking; the smaller veins are distended and may show varicosities. The perivascular * Breteau, Des Maladies Syphilitiques Precoces, Paris Thesis, 1889. 890 DISEASES OF THE NERVOUS SYSTEM. lymph spaces contain numerous leucocytes, and the smaller arteries them- selves are frequently the seat of hyaline thrombi. The ganglion cells are swollen and irregular in outline, the protoplasm is extremely granu- lar and vacuolated, and the nuclei, though usually invisible, may show signs of division, and the processes of the cells are not seen. In cases which persist for some time we have an opportunity of seeing the later stages of acute myelitis. The acute, inflammatory, hypersemic or red softening is succeeded by stages in which the affected area becomes more yellow from gradual alteration of the blood-pigment, and finally white in color from the advancing fatty degeneration. In cases of com- pression myelitis, a sclerosis may gradually be produced with the anatom- ical picture of a chronic diffuse myelitis. Symptoms.—(a) Acute Central Myelitis.—It is this form which conies on spontaneously after cold, or in connection with syphilis or one of the infectious diseases, or is seen in a typical manner in the extension from injuries or from tumor. The onset, though scarcely so abrupt as in haemorrhage, may be sudden; a person may be attacked on the street and have difficulty in getting home. In some instances, the onset is preceded by pains in the legs or back, or a girdle sensation is present. It may be marked by chills, occasionally by convulsions; fever is usually present from the beginning—at first slight, but subsequently it may become high. The motor functions are rapidly lost, sometimes as quickly as in Lan- dry’s ascending paralysis. The paraplegia may be complete, and, if the myelitis extends to the cervical region, there may be impairment of mo- tion, and ultimately complete loss of power of the upper extremities as well. The sensation is lost, but there may at first be hyperaesthesia. The reflexes in the initial stage are increased, but in acute central myelitis, un- less limited in extent to the dorsal and cervical regions, the reflexes are usually abolished. The rectum and bladder are paralyzed. Trophic dis- turbances are marked; the muscles waste rapidly; the skin is often con- gested, and there may be localized sweating. The temperature of the affected limbs may be lowered. Acute bed-sores may develop over the sacrum or on the heels, and sometimes a multiple arthritis is present. In these acute cases the general symptoms become greatly aggravated, the pulse is rapid, the tongue becomes dry; there is delirium, the fever in- creases, and may reach 107° or 108°. The course of the disease is variable. In very acute cases death follows m from five to ten days. The cases following the infectious diseases par- ticularly the fevers and sometimes syphilis, may run a milder course. The diagnosis of this variety of acute myelitis is rarely difficult. In common with the acute ascending paralysis of Landry, and with certain cases of multiple neuritis, it presents a rapid and progressive motor paraly- sis. From the former it is distinguished by the more marked involvement of sensation, the trophic disturbances, the paralysis of bladder and rectum, ACUTE AFFECTIONS OF THE SPINAL CORD. 891 the rapid wasting, the electrical changes, and the fever. From acute cases of multiple neuritis it may be more difficult to distinguish, as the sensory features in these cases may he marked, though there is rarely, if ever, in multiple neuritis complete anesthesia; the wasting, moreover, is more rapid in myelitis. The bladder and rectum are rarely involved—though in exceptional cases they may be—and, most important of all, the trophic changes, the development of bullae, bed-sores, etc., are not seen in multiple neuritis. (d) Acute Transverse Myelitis.—The symptoms naturally differ with the situation of the lesion. (1) Acute transverse myelitis in the dorsal region, the most common situation, produces a very characteristic picture. The symptoms of onset are variable. There may be initial pains or numbness and tingling in the legs. The paralysis may set in quickly and become complete within a few days; but more commonly it is preceded for a day or two by sensa- tions of pain, heaviness, and dragging in the legs. The paralysis of the lower limbs is usually complete, and if at the level, say, of the sixth dorsal vertebra, the abdominal muscles are involved. Sensation may be partially or completely lost. At the onset there may be numbness, tingling, or even hypersesthesia in the legs. At the level of the lesion there is often a zone of hyperaesthesia, which is discovered by passing a test-tube containing hot water along the spine, when the sensation of warmth changes to one of actual pain. A girdle sensation may occur early, and when the lesion is in this situation it is usually felt between the ensiform and umbilical regions. The reflex functions are variable. There may at first be abolition of the re- flexes ; subsequently, the reflexes, passing through the segments lower than the one affected, may be exaggerated and the limbs may pass into a con- dition of spastic rigidity. It does not always happen, however, that the re- flexes are increased in a total transverse lesion of the cord. They may be entirely lost, as pointed out some years ago by Bastian, and insisted upon by him in a recent memoir.* F. T. Miles has also called attention to this fact and reported five cases in which the reflexes were lost in total transverse lesion of the cord. That this is not due to the preliminary shock is shown by the fact that the abolition of the reflexes may continue for four or more months. The trophic changes are not marked. The muscles become ex- tremely flabby, but not wasted in an extreme degree ; subsequently rigidity develops. If the gray matter of the lumbar cord is involved, the flaccidity persists and the wasting may be considerable. The reaction of degenera- tion is not present. The temperature of the paralyzed limbs is variable. It may at first rise, then fall and become subnormal. Lesions of the skin are not uncommon, and bed-sores are apt to form. There is at first re- tention of urine and subsequent incontinence. If the lumbar centres are involved, there are from the outset vesical symptoms. The urine is alka- * Medico-Chirurgical Transactions, vol. lxxiii. 892 DISEASES OF TIIE NERVOUS SYSTEM. line in reaction and may rapidly become ammoniacal. The bowels are constipated and there is usually incontinence of the faeces. Some writers attribute the cystitis associated with transverse myelitis to disturbed tro- phic influence. The course of complete transverse myelitis depends a good deal upon its cause. Death may result from extension. Segments of the cord may be completely and permanently destroyed, in which case there is persistent paraplegia. The pyramidal fibres below the lesion undergo the secondary degeneration, and there is an ascending degeneration of the posterior me- dian columns. If the lower segments of the cord are involved the legs may remain flaccid. In some instances a transverse myelitis of the dorsal region involves the anterior horns above and below the lesion, producing flaccidity of the muscles, with wasting, fibrillar contractions, and the reac- tion of degeneration. More commonly, however, in the cases which last many months there is more or less rigidity of the muscles with spasm or persistent contraction of the flexors of the knee. (2) Transverse Myelitis of the Cervical Region.—If at the level of the sixth or seventh cervical nerves, there is paralysis of the upper extremities, more or less complete, sometimes sparing the muscles of the shoulder. Gradually there is loss of sensation. The paralysis is usually complete be- low the point of lesion, but there are rare instances in which the arms only are affected, the so-called cervical paraplegia. In addition to the symp- toms already mentioned there are several which are more characteristic of transverse myelitis in the cervical region, such as the occurrence of vomit- ing, hiccough, and slow pulse, which may sink to twenty or thirty, pupillary changes—myosis—sometimes attacks of dysphagia, dyspnoea, or syncope. II. Myelitis of the Anterior Horns Definition.—An affection occurring most commonly within the first three years of life, characterized by fever, loss of power in certain mus- cles, and rapid atrophy. Etiology.—The cause of the disease is unknown. It has been at- tributed to cold, to the irritation from dentition, or to overexertion. Since the days of Mephibosheth, parents have been inclined to attribute this form of paralysis to the carelessness of nurses in letting the children fall, but very rarely is the disease induced by traumatism, and in perhaps a majority of the cases the child is attacked while in full health. As Sinkler has pointed out, the cases are more common in the warm months. Boys are more liable to be affected than girls. Several instances of the occur- rence of numerous cases together in epidemic form have been described. Medin reports from Stockholm an epidemic in which from the 9tli of August to the 23d of September 29 cases came under observation. In two instances two children in the same family were attacked within a few days. (Polio-myelitis Anterior j Atrophic Spinal Paralysis). ACUTE AFFECTIONS OF THE SPINAL CORD. 893 The most remarkable epidemic is that which occurred in the vicinity of Rutland, Vt., and which has been recorded by Caverly (New York Medical Record, 1894, ii). One hundred and nineteen cases occurred during the summer of 1894; eighty-five were under six years of age; eighteen died. Although most frequent in children, it develops occasionally in young adults, or even in middle-aged persons. Morbid Anatomy.—The disease is oftenest seen in either the cer- vical or lumbar enlargements. In very early cases, such as those de- scribed by David Drummond and Charlewood Turner, the lesion has been that of an acute haemorrhagic myelitis with degeneration and rapid de- struction of the large ganglion cells. The condition may be strictly con- fined to the anterior cornua; in some instances there is slight meningeal involvement. The investigations of Goldscheider, Siemerling, and others have demonstrated the arterial origin of the disease, which is localized in the parts supplied by the anterior median branch of the anterior spinal artery. Occasionally the changes are found in the region of distribution of the anterior radicular arteries. Marie thinks that the initial process is embolism or thrombosis of the arteries of the anterior horns, the result of an acute infection.* In cases in which the examination is not made for some months or years the changes are very characteristic. The an- terior cornu in the affected region is greatly atrophied and the large motor cells are either entirely absent or only a few remain. The affected half of the cord may be considerably smaller than the other. The antero- lateral column may show slight sclerotic changes, chiefly in the pyramidal tract. The corresponding anterior nerve roots are atrophied, and the muscles are wasted and gradually undergo a fatty and sclerotic change. Symptoms.—In a majority of the cases, after slight indisposition and feverishness, the child is noticed to have lost the use of one limb. Convulsions at the outset are rare, not constant as in the acute cerebral palsies of children. Fever is usually present, the temperature rising to 101°, sometimes to 103°. Pain is rarely complained of; there may oc- casionally be slight aching in the joints. The paralysis is abrupt in its onset and, as a rule, is not progressive, but reaches its maximum in a very short time, even within twenty-four hours. It is rarely gen- eralized. The suddenness of onset is remarkable and suggests a pri- mary affection of the blood-vessels, a view which the hgemorrhagic char- acter of the early lesion supports. The distribution of the paralysis is very variable. One or both arms may be affected, one arm and one leg, or both legs; or it may be crossed paralysis, the right leg with the left arm. In the upper extremities the paralysis is rarely complete and groups of muscles may be affected. As Remak has pointed out, there is an * See R. T. Williamson’s Studies on the Relation of Spinal Diseases to the Distri- bution and Lesions of the Blood-Vessels. Medical Chronicle, New Series, vol. ii. 894 DISEASES OF THE NERVOUS SYSTEM. upper-arm and a lower-arm type of palsy. The deltoid, the biceps, bra- chialis anticus, and supinator longus may be affected in the former, and in the latter the extensors or flexors of the fingers and wrists. This dis- tribution is due to the fact that the groups of nerve-cells are attacked which preside over certain muscles acting functionally together. In the legs the tibialis anticus and extensor groups of muscles are more affected than the hamstrings and glutei. The muscles of the face are very rarely, the sphincters hardly ever involved. While the rule is for the paralysis to be abrupt and sudden, there are cases in which it comes on slowly and takes from three to five days for its development. At first the affected limb looks natural, and as children between two and three are usually fat, very little change may be noticed for some time ; but the atrophy proceeds rapidly, and the limb becomes flaccid and feels soft and flabby. Usually as early as the end of the first week the reaction of de- generation is present. The nerves are found to have lost their irritability. The muscles do not react to the induced current, but to the constant cur- rent they respond by a sluggish contraction, usually to a weaker current than is normal, and more to the positive pole than to the negative. The paralysis remains stationary for a time, and then there is gradual improve- ment. Complete recovery is rare, and, when the anatomical condition is considered, is scarcely to be expected. The large motor cells of the cor- nua, when thoroughly disintegrated, cannot be restored. In too many cases the improvement is only slight and permanent paralysis remains in certain groups. Sensation is unaffected; the skin reflexes are absent, and the deep reflexes are usually lost. When the paralysis persists the wasting is extreme, the growth of the bones of the affected limb is arrested, or at any rate retarded, and the joints may be very relaxed; as, for instance, when the deltoid is affected the head of the humerus is no longer kept in contact with the glenoid cavity. In the later stages very serious deformities are produced by the contracture of the muscles. Diagnosis.—The condition is only too evident in the majority of cases. There is a flaccid, flabby paralysis of one or more limbs which has set in abruptly. The rapid wasting, the lax state of the muscles, the electrical reactions, and the absence of reflexes distinguish it from the cerebral palsies. The pseudo-paresis of rickets is a condition to be care- fully distinguished. In this the loss of power is in the legs, rapid atrophy is not present, certain movements are possible but painful. The general liyperaesthesia of the skin, the characteristic changes in the bones, and the diffuse sweats are present. Disease of the hip or knee may produce a pseudo-paralysis which can with care be readily distinguished. Prognosis.—The outlook in any case for complete recovery is bad. The natural course of the disease must be borne in mind; the sudden onset, the rapid but not progressive loss of power, a stationary period, then marked improvement in certain muscle groups, and finally in many cases ACUTE AFFECTIONS OF THE SPINAL CORD. 895 -contractures and deformities. There is no other disease in which the physician is so often subject to unjust criticism, and the friends should be told at the outset that in the severe and extensive paralysis complete recovery should not he expected. The best to be hoped for is a gradual restoration of power in certain muscle groups. In estimating the probable grade of permanent paralysis, the electrical examination is of great value. Treatment of Acute Myelitis.—In the rapidly developing form due either to a ditfuse inflammation in the gray matter or to transverse myelitis, the important measures are: Scrupulous cleanliness, care and watchfulness in guarding against bed-sores, the avoidance of cystitis, either by systematic catheterization or, if there is incontinence, by a carefully adjusted bed urinal, or the use of antiseptic cotton-wool repeatedly changed. In an acute onset in a healthy subject the spine may be cupped. Counter-irritation is of doubtful advantage. Chapman’s ice-bag is some- times useful. No drugs have the slightest influence upon an acute myelitis, and even in subjects with well-marked syphilis neither mercury nor iodide of potassium is curative. Tonic remedies, such as quinine, arsenic, and .strychnia, may be used in the later stages. When the muscles have wasted, massage is beneficial in maintaining their nutrition. Electricity should not be used in the early stages of myelitis. It is of no value in the trans- verse myelitis in the dorsal region with retention of the nutrition in the muscles of the leg. The treatment of acute infantile paralysis has a bright and a dark side. In a case of any extent complete recovery cannot be expected; on the other hand, it is remarkable how much improvement may finally take place in a limb which is at first completely flaccid and helpless. The fol- lowing treatment may be pursued: If seen in the febrile stage, a brisk laxative and a fever mixture may be given. The child should be in bed and the affected limb or limbs wrapped in cotton. As in the great majority of cases the damage is already done when the physician is called and the disease makes no further progress, the application of blisters and other forms of counter-irritation to the back is irrational and only cruel to the child. The general nutrition should be carefully maintained by feeding the child well, and taking it out of doors every day. As soon as the child can bear friction the affected part should be carefully rubbed; at first once a day, subsequently morning and evening. Any intelligent mother can be taught systematically to rub, knead, and pinch the muscles, using either the bare hand or, better still, sweet oil or cod-liver oil. This is worth all the other measures advised in the disease, and should be systematically practised for months, or even, if necessary, a year or more. Electricity has a much more limited use, and cannot be compared with massage in maintaining the nutrition of the muscles. The faradic current should be applied to those muscles which respond. The essence of the treatment is in main- taining the nutrition of the muscles, so that in the gradual improvement 896 DISEASES OF THE NERVOUS SYSTEM. which takes place in parts, at least, of the affected segments of the cord the motor impulses may have to deal with well-nourished, not atrophied muscle fibres. Of medicines, in the early stage ergot and belladonna have been warmly recommended, but it is unlikely that they have the slightest influence. Later in the disease strychnia may be used with advantage in one or two minim doses of the liquor strychninse, which, if it has no other effect, is a useful tonic. The most distressing cases are those which come under the notice of the physician six, eight, or twelve months after the onset of the paralysis, when one leg or one arm or both legs are flaccid and have little or no motion. Can nothing be done ? A careful electrical test should be made to ascertain which muscles respond. This may not be apparent at first, and several applications may be necessary before any contractility is noticed. With a few lessons an intelligent mother can be taught to use the electricity as well as to apply the massage. If in a case in which the paralysis has lasted for six or eight months no observable improvement takes place in the next six months with thorough and systematic treat- ment, little or no hope can be entertained of further change. In the later stage care should be taken to prevent the deformities resulting from the contractions. Great benefit results from a carefully applied apparatus. III. Acute and Subacute Polio-myelitis in Adults, An acute polio-myelitis in adults, the exact counterpart of the disease in children, is recognized. A majority, however, of the cases described under this heading have been multiple neuritis; but the suddenness of onset, the rapid wasting, and the marked reaction of degeneration are thought by some to be distinguishing features. Multiple neuritis may, however, set in with rapidity; there may be great wasting and the reaction of degeneration is sometimes present. The time element alone may deter- mine the true nature. Recovery in a case of extensive multiple paralysis from polio-myelitis will certainly be with loss of power in certain groups of muscles; whereas, in multiple neuritis the recovery, while slow, may be perfect. The subacute form, the paralysie generate spindle anterieure subaigue of Duchenne, is in all probability a peripheral palsy. The paralysis usually begins in the legs with atrophy of the muscles, then the arms are involved, but not the face. Sensation is, as a rule, not involved. IV. Acute Ascending (Landry’s) Paralysis. Definition.—An advancing paralysis, beginning in the legs, rapidly extending to the trunk and arms, and finally, in many cases, involving the muscles of respiration. It presents a remarkable similarity in its symp- ACUTE AFFECTIONS OF THE SPINAL CORD. 897 toms to certain cases of polyneuritus, with which it is now grouped by many writers. Etiology and Pathology.—The disease occurs most commonly in males between the twentieth and thirtieth years. It has sometimes fol- lowed the specific fevers. An elaborate study of 93 cases collected from the literature has been made by James Ross, who concludes that in etiol- ogy, symptoms, course, and termination it conforms to a peripheral neu- ritis. Neuwerk and Barth have reached a similar conclusion. In their case an interstitial neuritis was found in the nerve roots, but the peripheral nerves were normal. On the other hand, cases have been reported of rapidly ascending paralysis in which the periphral nerves and nerve roots were unaffected. In a case of eleven days’ duration recently studied by Hun, the lesions were certainly too slight to account for the advancing and wide-spread paralysis, and, with our present knowledge, Ilun is cor- rect in stating that “ acute ascending paralysis—defined so as to exclude all cases in which the sensory symptoms are prominent, or in which well- marked bulbar symptoms are not present—must therefore be regarded as a clinical entity for which no corresponding lesion has as yet been discov- ered.” It is not improbable that some toxic agent is responsible for the symptoms. Symptoms.—Weakness of the legs, gradually progressing, often with tolerable rapidity, is the first symptom. In some cases within a few hours the' paralysis of the legs becomes complete. The muscles of the trunk are next affected, and within a few days, or even less in more acute cases, the arms are also involved. The neck muscles are next attacked, and finally the muscles of respiration, deglutition, and articulation. The reflexes are lost, but the muscles neither waste nor show electrical changes. The sensory symptoms are variable ; in some cases tingling, numbness, and hyperaesthesia have been present. In the more characteristic cases sensa- tion is intact and the sphincters are uninvolved. Enlargement of the spleen has been noticed in several cases. The course of the disease is variable. It may prove fatal in less than two days. Other cases persist for a week or for two weeks. In some instances recovery has occurred, but in a large proportion of the cases the disease is fatal. The diagnosis is difficult, particularly from certain forms of multiple neuritis, and if we include in Landry’s paralysis the cases in which sensa- tion is involved, distinction between the two affections is impossible. We apparently have to recognize the existence of a rapidly advancing motor paralysis without involvement of the sphincters, without wasting or elec- trical changes in the muscles, without trophic lesions, and without fever— features sufficient to distinguish it from either the acute central myelitis or the polio-myelitis anterior. It is doubtful, however, whether these characters always suffice to enable us to differentiate the cases of multiple neuritis. 898 DISEASES OF THE NERVOUS SYSTEM. CHRONIC AFFECTIONS OF THE SPINAL CORD I. Spastic Paraplegia. Definition.—Loss of power with spasm of the muscles of the lower extremities. While clinically spastic paraplegia, or, as it is sometimes called, tabes dorsalis spasmodique, is a well-defined, readily recognizable affection, etio- logically and anatomically it presents marked differences, and various groups must be separated, all of which present, however, the combination of spasm with loss of power. As the pyramidal tracts are involved, the term lateral sclerosis is sometimes used as the equivalent of spastic para- plegia. The lesion is in many cases a chronic myelitis. I shall consider the following forms : (1) Secondary Spastic Paralysis.—Following a transverse lesion of the cord, whether the result of slow compression (as in caries), chronic mye- litis, the pressure of tumor, chronic meningo-myelitis, or multiple sclerosis, degeneration takes place in the pyramidal tracts, below the point of dis- ease. The legs soon become stiff and rigid, and the reflexes increase. Bastian has shown that in compression paraplegia of the transverse lesion is complete, the limbs may be flaccid, without increase in the reflexes— paraplegic flasque of the French. The condition of the patient in these secondary forms varies very much. In chronic myelitis or in multiple sclerosis he may be able to walk about, but wfith a characteristic spastic gait. In the compression myelitis, in fracture, or in caries, there may be complete loss of power with rigidity. (2) Primary Spastic Paraplegia.—This is believed to depend upon a primary sclerosis of the lateral or pyramidal tracts. The question is still debated whether a primary lesion of the lateral tracts ever takes place, or whether, in such instances, there is not always some lesion of the motor eells in the anterior horns. Cases may persist for years without any atrophy. In other instances there are signs of involvement of the posterior columns as well, forming the condition of ataxic paraplegia, which will be considered separately. So far as I know, the only case which is claimed to demonstrate the existence of a primary lateral sclerosis is that of Dresch- feld’s, which occurred in 1881. (3) Erb’s Syphilitic Spastic Paralysis.—Clinically it is common to meet with cases in adults, particularly in syphilitic subjects, who have pains in the back, perhaps a girdle sensation, and a gradually developing progressive spastic paraplegia. It may be impossible from the history or CHRONIC AFFECTIONS OF TnE SPINAL CORD. 899 the physical examination to determine whether the condition is secondary to a transverse myelitis or a meningo-myelitis, or whether the lesion is a primary degeneration of the pyramidal tracts. Since writing this paragraph in the first edition, Erb has described a symptom group under the term syphilitic spinal paralysis, to which much attention has been given. The points upon which he lays stress are a very gradual onset with a development finally of the features of a spastic paresis; the tendon reflexes are greatly increased, but the muscular rigid- ity is slight in comparison with the exaggerated deep reflexes. There is rarely much pain, and the sensory disturbances are trivial, but there may be parsesthesia and the girdle sensation. The bladder and rectum are usually involved, and there is sexual failure or impotence. And, lastly, improvement is not infrequent. A majority of instances of spastic paraly- sis of adults not the result of slow compression of the cord are associated with syphilis and belong to this group. The general symptoms of spastic paraplegia in adults are very distinc- tive. The patient complains of feeling tired, of stiffness in the legs, and perhaps of pains of a dull aching character in the back or in the calves. There may be no definite loss of power, even when the spastic condition is well established. In other instances there is definite weakness. The stiffness is felt most in the morning. In a well-developed case the gait is most characteristic. The legs are moved stiffly and with hesitation, the toes drag and catch against the ground, and, in extreme cases, when the ball of the foot rests upon the ground a distinct clonus develops. The legs are kept close together, the knees touch, and in certain cases the adductor spasm may cause cross-legged progression. On examination, the legs may at first appear tolerably supple, perhaps flexed and extended readily. In other cases the rigidity is marked, particularly when the limbs are extended. The spasm of the adductors of the thigh may be so extreme that the legs are separated with the greatest difficulty. In cases of this extreme rigidity the patient usually loses the power of walking. The nutrition is well maintained, the muscles may be hypertrophied. The reflexes are greatly increased. The slightest touch upon the patellar tendon produces an active knee-jerk. The rectus clonus and the ankle clonus are easily obtained. In some instances the slightest touch may throw the legs into violent clonic spasm, the condition to which Brown- Sequard gave the name of spinal epilepsy. The superficial reflexes are also increased. The arms may be unaffected for years, but as a late mani- festation rigidity may develop. The diagnosis is readily made, but it is often very difficult to deter- mine accurately the nature of the underlying pathological condition. A history of syphilis is present in many of the cases. The course of the disease is progressively downward. Years may elapse before the patient is bedridden. Involvement of the sphincters, as a rule, is late ; occasion- ally, however, it is early. The sensory symptoms rarely progress, and the 900 DISEASES OF THE NERVOUS SYSTEM. patients may retain the general nutrition and enjoy excellent health. Ocular symptoms are rare. (4) The Spastic Paraplegia of Infants (Paraplegia cerebralis spastica —Heine).—This is usually a birth palsy, often the result of difficult labor. In twenty-three of the twenty-four of Little’s cases, there was either diffi- cult labor or premature delivery. The stiffness of the legs may not be noticed for some months after birth, but usually on dressing the child the mother notices the rigidity. When attempts are made to walk the stiff- ness and awkwardness then become apparent. On standing, the attitude is very characteristic. There is talipes equinus, varying from the slightest raising of the heel to a condition in which the child stands on tiptoe. In older children, as they walk, the toe-cap of the shoe is usually much worn. The strong abductor action may produce typical cross-legged progression, in which each foot is dragged over and planted in front, or even on the other side of its fellow. In attempting to flex the legs there is a marked resistance, which gradually yields—the lead-pipe contraction, as Weir Mitchell calls it. The reflexes are increased, though in some children it is not an easy matter to obtain them. The ankle clonus, as a rule, is not obtainable. Sensation is unimpaired, and the bladder and rectum are not involved. The symptoms of this affection in children are almost identical with the spastic paraplegia of adults. The arms may be involved—spastic diplegia. The disease is probably of cortical origin. There are frequently symptoms indicating cerebral defects, such as idiocy, imbecility, and nystagmus. Some of the cases depend, no doubt, upon bilateral menin- geal haemorrhage occurring during delivery. Others are probably due to arrest of development of the pyramidal tracts. This condition in children must not be confounded with tetany or with the pseudo-paralytic rigidity so often associated with rickets. (5) Hereditary Form.—Much interest has been aroused recently in this type, cases of which have been described by Gee, Bernhardt, Latimer, New mark, Tooth, Sachs, and others. Apparently wre have to distinguish a family form, in which the disease develops in infancy or childhood, and the cases have all the characters of a paraplegia spastica cerebralis. In this group, the presence of mental disturbances, nystagmus, optic-nerve atrophy, and the speech disturbances indicate quite clearly a cerebral lesion, to which the spinal affection is consecutive. On the other hand, there are cases of spastic paraplegia occurring in members of the same family, developing later in life, often after middle age, in which the lesion would appear to be confined to the spinal cord, a primary degenera- tion of the pyramidal fasciculi. In one of Striimpel’s cases the cord alone was involved. (6) Ataxic Paraplegia.—This name is applied by Gowers to a disease characterized clinically by a combination of ataxia and spastic paraplegia, and anatomically by involvement of the posterior and lateral columns. CHRONIC AFFECTIONS OF THE SPINAL CORD. 901 The disease is most common in middle-aged males. Exposure to cold and traumatism have been occasional antecedents. In striking contrast to ordinary tabes a history of syphilis is rarely to be obtained. The anatomical features are a sclerosis of the posterior columns, which is not more marked in the lumbar region and not specially localized in the root zone of the postero-external columns. The involvement of the lateral columns is diffuse, not always limited to the pyramidal tracts, and there may be an annular sclerosis. The symptoms are well defined. The patient complains of a tired feeling in the legs, not often of actual pain. The sensory symptoms of true tabes are absent. An unsteadiness in the gait gradually develops with progressive weakness. The reflexes are increased from the outset, and there may be well-developed ankle clonus. Rigidity of the legs slowly comes on, but is rarely so marked as in the uncomplicated cases of lateral sclerosis. From the start, incoordination is a well-characterized feature, and the difficulty of walking in the dark or swaying when the eyes are closed may, as in true tabes, be the first symptom to attract at- tention. In walking the patient uses a stick, keeps the eyes fixed on the ground, the legs far apart, but the stamping gait, with elevation and sud- den descent of the feet, is not often seen. The incoordination may extend to the arms. Sensory symptoms are rare, but Gowers calls attention to a dull, aching pain in the sacral region. The sphincters usually become involved. Eye symptoms are rare. Late in the disease mental symptoms may develop, similar to those of general paresis. In well-marked cases the diagnosis is easy. The combination of marked incoordination with retention of the reflexes and more or less spasm are characteristic features. The absence of ocular and sensory symptoms is an important point. (7) Hysterical Spastic Paraplegia.—There is no spinal-cord disease which may be so accurately mimicked by hysterical patients as spastic paraplegia. There is wasting in the hysterical paraplegia, the sensory symptoms are not marked, the loss of, power is not complete, and there is not that extensor spasm so characteristic of organic disease. The hyster- ical contracture will be considered later. The reflexes are, as a rule, increased. The knee-jerk is present, and there may be well-developed ankle clonus. Gowers calls attention to the fact that it is usually a spurious clonus, “ due to a half-voluntary contrac- tion in the calf muscles.” A true clonus does occur, and there may be the greatest difficulty in determining whether or not the case is one of hysterical paraplegia. (8) Primary Combined Sclerosis (Putnam).—In addition to the ataxic paraplegia just mentioned, here may be considered certain cases which are characterized anatomically by a relatively chronic sclerosis of the posterior columns, of the lateral columns, chiefly the pyramidal tract, and also of the cerebellar tract. With these are usually associated more acute changes DISEASES OF THE NERVOUS SYSTEM. 902 in adjoining areas, either diffuse or systemic, some grade of degeneration in the gray matter, and involvement of the nerve roots. This form has been studied by J. J. Putnam and Dana. The cases are usually in women —seven out of nineteen collected by Dana; the ages, from forty-five to sixty-four. The disease runs a rather rapid course. Neuropathic inherit- ance is present in some instances. Putnam thinks that possibly both lead and arsenic play a part in the etiology. The symptoms are both sensory and motor. The onset is usually with numbness in the extremities, progressive loss of strength, and emaciation. Paraplegia gradually develops, before which there have been, as a rule,, spastic symptoms with exaggerated knee-jerk. The arms are affected less than the legs. Mental symptoms similar to dementia paralytica may de- velop toward the close. The diagnosis of this mixed sclerosis rests upon the combination of sensory and motor symptoms with the presence of exaggerated reflexes. As stated, the sensory features consist chiefly of paraesthesia, and there may be difficulty in distinguishing the condition from multiple neuritis. The frequency of the disease in more or less enfeebled or anaemic women past middle life is also an important feature. Treatment of Spastic Paraplegia.—In the majority of cases spastic paraplegia is incurable. The cases which result from transitory compression, as in caries, may get well; but in the other forms the disease is uniformly progressive, and remedies have little or no control. When syphilis is suspected a thorough course of mercury and iodide of potassium should be given. Scrupulous attention should be paid to the bladder symptoms, and the same measures may be used as will be advised in loco- motor ataxia. In the infantile form of paraplegia much may be done by the orthopaedic surgeon to overcome rigidity and contracture. In several instances I have known persistent friction with forcible flexion and exten- sion and the application of proper apparatus enable a patient to get about comfortably. (Tabes Dorsalis; Posterior Spinal Sclerosis). II. Locomotor Ataxia. Definition.—An affection of the nervous system characterized clin- ically by incoordination, sensory and trophic disturbances, and in- volvement of the special senses, particularly the eyes. Anatomically there are found sclerosis of the posterior columns of the cord, degeneration of the spinal ganglia and of the posterior roots, foci of degeneration in the basal ganglia, and sometimes chronic degenerative changes in the cortex cerebri. Etiology.—It is a wide-spread disease, more frequent in cities than in the country. The relative proportion may be judged from the fact that of 1,816 cases in my neurological dispensary in two years there were 25 CHRONIC AFFECTIONS OF THE SPINAL CORD. 903 cases of locomotor ataxia. Males are attacked more frequently than females, the proportion being at least ten to one. Mitchell has called attention to the fact that it is a rare disease in the negro. Of 25 cases at my clinic, 3 were in negroes. It is a disease of adult life, a majority of the cases occurring between the thirtieth and fortieth years. Occasionally cases are seen in young men. The form of ataxia which occurs in chil- dren is a different disease. Of special causes syphilis is the most im- portant. According to the figures of Erb, Fournier, and Gowers, in from fifty to seventy-five per cent of all cases there is a history of this disease. Erb’s recent figures are most striking; of 300 cases of tabes in private practice 89 per cent had had syphilis. In Fournier’s recent Les Affections Parasyphilitiques the whole question is treated in a masterly manner. Excessive fatigue, overexertion, exposure to cold and wet, and sexual excesses are all assigned as causes. There are instances in which the dis- ease has closely followed severe exposure. James Stewart has noted that the Ottawa lumbermen, who live a very hard life in the camps during the winter months, are frequently the subjects of locomotor ataxia. Trauma has been noted in a few cases. Alcoholic excess does not seem to predis- pose to the disease. Among patients in the better classes of life I do not remember one in which there had been a previous history of prolonged drunkenness. Morbid Anatomy and Pathology.—When a patient has died in the advanced stage of the" disease the following are the most important changes: (a) The peripheral nerves may show signs of degeneration. Neuritis may indeed be present even when there have been no special symptoms indicating it. In other instances there is not only neuritis, but muscular atrophy. (b) The posterior roots (and their ganglia) of the spinal cord are small, gray, and atrophic, and the cells of the ganglia are degenerated. (c) The meninges of the posterior and lateral columns are thickened, more firmly adherent than normally, and the blood-vessels usually show signs of arterio-sclerosis. (cl) The changes in the spinal cord are as follows: (1) In advanced cases the posterior columns are uniformly sclerotic and the dorsal and lumbar regions are most extensively involved. In long-standing cases there is generally an increase of connective tissue throughout the cord and there may be degeneration (2) of the ascending antero-lateral tract; (3) of the direct cerebellar tract; (4) of the pyramidal tract. (e) The cerebral changes—of less consequence than the spinal—may consist of (1) sclerosis in the restiform bodies, in the inferior peduncles of the cerebellum, and of certain of the cranial nerves, particularly the third, the optic, and the auditory; (2) cortical changes, consisting in some cases of a diffuse meningo-encephalitis. DISEASES OF THE NERVOUS SYSTEM. 904 Our conception of tabes dorsalis has undergone radical alteration, and the studies of Leyden, Kedlich, Marie, and others have shown that it can no longer be regarded as a primary systemic sclerosis of the posterior columns. These, it will be remembered, are made up, in great part, of the axis-cylinder processes of the spinal ganglia, and they, with their branches, represent in the cord the paths of sensory conduction. The peripheral sensory nerves represent the protoplasmic processes of the spinal ganglia, which important structures are the trophic centres both for the sensory nerves as well as for the axis-cylinder processes which make up the pos- terior columns of the cord. Marie calls attention also to the possibility of the existence of peripheral or terminal ganglion cells which are found in different organs—cells from which certain of the sensory fibres are derived which go to form the posterior nerve-roots. According to the general laws of nerve physiology, as mentioned at page 816, lesions of the nerve ganglia would be followed by degeneration of the posterior root-fibres and of their continuation in the cord, and this is practically what the recent theory of tabes involves. The changes in the posterior columns are merely a sequence, and not the primary disease. The fibres of the posterior root are divided into three sets: (1) The short fibres, which pass almost directly into the posterior cornu after entering the cord. (2) Fibres of moderate length, which run upward in the cord; some of them enter the posterior horn at its middle part, while others pass into Clarke’s column. The fibres of this group run in 'the column of Bur- dach. (3) A group of long fibres, which are derived chiefly from the roots of the cauda equina, and which pass the whole length of the cord to enter certain nuclei in the medulla. They form the column of Goll. The initial cord lesion in tabes is found in the posterior root-zone afid in the zone or tract of Lissauer, a narrow portion situated between the margin of the cord and the apex of the posterior horn. In the column of Burdach the sclerosis is in almost direct proportion to the duration of the disease, slight at first and centrally placed, and becoming wide-spread as the disease advances. The column of Goll is affected slightly in the early stages, but in the advanced stage there is extensive sclerosis. Marie cor- relates the sclerosis of these different parts with the different groups of nerve-fibres of the posterior root, the posterior root-zone and the zone of Lissauer degenerating from the involvement of the short fibres; the scle- rosis of the columns of Burdach and the disappearance of the network of the nerve-fibres in the column of Clarke being due to the degenera- tion of the second group, the fibres of moderate length; while the scle- rosis of the columns of Goll is caused by the degeneration of the third group, namely, the long fibres. He suggests also that groups of fibres in the different posterior roots are not simultaneously affected, and the lesions may be in an advanced stage in one region and but slight in the CHRONIC AFFECTIONS OF THE SPINAL CORD. 905 other. “ The lesions of the spinal cord in tales occur by segments, each posterior root bringing into the posterior column a fresh contingent of degenerated fibres.” According, too, to this interesting hypothesis the lesions of the ganglia of the posterior roots are responsible, in part at least, for the peripheral neuritis, since in degeneration of the spinal ganglia and consequent loss of trophic influence there would necessarily be degeneration in the periph- eral nerve-trunks. Possibly, too, Marie suggests, the degeneration of the peripheral ganglion cells may have a good deal to do with the neuritis of tabes. Symptoms.—These are best considered under the three stages of pre-ataxic, ataxic, and paralytic. Pre-ataxic Stage.—The following are the most characteristic features of this period: Pains, usually of a sharp stabbing character; hence the term light- ning pains. They last for only a second or two and are most common in the legs. They may be associated with a hot, burning feeling. Occasion- ally herpes may develop at the site of the pain. They may occur at irregu- lar intervals, and are more prone to follow excesses or to come on when the health is impaired. Ocular Symptoms.—(a) Ptosis, which may be single or double and is by no means uncommon either alone or (b) in association with external strabismus. The first complaint may be of double vision. Occasionally there may be paralysis of all the external muscles of the eye, producing ophthalmoplegia externa, (c) Argyll-Robertson pupil, in which, as already mentioned, there is loss of the iris reflex to light, but contraction during accommodation. The pupils are usually small—spinal myosis. (d) Op- tic atrophy. This is often an early or even the first symptom. The loss of vision progresses, and in a large majority of cases leads to total blind- ness. Loss of the Knee-jerk.—This is one of the earliest symptoms, and may occur years before there is ataxia. Taken alone it is of no moment, as there are individuals in whom the knee-jerk is absent; but in connec- tion with the lightning pains and the ocular symptoms, it is of especial importance. These are the most common symptoms of the pre-ataxic stage, and may persist for years without the development of incoordi- nation. The patient may look well and feel well, and be troubled only by occasional attacks of lightning pains; or there is persistent ptosis, external strabismus develops, or, what is more serious, a progressive atrophy of the optic nerve. There is often a gradual loss of sexual power. The disease may never progress beyond this stage, and when optic atrophy develops early and leads to blindness, the ataxia rarely, if ever, supervenes. There is a sort of antagonism between the ocular symptoms and the progress of the ataxia. Charcot laid considerable stress upon this, 906 DISEASES OF THE NERVOUS SYSTEM. and Dejerine assured me that of the enormous tabetic material at the Bicetre in not a single instance in which optic atrophy had come on early and progressed to blindness was the patient ataxic, although there were cases which had had the lightning pains and lesions of the optic nerves for twenty-five years. Ataxic Stage.—Motor Symptoms.—The ataxia develops gradually. One of the first indications to the patient is inability to get about readily in the dark or to maintain his equilibrium when washing his face with the eyes shut. When the patient stands with the feet together and the eyes closed, he sways and has difficulty in maintaining his position, and he may be quite unable to stand on one leg. This is known as Romberg’s symptom. He does not start off promptly at the word of command. On turning quickly he is apt to fall. He descends stairs with difficulty. Gradually the characteristic-ataxic gait develops. The patient, as a rule, walks with a stick, the eyes are directed to the ground, the body is thrown forward, and the legs are wide apart. In walking, the leg is thrown out violently, the foot is raised too high and is brought down in a stamping manner with the heel first, or the whole sole comes in contact with the ground. Ultimately the patient may be unable to walk without the assist- ance of two canes. This gait is very characteristic, and unlike that seen in any other disease. The incoordination is not only in walking, but in the performance of other movements. If the patient is asked, when in the recumbent posture, to touch the knee with one foot, the irregularity in the movement is very evident. Incoordination of the arms is less com- mon, but usually develops in some grade. It may in rare instances exist before the incoordination of the legs. It may be tested by asking the pa- tient to close his eyes and to touch the tip of the nose or the tip of the ear with the finger, or with the arms thrust out to bring the tips of the fingers together. The incoordination may early be noticed by a difficulty which the patient experiences in buttoning his collar or in performing one of the ordinary routine acts of dressing. One of the most striking features of the disease is that with marked incoordination there is no loss of muscular power. The grip of the hands may be strong and firm, the power of the legs, tested by trying to flex them, may be unimpaired, and their nutrition, except toward the close, may be unaffected. Sensory Symptoms.—The lightning pains may persist. They vary greatly in different cases. Some patients are rendered miserable by the frequent occurrence of the attacks; others escape altogether. In addition, common symptoms are tingling, pins and needles, particularly in the feet, and areas of hyperaesthesia or of anaesthesia. The patient may complain of a change in the sensation in the soles of the feet, as if cotton was inter- posed between the floor and the skin. Sensory disturbances occur less frequently in the hands. Retardation of tactile sensation is common, and a pin-prick on the foot, instead of being instantaneously felt, is not per- CHRONIC AFFECTIONS OF THE SPINAL CORD. 907 ceived for a second or two or may be delayed for as much as ten seconds. The pain felt may persist. A curious phenomenon is the loss of the power of localizing the pain. For instance, if the patient is pricked on one limb he may say that he feels it on the other (alloclieiria), or a pin-prick on the foot may be felt in both feet. The muscular sense becomes much im- paired and the patient no longer recognizes the position in which his limbs are placed. This may be present in the pre-ataxic stage. Reflexes.—As mentioned, the loss of the knee-jerk is one of the earliest symptoms of the disease. Occasionally a case is found in which it is re- tained. The skin reflexes may at first be increased, but later are usually involved with the deep reflexes. Special Senses.—The eye symptoms noted above may be present, but, as mentioned, ataxia is rare with atrophy of the optic nerve. Deafness may develop, due to lesion of the auditory nerve. There may also be attacks of vertigo. Olfactory symptoms are rare. Visceral Symptoms.—Among the most remarkable sensory disturbances are the tabetic crises, severe paroxysms of pain referred to various viscera; thus laryngeal, gastric, nephralgic, rectal, urethral, and clitoral crises have been described. The most common are the gastric and laryngeal. In the former there are intense pains in the stomach, vomiting, and a secretion of hyperacid gastric juice. The attack may last for several days or even longer. There may be severe pain without any vomiting. The attacks are of variable intensity and usually require morphia. Paroxysms of rectal pain and tenesmus are described. They have not been common in my experience. Laryngeal crises also are rare. There may be true spasm with dyspnoea and noisy inspiration. In one instance at least the patient has died in the attack. The sphincters are frequently involved. Early in the disease there may be a retardation or hesitancy in making water. Later there is reten- tion, and cystitis may occur. Unless great care is taken the inflammation may extend to the kidneys. Constipation is extremely common. Late in the disease the sphincter ani is weakened. The sexual power is usually lost in the ataxic stage. Trophic Changes.—Skin rashes may develop in the course of the light- ning pains, such as herpes, oedema, or local sweating. Alteration in the nails may occur. A perforating ulcer may develop on the foot, usually beneath the great toe. Onychia may prove very troublesome. The arthropathies or joint lesions affect chiefly the knees. They are unquestionably associated with the disease itself, and not necessarily a result of trauma. The condition, known as Charcot’s joint, is anatomic- ally similar to that of chronic arthritis deformans. The effusion may be rapid and there may be great disintegration and destruction of the carti- lages and bones, leading to dislocation and deformity. Pus was present in a well-marked Charcot’s joint in a patient of C. K. Mills at the Phila- delphia Hospital. Spontaneous fractures may occur. Among other trophic 908 DISEASES OF THE NERVOUS SYSTEM. disturbances may be mentioned atrophy of the muscles, which is usually a late manifestation, but may be localized and associated with neuritis. In any very large collection of cases many instances of atrophy are found, due either to involvement of the anterior horns or to peripheral neuritis. Cerebral Symptoms.—Hemiplegia may develop at any stage of the disease, more commonly when it is well advanced. It may be due to haemorrhagic softening in consequence of disease of the vessels or to pro- gressive cortical changes. Hemiansestliesia is sometimes present. Very rarely the hemiplegia is due to coarse syphilitic disease. Dementia paralytica frequently exists with tabes, and it may be ex- tremely difficult to determine which has been the primary affection. In a majority of the cases the locomotor ataxia has preceded the symptoms of general paresis. In other instances melancholia, dementia, or paranoia develop. (c) Paralytic Stage.—After persisting for an indefinite number of years the patient gradually loses the power of walking and becomes bed- ridden or paralyzed. In this condition he is very likely to be carried off by some intercurrent affection, such as pyelo-nephritis, pneumonia, or tuberculosis. The Course of the Disease.—A patient may remain in the pre-ataxic stage for an indefinite period; and the loss of knee-jerk and the gray atrophy of the optic nerves may be the sole indications of the true nature of the disease. In such cases incoordination rarely develops. In a ma- jority of cases the progress is slow, and after six or eight years, sometimes less, the ataxia is well developed. The symptoms may vary a good deal; thus the pains, which may have been excessive at first, often lessen. The disease may remain stationary for years; then exacerbations occur and it makes rapid progress. Occasionally the disease seems to be arrested. There are instances of what may be called acute ataxia, in which, within a year or even less, the incoordination is marked, and the paralytic stage may develop within a few months. The disease itself rarely causes death, and after becoming bedridden the patient may live for fifteen or twenty years. Diagnosis.—In the pre-ataxic stage the combination of lightning pains and the absence of knee-jerk is distinctive. The association of pro- gressive atrophy of the optic nerves with loss of knee-jerk is also charac- teristic. The early ocular palsies are of the greatest importance. A squint, ptosis, or the Argyll-Robertson pupil may be the first symptom, and may exist with the loss only of the knee-jerk. Loss of the knee-jerk alone, however, does occasionally occur in healthy individuals. The diseases most likely to be confounded with locomotor ataxia are : (1) Peripheral Neuritis.—The pseudo-tabetic gait of arsenical, alcoholic, or diabetic paralysis is quite unlike that of locomotor ataxia. In these forms there is a paralysis of the feet and the leg is lifted high in order that the toes may clear the floor. The use of the word tabes in this con- CHRONIC AFFECTIONS OF TIIE SPINAL CORD. 909 nection should no longer be continued. If in any doubt, the absence of the lightning pains and eye symptoms and the history will suffice in the majority of cases to make the diagnosis clear. In diphtheritic paralysis the early loss of knee-jerk and the associated eye symptoms may suggest tabes, but the history, the existence of paralysis of the throat, and the absence of pains render a diagnosis easy. (2) Ataxic Paraplegia.—Marked incoordination with spastic paralysis is characteristic of the condition which Gowers has termed ataxic para- plegia. In a majority of the cases this affection is distinguished also by the absence of pains and of eye symptoms. (3) Cerebellar Disease.—The cerebellar incoordination has only a super- ficial resemblance to that of locomotor ataxia; the knee-jerk is present, there are no lightning pains, no sensory disturbances; while, on the other hand, there are headache, optic neuritis, and vomiting. (4) Some acute affections involving the posterior columns of the cord may be followed by incoordination and resemble tabes very closely. In a case recently under my care, the gait was characteristic and Romberg’s symptom was present. The knee-jerk, however, was retained and there were no ocular symptoms. The condition had developed within three or four months, and there was a well-marked history of syphilis. Under large doses of iodide of potassium the ataxia and other symptoms com- pletely disappeared. (5) General Paresis.—In some cases this offers a serious difficulty. In the first place, in general paresis, tabetic symptoms often develop; on the other hand, there are cases of locomotor ataxia in which, toward the end, there are symptoms of general paresis. Cases of unusually acute ataxia with mental symptoms belong, as a rule, to the former disease. The ques- tion will be considered under general paresis. (6) Visceral crises and neuralgic symptoms may lead to error, and in middle-aged men with severe, recurring attacks of gastralgia it is always well to bear in mind the possibility of tabes, and to make a careful exam- ination of the eyes and of the knee-jerk. Prognosis.—Complete recovery cannot be expected, but arrest of the progress is not uncommon and a marked amelioration of the symptoms is frequent. Optic-nerve atrophy, one of the most serious events in the dis- ease, has this hopeful aspect—that incoordination rarely follows and the progress may be arrested. The optic atrophy itself is occasionally checked. On the whole, the prognosis in tabes is bad. The experience of such men as Weir Mitchell, Charcot, and Gowers is distinctly opposed to the belief that locomotor ataxia is ever completely cured.* No such instance has come under my personal observation. Treatment.—To arrest the progress and to relieve, if possible, the symptoms are the objects which the practitioner should have in view. A * For a study of reputed cures, see L. C. Gray, N. Y. Medical Journal, November, 1889. 910 DISEASES OF THE NERVOUS SYSTEM. quiet, well-regulated method of life is essential. It is not well, as a rule, for a patient to give up his occupation so long as he is able to keep about and perform ordinary work. I know tabetics who have for years conducted large businesses, and there have been several notable instances in our pro- fession of men who have risen to distinction in spite of the existence of this disease. Excesses of all sorts, more particularly in baccho et venere, should be carefully avoided. A man in the pre-ataxic stage should not marry. Care should be taken in the diet, particularly if gastric crises have oc- curred. To secure arrest of the disease many remedies have been em- ployed. Although syphilis plays such an important role in the etiology, it is universally acknowledged that neither mercury nor the iodide of po- tassium have as a rule the slightest influence over the tabetic lesions. To this there is but one exception—when the syphilis is comparatively recent; when the symptoms develop within two years of the primary infection, there is then a possibility of arrest by mercury and iodide of potassium. However, they do not always relieve. In two cases of very rapidly pro- gressing tabes following syphilis this medication was of no avail. Not only is an anti-syphilitic treatment of no benefit in the majority of cases of locomotor ataxia, but my experience tallies with that of Gowers in that it may even hasten the progress of the disease. Of remedies which may be tried and are believed by some writers to retard the progress, the fol- lowing are recommended : Arsenic in full doses, nitrate of silver in quarter- grain doses, Calabar bean, ergot, and the preparations of gold. The treatment by suspension introduced a few years ago has already been practically abandoned. Good effects certainly have followed in a few cases, but it was unreasonable from the outset, either on therapeutic or scientific grounds, to hope that by such a measure permanent changes could be induced in the pathological condition. The benefits were due in great part to suggestion and to psychical effects. In any case it must be used with caution. For the pains, complete rest in bed, as advised by Weir Mitchell, and counter-irritation to the spine (either blisters or the thermo-cautery) may be employed. The severe spells which come on particularly after excesses of any kind are often promptly relieved by a hot bath or by a Turkish bath. A prolonged course of nitrate of silver seems in some cases to allay the pains and lessen the liability to the attacks. I have never seen ill effects from its use in the spinal scleroses. Antipyrin and antifebrin may be em- ployed, and occasionally do good, but their analgesic powers in this disease have been greatly overrated. Cannabis indica is sometimes useful. In the severe paroxysms of pain hypodermics of morphia or of cocaine must be used. The use of morphia should be postponed as long as possi- ble. Electricity is of. very little benefit. For the severe attacks of gas- tralgia, morphia is also required. The laryngeal crises are rarely danger- ous. An application of cocaine may be made during the spasm, or a few whiffs of chloroform may be given, or nitrite of amyl. In all cases of tabes CHRONIC AFFECTIONS OF THE SPINAL CORD. 911 with increased arterial tension the prolonged use of nitroglycerin, given in increasing doses until the physiological effect is produced, is of great service in allaying the neuralgic pains and diminishing the frequency of the crises. Its use must be guarded when there is aortic insufficiency. The special indication is increased tension. The bladder symptoms de- mand constant care. When the organ cannot be perfectly emptied the catheter should be used, and the patient may be taught its use and how to keep it thoroughly sterilized. III. Hereditary Ataxia (Friedreich's Ataxia). In 1861 Friedreich reported six cases of a form of hereditary ataxia, and the affection has usually gone by his name. Unfortunately, 'paramyo- clonus multiplex is also called Friedreich’s disease; so it is best, if his name is used in connection with this affection, to term it Friedreich’s ataxia. It is a very different disease in many respects from ordinary tabes. It may or may not be hereditary. It is really a family disease, several brothers and sisters being, as a rule, affected. The 143 cases analyzed by Griffith occurred in 71 unrelated families. In his series inheritance of the disease itself occurred in only 33 cases. Various influences in the parents have been noted; alcoholism in only 7 cases. Syphilis has rarely been present. Of the 143 cases, 86 were males and 57 females. The disease sets in early in life, and in Griffith’s series 15 occurred before the age of two years, 39 before the sixth year, 45 between the sixth and tenth years, 20 between the eleventh and fifteenth years, 18 between the sixteenth and twentieth years, and 5 between the twentieth and twenty-fifth years. The morbid anatomy shows an extensive sclerosis of the posterior and lateral columns of the spinal cord. The periphery, and the cere- bellar tracts are usually involved. The recent observations of Dejerine and Letulle are of special interest, since they seem to indicate that the change in this disease is a neurogliar (ectodermal) sclerosis, differing en- tirely from the ordinary spinal sclerosis. According to this view, Fried- reich’s disease is a gliosis of the posterior columns due to developmental errors; but the question is still unsettled. Symptoms.—The ataxia ig unlike the ordinary form. The inco- ordination begins in the legs, but the gait is peculiar. It is swaying, irregular, and more like that of a drunken man. There is not the char- acteristic stamping gait of the true tabes Romberg’s symptom may or may not be present. The ataxia of the arms occurs early and is very marked; the movements are almost choreiform, irregular, and somewhat swaying. In making any voluntary movement the action is overdone, the prehension is claw-like, and the fingers may be spread or overex- tended just before grasping an object. The hand frequently moves about an object for a moment and then suddenly pounces upon it. There are irregular, swaying movements, some of which are choreiform, of the head 912 DISEASES OF THE NERVOUS SYSTEM. and shoulders. There is present in many cases what is known as static ataxia, that is to say, ataxia of quiet action—irregular, slow movements of the fingers or the hands while at rest. Sensory symptoms are not usually present. The reflexes may be lost. In Griffith’s table they were abolished in 91 cases. Nystagmus is a characteristic symptom. Atrophy of the optic nerve rarely occurs. A striking feature is early deformity of the feet. There is talipes equinus, and the patient walks on the outer edge of the feet. The big toe is flexed dorsally on the first phalanx. Lateral curvature of the spine is very common. Trophic lesions are rare. As the disease advances paralysis comes on and may ultimately be complete. Some of the patients never walk. Disturbance of speech is common. It is usually slow and scanning; the expression is often dull; the mental power is, as a rule, maintained, but late in the disease becomes impaired. The diagnosis of the disease is not difficult when several members of a family are affected. The onset in childhood, the curious form of inco- ordination, the early talipes equinus, the position of the great toe, the scoliosis, the nystagmus, and scanning speech make up an unmistakable picture. The disease is often confounded with chorea, with the ordinary form of which it has nothing in common. With hereditary chorea it has certain similarities, but usually this disease does not set in until after the thirtieth year. The disease lasts for many years and is incurable. Care should be taken to prevent contractures. Cerebellar Type.—There is a form of hereditary ataxia, described by Marie as cerebellar lieredo-ataxia, which starts later in life, after the age of twenty, with disability in the legs, but the gait is less ataxic than “groggy.” The knee-jerks are retained, and a spastic condition of the legs ultimately develops. There is no scoliosis, nor does club-foot develop. Sanger Brown’s cases, twenty-five in one family, and J. H. Neff’s, thirteen, appear to belong to this type. The cerebellum has been found atrophied in two cases. IV. Syringo-myelia. Definition.—A gliomatous new formation about the central canal of the spinal cord, with cavity formation. Etiology and Morbid Anatomy.—Syringo-myelia must be dis- tinguished from dilatation of the central canal—hydromyelus—slight grades of which are not very uncommon either as a congenital condition or as a result of the pressure of tumors. The cavity of syringo-myelia has a variable extent in the cord, sometimes existing in the entire length, but in many cases involving only the cervical and dorsal regions or a more limited area. It is usually in the posterior portion of the cord and may extend only into one posterior cornu. The transverse section may be oval or cir- CHRONIC AFFECTIONS OF THE SPINAL CORD. 913 cular or narrow and fissure-like. It varies at different levels. The condi- tion is now regarded as a gliosis, a development of embryonal neurogliar tissue in which haemorrhage or degeneration takes place with the formation of cavities. Of 190 cases, 133 were in men, 57 in women (Schlesinger). A large majority of the cases begin before the thirtieth year. The disease has been met with in three members of the same family. Symptoms.—The clinical features are extremely complex. In the classical form there are irregular pains, chiefly in the cervical region; muscular atrophy develops, which may be confined to the arms, or some- times extends to the legs. The reflexes are increased and a spastic condi- tion develops in the legs. Ultimately the clinical picture may be that of an amyotrophic lateral sclerosis. The tactile sensation is usually intact and the muscular sense is retained, but painful and thermic sensations are not recognized, or there may be in rare instances complete anaesthesia of the skin and of the mucous membranes (Dejerine). This combination of loss of painful and thermic sensations with paralysis of an amyotrophic type is regarded as pathognomonic of the disease. The special senses are usually intact and the sphincters uninvolved. Trophic troubles are not uncommon. Owing to the loss of the painful and heat sensations, the patients are apt to injure themselves. Scoliosis also may be present in these cases. The loss of painful and thermic impressions is due to the fact that these pass to the brain in the peri-ependymal gray matter, par- ticularly that portion in the posterior roots, which is almost constantly involved in syringo-myelia. The tactile sensation is retained because the postero-external column is uninvolved. Schlesinger, in his recent monograph (1895), recognizes the following types: (1) With the classical features above described, which may begin in the cervical or lumbar regions; (2) a motor type, with the picture of an amyotrophic or a spastic paralysis—the sensation may be undisturbed for years; (3) with predominant sensory features, simulating hysterical hemiplegia, or with general pain and temperature anaesthesia; (4) with pronounced trophic disturbances—to this type belong the cases described as Morvan’s disease, an affection characterized by neuralgic pains, cuta- neous anaesthesia, and painless, destructive whitlows; and (5) the tabetic type, either a combination of the symptoms of tabes in the lower, and of syringo-myelia in the upper extremities, or a pure tabetic symptom-com- plex, due to invasion by the gliosis of the posterior columns (Oppenheim). Arthropathies occur in about ten per cent of the cases. In typical cases the diagnosis is easy. The combination of an amyo- trophic paralysis, the picture of progressive muscular atrophy of the Aran- Duchenne type, with retention of tactile and loss of thermic and painful sensation, is probably pathognomonic of the disease. Of affections with which it may be confounded, anaesthetic leprosy is the most important, since the anaesthesia and the wasting may closely simulate it; but, as a 914 DISEASES OF THE NERVOUS SYSTEM. rule, in leprosy trophic changes are more or less marked. There is often loss of phalanges and there is no characteristic dissociation of sensory impressions. V. Compression of the Spinal Cord (Compression Myelitis). Definition.—Interruption of the functions of the cord by slow com- pression Etiology.—Caries of the spine, new growths, aneurism, and para- sites are the important causes of slow compression. Caries, or Pott’s dis- ease, as it is usually called, after the surgeon who first described it, is in the great majority of instances a tuberculous .affection. In a few cases it is due to syphilis and occasionally to extension of disease from the phar- ynx. It is most common in early life, but may occur after middle age. It follows trauma in a few cases. Compression occasionally results from aneurism of the thoracic aorta or the abdominal aorta, in the neighborhood of the coeliac axis. Malignant growths frequently cause a compression paraplegia. A retroperitoneal sarcoma or the lympliadenomatous growths of Hodgkin’s disease may invade the vertebras. More commonly, however, the involve- ment is secondary to scirrhus of the breast. Of parasites, the echinococcus and the cysticercus occasionally occur in the spinal canal. Symptoms.—These may be considered as they affect the bones, the nerves, and the cord. (1) Vertebral.—In malignant disease and in aneurism erosion of the bodies may take place without producing any deformity of the spine. Fatal hemorrhage may follow erosion of the vertebral artery. In caries, on the other hand, it is the rule to find more or less deformity, amounting often to angular curvature. The compression is largely due to the thick- ening of the dura and the presence of caseous and inflammatory products between this membrane and the bone. The compression is rarely pro- duced directly by the bone. Pain is a constant and, in the case of aneu- rism and tumor, agonizing feature. In caries, the spinal processes of the affected vertebra are tender on pressure, and pain follows jarring move- ments or twisting of the spine. There may be extensive tuberculous disease without much deformity, particularly in the cervical region. (2) Nerve-root Symptoms.—These result from compression of the nerve-roots as they pass out between the vertebra. A cervico-brachial neuralgia may be an early symptom. It is remarkable how frequently, even in exteiisive caries, they escape and the patient does not complain of radiating pains in the distribution of the nerves from the affected segment. Pains are more common in cancer of the spine secondary to that of the breast, and in such cases may be agonizing. There maybe acutely painful areas—the ancestliesia dolorosa, or regions of the skin which are an- esthetic to tactile and painful impressions. Trophic disturbances may CHRONIC AFFECTIONS OF THE SPINAL CORD. 915 occur, particularly herpes. In the cervical or lumbar regions pressure on the anterior roots may give rise to wasting of the muscles supplied by the affected nerves. (3) Cord Symptoms. («) Cervical Region.—Not infrequently the caries is high up between the axis and the atlas or between the latter and the occipital bone. 'In such instances a retropharyngeal abscess may be present, giving rise to difficulty in swallowing. There may be spasm of the cervical muscles, the head may be fixed, and movements may either be impossible or cause great pain. In a case of this kind in the Montreal General Hospital movement was liable to be followed by transient, instan- taneous paralysis of all four extremities, owing to compression of the cord. In one of these attacks the patient died. In the lower cervical region there may be signs of interference with the cilio-spinal centre and dilatation of the pupils. Occasionally there is flushing of the face and ear of one side or unilateral sweating. Deform- ity is not so common, but healing may take place with the production of a callus of enormous breadth, with complete rigidity of the neck. (£) Dorsal Region.—The deformity is here more marked and pressure symptoms are more common. The time of onset of the paralysis varies very much. It may be an early symptom, even before the curvature is manifest. More commonly it is late, occurring many months after the curvature has developed. The paraplegia is slow in its development; the patient at first feels weak in the legs or has disturbance of sensation, numbness, tingling, pins and needles. The girdle sensation may be marked, or severe pains in the course of the intercostal nerves. Motion is, as a rule, more quickly lost than sensation. Finally, there is complete interruption with the production of paraplegia, usually of the spastic type, with exaggeration of the reflexes. This may persist for months, or even for more than a year, and recovery still be possible. (c) Lumbar Region.—In the lower dorsal and lumbar regions the symptoms are practically the same, but the sphincter centres are involved and the reflexes are not exaggerated. Diagnosis.—Caries is by far the most frequent cause of slow com- pression of the cord, and when there are external signs the recognition is easy. There are cases in which the exudation in the spinal canal between the dura and the bone leads to compression before there are any signs of caries, and if the root symptoms are absent it may be extremely difficult to arrive at a diagnosis. Janeway has called attention to persistent lum- bago as a symptom of importance in masked Pott’s disease, particularly after injury. Brown-S6quard’s paralysis is more common in tumor and in injuries than in caries. Pressure on the nerve-roots, too, is less fre- quent in caries than in malignant disease. The cervical form of pachy- meningitis also produces a pressure paralysis, the symptoms of which have already been detailed. Pressure from cancer is naturally suggested when spinal symptoms follow within a tew years after an operation. In para- 916 DISEASES OF THE NERVOUS SYSTEM. plegia following tumor of the vertebra secondary to cancer of the breast, and in the erosion of the spine by retroperitoneal growths, the suffering is most intense. The condition has been well termed paraplegia dolorosa. Treatment.—In compression by aneurism or tumor the condition is hopeless. In the former the pains are often not very severe, but in the latter morphia is always necessary. On the other hand, compression by caries is often successfully relieved even after the paralysis has persisted for a long period. When caries is recognized early, rest and support to the spine by the various methods now used by surgeons may do much to prevent the onset of paraplegia. When paralysis has developed, rest with extension gives the best hope of recovery. It is to be remembered that restoration may occur after compression of the cord has lasted for many months, ©r even more than a year. Cases have been cured by rest alone; the extradural and inflammatory products are absorbed and the caries heal. The most brilliant results in these cases have been obtained by suspension, a method introduced by J. K. Mitchell in 1826, and pursued with remarkable success by his son, Weir Mitchell. During my association with the Infirmary for Nervous Diseases I had numerous opportunities of witnessing the really remarkable effects of persistent suspension, even in apparently desperate and protracted cases. Mitchell’s conclusions are that suspension should be employed early in Pott’s disease; that used with care it enables us slowly to lessen the curve; that in these cases there must be, in some form, a replacement of the crumpled tissues; that unless there is great loss of power the use of the spine-car or chair of J. K. Mitchell enables suspension, especially in children, to be combined with some exercise; that no case of Pott’s disease should be considered desperate without its trial; that suspension has succeeded after failures of other accepted meth- ods ; that the pull probably acts more or less directly on the cord itself, and that the gain is not explicable merely by obvious effects on the angu- lar bony curve; that the methods of extension to be used in carious cases may be very varied, provided only we get active extension; that the plan and the length of time of extension must be made to conform to the needs, endurance, and sensation of the individual case. It may be months before there are any signs of improvement. In protracted cases, after suspension has been tried for months, laminectomy may be considered, and has in some instances been successful. The general treatment of caries is that of tuberculosis—fresh air, good food, cod-liver oil, and arsenic. Counter-irritation in these instances is of doubtful value. VI. Lesions of the Cauda Equina and Conus Medullaris. The sjjinal cord extends only to the second lumbar vertebra. Injury, tumors, and caries at or below this level involve not the cord itself, but the bundle of nerves known as the cauda equina and the terminal portion of the cord, the conus medullaris. Much attention has been given recently CHRONIC AFFECTIONS OF THE SPINAL CORD. 917 to lesions of this part. The whole subject is admirably discussed in Thor- burn’s work. Fractures and dislocations are common in the lumbo-sacral region, tumors not infrequently involve the filaments of the cauda equina, and some of the nerves may be entangled in the cicatrix of a spina bifida. In a fracture or dislocation of the first lumbar vertebra the conus me- dullaris may ■ be compressed with the last sacral nerves given off from it. In a case recently reported by Kirchhoff there was laceration of the conus with complete paralysis of the bladder and rectum, a case which is held to favor the view that the ano-vesical centre in man is situated in this region of the cord. There are several instances on record in which injury of the cauda equina has produced paralysis of the bladder and rectum alone, sometimes with a slight patch of anassthesia in the neighborhood of the coccyx or the perinasum. More commonly branches of the sacral or lum- bar nerve-roots are involved, producing an irregularly distributed motor and sensory paralysis in the legs. When the lumbar nerve-roots from the second to the fifth are compressed there is paralysis of the muscles of the legs, with the exception of the flexors of the ankles, the peronaei, the long flexors of the toes, and the intrinsic muscles of the feet, and loss of sensa- tion in the front, inner, and outer part of the thighs, the inner side of the legs, and the inner side of the foot. The sacral roots may alone be in- volved. Thus in a case which I have reported the patient fell from a bridge and had paralysis of the legs and of the bladder and rectum. When seen sixteen years after the injury, there was slight weakness, with wasting of the left leg; there was complete loss of the function in the ano-vesical and gen- ital centres, and anaesthesia in a strip at the back part of the thigh (in the distribution of the small sciatic), and of the perinaeum, scrotum, and penis. The urethra was also insensitive. Starr’s table and Head’s figures, given in the general introduction, will be found useful in determining the nerve fibres and segments involved in these cases of injury of the cauda equina. VII. Tumors of the Spinal Cord and its Membranes. New growths may develop in the cord or in its membranes, or may extend into them from the spine. The first two alone will be considered. Occasionally lipoma and parasites occur in the extradural space. Within the dura fibromata, sarcomata, and syphilitic and tuberculous growths are most common. In the cord itself, and attached to the pia mater, the tuberculous, syphilitic, and gliomatous growths are most frequent. Of 50 cases of tumor of the spinal cord and its envelopes analyzed by Mills and Lloyd, only 3 were parasitic. Of these 26 were some form of neo- plasm, of which sarcomata were most common, 5 were gummatous, and 4 tuberculous. Herter has recently reported 3 cases of solitary tubercle in the cord, and has analyzed others from the literature. Of 24 cases in which the age was given, 15 occurred between the ages of fifteen and thirty-five, and 5 before the fifth year. The tumor is most common in 918 DISEASES OF TIIE NERVOUS SYSTEM. the dorsal and lumbar regions, and is Usually met with in connection with tuberculous lesions elsewhere. The anatomical effects of tumors are very varied. Slow compression is usually produced by growths external to the cord, and it is remarkable what a high grade of compression the cord will bear without serious inter- ference with its functions. In cases of prolonged interruption ascending and descending degenerations occur. Tumors developing within the cord may lead to syringo-myelia. And, lastly, tumors not infrequently excite intense myelitis. Symptoms.—These will naturally vary a good deal with the segment involved and with the degree of pressure and the extent of implication of the nerve-roots. Within the cord the symptoms are those of a gradually progressing paraplegia, which may at first have the picture of a Brown-Sequard paral- ysis. Atrophy follows the involvement of the anterior cornua, and vaso- motor disturbances may be marked. The reflexes are lost at the level of the lesion, but if in the dorsal cord, the reflexes are retained in the legs. The symptoms are apt to be complicated with those of acute or subacute myelitis, which may completely alter the clinical picture. Tumors of the spinal membranes are characterized by the early onset and persistence of the root symptoms, which consist of radiating pains, girdle sensation, hypersesthesia, or anaesthesia in various portions of the trunk. There may even be severe pain in the anaesthetic areas. Irritation of the motor roots may cause spasm of the muscles supplied, or wasting with paralysis. The paraplegia supervenes some time after the occurrence of the root symp- toms. In the dorsal region the level of the growth is usually accurately defined by the level of the pain and the condition of the reflexes. The diagnosis of tumor within the cord is sometimes easy, the charac- teristic features being the constancy and severity of the root symptoms at the level of the growth and the progressive paralysis. Caries may cause identical symptoms, but the radiating pains are rarely so severe. Cervical meningitis simulates tumor very closely, and in reality produces identical effects, but the very slow progress and the bilateral character from the outset may be sufficient to distinguish this. In chronic transverse myelitis the symptoms may, according to Grow- ers, simulate tumor very closely and present radiating pains, a sense of constriction, and progressive paralysis. The nature of the tumor can rarely be indicated with precision. With a marked syphilitic history gumma may naturally be suspected, and with coexisting tuberculous disease a solitary tubercle. Treatment.—If the possibility of syphilitic infection is present the iodide of potassium should be given in large and increasing doses. For the severe pains counter-irritation is sometimes beneficial, particularly the thermo-cautery ; morphia is, however, often necessary. In a few instances tumors of the cord or of the membranes are amena- CHRONIC AFFECTIONS OF THE SPINAL CORD. 919 ble to surgical treatment. The removal by Horsley of a growth from the spinal membranes was one of the most brilliant of recent operations. Abscess of the cord is a rare lesion, of which only three or four cases have been described, all metastatic. It may occur without meningitis. VIII. Progressive (Spinal) Muscular Atrophy (>Chronic Degeneration of the Motor Nuclei—Poliomyelitis Anterior Chronica). Definition.—A disease characterized by degeneration of groups of the motor nnclei in the cord and medulla, with wasting of the correspond- ing muscles. The pyramidal tracts are usually involved, and the paralysis may have a spastic character. In some cases the degeneration has been traced to the ganglion cells of the motor cortex. Three affections, as a rule described apart, belong together in this category: (a) Progressive muscular atrophy of spinal origin; (b) amyo- trophic lateral sclerosis; and (c) progressive bulbar paralysis. A slow atrophic change in the motor nuclei is the anatomical basis, and the dis- ease, as Charcot states, is one of the whole motor path, involving, in many cases, the cortical, bulbar, and spinal centres. There may be simple mus- cular atrophy with little or no spasm, or progressive wasting with marked spasm and great increase in the reflexes. In others, there are added symp- toms of involvement of the motor nuclei in the medulla—a glosso-labio- laryngeal paralysis; while in others, again, with atrophy (especially of the arms), a spastic condition of the legs, and bulbar phenomena, tremors develop and signs of cortical lesion. These various stages may be traced in the same case. I have for ten years had under observation a man whose illness began with weakness and atrophy of the hand muscles. Gradually the legs began to get stiff and the gait spastic; the arms subsequently wasted and the reflexes were increased. After these symptoms had per- sisted with increasing intensity for six or seven years, certain of the motor nuclei of the medulla became involved, the speech became thick, and the movements of the lips and tongue were impaired. Tremor has developed of late in the arms and hands. With these chronic changes the visceral functions have remained unimpaired and the mind unaffected. It has been a lesion of the motor segments, beginning in the lower and gradually extending upward. The disease began as progressive atrophy, and gradually assumed a typical picture of amyotrophic lateral sclerosis, and now the bulbar features are well marked and the tremor would in- dicate that the cortex is also involved. For convenience, bulbar paralysis will be considered separately, and I shall here take up together progressive muscular atrophy and amyotrophic lateral sclerosis. The disease is known as the Aran-Duchenne type of progressive mus- cular atrophy, after the French physicians who early described it, and as Cruveilhier’s palsy. Lockhard Clarke demonstrated that it was a spinal 920 DISEASES OF THE NERVOUS SYSTEM. lesion. Charcot separated the two types—one with simple wasting, in which the anterior horns are alone involved ; and the other in which, with degeneration of the cornua, the pyramidal tracts are affected, causing wasting plus a spastic condition. To this he gave the name of amyotro- phic lateral sclerosis. There is but little evidence, however, to show that the anterior horns are ever affected without secondary changes in the pyramidal tracts, and Leyden and Gowers regard the two diseases as iden- tical. Etiology.—The cause of the disease is unknown. It is more frequent in males than in females. It attacks adults, developing after the thirtieth year, though occasionally younger persons are attacked. A large majority of all cases of progressive muscular atrophy under twenty-five years of age are of myopathic (i. e., muscular), not myelopathic (i. e., spinal) origin. Cold, wet, exposure, fright, and mental worries are mentioned as possible causes. Hereditary influences are present in certain cases. The father of the man whose case is referred to above died of progressive wasting of the muscles, but there have been no other cases in the family. It is highly probable that when many members of a family are affected the disease is not spinal, but an idiopathic muscular atrophy ; and yet, in the Farr family, which I recorded a few years ago, in which thirteen members were affected in two generations, with the exception of two, the cases occurred or proved fatal above the age of forty, and the late onset speaks rather for a spinal affection. The amyotrophic form may develop late in life— after seventy—as a senile change. Morbid Anatomy.—The following are the important anatomical changes: (a) The muscles waste and undergo fatty and sclerotic changes. The terminal branches of the motor nerves are degenerated. (b) The anterior roots are atrophied in those sections of the cord corresponding to the wasted muscles, (e) The gray matter shows the most marked altera- tion. The large ganglion cells of the anterior horns are atrophied, or, in places, have entirely disappeared, the neurogliar tissue is increased, and the fibres of the anterior nerve-root passing through the white matter are wasted. (d) In a majority of all the cases there is sclerosis in the antero- lateral tracts, hut the direct cerebellar and the antero-lateral ascending tracts are spared. It was to this combination of atrophy of the anterior horns and sclerosis of the antero-lateral columns that Charcot gave the name amyotrophic lateral sclerosis. (e) The degeneration of the gray matter is rarely confined to the cord, but extends to the medulla; the motor nuclei are found extensively wasted in cases which have shown bulbar symptoms during life. (/) Cerebral changes also occur. The pyramidal tracts have been found degenerated through the pons and cap- sule, and in the motor cortex the large ganglion cells are wasted. The essential anatomical change is a slow degeneration of the motor path, involving specially the nerve-cells of the anterior cornua and the anterior root-fibres, to which the loss of power and wasting in the muscles CHRONIC AFFECTIONS OF THE SPINAL CORD. 921 are secondary. The upper segment is also involved, either simultaneously or at a later period. Symptoms.—Irregular pains may precede the onset of the wasting. In one case the pains were about the hip and shoulder joints and the pa- tient was treated for chronic rheumatism. The hands are first affected, and there is difficulty in performing delicate manipulations. The muscles of the ball of the thumb waste early, then the interossei and lumbricales, leaving marked depressions between the metacarpal bones. Ultimately the contraction of the flexor and extensor muscles and the extreme atrophy of the thumb muscles, the interossei, and lumbricales produces the claw- hand—main en griffe of Duchenne. The flexors of the forearm are usu- ally involved before the extensors. In the shoulder-girdle the deltoid wastes first; it may waste even before the other muscles of the upper ex- tremity. The trunk muscles are gradually attacked; the upper part of the trapezius long remains unaffected. Owing to the feebleness of the muscles which support it, the head tends to fall forward. The platysma myoides is unaffected and often hypertrophies. The arms and the trunk muscles may be much atrophied before the legs are attacked. The glutei, the vasti, and the tibialis anticus are first attacked when the dis- ease begins in the legs. In the member of the Farr family who came under my notice (if this was really a myelopathic disorder) the wasting began in the gluteal and hamstring muscles of the left leg. The face muscles are attacked late. Ultimately the intercostal and abdominal muscles may be involved, the wasting proceeds to an extreme grade, and the patient may be actually “ skin and bone,” and, as “ living skeletons,” the cases are not uncommon in “ museums ” and “ side-shows.” Deformi- ties and contractures result, and lordosis is almost always present. A curious twitching of the muscles (fibrillation) is a common symptom, and may occur in muscles which are not yet attacked. It is not, as was for- merly supposed, a characteristic feature of the disease. The irritability of the muscle is increased. Sensation is unimpaired, but the patient may complain of numbness and coldness of the affected limbs. The galvanic and faradic irritability of the muscles progressively diminishes and may become extinct, the galvanic persisting for the longest time. In cases of rapid wasting and paralysis there may be the reaction of degeneration. The excitability of the nerve-trunks may persist after the muscles have ceased to respond. The loss of power is usually proportionate to the wasting. The foregoing description applies to the group of cases in which the atrophy and paralysis are flaccid—atonic, as Gowers calls it. In other cases, those which Charcot describes as amyotrophic lateral sclerosis, with the wasting there is more or less spasm, which may exist from the outset. This tonic atrophy may involve the legs chiefly or is present in the arms and legs. The reflexes are greatly increased. It is one of the rare con- ditions in which a jaw clonus may be obtained. The most typical condition of spastic paraplegia may be produced. On starting to walk, the patient DISEASES OF THE NERVOUS SYSTEM. 922 seems glued to the ground and makes ineffectual attempts to lift the toes; then four or five short, quick steps are taken on the toes with the body thrown forward; and finally he starts off, sometimes Avith great rapidity. Some of the patients can Avalk up and down stairs better than on the level. The wasting is never so extreme as in the atonic form, and the loss of power may be out of proportion to it. The sphincters are unaffected. Sexual power may be lost early. As the degeneration extends upward an important change takes place from the development of bulbar symptoms, which may, however, precede the spinal manifestations. The lips, tongue, face, pharynx, and larynx may be involved. The lij)s may be affected and articulation impaired for years before serious symptoms occur. In the final stage there may be tremor, the memory fails, and a condition of dementia may develop. Gowers gives the following useful classification of the varieties of this affection: (1) Atonic atrophy, becoming extreme ; (2) muscular weakness with spasm, but without wasting or Avith only slight Avasting; and (3) atonic atrophy, rarely extreme in degree, Avitli excess of the reflexes. These conditions may “ coexist in every degree and combination—betAveen universal atonic atrophy on the one hand and universal spastic paralysis Avith out wasting on the other.” Diagnosis.—The affection must be distinguished from the primary muscular atrophies Avhich usually occur in younger persons, often affect many members of a family, and have a different distribution, beginning either in the muscles of the shoulder girdle—sparing the hands or involv- ing the face and upper-arm muscles—or the peroneal group. Muscular atrophy in the adult, beginning in the muscles of the thumbs, gradually involving the interossei and lumbricales, as a rule is of myelopathic origin. Treatment.—The disease is incurable. I have neATer seen the slightest benefit from drugs or electricity. The doAvnward progress is slow but certain, though in a feAv cases a temporary arrest may take place. With a history of syphilis, mercury and iodide of potassium may be tried, and GoAvers recommends courses of arsenic and strychnine. Probably the most useful means is systematic massage, particularly in the spastic cases. Bulbar Paralysis (Glos so-labio-laryngeal Paralysis). An affection of the motor nuclei of the medulla oblongata, rarely pri- mary, more commonly a part of a general degenerative affection of the nuclei of the motor path. The disease is sometimes called by the name of Duchenne. Acute and chronic forms may be recognized. (1) Acute bulbar paralysis may be due to («) haemorrhagic or embolic softening in the pons and medulla; (b) acute inflammatory softening, analogous to polio-myelitis, occurring occasionally as a post-febrile affec- tion. The onset is usually sudden, hence the term apoplectiform. The cases CHRONIC AFFECTIONS OF THE SPINAL CORD. 923 are almost invariably bilateral. As the nuclei presiding over the muscles of the tongue and lips are involved the speech is almost or entirely lost. The saliva drools, the lips are flabby and flaccid, swallowing may be diffi- cult, and there may be loss of power in the laryngeal muscles. Usually these cases rapidly prove fatal, but occasionally a case with a sudden onset, like that figured by Gowers, may become chronic. In these acute cases there may be loss of power in one arm, or hemiplegia, sometimes alternate hemiplegia, with paralysis on one side of the face and loss of power on the other side of the body. (2) Chronic bulbar paralysis is an affection of adult life, rarely begin- ning under the fortieth year, and in a great majority of the cases it is only part of a general degeneration of the motor nuclei. The disease usually begins with slight defect in the speech, and the patient has difficulty in pronouncing the dentals and linguals. The paralysis starts in the tongue, and the superior lingual muscle gradually becomes atrophied, and finally the mucous membrane is thrown into transverse folds. In the process of wasting the fibrillary tremors are seen. Owing to the loss of power in the tongue, the food is with difficulty pushed back into the pharynx. The saliva also may be increased, and is apt to accumulate in the mouth. When the lips become involved the patient can neither whistle nor pronounce the vowels o and u. The mouth looks large, the lips are prominent, and there is constant drooling. The food is masticated with difficulty. Swal- lowing becomes difficult, owing partly to the regurgitation into the nos- trils, partly to the involvement of the pharyngeal muscles. The muscles of the vocal cords waste and the voice becomes feeble, but the laryngeal paralysis is rarely so extreme as that of the lips and tongue. The course of the disease is slow but progressive. Death often results from an aspiration pneumonia, sometimes from choking, more rarely from involvement of the respiratory centres. The mind usually remains clear. The patient may become emotional. In a majority of the cases the dis- ease is only part of a progressive atrophy, either simple or associated with a spastic condition. In the latter stage of amyotrophic lateral sclerosis the bulbar lesions may paralyze the lips long before the pharynx or larynx becomes affected. The diagnosis of the disease is readily made, either in the acute or chronic form. The involvement of the lips and tongue is usually well marked, while that of the palate may be long deferred. A condition has been described, however, which may closely simulate bulbar paralysis. This is the so-called pseudo-bulbar form or bulbar palsy of cerebral origin. Bilateral disease of the motor cortex in the lower part of the ascending frontal convolution may cause paralysis of the lips and tongue and pharynx, which closely simulates a lesion of the medulla. Sometimes the symptoms appear on one side, but in many instances they develop suddenly on both sides. A bilateral lesion has usually been found, but in several instances the disease was unilateral. 924 DISEASES OF THE NERVOUS SYSTEM. Progressive bulbar paralysis is an incurable affection. Transient im- provement may occur. Strychnine may be tried. Electricity is of doubt- ful benefit. Special care must be taken in feeding these patients, and when deglutition becomes much impaired the stomach-tube should be employed. IV. DISEASES OF THE BRAIN. I. TOPICAL DIAGNOSIS. Only certain regions of the brain give localizing symptoms. These are the cortical motor centres, the speech centres, the centres for the special senses, and the tracts which connect these cortical areas with each other and with other parts of the nervous system. The following is a brief summary of the effects of lesions from the cortex to the spinal cord : 1. The Cerebral Cortex.—(a) Destructive lesions of the motor cortex cause spastic paralysis in the muscles of the opposite side of the body. The extent of the paralysis depends upon that of the lesion. It is apt to be limited to the muscles of an extremity, giving rise to the cerebral mono- plegias (Fig. 11,1). A lesion may involve two centres lying close together, thus producing paralysis of the face and arm, or of the arm and leg, but not of the face and leg without involvement of the arm. Very rarely the whole motor cortex is involved, causing paralysis of one side—cortical hemiplegia. Combined with the muscular weakness there is usually some disturb- ance of sensation, particularly tactile impressions and those of the mus- cular sense. (b) Irritative lesions cause localized spasms as described above. These convulsions are usually preceded and accompanied by sensory impressions. Tingling or pain, or a sense of motion in the part, is often the signal symptom (Seguin), and is of great importance in determining the seat of the lesion. Lesions are often both destructive and irritative, and we have combi- nations of the symptoms produced by each. For instance, certain muscles may be paralyzed, and those represented near them in the cortex may be the seat of localized convulsions, or the paralyzed limb itself may be at times subject to convulsive spasms, or muscles which have been convulsed may become paralyzed. In this manner it is often possible to trace the progress of a lesion involving the motor cortex. We have seen in a previous section that lesions involving the centres for the special senses may give rise to focal symptoms, and shall simply refer to them here. The symptoms caused by lesions of the speech centres will be described under aphasia, and it is only necessary to note the near TOPICAL DIAGNOSIS. 925 situation of the motor speech area (Broca’s centre) in the left third frontal convolution to the centres of the face and arm on that side, and to state that motor aphasia is often associated with monoplegia of the right side of the face and the right arm. Accompanying the paralysis follow- ing a Jacksonian fit of the right face or arm there is often a transient motor aphasia. (2) Centrum Ovale.—Lesions in this part of the motor path cause paralysis, which has the distribution of a cortical palsy when the lesion is near the cortex, and of that due to a lesion of the internal capsule when it is near that region. They may be associated with symptoms due to the interruption of the other system of fibres running in the centrum ovale, and there may be sensory distnrbances—hemianaesthesia and hemianopia— and if the lesion is in the left hemisphere one of the different forms of aphasia may accompany the paralysis. (3) Internal Capsule.—Here all the fibres of the upper motor segment are gathered together in a compact bundle, and a lesion in this region is apt to cause complete hemiplegia of the opposite side, and if the lesion involves the hinder third of the posterior limb there is also hemiansesthe- sia, including even the special senses (Fig. 4). (4) Crura Cerebri.—From this level through the pons, medulla, and cord, the upper and lower motor segments are represented, the first by the pyramidal fibres, the latter by the motor nuclei and the nerve fibres arising from them. Lesions often affect both motor segments, and pro- duce paralysis having the characteristics of each. Thus a single lesion may involve the pyramidal tract and cause a spastic paralysis on the opposite side of the body, and also involve the nucleus or the fibres of one of the cranial nerves, and so produce a lower-segment paralysis on the same side as the lesion—crossed paralysis. In the crus the third and fourth cranial nerves run over the pyramidal fibres, and a lesion of this region is apt to involve them, causing paralysis of the muscles of the eye on the same side as the lesion combined with a hemiplegia of the opposite side (Fig. 11, 3). The optic tract also crosses the crus and may be involved, giving hemianopsia in the opposite halves of the visual fields. (5) Pons and Medulla.—Lesions involving the pyramidal tract, to- gether with any one of the motor cranial nerves of this region, cause crossed paralysis. A lesion in the lower part of the pons is apt to cause a lower-segment paralysis of the face on the same side, and a spastic pa- ralysis of the arm and leg on the opposite side (Fig. 11, 4). The abdu- cens and hypoglossus nerves may also be paralyzed in the same manner. When the sensory fibres of the fifth nerve are interrupted, together with the sensory tract (the fillet) for the rest of the body, which has already crossed the middle line, there is a crossed sensory paralysis—i. e., disturbed sensation in the distribution of the fifth on the side of the lesion, and of all the rest of the body on the opposite side. 926 DISEASES OF THE NERVOUS SYSTEM. In lesions of the pons the patient often has a tendency to fall toward the side on which the lesion is, due probably to implication of the middle peduncle of the cerebellum. The symptoms produced by involvement of the different cranial nerves have been considered in detail in a previous section. (6) Cerebellum.—The functions of this part of the brain are still under consideration. Luciani, whose monograph is the most exhaustive, regards it as “ an end organ directly or indirectly related to certain pe- ripheral sensory organs and in direct efferent relationship with certain ganglia of the cerebro-spinal axis, and indirectly with the motor apparatus in general. It is functionally homogeneous, each part exercising the functions of the whole, but having special relations to the muscles of the corresponding side of the body ” (Krauss). Affections of the lateral lobes affect the corresponding side of the body, while lesions of the middle lobe affect both sides. Partial removal is followed by transient muscular weakness ; complete removal by extreme incoordination. Its one important function would appear to be the codr- dination of the muscular movements. W. C. Krauss has recently analyzed the lesions and symptoms in 100 cases of disease of this part. The morbid conditions were as follows : Sarcoma in 22 cases; tubercle in 22 ; glioma in 18 ; abscess in 10 ; tumor of unspecified nature in 13; cyst in 7 ; and one case each of softening, endothelioma, cyst and sarcoma, cancer, gumma, fibroma, and hsemor- rhage. The left lobe was affected thirty-two times, the right lobe thirty- two times, and the middle lobe seventeen times. Thus, tumor constituted by far the most important affection. There may be no symptoms what- ever if it is in one hemisphere only and does not involve the middle lobe. The most common symptoms in tumor are as follows Vertigo, which is more constant in this than in affections of any other region of the brain. Some believe this to be due to the central relations of the semicircular canals with the cerebellum. It was present in 48 of the cases of Krauss’s collection, not reported in 43. Headache was present in 83 cases. Vomiting occurred in 69 cases, not reported in 23. Optic neuritis was found in 66 cases, not reported in 23. Of symptoms which are designated as more particularly cerebellar, ataxia is the most important. The gait is irregular and staggering, and in attempting to walk the patient sways to and fro like a drunken man. As a rule, the patient walks and tends to fall toward the affected side, but the rule is not certain. Paresis of the trunk muscles, manifest in an inability to perform the movements of bending, erection, and lateral flexion of the trunk, may be present (Hughlings Jackson). Other less constant but suggestive symptoms are neuralgic pains in the region of the neck and occiput; blocking of the vense Galeni, and dilata- tion of the lateral ventricles,- causing in children hydrocephalus; pressure APHASIA. 927 on the medulla, producing paralyses of the cranial nerves, which may cause glycosuria or sudden death; and, lastly, bilateral rigidity from pres- sure on the motor paths. The reflexes, however, are very variable, and were absent in twelve cases. II. APHASIA. The speech mechanism consists of receptive, perceptive, and emissive centres in the cortex cerebri, disturbances of which cause aphasia, and centres in the medulla which preside over the muscles of articulation, dis- turbance of which produces anarthria, the condition of gradual loss of power of speech, such as occurs in bulbar paralysis. The studies of Bastian, Kussmaul, Wernicke, Lichtheim, and others have widened enormously our knowledge of speech disorders. Language is gradually acquired by imitation. Thus, in teaching a child to say hell, the sound of the uttered word enters the afferent path (auditory nerve) and reaches the auditory perceptive centre, from which an impulse is sent to the emissive or motor centre presiding over the nuclei in the medulla, through which the muscles of articulation are set in action. The arc in Lichtheim’s schema (Fig. 10) is a A, Mm. The child gradually ac- quires in this way word memories, which are stored at the centre A, and motor memories—the memories of the co-ordinated muscular movements necessary to utter words—which are stored at the centre M. In a similar manner, when shown the bell, the child acquires visual memories, which are conveyed through the optic nerve to the visual perceptive centres, o 0. So also the memo- ries of the sound of the bell when struck. The memory pict- ure of the shape of the bell, the memory of the appearance of the word bell as written, and the motor memories of the muscular movements required to write the word are distinct from each other; yet they are intimately connected, and form together what is termed the word-image. In addition to all this the child gradually acquires in his education ideas as to the use of the bell— intellectual concepts—the centre for which is represented at I in the diagram In volitional or intellectual speech, as in uttering the word hell, the path would be I, M m, and in writing the word, I, M, W, h. These various “memories” are as a rule stored or centred in the left hemisphere (see Fig. 3). Fig. 10.—Lichtheim’s schema. 928 DISEASES OF THE NERVOUS SYSTEM. The relations of written and spoken language are then with (a) sen* sory perceptive centres (hearing and sight and, in the blind, touch); (b) emissive or motor centres for speech and writing; and (c) psychical cen- tres, through which we obtain an intellectual conception of what is said or written, and by which we express voluntarily our ideas in lan- guage. There are two chief forms of aphasia—sensory and motor. (1) Sensory Aphasia; Apraxia; Word-blindness; Word-deafness.—By apraxia is understood a condition in which there is loss or impairment of the power to recognize the nature and characteristics of objects. Persons so affected act “ as if they no longer possessed such object memories, for they fail to recognize things formerly familiar. A fork, a cane, a pin, may be taken up and looked at by such a person, and yet held or used in a manner which clearly shows that it awakens no idea of its use. And this symp- tom, for which at first the term blindness of mind was used, is found to extend to other senses than that of sight. Thus the tick of a watch, the sound of a bell, a melody of music, may fail to arouse the idea which it formerly awakened, and the patient has then deafness of mind, or an odor or taste no longer calls up the notion of the thing smelled or tasted; and thus it is found that each or all of the sensory organs, when called into play, may fail to arouse an intelligent perception of the object exciting them. For the general symptoms of inability to recog- nize the use or import of an object the term apraxia is now employed.” (Starr.) Apraxia may occur alone, but more commonly is associated with varie- ties of sensory and motor aphasia. The patient may be able to read, but the words arouse no intelligent impression in his mind. While blind to memory-pictures aroused through sight, the perceptions may be stimu- lated by touch; thus there are instances on record of apraxic patients un- able to read by sight, who could on tracing the letters by touch name them correctly. Of the forms of apraxia, mind-blindness and mind- deafness are the most important. The cases of mind-blindness collected by Starr indicate that the lesion exists in the left hemisphere in right-handed persons, and in the right hemisphere in left-handed persons. The disease usually involves the angular and supramarginal gyri or the tracts proceeding from them. Blindness of the “ mind’s eye ” may at times be functional and transitory, and is associated with many forms of mental disturbance. In a remark- able case reported by Macewen, the patient, after an injury to the head, had suffered with headache and melancholia, but there was no paralysis. He was psychically blind and though he could see everything perfectly well and could read letters, objects conveyed no intelligent impression. A man before his eyes was recognized as some object, but not as a man until the sounds of the voice led to the recognition through the auditory centres. The skull was trephined over the angular gyrus and the inner APHASIA. 929 table was found to be depressed and a portion had been driven into the brain in this region. The patient recovered. Mind-blindness is the equiva- lent of visual amnesia. Word-blindness may occur alone or with motor aphasia. In un- complicated cases the patient is no longer able to recall the appear- ances of words, and does not recognize them on a printed or written page. The patient may be able to pronounce the letters and can often write correctly, but he cannot read what he has written. It is rare, however, for the patient to be able to write with any degree of facility. There are instances in which the patient, un- able to read, has yet been able to do mathematical problems and to recognize play cards. The lesion in cases of word-blindness is, in a majority of cases, in the angular and supramarginal gyri on the left side. It is commonly associated with hemianopia, and not infrequently with mind blindness (Fig. 3). Mind-deafness is a condition in which sounds, though heard and per- ceived as such, awaken no intelligent perceptions. A person who knows nothing of French has mind-deafness so far as the French language is concerned, and though he recognizes the words as words when spoken, and can repeat them, they awaken no auditory memories. The musical faculties may be lost in aphasics, who may become note-deaf and unable to appreciate melodies or to read music (amusia). This may occur with- out the existence of motor aphasia, and, on the other hand, there are cases on record in which with motor aphasia for ordinary speech the patient could sing and follow tunes correctly. Mind-deafness is also known as auditory amnesia. Word-deafness is a condition in which the patient no longer understands spoken language. The memory of the sound of the word is lost, and can neither be recalled nor recognized when heard. It is usually associated with other varieties of aphasia, though there are cases in which the patient has been able to read and write and speak. The lesion in word-deafness has been accurately defined in a number of cases to be in the posterior portion of the first and second temporal convolutions on the left side (Fig. 3). Other manifestations of mind-blindness are met with; thus a young man with secondary syphilis had several convulsive seizures, after one of which he remained unconscious for some time. On awakening, the mem- ory pictures of faces and places were a blank, and he neither knew his parents nor brothers, nor the streets of the town in which he lived. He had no aphasia proper, and no paralysis. (2) Motor or ataxic aphasia is a condition in which the memory of the efforts necessary to pronounce words is lost, owing to disturbance in the emissive centres. This is the variety long ago recognized by Broca, the lesion of which was localized by him in the third left frontal convolution. In pure cases the patient is able to read (not aloud) and understands perfectly what is said. He may not be able to utter a 930 DISEASES OF THE NERVOUS SYSTEM. single word; more commonly he can say one or two words, such as “no,” “yes,” and he not infrequently is able to repeat words. When shown an object, though not able to name it, he may evidently recog- nize what it is. If told the name, he may be able to repeat it. A man knowing the French and German languages may lose the power of ex- pressing his thoughts in them, while retaining his mother-tongue; or, if completely aphasic, may recover one before the other. As the third left frontal convolution is in close contact with the centres for the face and arm, these are not uncommonly involved, with the production of a partial or, in some instances, a complete right-sided hemiplegia. Alexia, or inability to read, occurs with motor aphasia and also with word- blindness. As a rule, in motor aphasia there is also inability to write — agraphia. When there is right brachial monoplegia it is difficult to test the capability, but there are instances of motor aphasia without paralysis, in which the power of voluntary writing is lost. The con- dition varies very much; thus a patient may not be able to write voluntarily or from dictation, and yet may copy perfectly. It is still a question whether there is a special writing centre. It has been placed by some writers at the base of the second frontal convolution, hut in a recent study Dejerine concludes that it is not separate from the speech centre. There is a form known as mixed aphasia, or paraphasia, in which the patient understands wliat is said, and speaks even long * sentences correctly, but he constantly tends to misplace wrords, and does not express his ideas in the proper words. All grades of this may be met with, from a state in which only a word or two is misplaced to an extreme condition in which the patient bilks jargon. In these cases the association tract is interrupted between the auditory perceptive and the emissive centres, hence it is sometimes known as Wernicke’s aphasia of conduction. The lesion is usually in the insula and in the convolutions which unite the frontal and temporal lobes. Liclitheim’s schema will assist the student in obtaining a rational idea of the varieties of aphasia: 1. In the condition of apraxia or mind-hlindness the ideation centres, I, are involved, often with the auditory and visual perceptive centres, A and 0. 2. A lesion at A, the centre for the auditory memories of words (first left temporal gyrus), is associated with word-deafness. 3. A lesion at 0, the centre for visual memories (angular and supra- marginal gyri), causes word-blindness. 4. Interruption of the tracts uniting A M and 0 M causes the conduc- tion aphasia of Wernicke—paraphasia. 5. Destruction of the centre M (Broca’s convolution) causes pure motor aphasia, in which the patient cannot express thoughts in speech. APHASIA. 931 A lesion at M usually destroys also the power of writing, but, as stated, it is believed by many that the centre for writing, W, is distinct from that of speech. In this case a lesion at M, which would destroy the power of voluntary speech, might leave open the connections be- tween 0 W and A W, by which the patient could copy or write from dictation. The problems of aphasia are in reality excessively complicated, and the student must not for a moment suppose that cases are as simple as diagrams indicate. A majority of them are very complex, but with patience the diagnosis of the different varieties can often be worked out. The following tests should be applied in each case of aphasia: (1) The power of recognizing the nature, uses, and relations of objects—i. e., whether apraxia is present or not; (2) the power to recall the name of familiar objects seen, smelled, or tasted, or of a sound when heard, or of an object touched; (3) the power to understand spoken words; (4) the capability of understanding printed or written language; (5) the power of appreciating and understanding musical tunes; (6) the power of voluntary speech—in this it is to be noted particularly whether he mis- places words or not; (7) the power of reading aloud and of understanding what he reads; (8) the power to write voluntarily and of reading what he has written ; (9) the power to copy; (10) the power to write at dictation ; and (11) the power of repeating words. Prognosis and Treatment.—In young persons the outlook is good, and the power of speech is gradually restored apparently by the education of the centres on the opposite side of the brain. In adults the condition is less hopeful, particularly in the cases of complete motor aphasia with right hemiplegia. The patient may remain speechless, though capable of understanding everything, and attempts at re-education may be futile. Partial recovery may occur, and the patient may be able to talk, but misplaces words. In sensory aphasia the condition may be only transient, and the different forms rarely persist alone without impair- ment of the powers of expression. The education of an aphasic person requires the greatest care and patience, particularly if, as so often happens, he is emotional and irritable. It is best to begin by the use of detached letters, and advance, not too rapidly, to words of only one syllable. Children often make rapid prog- ress, but in adults failure is only too frequent, even after the most pains- taking efforts. In the cases of right hemiplegia with aphasia the patient may be taught to write with the left hand. 932 DISEASES OF THE NERVOUS SYSTEM. III. AFFECTIONS OF THE MENINGES. Diseases of the Dura Mater (Pachymeningitis) {a) Pachymeningitis Externa.—Haemorrhage often occurs as a result of fracture. Inflammation of the external layer of the dura is rare. Caries of the bone, either extension from middle-ear disease or due to syphilis, is the principal cause. In the syphilitic cases there may be a great thickening of the inner table and a large collection of pus between the dura and the bone. Occasionally the pus is infiltrated between the two layers of the dura mater or may extend through and cause a dura-arachnitis. The symptoms of external pachymeningitis are indefinite. In the syphilitic cases there may be a small sinus communicating with the ex- terior. Compression symptoms may occur with or without paralysis. (b) Pachymeningitis Interna.—This occurs in three forms: (1) Pseudo- membranous, (2) purulent, and (3) hgemorrhagic. The first two are un- important. Pseudo-membranous inflammation of the lining membrane of the dura is not usually recognized, but a most characteristic example of it came under my observation as a secondary process in pneumonia. Purulent pachymeningitis may follow an injury, but is more commonly the result of extension from inflammation of the pia. It is remarkable how rarely pus is found between the dura and arachnoid membranes. Hemorrhagic Pachymeningitis (Hcematoma of the Dura Mater). This remarkable condition, first described by Yircliow, is very rare in general medical practice. During ten years no instance of it came under my observation at the Montreal General Hospital. On the other hand, in the post-mortem room of the Philadelphia Hospital, which received material from a large almshouse and asylum, the cases were not uncom- mon, and within three months I saw four characteristic examples, three of which came from the medical wards. On the other hand, the frequency AFFECTIONS OF THE MENINGES. 933 of the condition in asylum work may be gathered from the fact that Wig- glesworth found 42 examples in a series of 400 unselected post-mortem examinations. The disease is found chiefly in males and in persons over fifty years of age. It is most frequent in forms of chronic insanity and in chronic alcoholism. It has also been found in profound anaemia and other blood conditions, and is said to have followed certain of the acute fevers. The morbid anatomy is interesting. Virchow’s view that the delicate vascular membrane precedes the haemorrhage is undoubtedly correct. Practically we see one of three conditions in these cases: (a) Subdural vascular membranes, often of extreme delicacy; (b) simple subdural haem- orrhage ; (c) combination of the two, vascular membrane and blood-clot. Certainly the vascular membrane may exist without a trace of haemorrhage —simply a fibrous sheet of varying thickness, permeated with large vessels, which may form beautiful arborescent tufts. On the other hand, there are instances in which the subdural haemorrhage is found alone—in 15 out of Wigglesworth’s 42 cases—but it is possible that in some of these at least the haemorrhage may have destroyed all trace of the vascular mem- brane. In some cases a series of laminated clots are found, forming a layer from 3 to 5 mm. in thickness. Cysts may occur within this mem- brane. The source of the haemorrhage is probably the dural vessels. IIu- genin and others hold that the bleeding comes from the vessels of the pia mater, but certainly in the early stage of the condition there is no evi- dence of this; on the other hand, the highly vascular subdural membrane may be seen covered with the thinnest possible sheeting of clot, which has evidently come from the dura. The subdural haemorrhage is usually asso- ciated with atrophy of the convolutions, and it is held that this is one reason why it is so common in the insane; but there must be some other factor than atrophy, or we should meet with it in phthisis and various cachectic conditions in which the cerebral wasting is as common and almost as marked as in cases of insanity. The symptoms are indefinite, and the diagnosis cannot be made with certainty. Headache has been a prominent symptom in some cases, and when the condition exists on one side there may be hemiplegia. Extern sive bilateral disease may exist without any symptoms whatever. Diseases of the Pia Matee. (a) Acute Leptomeningitis.—In this form the exudation is between the pia and the arachnoid membranes. Etiology.—Acute inflammation of the pia mater occurs under the following circumstances : (1) As a result of an eruption of tubercles, most frequently in the basal meninges, forming the basilar or tuberculous men- ingitis which has been already considered (see tuberculosis). (2) In the epidemic cerebro-spinal fever. (3) Secondary to acute general diseases, 934 DISEASES OF THE NERVOUS SYSTEM. more particularly pneumonia, less frequently small-pox, typhoid fever, rheumatic fever, whooping cough, scarlet fever, and measles. In erysipelas meningitis may arise either by infection through the blood or by direct extension. Cases in which the inflammation passes through the bone are extremely rare; on the other hand, there are instances of exten- sive erysipelas of the face in which the disease travels along the nerve- roots and so reaches the meninges. In this group pneumonia is the only disease which is frequently followed by meningitis. In one hundred autopsies at the Montreal General Hospital in pneumonia, meningitis was found eight times, and I had several opportunities of seeing cases of simi- lar character in Philadelphia. In septicsemia and pyaemia, including ulcerative endocarditis in this category, acute meningitis is not very rare. In ulcerative endocarditis it is common, as may be judged from the statis- tics which I collected of 209 cases, of which 25 were complicated with meningitis. No instance has fallen under my observation in connection with typhoid fever or rheumatic fever. (4) Injury or disease of the bones of the skull, perforating wounds of the orbit, or as a sequence of abscess which is the result of injury. Under this section by far the most frequent cause is necrosis in the petrous portion of the temporal hone, which may excite either extensive inflammation of the pia mater or abscess of the brain. (5) In certain constitutional conditions, such as gout and Bright’s disease. This form is usually basilar and comes on insidiously. Gout is usually mentioned as a cause of meningitis, but it must be extremely rare. Duckworth does not refer to it in his work, and the symptoms of the so-called cerebral gout can scarcely be separated from those of urgemia. On the other hand, in Bright’s disease, I have met with at least three instances of well-marked meningitis, chiefly of the base. (6) While in a great majority of all cases of basilar meningitis in chil- dren tubercles may be found, a simple leptomeningitis infantum must also be recognized. Cases are not very uncommon. Two occurred in debili- tated children under my care at the Infants’ Home in Montreal, and I saw at least two specimens of the kind at the Philadelphia Hospital. The condition may he limited to the meninges at the base, particularly at the posterior part, and to the under surface of the cerebellum. It 1ms also been termed occlusive meningitis, owing to the fact that involving chiefly the posterior portion of the meninges about the cerebellum and medulla, the foramen of Magendie may be closed, with the result of acute, some- times purulent hydrocephalus, as described by Gee and Barlow. * (7) Other causes mentioned are sun-stroke and excessive study, which are probably doubtful. Syphilis, which is a common cause of chronic menin- gitis, rarely induces the acute form. Morbid Anatomy.—The basal or cortical meninges may be involved. In the form associated with pneumonia and ulcerative endocarditis the * On the Cervical Opisthotonos of Infants, St. Bartholomew’s Hospital Reports, 1878. AFFECTIONS OF THE MENINGES. 935 disease is bilateral and usually limited to the cortex. Iu extension from disease of the ear it is usually unilateral and may be accompanied with abscess or with thrombosis of the sinuses. In the non-tuberculous form in children, in the meningitis of chronic Bright’s disease, and in cachectic conditions the base is usually involved. The vessels are injected, the subarachnoid fluid is increased and becomes opaque. The arachnoid is also turbid, and there may be a yellowish-white, creamy exudate, or a gray- ish-green purulent matter beneath the arachnoid. The interpeduncular space may be completely filled with the exudate, which extends upon the under surface of the cerebellum. In the cases secondary to pneumonia the effusion beneath the arachnoid may be very thick and purulent, com- pletely hiding the convolutions. The ventricles also may be involved, though in these simple forms they rarely present the distention and soft- ening which is so frequent in the tuberculous meningitis. The leptomeningitis infantum may present a picture very similar to the tuberculous disease. There is exudation about the optic chiasma and in the Sylvian fissures and toward the cerebellum. In some instances we can say definitely that the condition is not tuberculous only after the most careful search in the meninges and central arteries, and when no tubercles are found in the lungs and bronchial glands. In other instances the men- ingitis may be limited to the posterior part of the base, about the pons, cerebellum, and fourth ventricle, and the lateral ventricles may present a most remarkable ependymitis. In a specimen recently shown to me by W. T. Howard, Jr., from a child aged three months (which had had an operation performed for imperforate anus), there was posterior basilar meningitis, the fourth ventricle was filled with pus, the walls thickened, rough, and infiltrated with pus; the lateral ventricles were enormously distended with pus, and the ependyma, which was from two to three milli- metres in diameter, was softened and in a condition of purulent infiltra- tion. A coccus and the bacterium coli commune were found in the pus. In a somewhat similar case at the Philadelphia Hospital the ependymitis was limited to the posterior and descending cornua, which were greatly distended and contained pus. The anterior cornua were little, if at all, affected, owing doubtless to the influence of gravity. This condition of intense purulent ependymitis is rare in the adult, but I remember to have seen an instance of it in a patient of Pepper’s at the University Hospital, Philadelphia. Symptoms.—I have already spoken at length of the clinical features of tuberculous meningitis, which is by far the most common and impor- tant form. The other varieties have a general resemblance to it, particu- larly those in which the base is affected. I have already, on several occa- sions, called attention to the fact that cortical meningitis is not to be recognized by any symptoms or set of symptoms from a condition which may be produced by the poison of many of the specific fevers. In the cases of so-called cerebral pneumonia, unless the base is involved and the 936 DISEASES OF THE NERVOUS SYSTEM. nerves affected, tlie disease is unrecognizable, since identical symptoms may be produced by intense engorgement of the meninges. In typhoid fever, in which meningitis is very rare, the twitchings, spasms, and re- tractions of the neck are almost invariably associated with cerebro-spinal congestion, not with meningitis. A knowledge of the etiology gives a very important clew. Thus, in middle-ear disease the development of high fever, delirium, vomiting, convulsions, and retraction of the head and neck would he extremely sug- gestive of meningitis or abscess. Headache, which may be severe and con- tinuous, is the most common symptom. In the fevers, particularly in pneumonia, there may be no complaint of headache. Delirium is fre- quently early, and is most marked when the fever is high. Convulsions are less common in simple than in tuberculous meningitis. They were not present in a single instance in the cases which I have seen in pneu- monia, ulcerative endocarditis, or septicaemia. In the simple meningitis of children they may occur. Rigidity and spasm or twitchings of the muscles are more common. Stiffness and retraction of the muscles of the neck are important symptoms; but they are by no means constant, and are most frequent when the inflammation extends to the meninges of the cervical cord. Vomiting is a common symptom in the early stages, particularly in basilar meningitis. Constipation is usually present. Optic neuritis is rare in the meningitis of the cortex, but is not uncommon when the base is involved. Important symptoms are due to lesions of the nerves at the base. Strabismus or ptosis may occur. The facial nerve may be involved, pro- ducing slight paralysis, or there may be damage to the fifth nerve, pro- ducing anaesthesia and, if the Gasserian ganglion is affected, trophic changes in the cornea. The pupils are ,at first contracted, subsequently dilated, and perhaps unequal. Fever is present, moderate in grade, rarely rising above 103°. In the non-tuberculous leptomeningitis of debilitated children and in Bright’s disease there may be little or no fever. The pulse may be increased in frequency at first and subsequently is slow and irregular. Treatment.—There are no remedies which in any way control the course of acute meningitis. An ice-bag should be applied to the head and, if the subject is young and full-blooded, general or local depletion may be practised. Absolute rest and quiet should be enjoined. When disease of the ear is present, a surgeon should be early called in con- sultation, and if there are symptoms of meningo-encephalitis which can in any way be localized trephining should be practised. An occasion- al saline purge will do more to relieve the congestion than blisters and local depletion. I have no belief whatever in the efficacy of counter- irritation to the back of the neck, and to apply a blister to a patient suffering with agonizing headache in meningitis is needlessly to add to the suffering. If counter-irritation is deemed essential, the thermo-cau- AFFECTIONS OF THE BLOOD-VESSELS. 937 tery, lightly applied, is more satisfactory. Large doses of the perchloride of iron, iodide of potassium, and mercury are recommended by some authors. The application of an ice-cap, attention to the bowels and stomach, and keeping the fever at a moderate height by sponging, are the necessary measures in a disease recognized as almost invariably fatal, and in which the cases of recovery are extremely doubtful. Quincke’s lumbar puncture (see page 979) has been used with success by Furbringer; 60 c. c. of cloudy fluid were removed, in which tubercle bacilli were found. The headache and other cerebral symptoms disappeared, and the patient, a man of twenty, recovered. Wallis Ord and Waterhouse report a case of recovery, in a child of five years, after trephining and drainage. (*) Chronic Leptomeningitis.—This is rarely seen apart from syphilis or tuberculosis, in which the meningitis is associated with the growth of the granulomata in the meninges and about the vessels. The symptoms in such cases are extremely variable, depending entirely upon the situa- tion of the growth. They may closely resemble those of tumor and be associated with localized convulsions. The leptomeningitis infantum may be chronic. In the cases reported by Gee and Barlow the duration in some instances extended even to a year and a half. The involvement of the posterior part of the meninges and of the ventricles may lead to dilata- tion and hydrocephalus. The symptoms upon which these authors lay stress are convulsions, and retraction of the head, which is particularly marked when the child is made to sit up. There may be rigidity of the limbs and epileptiform convulsions. IV. AFFECTIONS OF THE BLOOD-VESSELS Hyperemia. Congestion of the brain has played an important part in cerebral pathology. Undoubtedly there are great variations in the amount of blood in the cerebral vessels; this is universally conceded, but how far these changes are associated with a definite group of symptoms is not quite so clear. The hyperasmia may be either active or passive. Active hypercemia is associated with febrile conditions, with increased action of the heart, chilling of the surface, contraction of the superficial vessels, and with the suppression of certain customary discharges. Among other recognized causes are plethora, functional irritation, such as is asso- ciated with excessive brain work, and the action of certain substances, such as alcohol and nitrite of amyl. Passive hypercemia results from obstruction in the cerebral sinuses and veins, engorgement in the lesser circulation, as in mitral stenosis, emphysema, from pressure on the superior cava by aneurisms and tumors, and in the venous engorgement which takes place in prolonged straining 938 DISEASES OF THE NERVOUS SYSTEM. efforts. In its most intense form it is seen in the compression of the superior cava by tumors and in death from strangulation. The anatomical changes in congestion of the brain are by no means striking. Active hyperaemia is never visible post mortem. The veins of the cortex are distended, the gray matter has a deeper color, and its vessels are full. The arteries at the base and in the Sylvian fissures con- tain blood. Nothing, however, can be more uncertain or indefinite than the post-mortem appearances of hyperaemia of the brain. The most intense distention of the vessels is seen in early death during the specific fevers, or in the secondary passive congestion due to obstruction in the superior cava or in the lesser circulation. Symptoms.—There are no characteristic or constant features of cerebral hyperaemia. It may exist in the most extreme grade without the slightest disturbance of the cerebral functions, as is witnessed frequently in the pressure of tumors on the superior vena cava. How far the head- ache and delirium of the early stage of the infectious fevers is to be assigned to hyperaemia of the blood-vessels of the brain it is not easy to determine. The headache, dizziness, and unpleasant sensations in aortic insufficiency and in some instances of hypertrophy of the heart may be due to the cerebral congestion. As a separate clinical entity, congestion of the brain rarely comes under observation. I have no knowledge of instances associated with delirium, fever, insomnia, and convulsions, or of the so-called apoplectiform variety described by some writers. Very plethoric persons are subject to attacks of headache with flushing of the face and irritability of temper, attacks which may recur frequently and are sometimes relieved by bleed- ing at the nose. These are usually attributed to congestion of the brain. When passive hyperaemia reaches a high grade, there may be torpor, dul- ness of the intellect, and ultimately deep coma. Anasmia. This may be induced by loss of blood, either quickly, as in haemor- rhage, or gradually, as in the severe primary and secondary anaemias. The anaemia may be local and due to causes which interfere with the blood supply to the brain, as narrowing of the vessels by endarteritis, pressure, narrowing of the aortic orifice, or it may follow an unequal distribution of the blood in consequence of dilatation of certain vascular territories. Thus, rapid distention of the intestinal vessels, such as occurs after the removal of ascitic fluid, may cause sudden death from cerebral anaemia. The commonest illustration of this is the fainting fit from emotion, in which the blood supply to the brain is insufficient on account of the diminished arterial pressure. Anaemia of the cerebral vessels may be caused by pressure of fluid in the ventricles. The partial anaemia results from obliteration of branches of the circle of Willis by embolism or throm- AFFECTIONS OF THE BLOOD-VESSELS. 939 bosis. Ligature of one carotid sometimes causes a transient marked anae- mia and disturbance of function on one side of the brain. The anatomical condition' of the brain in anaemia is very striking. The membranes are pale, only the large veins are full, the small vessels *Dver the gyri are empty, and an unusual amount of cerebro-spinal fluid is present. On section both the gray and white matter look extremely pale and the cut surface is moist. Very few panda vasculosa are seen. Symptoms.—The effects of anaemia of the brain are well illustrated by a fainting fit in which loss of consciousness follows the heart weakness. When the result of haemorrhage, there are drowsiness, giddiness, inability to stand, flashes of light, and noises in the ear; the respiration becomes hur- ried ; the skin is cool and covered with sweat; and gradually, if the bleed- ing continues, consciousness is lost and death may occur with convulsions. In ordinary syncope the loss of consciousness is usually transient and the recumbent posture alone may suffice to restore the patient to con- sciousness. In the more chronic forms of brain anaemia, such as result from the gradual impoverishment of the blood, as in protracted illness or in starvation, the condition known as irritable weakness results. Mental effort is difficult, the slightest irritation is followed by undue excitement, the patient complains of giddiness and noises in the ears, or there may be hallucinations or delirium. These symptoms are met with in an extreme grade as a result of prolonged starvation. An interesting set of symptoms, to which the term liydrencephaloid was applied by Marshall Hall, occurs in the debility produced by prolonged diarrhoea in children. The child is in a semi-comatose condition with the eyes open, the pupils contracted, and the fontanelle depressed. In the earlier period there may be convulsions. The coma may gradually deepen, the pupils become dilated, and there may be strabismus and even retrac- tion of the head, symptoms which closely simulate basilar meningitis. CEdema of the Brain. In the pathology of brain lesions cedema formerly played a role almost equal in importance to congestion. It occurs under the following condi- tions : In general atrophy of the convolutions, in which case the cedema is represented by an increase in the cerebro-spinal fluid and in that of the meshes of the pia. In extreme hypersemia from obstruction, as in mitral stenosis or in tumors, there may be a condition of congestive cedema, in which, in addition to great filling of the blood-vessels, the substance of the brain itself is unusually moist. The most acute cedema is a local pro- cess found around tumors and abscesses. An intense infiltration, local or general, may occur in Bright’s disease, and to it, as Traube suggested, cer- tain of the urasmic symptoms may be due. The anatomical changes are not unlike those of anaemia. When a sequence of progressive atrophy, the fluid is chiefly within and beneath 940 DISEASES OF TIIE NERVOUS SYSTEM. the membranes. The brain substance is anaemic and moist, and has a wet, glistening appearance, which is very characteristic. In some in- stances the oedema is more intense and local and the brain substance may look infiltrated with fluid. The amount of fluid in the ventricles is usu- ally increased. The symptoms are in great part those of anaemia, and are not well defined. As just stated, some of the cerebral features of uraemia may depend upon it. Of late years cases have been reported by Raymond, Tenneson, and Dercum, in which unilateral convulsions or paralysis have occurred in connection with chronic Bright’s disease, and in which the condition appeared to be associated with oedema of the brain. The older writers laid great stress upon an apoplexia serosa, which may really have been a general oedema of the brain. Cerebral Hemorrhage. The bleeding may come from branches of either of the two great groups of cerebral vessels—the basal, comprising the circle of Willis and the central arteries passing from it, or the cortical group, the anterior, middle, and the posterior cerebral vessels. In a majority of the cases the haemorrhage is from the central branches, more particularly from those given off by the middle cerebral arteries in the anterior perforated spaces, and which supply the corpora striata and internal capsules. One of the largest of these branches which passes to the third division of the lenticular nucleus and to the hinder part of the internal capsule is so frequently in- volved in haemorrhage that it has been called by Charcot the artery of cerebral haemorrhage. The bleeding may be into the substance of the brain, to which alone the term cerebral apoplexy is applied, or into the membranes, in which case it is termed meningeal haemorrhage; both, however, are usually included under the terms intracranial or cerebral haemorrhage. Etiology.—The conditions which produce lesions of the blood-ves- sels play a very important part; thus the natural tendency to degeneration of the vessels in advanced life makes apoplexy much more common after the fiftieth year. It may, however, occur in children under ten. On account of the greater liability to arterial disease (associated probably with muscular exertion and the abuse of alcohol), men are more subject to cerebral haemorrhage than women. Heredity was formerly thought to be an important factor in this affection, and the apoplectic habitus or build is still referred to. By this is meant a stout, plethoric body of me- dium size, with a short neck. Heredity influences cerebral haemorrhage entirely through the arteries, and there are families in which they degener- ate early, usually in association with renal changes. The secondary hyper- trophy of the heart brings with it serious dangers, which have already been discussed in the section upon arteries. The three special factors in AFPECTIONS OF THE BLOOD-VESSELS. inducing arterio-sclerosis—the abuse of alcohol, syphilis, and prolonged muscular exertion—are found to be important antecedents in a large num- ber of cases of cerebral haemorrhage. The endocarditis of rheumatism and other fevers may indirectly lead to apoplexy by causing embolism and aneurism of the vessels of the brain. Cerebral haemorrhage occurs occasionally in the specific fevers and in profound alterations of the blood, as in leukaemia and pernicious anaemia. The actual exciting cause of the haemorrhage is not evident in the majority of cases. The attack may be sudden and without any pre- liminary symptoms. In other instances violent exertion, particularly straining efforts, or the excited action of the heart in emotion may cause a rupture. Morbid Anatomy.—The lesions causing apoplexy are almost in- variably in the cerebral arteries, in which the following changes may lead directly to it: (a) Periarteritis with the production of miliary aneurisms, rupture of which is the most common cause of cerebral haemorrhage. They occur most frequently on the central arteries, but also on the smaller branches of the cortical vessels. On section of the brain substance they may be seen as localized, small dark bodies about the size of a pin’s head. Sometimes they are seen in numbers upon the arteries carefully withdrawn from the anterior perforated spaces. According to Charcot and Bouchard, who have described them, they are most frequent in the central ganglia. In apo- plexy after the fortieth year if sought for they are rarely missed. (b) Aneurism of the branches of the circle of Willis. These are by no means uncommon, and will be considered subsequently. (c) Endarteritis and periarteritis in the cerebral vessels most commonly lead to apoplexy by the production of aneurisms, either miliary or coarse. There are instances in which the most careful search fails to reveal any- thing but diffuse degeneration of the cerebral vessels, particularly of the smaller branches; so that we must conclude that spontaneous rupture may occur without the previous formation of aneurism. The haemorrhage may be meningeal, cerebral, or intraventricular. Meningeal Hcemorrhage may be outside the dura, between this mem- brane and the bone, or between the dura and arachnoid, or between the arachnoid and the pia mater. The following are the chief causes of this form of haemorrhage: Fracture of the skull, in which case the blood usu- ally comes from the lacerated meningeal vessels, sometimes from the torn sinuses. In these cases the blood is usually outside the dura or between it and the arachnoid. The next most frequent cause is rupture of aneurisms on the larger cerebral vessels. The blood is usually subarachnoid. An intracerebral haemorrhage may burst into the meninges. A special form of meningeal haemorrhage is found in the new-born, associated with injury during birth. And lastly, meningeal haemorrhage may occur in the con- stitutional diseases and fevers. The blood may be in a large quantity at DISEASES OF TEE NERVOUS SYSTEM. the base; in cases of ruptured aneurism, particularly, it may extend into the cord or upon the cortex. Owing to the greater frequency of the aneu- risms in the middle cerebral vessels, the Sylvian fissures are often dis- tended with blood. Intracerebral hcemorrhage is most frequent in the neighborhood of the corpus striatum, particularly toward the outer section of the lenticular nucleus. The haemorrhage may be small and limited to the lenticular body and the internal capsule, or it may break the centrum ovale, or burst into the lateral ventricle, or extend to the insula. Haemorrhages con- fined to the white matter—the centrum ovale—are rare. Localized bleed- ing may occur in the crura or in the pons. Haemorrhage into the cere- bellum is not uncommon, and usually comes from the superior cerebellar artery. The extravasation may be limited to the substance or rupture into the fourth ventricle. Twice I have known sudden death in girls under twenty-five to be due to cerebellar haemorrhage. Ventricular Hcemorrhage.—This rarely comes from the vessels of the plexuses or of the walls. It is not infrequent in early life and may occur during birth. Of 94 cases collected by Edward Sanders, 7 occurred during the first year, and 14 under the twentieth year. In the cases which I have seen in adults it has almost always been caused by rupture of a vessel in the neighborhood of the caudate nucleus. The blood may be found in one ventricle only, but more commonly it is in both lateral ventricles, and may pass into the third ventricle and through the aqueduct of Sylvius into the fourth ventricle, forming a complete mould in blood of the ventricular system. Subsequent Changes.—The blood gradually changes in color, and ulti- mately the haemoglobin is converted into the reddish-brown haematoidin. Inflammation occurs about the apoplectic area, limiting and confining it, and ultimately a definite wall may be produced, inclosing a cyst with fluid contents. In other instances a cyst is not formed, but the connective-tissue proliferates and leaves a pigmented scar. In meningeal haemorrhage the effused blood may be gradually absorbed and leave only a staining of the membranes. In other cases, particularly in infants, when the effusion is cortical and abundant, there may be localized wasting of the convolutions and the production of a cyst in the meninges. Possibly certain of the cases of porencephaly are caused in this way. Secondary degeneration follows when the motor cortex or motor path is involved. Thus, in persons dying some years after a cerebral apoplexy which has produced hemiplegia, the degeneration may be traced in the crus, in the anterior part of the pons, in the pyramidal fibres of the me- dulla, in the direct fibres of the cord of the same side, and in the crossed pyramidal fibres of the opposite side. Symptoms.—These may be divided into primary, or those connected with the onset, and secondary, or those which develop later after the early manifestations have passed away. AFFECTIONS OF THE BLOOD-VESSELS. 943 Primary Symptoms.—Premonitory indications are rare. As a rule, the patient is seized while in full health or about the performance of some every-day action, occasionally an action requiring strain or extra exer- tion. Now and then instances are found in which there are sensations of numbness or tingling or pains in the limbs, or even choreiform movements in the muscles of the opposite side, the so-called prehemiplegic chorea. The onset of the apoplexy, as cerebral haemorrhage is usually called, varies greatly. There may be sudden loss of consciousness and complete relaxa- tion of the extremities. In such instances the name apoplectic stroke is particularly appropriate. In other cases the onset is more gradual and the loss of consciousness may not occur for a few minutes after the patient has fallen, or after the paralysis of the limbs is manifest. In the apoplec- tic attack the condition is as follows : There is deep unconsciousness; the patient cannot be roused. The face is injected, sometimes cyanotic, or of an ashen-gray hue. The pupils vary; usually they are dilated and in- active. The respirations are slow, noisy, and accompanied with stertor. Sometimes the Cheyne-Stokes rhythm may be present. The chest move- ments on the paralyzed side may be restricted, in rare instances on the opposite side. The pulse is usually full, slow, and of increased tension. The temperature may be normal, but is often found subnormal, and, as in a case reported by Bastian, may sink below 95°. In cases of basal haemor- rhage the temperature, on the other hand, may be high. The urine and faeces are usually passed involuntarily. Convulsions are not common. It may be difficult to decide whether the condition is apoplexy associated with hemiplegia or sudden coma from other causes. An indication of hemiplegia may be discovered in the difference in the tonus of the muscles on the two sides. If the arm or the leg is lifted, it drops “ dead ” on the affected side, while on the other it falls more slowly. Rigidity also may be present. In watching the movements of the facial muscles in the ster- torous respiration it will be seen that on the paralyzed side the relaxation permits the cheek to be blown out in a more marked manner. The head and eyes may be turned strongly to one side—conjugate deviation. In other cases, in which the onset is not so abrupt, the patient may not lose consciousness, but in the course of a few hours there is loss of pow- er, unconsciousness gradually develops, and deepens into profound coma. This is sometimes termed ingravescent apoplexy. The attack may occur during sleep. The patient may be found unconscious, or wakes to find that the power is lost on one side. Small hasmorrhages in the territory of the central arteries may cause hemiplegia without loss of consciousness. Usually within forty-eight hours after the onset of an attack there is febrile reaction, and more or less constitutional disturbance associated with inflammatory changes about the haemorrhage. The patient may die in this reaction, or, if consciousness has been regained, there may be delirium or recurrence of the coma. At this period the so-called early rigidity may develop in the paralyzed limbs. Trophic changes may occur, 944 DISEASES OF THE NERVOUS SYSTEM. such as sloughing or the formation of vesicles. The most serious of these is the sloughing eschar of the lower part of the back, or on the paralyzed side, which may appear within forty-eight hours of the onset and is usually of grave significance. The congestion at the bases of the lungs so com- mon in apoplexy is regarded by some as a trophic change. Conjugate Deviation.—In a right hemiplegia the eyes and head may be turned to the left side ; that is to say, the eyes look toward the cerebral lesion. This is almost the rule in the conjugate deviation of the head and eyes which occurs early in hemiplegia. When, however, convulsions or spasm develop or the state of so-called early rigidity in hemiplegia, the conjugate deviation of the head and eyes may be in the opposite direction ; that is to say, the eyes look away from the lesion and the head is rotated toward the convulsed side. This symptom may be associated with cortical lesions, particularly, according to some authors, when in the neighbor- hood of the supramarginal and angular gyri. It may also occur in a lesion of the internal capsule or in the pons, but in the latter situation the conjugate deviation is the reverse of that which occurs in other cases, as the patient looks away from the lesion, and in spasm or con- vulsion looks toward the lesion. In cases in which consciousness is re- stored and the patient improves, the unilateral paralysis which persists is known as Hemiplegia.—Hemiplegia is complete when it involves face, arm, and leg, or partial when it involves only one or other of these parts. This may be the result of a lesion (a) of the motor cortex; (b) of the pyramidal fibres in corona radiata and in the internal capsule; (c) of a lesion in the crus cerebri; or (d) in the pons Yarolii (see page 945). Haemorrhage is perhaps the most common cause, but tumors and spots of softening may also induce it. The special details of the hemiplegia may here be consid- ered. The face is involved on the same side as the arm and leg. This results from the fact that the facial muscles stand in precisely the same re- lation to the cortical centres as those of the arm and leg, the fibres of the upper motor segment of the facial nerve from the cortex decussating just as do those of the nerves of the limbs. The facial paralysis is partial, in- volving only the lower portion of the nerve, so that the orbicularis oculi and the frontalis muscles are uninvolved. The signs of the facial paralysis are usually well marked. There may be a slight difficulty in elevating the eyebrows or in closing the eye on the paralyzed side, or in rare cases the facial paralysis is complete, but the movements may be present with emo- tion, as laughing or crying. The hypoglossal nerve also is involved. In consequence, the patient cannot put out the tongue straight, but it devi- ates toward the paralyzed side, inasmuch as the genio-hyo-glossus of the sound side is unopposed. With right hemiplegia there may be aphasia. The arm is, as a rule, more completely paralyzed than the leg. The loss of power may be absolute or partial. In severe cases it is at first complete. In others, when the paralysis in the face and arm is com- plete that of the leg is only partial. The face and arm may alone be par- AFFECTIONS OF THE BLOOD-VESSELS. 945 Fig. 11.—Diagram of motor path from right brain. The upper segment is black, the lower red. The nuclei of the motor cranial nerves are shown on the left side; on the right side the cranial nerves of that side are indicated. A lesion at 1 would cause upper segment paralysis in the arm of the opposite side—cerebral mono- plegia ; at 2, upper segment paralysis of the whole opposite side of the body— hemiplegia; at 8, upper segment paralysis of the opposite face, arm, and leg, and lower segment paralysis of the eye muscles on the same side—crossed paralysis; at 4, upper segment paralysis of opposite arm and leg, and lower segment paraly- sis of the face and the external rectus on the same side—crossed paralysis; at 5, upper segment paralysis of all muscles below lesion, and lower segment paralysis of muscles represented at level of lesion—spinal paraplegia; at 6, lower segment paralysis of muscles localized at seat of lesion—anterior poliomyelitis. (Van Ge- huchten, modified.) 946 DISEASES OF THE NERVOUS SYSTEM. alyzed, while the leg escapes. Less commonly the leg is more affected than the arm, and the face may be only slightly involved. Certain muscles escape in hemiplegia, particularly those associated in symmetrical movements, as the thoracic and abdominal muscles, a fact which Broadbent explains by supposing that as the spinal nuclei control- ling these movements on both sides constantly act together, they may, by means of this intimate connection, be stimulated by impulses coming from only one side of the brain. Crossed Hemiplegia.—A paralysis in which there is loss of function in a cranial nerve on one side with loss of power (or of sensation) on the opposite side of the body is called a crossed or alternate hemiplegia. It is met with in lesions, commonly haemorrhage in the crus, the pons, and the medulla (Fig. 11, 3 and 4). {a) Crus.—The bleeding may come from vessels traversing the crus to reach the thalamus, or, most important of all, from rupture of the artery of the motor oculi nuclei. In the classical case of Weber, on section of the lower part of the left crus an oblong clot 15 mm. in length lay just below the internal and inferior surface. The characteristic features of a lesion in this locality are paralysis of arm, face, and leg of the opposite side, and motor oculi paralysis of the same side—the syndrome of Weber. Sensory and motor changes have also been present. Haemorrhage into the teg- mentum is not necessarily associated with hemiplegia, but there may be incomplete paralysis of the motor oculi nerve, with disturbance of sensa- tion on the opposite side of the body. (b) Pons and Medulla.—Lesions may involve the pyramidal tract and one or more of the cranial nerves. If at the lower aspect of the pons, the facial nerve may be involved, causing paralysis of the face on the same side and hemiplegia of the opposite side. The fifth nerve may be involved, with the fillet (the sensory tract), causing loss of sensation in the area of distribution of the fifth on the same side as the lesion and loss of sensation on the opposite side of the body. The sensory disturbances are variable. Hemianaesthesia may coexist with hemiplegia, but in many instances there is only slight numbness of sensation. When the hemiansesthesia is marked, it is usually the result of a lesion in the internal capsule. In C. L. Dana’s study of sensory localization he found that anaesthesia of organic cortical origin was always limited or more pronounced in certain parts, as the face, arm, or leg, and was generally incomplete. Total anaesthesia was either of functional or subcortical origin. Marked anaesthesia was much more common in soft- ening than in haemorrhage. Complete hemianaesthesia is certainly rare in haemorrhage. Disturbance of the special senses is not common. Ilemi- anopia may exist on the same side as the lesion, and there may be dimi- nution in the acuteness of the senses of hearing, taste, and smell. As a rule, there is at first no wasting of the paralyzed limbs. The deep reflexes are increased on the paralyzed side, and ankle clonus may be AFFECTIONS OF THE BLOOD-VESSELS. 947 present. The plantar and other superficial reflexes are usually dimin- ished. The sphincters are not affected. The course of the disease depends upon the situation and extent of the lesion. If slight, the hemiplegia may disappear completely within a few days or a few weeks. In severe cases the rule is that the leg gradually recovers before the arm, and the muscles of the shoulder girdle and upper arm before those of the forearm and hand. The face may recover quickly. Except in the very slight lesions, in which the hemiplegia is transient, changes take place which may be grouped as Secondary Symptoms.—These correspond to the chronic stage. In a case in which little or no improvement takes place within eight or ten weeks, it will be found that the paralyzed limbs undergo certain changes. The leg, as a rule, recovers enough power to enable the patient to get about, although the foot is dragged. In both arm and leg the condition of secondary contraction or late rigidity comes on and is always most marked in the upper extremity. The arm becomes permanently flexed at the elbow and resists all attempts at extension. The wrist is flexed upon the forearm and the fingers upon the hand. The position of the arm and hand is very characteristic. There is frequently, as the con- tractures develop, a great deal of pain. In the leg the contracture is rarely so extreme. The loss of power is most marked in the muscles of the foot, and to prevent the toes from dragging the knee in walking is much flexed, or more commonly the foot is swung round in a half- circle. The reflexes are at this stage greatly increased. These contractures are permanent and incurable, and are associated with a secondary descend- ing sclerosis of the motor path. There are instances, however, in which rigidity and contracture do not occur, but the arm remains flaccid, the leg having regained its power. This hemiplegie jlasque of Bouchard is found most commonly in children. Among other secondary changes in late hemiplegia may be mentioned the following: Tremor of the affected limbs, post-paralytic chorea, the mobile spasm known as athetosis, arthropa- thies in the joints of the affected side, and muscular atrophy. Athetosis and post-hemiplegic chorea will be considered in the hemiplegia of chil- dren. A word may here be said upon the subject of muscular atrophy of cerebral origin. As a rule, atrophy is not a marked feature in hemiplegia, but in some instances it does develop. It has been shown to be due in some cases to secondary alterations in the gray matter of the anterior horns, as in a case reported by Charcot. Recently, however, attention has been called by Quincke to the fact that atrophy may follow as a direct result of the cere- bral lesion. In his case, atrophy of the arm followed the development of a glioma in the anterior central convolutions. The gray matter of the anterior horns was normal. This wasting of cerebral origin occurs most frequently in children. 948 DISEASES OF THE NERVOUS SYSTEM. Diagnosis.—There are three groups of cases which offer increasing difficulty in recognition. (1) Cases in which the onset is gradual, a day or two elapsing before the paralysis is fully developed and consciousness completely lost, are readily recognized, though it may be difficult to determine whether the lesion is due to thrombosis or to haemorrhage. (2) In the sudden apoplectic stroke in which the patient rapidly loses consciousness, the difficulty in diagnosis may be still greater, particularly if the patient is in de6p coma when first seen. The first point to be decided is the existence of hemiplegia. This may be difficult, although, as a rule, even in deep coma the limbs on the para- lyzed side are more flaccid and drop instantly when lifted; whereas, on the non-paralyzed side the muscles retain some degree of tonus. The reflexes may be increased on the affected side and there may be conjugate deviation of the head and eyes. Rigidity in the limbs of one side is in favor of a hemiplegic lesion. It is practically impossible in a majority of these cases to say whether the lesion is due to haemorrhage, embolism, or thrombosis. (3) Large haemorrhage into the ventricles or into the pons may pro- duce sudden loss of consciousness with complete relaxation, so that the condition may simulate coma from uraemia, alcoholism, opium poisoning, or epilepsy. The previous history and the mode of onset may give valua- ble information. In epilepsy convulsions have preceded the coma; in alcoholism there is a history of constant drinking, while in opium poison- ing the coma develops more gradually; but in many instances the diffi- culty is practically very great, and on more than one occasion I have seen mortifying post-mortem disclosures under these circumstances. In ven- tricular hasmorrhage the coma is sudden and develops rapidly. The hemiplegic symptoms may be transient, quickly giving place to complete relaxation. Convulsions occur in many cases, and may be the very symp- tom to lead astray—as in a case of ventricular haemorrhage which occurred in a puerperal patient, in whom, naturally enough, the condition was thought to be uraemic. Rigidity is often present. In haemorrhage into the pons convulsions are frequent. The pupils may be strongly con- tracted, conjugate deviation may occur, and the temperature is apt to rise rapidly. The contraction of the pupils in pontine haemorrhage naturally suggests opium poisoning. The difference in temperature in the two con- ditions is a valuable diagnostic point. It may be impossible at first to give a definite diagnosis. In admissions to hospitals or in emergency cases the physician should be particularly careful about the following points: The examination of the head for in- jury or fracture; the urine should be tested for albumen and examined for sugar; a careful examination should be made of the limbs with refer- ence to their degree of relaxation or the presence of rigidity, and the con- dition of the reflexes; the state of the pupils should be noted and the AFFECTIONS OF THE BLOOD-VESSELS. 949 temperature taken. The most serious mistakes are made in the case of patients who are drunk at the time of the attack, a combination by no means uncommon in the class of patients admitted to hospital. Under these circumstances the case may be looked upon as one of alcoholic coma. It is best to regard each case as serious and to bear in mind that this is a condition in which, above all others, mistakes are common. Prognosis.—From cortical haemorrhage, unless very extensive, the recovery may be complete without a trace of contracture. This is more common when the haemorrhage follows injury than when it results from disease of the arteries. Infantile meningeal haemorrhage, on the other hand, is a condition which may produce idiocy or spastic diplegia. Large haemorrhages into the corona radiata and those which rupture into the ventricles rapidly prove fatal. The hemiplegia which follows lesions of the internal capsule, the re- sult of rupture of the artery of the corpus striatum, is usually persistent and followed by contracture. When the posterior fibres are involved there may be hemianaesthesia, and later hemichorea or athetosis. In any case of cerebral apoplexy the following symptoms are of grave omen : per- sistence or deepening of the coma during the second and third day; rapid rise in temperature within the first forty-eight hours after the initial fall. In the reaction which takes place on the second or third day, the tem- perature usually rises, and its gradual fall on the third or fourth day with return of consciousness is a favorable indication. The rapid formation of bed-sores, particularly the malignant decubitus of Charcot, is a fatal indi- cation. The occurrence of albumen and sugar, if abundant, in the urine is an unfavorable symptom. When consciousness returns and the patient is improving, the ques- tion is anxiously asked as to the paralysis. The extent of this cannot be determined for some weeks. With slight lesions it may pass off entirely. If persistent at the end of a month some grade of permanent palsy is cer- tain to remain, and gradually the late rigidity supervenes. ExUbolism axd Thrombosis (Cerebral Softening). (a) Embolism.—The embolus usually enters the carotid, rarely the vertebral artery. In the great majority of cases it comes from the left heart and is either a vegetation of a fresh endocarditis or, more com- monly, of a recurring endocarditis, or from the segments involved in an ulcerative process. Less often the embolus is a portion of a clot which has formed in the auricular appendix. Portions of clot from an aneurism, thrombi from atheroma of the aorta, or from the territory of the pulmonary veins, may also cause blocking of the branches of the circle of Willis. In the puerperal condition cerebral embolism is not in- frequent. It may occur in women with heart-disease, but in other in- stances the heart is uninvolved, and the condition has been thought to be 950 DISEASES OF THE NERVOUS SYSTEM. associated, with the development of heart-clots, owing to increased coagu- lability of the blood. A majority of cases of embolism occur in heart- disease, 89 per cent (Saveliew). Cases are rare in the acute endocarditis of rheumatism, chorea, and febrile conditions. It is much more common in the secondary recurring endocarditis which attacks old sclerotic valves. The embolus most frequently passes to the left middle cerebral artery, as it enters the left carotid oftener than the right because of the more direct course of the blood in the former. The posterior cerebral and the verte- bral are less often affected. A large plug may lodge at the bifurcation of the basilar. Embolism of the cerebellar vessels is rare. Embolism occurs more frequently in women, owing, no doubt, to the greater frequency of mitral stenosis. Contrary to this general statement, Newton Pitt’s statistics of 79 cases at Guy’s Hospital indicate, however, that males are more frequently affected; for in this series there were 44 males and 35 females. Saveliew gives 54 per cent in women. (b) Thrombosis.—Clotting of blood in the cerebral vessels occurs about an embolus, as the result of a lesion of the arterial wall (either endarte- ritis with or without atheroma or, particularly, the syphilitic arteritis), in aneurisms both coarse and miliary, and very rarely as a result of abnormal conditions of the blood. Thrombosis occasionally follows ligation of the carotid artery. The thrombosis is most common in the middle cerebral and in the basilar arteries. According to Kolisko, softening of limited areas, sufficient to induce hemiplegia, may be caused by sudden collapse of certain cerebral arteries from cardiac weakness. Anatomical Changes.—Degeneration and softening of the territory sup- plied by the vessels is the ultimate result. Blocking in a terminal artery may be followed by a condition resembling infarct, in which the territory is deeply infiltrated with blood. More commonly the change is much less striking, and the affected region may look only a little paler than normal or slightly softer. Gradually the process of softening proceeds, the tissue is infiltrated with serum and is moist, the nerve-fibres degenerate and become fatty. The neuroglia is swollen and cedematous. The color of the softened area depends upon the amount of blood. The haemoglobin undergoes gradual transformation, and the early red color may give place to yellow. Formerly much stress was laid upon the difference between reel, yellow, and white softening. The red and yellow are seen chiefly on the cortex. Sometimes the red softening is particularly marked in cases of embolism and in the neighborhood of tumors. The gray matter shows many punctiform haemorrhages—capillary apoplexy. There is a variety of yellow softening—the plaques jaunes—common in elderly persons, which occurs in the gray matter of the convolutions. The spots are from one to two centimetres in diameter, sometimes are angular in shape, the edges cleanly cut, and the softened area is represented by either a turbid, yellow material, or in some instances there is a space crossed by fine trabeculae, in the meshes of which there is fluid. White softening AFFECTIONS OF THE BLOOD-VESSELS. 951 occurs most frequently in the white matter, and is seen best about tumors and abscesses. Inflammatory changes are common in and about the soft- ened areas. When the embolus is derived from an infected focus, as in ulcerative endocarditis, suppuration may follow. The final changes vary very much. The degenerated and dead tissue elements are gradually but slowly removed, and if the region is small may be replaced by growth of connective tissue and the formation of a scar. If large, the resorption results in the formation of a cyst. It is surprising for how long an area of softening may persist without much change. The position and extent of the softening depend upon the obstructed artery. An embolus which blocks the middle cerebral at its origin in- volves both the arteries in the anterior perforated space and the cortical branches, and in such a case there is softening in the neighborhood of the corpus striatum, as well as in part of the region supplied by the corti- cal vessels. The freedom of anastomosis between these branches varies a good deal. Thus, there are instances of embolism of the middle cere- bral artery in which the softening has only involved the territory of the central branches, in which case blood has reached the cortex through the anterior and posterior cerebrals. When the middle cerebral is blocked (as is perhaps oftenest the case) beyond the point of origin of the central arteries, one or other of its branches is usually most involved- The embo- lus may lodge in the vessel passing to the third frontal convolution, or in the artery of the ascending frontal or ascending parietal; or it may lodge in the branch passing to the supramarginal and angular gyri, or it may enter the lowest branch which is distributed to the upper convolutions of the temporo-sphenoidal lobe. These are practically terminal arteries, and instances frequently occur of softening limited to a part, at any rate, of the territory supplied by them. Some of the most accurate focalizing lesions are in this way produced. Symptoms.—Extensive thrombotic softening may exist without any symptoms. It is not uncommon in the post-mortem examination of the bodies of elderly persons to find the plaques jaunes scattered over the convolutions. So, too, softening may take place in the “ silent ” regions, as they are termed, without exciting any symptoms. When the central or cortical branches of the middle cerebral arteries are involved the symp- toms are similar to those of haemorrhage. Permanent or transient hemi- plegia results. When the central arteries are involved the softening in the internal capsule is commonly followed by permanent hemiplegia. There are certain peculiarities associated writh embolism and with throm- bosis respectively. In embolism the patient is usually the subject of heart-trouble, or there exist some of the conditions already mentioned. The onset is sudden, without premonitory symptoms. When the embolism blocks the left middle cerebral artery the hemiplegia is usually associated with aphasia. In thrombosis, on the other hand, the onset is more gradual; the patient 952 DISEASES OF THE NERVOUS SYSTEM. has previously complained of headache, vertigo, tingling in the fingers; the speech may have been embarrassed for some days; the patient has had loss of memory or is incoherent, or paralysis begins at one part, as the hand, and extends slowly, and the hemiplegia may be incomplete or variable. Abrupt loss of consciousness is much less common, and when the lesion is small consciousness is retained. Thus, in thrombosis due to syphilitic disease, the hemiplegia may come on gradually without the slightest disturbance of consciousness. The hemiplegia following thrombosis or embolism has practically the characteristics, both primary and secondary, described under haemorrhage. The following may be the elfects of blocking the different vessels: (a) Vertebral.—The left branch is more frequently plugged. The effects are involvement of the nuclei in the medulla and symptoms of acute bulbar paralysis. It rarely occurs alone ; more commonly with (b) Blocking of the basilar artery. When this is entirely occluded, there may he bilateral paralysis from involvement of both motor paths. Bulbar symptoms may be present; rigidity or spasm may occur. The temperature may rise rapidly. The symptoms, in fact, are those of apo- plexy of the pons. (c) The posterior cerebral supplies the occipital lobe on its inner face and the greater part of the temporo-sphenoidal lobe. Localized areas of softening may exist without symptoms. Blocking of the branch passing to the cuneus may be followed by hemianopia. Iiemianaesthesia may re- sult from involvement of the posterior part of the internal capsule. (d) Internal Carotid.—The symptoms are variable. As is well known, the vessel is in a majority of cases ligated without risk. In other in- stances transient hemiplegia follows; in others again the hemiplegia is per- manent. These variations depend on the anastomoses in the circle of Wil- lis. If these are large and free, no paralysis follows, but in cases in which the posterior communicating and the anterior communicating vessels are small or absent, the paralysis may persist. In No. 7 of my Elwyn series of cases of infantile hemiplegia, the woman, aged twenty-four, when six years old, had the right carotid ligated for abscess following scarlet fever, with the result of permanent hemiplegia. Blocking of the internal ca- rotid within the skull by thrombosis or embolism is followed by hemiplegia, coma, and usually death. The clot is rarely confined to the carotid itself, but spreads into its branches and may involve the ophthalmic artery. (e) Middle Cerebral.—This is the vessel most commonly involved, and, as already mentioned, if plugged before the central arteries are given off, permanent hemiplegia usually follows from softening of the internal cap- sule. Blocking of the branches beyond this point may be followed by hemiplegia, which is more likely to be transient, involves chiefly the arm and face, and if on the left side is associated with aphasia. The individual AFFECTIONS OF THE BLOOD-VESSELS. 953 branches passing to the third frontal, ascending parietal, to the supramar- ginal and angular gyri, or to the temporal gyri may be plugged. (/) Anterior Cerebral.—No symptoms may follow, and even when the branches which supply the paracental lobule and the top of the ascending convolutions are plugged the branches from the middle cerebral are usu- ally able to effect a collateral circulation in these parts. Hebetude and dulness of intellect may occur with obstruction of the vessel. There is unquestionably greater freedom of communication in the cortical branches of the different arteries than is usually admitted, al- though it is not possible, for example, to inject the posterior cerebral through the middle cerebral, or the middle cerebral from the anterior; but the absence of softening in some instances in which smaller branches are blocked shows how completely may be the compensation. The dila- tation of the collateral branches may take place very rapidly ; thus a pa- tient with chronic nephritis died about twenty-four hours after the hemi- plegic attack. There were recent vegetations on the mitral and an embolus in the right middle cerebral artery just beyond the first two branches (temporal). The central portion of the hemisphere was swollen and cedematous. The right anterior cerebral was greatly dilated, and by measurement its diameter was found to be nearly three times that of the left. Treatment of Cerebral Haemorrhage.—The patient should be placed with the head high, and measures immediately taken to reduce the arterial pressure. Of these the most rapid and satisfactory is venesection, which should be practiced whenever the arterial tension is much in- creased. With a small pulse of low tension and signs of cardiac weak- ness it is contra-indicated. The chief difficulty is in determining whether the apoplexy is really due to haemorrhage, or to thrombosis or embolism, since in the latter group of cases bleeding probably does harm. As a rule, however, in middle-aged men with arterio-sclerosis, an accentuated aortic second sound, and hypertrophy of the left ventricle, bleeding is indicated. Horsley and Spencer have recently, on experimental grounds, recom- mended the practice, formerly employed empirically, of compression of the carotid, particularly in the ingravescent form ; or even, in suitable cases, passing a ligature round the vessel. An ice-bag may be placed on the head and hot bottles to the feet. The bowels should be freely opened, either by calomel, or croton oil placed on the tongue. Counter-irritation to the neck or to the feet is not necessary. When dyspnoea, stertor, and signs of mechanical obstruction are present, the patient should be turned on the side, as recommended by Bowles. This procedure also lessens the liability to congestion of the lungs. Special care should be taken to avoid bed-sores ; and if bottles are used to the feet, they should not be too hot, since blisters may be readily caused by much lower temperature than in health. In the fever of reac- tion, aconite may be indicated, but should be cautiously used. Stimu- 954 DISEASES OF THE NERVOUS SYSTEM. lants are not necessary, unless the pulse becomes feeble and signs of col- lapse supervene. The treatment of softening from thrombosis or embolism is very un- satisfactory. Venesection is not indicated, as it lowers the tension and rather promotes clotting. If, as is often the case, the heart’s action is feeble and irregular, stimulants and small doses of digitalis may be given with, if necessary, ether or ammonia. The bowels should be kept open, but it is not well to purge actively, as in haemorrhage. In the thrombosis which follows syphilitic disease of the arteries, and which is met with most frequently in men between twenty and forty (in whom the hemiplegia often sets in without loss of consciousness), the iodide of potassium should be freely used, giving from twenty to thirty grains three times a day, or, if necessary, larger doses. If the syphilis has been recent, mercurials are also indicated. Practically these are the only cases of hemiplegia in which we see satisfactory results from treatment. Operative treatment has been suggested, and when the diagnosis of subdural haemorrhage can be made it is justifiable. An attempt to reach a central haemorrhage in the neighborhood of the internal capsule would only increase the damage to the brain-substance. Very little can be done for the hemiplegia which remains. The damage is too often irreparable and permanent, and it is very improbable that iodide of potassium, or any other remedy, hastens in the slightest degree Nature’s dealing with the blood-clot. The paralyzed limbs may be gently rubbed once or twice a day, and this should be systematically carried out, in order to maintain the nutri- tion of the muscles and to prevent, if possible, contractures. After the lapse of a fortnight the muscles may be stimulated by the faradic current; but when contractures develop, electricity is useless, and the passive move- ments and frictions are alone indicated. In a case of complete hemiplegia, the friends should at the outset be frankly told that the chances of full recovery are slight. Power is usually restored in the leg sufficient to enable the patient to get about, but in the majority of instances the finer movements of the hand are per- manently lost. The general health should be looked after, the boAvels regulated, and the secretions of the skin and kidneys kept active. In permanent hemiplegia in persons above the middle period of life, more or less mental weakness is apt to follow the attack, and the patient may be- come irritable and emotional. And, lastly, when hemiplegia has persisted for more than three months and contractures have developed, it is the duty of the physician to explain to the patient, or to his friends, that the condition is past relief, that medi- cines and electricity will do no good, and that there is no possible hope of cure. AFFECTIONS OF THE BLOOD-VESSELS. 955 Aneurism of the Cerebral Arteries. Miliary aneurisms are not included, but reference is made only to aneurism of the larger branches. The condition is not uncommon. There were twelve instances in my first eight hundred autopsies in Montreal.* This is a considerably larger proportion than in Newton Pitt’s collection from Guy’s Hospital, nineteen times in nine thousand inspections. Etiology.—Males are more frequently affected than females. Of my twelve cases seven were males. The disease is most common at the middle period of life. One of my cases was a lad of six. Pitt describes one at the same age. The chief causes are (a) endarteritis, either simple or syphilitic, which leads to weakness of the wall and dilatation; and (i) embolism. As pointed out by Church, these aneurisms are often found with endocarditis. Pitt, in his recent study of the subject, concludes that it is exceptional to find cerebral aneurism unassociated with fungating endocarditis. The embolus disappears, and dilatation follows the second- ary inflammatory changes in the coats of the vessel. Morbid Anatomy.—The middle cerebral branches are most fre- quently involved. In my twelve cases the distribution on the arteries was as follows: Internal carotid, 1; middle cerebral, 5; basilar, 3; anterior communicating, 3. With the exception of one case they were saccular and communicated with the lumen of the vessel by an orifice smaller than the circumference of the sac. In the 154 cases which make up the statis- tics of Lebert, Durand, and Bartholow the middle cerebral was involved in 44, the basilar in 41, internal carotid in 23, anterior cerebral in 14, pos- terior communicating in 8, anterior communicating in 8, vertebral in 7, posterior cerebral in 6, inferior cerebellar in 3 (Gowers). The size of the aneurism varies from that of a pea to that of a walnut. The haemorrhage may be entirely meningeal with very slight laceration of the brain sub- stance, but the bleeding may be, as Coats has shown, entirely within the substance. Symptoms.—The aneurism may attain considerable size and cause no symptoms. In a majority of the cases the first intimation is the rupt- ure and the fatal apoplexy. Distinct symptoms are most frequently caused by aneurism of the internal carotid, which may compress the optic nerve or the commissure, causing neuritis or paralysis of the third nerve. A murmur may be audible on auscultation of the skull. Aneurism in this situation may give rise to irritative and pressure symptoms at the base of the brain or to hemianopsia. In the remarkable case reported by Weir Mitchell and Dercum an aneurism compressed the chiasma and produced bilateral temporal hemianopsia. Aneurism of the vertebral or of the basilar may involve the nerves from * Canada Medical and Surgical Journal, vol. xiv. 956 DISEASES OF THE NERVOUS SYSTEM. the fifth to the tAvelfth. A large sac at the termination of the basilar may compress the third nerves or the crura. The diagnosis is, as a rule, impossible. The larger sacs produce the symptoms of tumor, and their rupture is usually fatal. Endarteritis. In no group of vessels do we more frequently see chronic degenera- tive changes than in those of the circle of Willis. The condition oc- curs as: (a) Arteriosclerosis, producing localized or diffused thickening of the intima with the formation of atheromatous patches or areas of calcifica- tion. In the later stages, as seen in elderly people, the arteries of the circle of Willis may be dilated, stiff, or almost universally calcified. (b) Syphilitic Endarteritis.—As already mentioned under the section of syphilis, gummatous endarteritis is specially prone to attack the cere- bral vessels. It has in itself no specific characters—that is to say, it is impossible in given sections to pick out an endarteritis syphilitica from an ordinary endarteritis obliterans. On the other hand, as already stated, the nodular periarteritis is never seen except in syphilis. Thrombosis of the Cerebral Sinuses and Veins. The condition may be primary or secondary. Primary thrombosis of the sinuses and veins is rare. It occurs (a) in children, particularly during the first six months of life, usually in con- nection with diarrhoea. It has, in my experience, been a rare condition. I have never seen an example of spontaneous thrombosis of the sinuses in a child, and only two instances, both in connection with meningitis, in which the cortical veins contained clots. Gowers believes that it is of fre- quent occurrence, and that thrombosis of the veins is not an uncommon cause of infantile hemiplegia. (b) In connection Avith chlorosis and anaemia. Brayton Ball has recently called attention to this interesting association, and has reported one case and collected ten or eleven others from the literature. All Avere in girls Avith anaemia or chlorosis. (c) In the terminal stages of cancer, phthisis, and other chronic dis- eases thrombosis may gradually occur in the sinuses and cortical veins. To the coagulum developing in these conditions the term marantic throm- bus is applied. Secondary Thrombosis is much more frequent and folloAvs extension of inflammation from contiguous parts to the sinus Avail. The com- mon causes are disease of the internal ear, fracture, compression of the sinuses by tumor, or suppurative disease outside the skull, particularly erysipelas. In these cases the lateral sinus is most frequently involved. AFFECTIONS OF TIIE BLOOD-VESSELS. 957 Of 57 fatal cases in which ear-disease caused death with cerebral lesions, there were 22 in which thrombosis existed in the lateral sinuses (Pitt). The thrombus may he small, or may fill the entire sinus and extend into the internal jugular vein. In more than one half of these instances the thrombus was suppurating. The disease spreads directly from the necro- sis on the posterior wall of the tympanum. It is not so common in disease of the mastoid cells. Symptoms.—Primary thrombosis of the longitudinal sinus may occur without exciting symptoms and is found accidentally at the post- mortem. There may be mental dulness with headache. Convulsions and vomiting may occur. In other instances there is nothing distinctive. In a patient who died under my care, at the Philadelphia Hospital, of phthisis, there was a gradual torpor, deepening to coma, without convulsions, local- izing symptoms, or optic neuritis. The condition was thought to he due to a terminal meningitis. In the chlorosis cases the head symp- toms have, as a rule, been marked. Ball’s patient was dull and stupid, had vomiting, dilatation of the pupils, and double choked disks. Slight paresis of the left side occurred. An interesting feature in her case was the development of swelling of the left leg. In the cases reported by An- drew, Church, Tuckwell, Isamhard Owen, and Wilks the patients had headache, vomiting, and delirium. Paralysis was not present. In Doug- las Powell’s case, with similar symptoms, there was loss of power on the left side. Bristowe reports a case of great interest in an anaemic girl of nineteen, who had convulsions, drowsiness, and vomiting. Tenderness and swelling developed in the position of the right internal jugular vein, and a few days later on the opposite side. The diagnosis was rendered definite by the occurrence of phlebitis in the veins of the right leg. The patient recovered. The onset of such symptoms as have been mentioned in an anaemic or chlorotic girl should lead to the suspicion of cerebral thrombosis. In infants the diagnosis can rarely be made. Involvement of the cavernous sinus may cause oedema about the eyelids or prominence of the eyes. In the secondary thrombi the symptoms are commonly those of septi- caemia. For instance, in over seventy per cent of Pitt’s cases the mode of death was by pulmonary pyaemia. This author draws the following im- portant conclusions: (1) The disease spreads oftener from the posterior wall of the middle ear than from the mastoid cells. (2) The otorrhcea is generally of some standing, but not always. (3) The onset is sudden, the chief symptoms being pyrexia, rigors, pains in the occipital region and in the neck, associated with a septicaemic condition. (4) Well-marked optic neuritis may be present. (5) The appearance of acute local pulmo- nary mischief or of distant suppuration is almost conclusive of thrombosis. (6) The average duration is about three weeks, and death is generally from pulmonary pyaemia. The chief points in the diagnosis may be gath- ered from these statements. 958 DISEASES OF THE NERVOUS SYSTEM. Pitt records an interesting case of recovery in a boy of ten, who had otorrhcea for years and was admitted with fever, earache, tenderness, and oedema. A week later he had a rigor, and optic neuritis developed on the right side. The mastoid was explored unsuccessfully. The fever and chills persisting, two days later the lateral sinus was explored. A mass of foul clot was removed and the jugular vein was tied, after which the boy made a satisfactory recovery. In the recent work of Macewen, On Pyogenic Infective Diseases of the Brain and Spinal Cord, will be found the most exhaustive presenta- tion of the subject of sinus thrombosis and its treatment. V. HEMIPLEGIA AND DIPLEGIA IN CHILDREN. It is as yet hard to say, without fuller knowledge of the etiology of these common conditions, where they should be classified. In a majority of the cases, whatever the nature of the primary pathological change, the final state is one of a chronic encephalitis, often with great atrojihy of the convolutions or the formation of large cyst-like spaces—porencephalus. Etiology.—Of 135 cages, comprising those from the Infirmary for Diseases of the Nervous System, Philadelphia, from the Elwyn Institution for Feeble-minded Children, under Kerlin, and from my clinic at the Johns Hopkins Hospital, 60 were in boys and 75 in girls. Eight hemiplegia occurred in 79, left in 56. In 15 cases the condition was said to be con- genital. In a great majority the disease sets in during the first or second year; thus of the total number of cases, 95 were under two. Cases above the fifth year are rare, only 10 in my series. Neither alcoholism nor syphilis in the parents appears to play an important role in this affection. Diffi- cult or abnormal labor is responsible for certain of the cases, particularly injury with the forceps. Trauma, such as falls or puncturing wounds, is more rare. The condition followed ligation of the common carotid in one case. Infectious diseases. All the authors lay special stress upon this factor. In 19 cases in my series the disease came on during or just after one of the specific fevers. I saw one case in which during the height of vaccination convulsions developed, followed by hemiplegia. In a great majority of the cases the disease sets in with a convulsion, in which the child may remain for several hours or longer, and after recovery the paraly- sis is noticed. I. Hemiplegia. HEMIPLEGIA AND DIPLEGIA IN CHILDREN. 959 Morbid Anatomy.—In an analysis which I have made of 90 au- topsies reported in the literature, the lesions may be grouped under three headings: («) Embolism, thrombosis, and haemorrhage, comprising 16 cases, in 7 of which there was blocking of a Sylvian artery, and in 9 haemor- rhage. A striking feature in this group is the advanced age of onset. Ten of the cases occurred in children over six years old. (b) Atrophy and sclerosis, comprising 50 cases. The wasting is either of groups of convolutions, an entire lobe, or the whole hemisphere. The meninges are usually closely adherent over the affected region, though sometimes they look normal. The convolutions are atrophied, firm, and hard, contrasting strongly with the normal gyri. The sclerosis may be diffuse and wide-spread over a hemisphere, or there may be nodular pro- jections—the hypertrophic sclerosis. Some of the cases show remarkable unilateral atrophy of the hemisphere. In one of my cases the atrophied hemisphere weighed 169 grammes and the normal 653 grammes. The brain tissue may be a mere shell over a dilated ventricle. (c) Porencephalus, which was present in 24 of the 90 autopsies. This term was applied by Heschel to a loss of substance in the form of cavi- ties and cysts at the surface of the brain, either opening into and bounded by the arachnoid, and even passing deeply into the hemisphere, or reach- ing to the ventricle. In the study by Audrey of 103 cases of porencepha- lus, hemiplegia was mentioned in 68 cases. Practically, then, in infantile hemiplegia cortical sclerosis and poren- cephalus are the important anatomical conditions. The primary change in the majority of these cases is still unknown. Porencephalia may result from a defect in development or from haemorrhage at birth. The etiology is clear in the limited number of cases of haemorrhage, embolism, and thrombosis, but there remains the large group in which the final change is sclerosis and atrophy. What is the priiriary lesion in these instances ? The clinical history shows that in nearly all these cases the onset is sud- den, with convulsions—often with slight fever. Strumpell believes that this condition is due to an inflammation of the gray matter—polio-en- cephalitis—a view which has not been very widely accepted, as the ana- tomical proofs are wanting. Gowers suggests that thrombosis may he present in some instances. This might probably account for the final condition of sclerosis, but clinically thrombosis of the veins rarely occurs in healthy children, which appear to be those most frequently attacked by infantile hemiplegia, and post-mortem proof is yet wanting of the association of thrombosis with the disease. Symptoms.—(a) The onset. The disease may set in suddenly without spasms or loss of consciousness. In more than half the cases the child is attacked with partial or general convulsions and loss of conscious- ness, which may last from a few hours to many days. This is one of the most striking features in the disease. Fever is usually present. The 960 DISEASES OF THE NERVOUS SYSTEM. hemiplegia, noticed as the child recovers consciousness, is generally com- plete. Sometimes the paralysis is not complete at first, but develops after subsequent convulsions. The right side is more frequently affected than the left. The face is commonly not involved. (b) Residual symptoms. In some cases the paralysis gradually disap- pears and leaves scarcely a trace as the child grows up. The leg, as a rule, recovers more rapidly and more fully than the arm, and the paralysis may be scarcely noticeable. In a majority of cases, however, there is a characteristic hemiplegic gait. The paralysis is most marked in the arm, which is usually wasted; the forearm is flexed at right angles, the hand is flexed, and the fingers are contracted. Motion may be almost completely lost; in other instances the arm can be lifted above the head. Late rigidity, which almost always develops, is the symptom which suggested the name hemiplegia spastica cerebralis to Heine, the ortho- paedic surgeon who first accurately described these cases. It is, however, not constant. The limbs may be quite relaxed even years after the onset. The reflexes are usually increased. In several instances, however, I have known them to be absent. Sensation is, as a rule, not disturbed. Aphasia is a not uncommon symptom, and occurred in 16 cases of my series—a smaller number than given in the series of Wallenberg, Gaudard, and Sachs. Mental Defects.—One of the most serious consequences of infantile hemiplegia is the failure of mental development. A considerable number of these cases drift into the institutions for feeble-minded children. Three grades may be distinguished—idiocy, which is most common when the hemiplegia has existed from birth; imbecility, which often increases with the development of epilepsy; and feeble-mindedness, a retarded rather than an arrested development. Epilepsy.—Of the cases in my series, 41 were subjects of convulsive seizures, which is one of the most distressing sequences of the disease. The seizures may be either transient attacks of petit mal, true Jacksonian fits, beginning in and confined to the affected side, or general convulsions. Post-hemiplegic Movements.—It was in cases of this sort that Weir Mitchell first described the post-hemiplegic movements. They are ex- tremely common, and were present in 34 of my series. There may be either slight tremor in the affected muscles, or incoordinate choreiform movements—the so-called post-hemiplegic chorea—or, lastly, Athetosis.—In this condition, described by Hammond, there are re- markable spasms of the paralyzed extremities, chiefly of the fingers and toes, and in rare instances of the muscles of the mouth. The movements are involuntary and somewhat rhythmical; in the hand, movements of adduction or abduction and of supination and pronation follow each other in orderly sequence. There may be hyperextension of the fingers, during which they are spread wide apart. This condition is much more frequent in children than in adults. In the latter it may be combined HEMIPLEGIA AND DIPLEGIA IN CHILDREN. 961 with hemianaesthesia, and the lesion is not cortical, but basic in the neigh- borhood of the thalamus. The movements are sometimes increased by emotion. They usually persist during sleep. II. Spastic Diplegia—Birth Palsies. In this condition there is a paralysis with spasm of all extremities, dating from or shortly succeeding birth, more rarely following the fevers or an attack of convulsions. The legs are usually more involved than the arms; there is no wasting, no disturbance of sensation. The reflexes are increased. The mental condition is profoundly disturbed. The patients are usually imbeciles or idiots, helpless in mind and body. Ataxic and athetoid movements of the most exaggerated kind may occur. While a limited number only of cases of infantile hemiplegia are congenital, on the other hand, in spastic diplegia a large proportion of the cases results from injury at birth. Practically the spastic paraplegia of children should be considered with this condition, as its etiology is essen- tially the same. The arms, too, may be so slightly affected as to make it difficult to determine whether it is a case of diplegia or paraplegia. The cases usually date from birth, and a majority are born in first labors or are forceps cases. Ross suggests that in feet presentation there may be laceration or tearing of the cerebro-spinal membranes. Morbid Anatomy.—The birth palsies which ultimately induce the spastic diplegias or paraplegias are most frequently the result of meningeal hasmorrliage. The importance of this condition has been shown by the studies of Litzmann and Sarah J. McNutt. The bleeding may come from the veins, or, in one case which I saw with Hirst, from the longi- tudinal sinus. The bleeding has in many cases been thickest over the motor areas, and it seems probable that the sclerosis found in these cases may result from the compression of the blood-clot. In other instances the condition may be due to a foetal meningo-encephalitis. In sixteen autopsies collected in the literature, in which the patients died at ages varying from two to thirty, the anatomical condition wras either a diffuse atrophy, which was most common, or porencephalus. Symptoms.—At first nothing abnormal may be noticed about the child. In some instances there have been early and frequent convul- sions ; then at the age when the child should begin to walk it is noticed that the limbs are not used readily, and on examination a stiffness of the legs and arms is found. Even at the age of two the child may not be able to sit up, and often the head is not well supported by the neck mus- cles. The rigidity, as a rule, is more marked in the legs, and there is ad- ductor spasm. When supported on the feet, the child either rests on its toes and the inner surface of the feet, with the knees close together, or the legs may be crossed. The stiffness of the upper limbs varies. It may be scarcely noticeable or the rigidity may be as marked as in the legs. Con- 962 DISEASES OF THE NERVOUS SYSTEM. stant irregular movements of the arms are not uncommon. The child has great difficulty in grasping an object. The spasm and weakness may be more evident on one side than the other. The mental condition is, as a rule, defective and convulsive seizures are common. Associated with the spastic paraplegia are two allied conditions of con- siderable interest, characterized by spasm and disordered movements. A child with spastic diplegia may present, in an unusual degree, irregular movements of the muscles. In attempting to grasp an object the fingers may be thrown out in a stiff, spasmodic, irregular manner, or there may be constant irregular movements of the shoulders, arms, and hands, with slight incoordination of the head. Cases of this description have been de- scribed as chorea spastica, and they may he difficult to separate from mul- tiple sclerosis and from Friedreich’s ataxia. A still more remarkable condition is that of bilateral athetosis, in which there is a combination of spasm more or less marked with the most extraordinary bizarre movements of the muscles. The condition, as a rule, dates from infancy. The patient may not be able to walk. The head is turned from side to side; there are continual irregular movements of the face muscles, and the mouth is drawn and greatly distorted. The extremities are more or less rigid, particularly in extension. On making the slightest attempt to move, often spontaneously, there are extraordinary movements of the arms and legs, particularly of the arms, somewhat like though much more exaggerated than athetosis. The patients are often unable to help themselves on account of these movements. The reflexes are increased. The mental condition is variable. The patient may be idiotic, hut in two of the four cases which I have seen the patients were intelligent. Massalongo,* who has carefully studied this condition, describes three cases in one family. I have collected fifty-three cases from the literature, thirty-three of which occurred in males and twenty in females. There have been three autopsies. In Kurella’s case there was pachy- meningitis and bilateral lesions of the motor convolutions. Dejerine’s pa- tient had atrophy of the convolutions on both sides, while in my case the brain macroscopically presented no changes. III. Spastic Paraplegia. This condition, which is more fully described under the section upon the spinal cord, is in reality a cerebral affection, and may be due to condi- tions similar to those found in spastic diplegia. Indeed, it may at first be difficult to determine whether the arms are involved or not. The evi- dence of the cerebral origin of the affection is based upon the frequent co- existence of idiocy, imbecility, and nystagmus, and the occurrence of cases of spastic diplegia, in which the paraplegic symptoms are identical. All grades are met with, from pure spastic paraplegia with perfect use of the * Dell’ Atetosi Doppia, Collezione Italiana di Letture sulla Medicina, Series V, N. 3. SCLEROSIS OF THE BRAIN. 963 arms to the most extreme bilateral spasm. There have been, so far as I know, only two autopsies in this disease : the case of Forster, in which there was a moderate grade of general cortical sclerosis with slight dilata- tion of the ventricles, and the recent case of Sachs, in which there was a meningo-encephalitis with atrophy and descending degeneration of both lateral columns. Treatment.—The possibility of injury to the brain in protracted labor and in forceps cases should be borne in mind by the practitioner. The former entails the greatest risk. In infantile hemiplegia the physi- cian at the outset sees a case of ordinary convulsions, perhaps more pro- tracted and severe than usual. These should be checked as rapidly as possible by the use of the bromides, the application of cold or heat, and a brisk purge. During convulsions chloroform may be administered with safety even to the youngest children. When the paralysis is established not much can be hoped from medicines. In only rare instances does the paralysis entirely disappear. The indications are to favor the natural tendency to improve by maintaining the general nutrition of the child, to lessen the rigidity and contractures by massage and passive motion, and if necessary to correct deformities by mechanical or surgical measures. Much may be done by careful manipulation and rubbing and the applica- tion of a proper apparatus. In children the aphasia usually disappears. The epilepsy is a distressing and obstinate symptom, for which a cure can rarely be anticipated. Prolonged periods of quiescence are, however, not uncommon. In the Jacksonian fits the bromides rarely do good, un- less there is much irritability and excitement. Operative measures, which have been carried out in several cases, have not been successful. The liability to feeble-mindedness is the most serious outlook in the in- fantile cerebral palsies. In many cases the damage is irreparable, and idiocy and imbecility result. With patient training and with care many of the children reach a fair measure of intelligence and self-reliance. VI. SCLEROSIS OF THE BRAIN. General Remarks.—The connective tissue of the central nervous system is of two kinds—one, the neuroglia, special and peculiar, derived from the ectoderm, with distinct morphological and chemical characters; the other, derived from the mesoderm, identical with the ordinary col- lagenous fibrous tissue of the body. Both play important parts in indura- tive processes in the brain and cord. A convenient division of the cerebro- spinal scleroses is into degenerative, inflammatory, and developmental forms. The degenerative scleroses comprise the largest and most important subdivision, in which provisionally the following groups may be made: («) The common secondary degeneration which follows when nerve-fibres 964 DISEASES OF THE NERVOUS SYSTEM. are cut off from their trophic centres; (b) toxic forms, among which may be placed the scleroses from lead and ergot, and, most important of all, the sclerosis of the posterior column, due in such a large proportion of cases to the virus of syphilis. Other unknown toxic agents may possibly induce degeneration of the nerve-fibres in certain tracts. The systemic paths in the cord differ apparently in their susceptibility and the posterior columns appear most prone to undergo this change; (c) the sclerosis associated with change in the smaller arteries and capillaries, which is met with as a senile process in the convolutions. In all probability some of the forms of insular sclerosis are due to primary alterations in the blood-vessels; but it is not yet settled whether the lesion in these cases is a primary degen- eration of the nerve cells and fibres to which the sclerosis is secondary, or whether the essential factor is an alteration in nutrition caused by lesions of the capillaries and smaller arteries. The inflammatory scleroses embrace a less important and less extensive group, comprising secondary forms which develop in consequence of irri- tative inflammation about tumors, foreign bodies, haemorrhages, and abscess. Histologically these are chiefly mesodermic (vascular) scleroses, which arise from the connective tissue about the blood-vessels. Possibly a similar change may follow the primary, acute encephalitis, which Strumpell holds is the initial lesion in the cortical sclerosis which is so commonly found post mortem in infantile hemiplegia. The developmental scleroses are believed to be of a purely neurogliar character, and embrace the new growth about the central canal in syringomyelia and, according to recent French writers, the sclerosis of the posterior columns in Friedreich’s ataxia. It is stated that histo- logically this form is different from the ordinary variety. It may be, too, that the diffuse cortical sclerosis met with as a congenital condi- tion without thickening of the meninges belongs to this type. It is not improbable that many forms of sclerosis are of a mixed character, in which both the ectodermic and mesodermic connective tissues are in- volved. Anatomically we meet Avith the following varieties: (1) Miliary sclerosis is a term which has been applied to several dif- ferent conditions. Gowers mentions a case in which there Avere grayisli- red spots at the junction of the white and gray matters, and in which the neuroglia Avas increased. There is also a condition in which, on the sur- face of the convolutions, there are small nodular projections, A’arying from a half to five or more millimetres in diameter. Single nodules of this sort are not uncommon; sometimes they are abundant. So far as is knoAvn no symptoms are produced by them. (2) Diffuse sclerosis, which may invoh'e an entire hemisphere, or a single lobe, in which case the term sclerose lobaire has been applied to it by the French. It is not an important condition in general medical practice, but occurs most frequently in idiots and imbeciles. In extenshTe SCLEROSIS OF THE BRAIN. 965 cortical sclerosis of one hemisphere the ventricle is usually dilated.* The symptoms of this condition depend upon the region affected. There may be a considerable extent of sclerosis without symptoms or without much mental impairment. In'a majority of cases there is hemiplegia or diplegia with imbecility or idiocy. (3) Tuberous Sclerosis,—In this remarkable form, which is also known as hypertrophic, there are on the convolutions areas projecting beyond the surface of an opaque white color and exceedingly firm. The sclerosis may not disturb the symmetry of the convolution, but simply cause a great enlargement, increase in the density, and a change in the color. These three forms are not of much practical interest except in asylum and institution work. The last variety forms a well-characterized disease of considerable importance, namely : (4) Insulae Sclerosis (Sclerose en plaques). Definition.—A chronic affection of the brain and cord, characterized by localized areas in which the nerve elements are more or less replaced by connective tissue. This may occur in the brain or cord alone, more commonly in both. Etiology.—This is obscure. Kahler, Marie, and others assign great importance to the infectious diseases, particularly scarlet fever. It is found most commonly in young persons, and cases are not uncommon in children, in whom Pritchard states that more than fifty cases have been reported. Morbid Anatomy.—The sclerotic areas are widely distributed through the brain and cord, and cases limited to either part alone are almost unknown. The grayish-red areas are scattered indifferently through the white and gray matter (E. W. Taylor). The patches are most abundant in the neighborhood of the ventricles, and in the pons, cerebellum, basal ganglia, and the medulla. The cord may be only slightly involved or there may be irregular areas in different regions. The nerve-roots and the branches of the cauda equina are often attacked. Histologically in the sclerosed patches there is great increase in the connective tissue, the fibres of which are denser and firmer. The gradual growth destroys the medulla of the nerves, but the axis cylinders persist in a remarkable way. Symptoms.—The onset is slow and the disease is chronic. Feeble- ness of the legs with irregular pains and stiffness are among the early symptoms. Indeed, the clinical picture may be that of spastic paraplegia with great increase in the reflexes. The following are the most important features: (a) Volitional Tremor.—There is no paralysis of the arms, but on at- * In my monograph on Cerebral Palsies of Children I have given a description of the distribution of the sclerosis in ten specimens in the museum at the Elwyn Insti- tution. 966 DISEASES OF THE NERVOUS SYSTEM. tempting to pick up an object there is trembling or rapid oscillation. A patient may be unable to lift even a glass of water to the mouth. The tremor may be marked in the legs and in the head, which shakes as he walks. When the patient is recumbent the muscles may be perfectly quiet. On attempting to raise the head from the pillow, trembling at once comes on. (b) Scanning Speech.—The words are pronounced slowly and separately, or the individual syllables may be accentuated. This stac- cato or syllabic utterance is a common feature, (c) Nystagmus, a rapid oscillatory movement of both eyes, constitutes an important symptom. Sensation is unaffected in a majority of the cases. Optic atrophy sometimes occurs, but not so frequently as in tabes. The sphincters, as a rule, are unaffected until the last stages. Mental debility is not uncom- mon. Remarkable remissions occur in the course of the disease, in which for a time all the symptoms may improve. Vertigo is common, and there may be sudden attacks of coma, such as occur in general paresis. The diagnosis in well-marked cases is easy. Volitional tremor, scan- ning speech, and nystagmus form a characteristic symptom-group. With this there is usually more or less spastic weakness of the legs. Paralysis agitans, certain cases of general paresis, and occasionally hysteria may simulate the disease very closely. If the case is not seen until near the end the diagnosis may be impossible. Buzzard holds that of all organic diseases of the nervous system disseminated sclerosis in its early stages is that which is most commonly mistaken for hysteria. The points to be relied upon in the differentiation are, in order of importance, the nystag- mus, the bladder disturbances, and the volitional tremor. The tremor in hysteria is not volitional. Much more puzzling, however, are the instances of pseudo-sclerose en plaques, which have been described by Westphal. French writers regard them as instances of hysterical tremor. In children the condition may with difficulty be separated from Friedreich’s ataxia. The prognosis is unfavorable. Ultimately, the patient, if not carried off by some intercurrent affection, becomes bedridden. Treatment.—No known treatment has any influence on the progress of sclerosis of the brain. Neither the iodides nor mercury have the slight- est effect, but a prolonged course of nitrate of silver may be tried, and ar- senic is recommended. VII. CHRONIC DIFFUSE MENINGO-ENCEPHALITIS (Dementia Paralytica ; General Paresis). Definition.—A chronic, progressive meningo-encephalitis associated with psychical and motor disturbances, finally leading to dementia and paralysis. Etiology.—Males are affected much more frequently than females. It occurs chiefly between the ages of thirty and fifty-five. Heredity is a CHRONIC DIFFUSE MENINGO-ENCEPHALITIS. 967 factor in only a few cases. An overwhelming majority of the cases are in married people. Statistics show that it is more common in the lower classes of society, but in this country in general medical practice the dis- ease is certainly more common in the well-to-do classes. An important predisposing cause is “ a life absorbed in ambitious projects with all its strongest mental efforts, its long-sustained anxieties, deferred hopes, and straining expectation ” (Mickle). The habits of life so frequently seen in active business men in our large cities, and well expressed by the phrase “ burning the candle at both ends,” strongly predispose to the disease. The important individual factor is syphilis, which is an antecedent in from 70 to 90 per cent of all cases. To this disease dementia paralytica and tabes dorsalis are so closely related that Fournier describes them under the heading Les Affections Parasyphilitiques. His recent work, with this title, is full of interesting details gleaned from an enormous ex- perience. He suggests that these two disorders may be not merely diverse expressions of one and the same morbid entity, but that they possibly may be one and the same disease. Morbid Anatomy.—The essential histological changes in the cere- bral cortex are thus summarized by Bevan Lewis: (1) A stage of inflam- matory change in the tunica adventitia of the arteries with excessive nu- clear proliferation, profound changes in the vascular channels, and trophic changes induced in the tissues around. (2) A stage of extraordinary development of the lymph-connective system of the brain, with a parallel degeneration and disappearance of nerve elements and the axis cylinders of which they are denuded. (3) A stage of general fibrillation with shrinking and extreme atrophy of the parts involved. The macroscopical changes are : Increase in the cerebro-spinal fluid, cedema of the pia, and thickening and opacity of the meninges, which are adherent in places and tear the cortex on removal. The dura is sometimes thickened, and pachymeningitis haemorrhagica interna may be present. The convolutions are atrophied, usually in a marked degree, and in consequence the brain looks small. This is particularly noticeable in the frontal and parietal regions. On section it cuts with firmness. In ex- treme cases the gray matter may be obscurely outlined. The grade of sclerosis varies much in different eases. The white matter may be firmer in consistence, but it does not show such important changes. The ven- tricles are dilated and the ependyma extremely granular. In addition, there are frequently areas of softening or haemorrhage associated with chronic arterio-sclerosis. Spinal cord. Changes are almost constantly found, usually sclerosis of the posterior columns, either alone or, more commonly, with involve- ment of the lateral. Symptoms.—(a) Prodromal Stage.—This is of variable duration, and is characterized by a general mental state which finds expression in 968 DISEASES OF THE NERVOUS SYSTEM. symptoms trivial in themselves but important in connection with others. Irritability, inattention to business amounting sometimes to indifference or apathy, and sometimes a change in character marked by acts which may astonish the friends and relatives may be the first indications. In- stead of apathy or indifference there may be an extraordinary degree of physical and mental restlessness. The patient is continually planning and scheming, or may launch into extravagances and speculation of the wildest character. A common feature at this period is the display of an un- bounded egoism. He boasts of his personal attainments, his property, his position in life, or of his wife and children. Following these features are important indications of moral perversion, manifested in offences against decency or the law, many of which acts have about them a suspicious effrontery. Forgetfulness is common, and may be shown in inattention to business details and in the minor courtesies of life. At this period there may be no motor phenomena. The onset of the disease is usually insidi- ous, although cases are reported in which epileptiform or apoplectiform seizures were the first symptoms. Among the early motor features are tremor of the tongue and lips in speaking, slowness of speech and hesi- tancy, inequality of the pupils, and the Argyll-Robertson pupil. (b) Second Stage.—This is characterized in brief by mental exaltation or excitement and a progress in the motor symptoms. “ The intensity of the excitement is often extreme, acute maniacal states are frequent; in- cessant restlessness, obstinate sleeplessness, noisy, boisterous excitement, and blind, uncalculating violence especially characterize such states ” (Lewis). It is at this stage that the delusion of grandeur becomes marked and the patient believes himself to be possessed of countless millions or to have reached the most exalted sphere possible in profession or occupation. This expansive delirium, as it is called, is, howrever, not characteristic, as wras formerly supposed, of paralytic dementia. Besides, it does not always occur, but in its stead there may be marked melancholia or hypochon- driasis, or, in other instances, alternate attacks of delirium and depres- siom The facies has a peculiar stolidity, and in speaking there is marked tremulousness of the lips and facial muscles. The tongue is also tremu- lous, and may be protruded with difficulty. The speech is slow, inter- rupted, and blurred. Writing becomes difficult on account of unsteadi- ness of the hand. The subject matter of the patient’s letters gives valu- able indications of the mental condition. In many instances the pupils are unequal, irregular, sluggish, sometimes large. Important symptoms in this stage are apoplectiform seizures and paralysis. There may be slight syncopal attacks in which the patient turns pale and may fall. Some of these are petit mat. In the true apoplectiform seizure the pa- tient falls suddenly, becomes unconscious, the limbs are relaxed, the face is flushed, the breathing stertorous, the temperature increased, and death may occur. The epileptic seizures are more common than the apoplecti- CHRONIC DIFFUSE MENINGO-ENCEPHALITIS. 969 form and may occur early in the disease. A definite aura is not uncom- mon. The attack usually begins on one side and may not spread. There may be tvvitchings either in the facial or brachial muscles. Typical Jack- sonian epilepsy may occur. In a case which died recently under my care, these seizures were among the early symptoms and the disease was re- garded as cerebral syphilis. Paralysis, either monoplegic or hemiplegic, may follow these epileptic seizures, or may come on with great suddenness and be transient. In this stage the gait becomes impaired, the patient trips readily, has difficulty in going up or down stairs, and the walk may be spastic or occasionally tabetic. This paresis may be progressive. The knee-jerk is usually increased. Bladder or rectal symptoms gradually develop. The patient becomes helpless, bedridden, and completely de- mented, and unless care is taken may suffer from bedsores. Death occurs from exhaustion or from some intercurrent affection. The absence of pain reaction on pressure upon the ulnar nerve behind the elbow (Bierna- cik symptom) is apparently not of any special value. The spinal-cord features of dementia paralytica may come on with or precede the mental troubles; in 80 per cent of the cases they follow them. There are cases in which one is in cloubt for a time whether the symptoms indicate tabes or dementia paralytica, and it is well to bear in mind that every feature of pre-ataxic tabes may exist in the early stage of general paresis. Diagnosis—The recognition of the disease in the earliest stage is ex- tremely difficult, as it is often impossible to decide that the slight altera- tion in conduct is anything more than one of the moods or phases to which most men are at times subject. The following description by Fol- som is an admirable presentation of the diagnostic characters of the early stage of the disease : “ It should arouse suspicion if, for instance, a strong, healthy man, in or near the prime of life, distinctly not of the ‘ nervous,’ neurotic, or neurasthenic type, shows some loss of interest in his affairs or impaired faculty of attending to them; if he becomes varyingly absent- minded, heedless, indifferent, negligent, apathetic, inconsiderate, and, al- though able to follow his routine duties, his ability to take up new work is, no matter how little, diminished; if he can less well command mental attention and concentration, conception, perception, reflection, judgment; if there is an unwonted lack of initiative, and if exertion causes unwonted mental and physical fatigue; if the emotions are intensified and easily change, or are excited readily from trifling causes ; if the sexual instinct is not reasonably controlled ; if the finer feelings are even slightly blunted ; if the person in question regards with a placid apathy his own acts of indifference and irritability and their consequences, and especially if at times he sees himself in his true light and suddenly fails again to do so; if any symptoms of cerebral vaso-motor disturbances are noticed, however vague or variable.” There are cases of cerebral syphilis which closely simulate dementia para- lytica. The mode of onset is important, particularly since paralytic symp- 970 DISEASES OF THE NERVOUS SYSTEM. toms are usually early in syphilis. The affection of the speech and tongue is not present. Epileptic seizures are more common and more liable to be cortical or Jacksonian in character. The expansive delirium is rare. While symptoms of general paresis are not common in connection with the development of gummata or definite gummatous meningitis, there are, on the other hand, instances of paresis which follow syphilitic infection so closely that an etiological connection between the two must be acknowl- edged. Post mortem in such cases there may be nothing more than a general arterio-sclerosis and diffuse meningo-encephalitis, which may pre- sent nothing distinctive, but the lesions, nevertheless, may be caused by the syphilitic virus. There are certain forms of lead encephalopathy which resemble general paresis, and, considering the association of plumbism with arterio-sclerosis, it is not unlikely that the anatomical substratum of the disease may result from this poison. Prognosis.—The disease rarely ends in recovery. As a rule the prog- ress is slowly downward and the case terminates in a few years, although it is occasionally prolonged ten or fifteen years. Treatment.—The only hope of permanent relief is in the cases follow- ing syphilis, which should be placed upon large doses of iodide of potas- sium. Careful nursing and the orderly life of an asylum are the only measures necessary in a great majority of the cases. For sleeplessness and the epileptic seizures bromides may be used. Prolonged remissions, which are not uncommon, are often erroneously attributed to the action of remedies. VIII. TUMORS OF THE BRAIN. The following are the most common varieties of new growths within the cranium : («) Tubercle, which may form large or small growths, usually multiple. They are most frequent early in life. Three fourths of the cases occur under twenty, and one half of the patients are under ten years of age (Gowers). Of 299 cases of tumor in persons under nineteen collected from various sources by Starr, 152 were tubercle. They are most numer- ous in the cerebellum and about the base. (6) Syphiloma is most commonly found in the hemispheres or about the pons. The tumors are superficial, attached to the arteries or the me- ninges, and rarely grow to a large size. They may be multiple. (c) Glioma and Neuroglioma.—These vary greatly in appearance. They may be firm and hard, almost like an area of sclerosis, or soft and very vascular. They persist remarkably for many years. Klebs has called attention to the occurrence of elements in them not unlike ganglion-cells. Tumors of this character contain “ the spinnen ” or spider cells; enormous spindle-shaped cells with single large nuclei; cells like the ganglion-cells of nerve-centres with nuclei and one or more processes; and translucent, TUMORS OF THE BRAIN. 971 band-like fibres, tapering at each end, which result from a vitreous or hya- line transformation of the large spindle-cells. (d) Sarcoynci occurs most commonly in the membranes of the brain and in the pons. It forms some of the largest and most diffusely infil- trating of intracranial growths. (e) Carcinoma not infrequently is secondary to cancer in other parts. It is seldom primary. Occasionally cancerous tumors have been found in symmetrical parts of the brain. (/) Other varieties occur, such as fibroid growths, which usually develop from the membranes ; bony tumors, which grow sometimes from the falx, and psammoma and cholesteatoma. Tatty tumors are occasion- ally found on the corpus callosum. (g) Cysts occur between the membranes and the brain, the result of 'haemorrhage or of softening. Porenceplialus is a sequence of congenital atrophy or of haemorrhage, or may be due to a developmental defect. Hydatid cysts will be referred to in the section on parasites. An interest- ing variety of the cysts is that which follows severe injury to the skull in early life. Symptoms.—(1) General.—The following are the most important: Headache, either dull, aching, and continuous, or sharp, stabbing, and par- oxysmal. It may be diffused over the entire head or limited to the back or front. In the former case it may extend down the neck, and in the latter be accompanied with neuralgic pains in the face. Occasionally the pain may be very localized and associated with tenderness on pressure. Optic Neuritis.—This occurs in four fifths of all the cases (Gowers). It is usually double, but occasionally is found in only one eye. A growth may develop slowly and attain considerable size without producing optic neuritis. On the other hand, it may occur with a very small tumor, more commonly in a growth at the base. , Vomiting.—This is a common feature, and with headache and optic neuritis makes up the characteristic symptom group of cerebral tumor. An important point is the absence of definite relation to the meals. It may be very obstinate, particularly in growths of the cerebellum and the pons. Giddiness.—This is often an early symptom. The patient complains of vertigo on rising suddenly or on turning quickly. Mental Disturbance. The patient may act in an odd, unnatural manner, or there may be stupor and heaviness. The patient may become emotional or silly, or symptoms resembling hysteria may develop. Convulsions, either general and resem- bling true epilepsy or localized (Jacksonian) in character. (2) Localizing Symptoms.—(a) Central Motor Area.—The symptoms are either irritative or destructive in character. Irritation in the lower third may produce spasm in the muscles of the face, in the angle of the mouth, or in the tongue. The spasm with tingling may be strictly lim- ited to one muscle group before extending to others, and this Seguin 972 DISEASES OF THE NERVOUS SYSTEM. terms the signal symptom. The middle third of the motor area contains the centres controlling the arm, and here, too, the spasm may begin in the fingers, in the thumb, in the muscles of the wrist, or in the shoulder. In the upper third of the motor areas the irritation may produce spasm beginning in the toes, in the ankles, or in the muscles of the leg. In many instances the patient can determine accurately the point of origin of the spasm, and there are important sensory disturbances, such as numb- ness and tingling, which may be felt first at the region affected. In all cases it is important to determine, first, the point of origin, the signal symptom; second, the order or march of the spasm; and third, the subsequent condition of the parts first affected, whether it is a state of paresis or anaesthesia. Destructive lesions in the motor zone cause pai'alysis, which is often preceded by local convulsive seizures; there may be a monoplegia, as of the leg, and convulsive seizures in the arm, often due to irritation in these centres. Tumors in the neighborhood of the motor area may cause local- ized spasms and subsequently, as the centres are invaded by the growth, paralysis occurs. On the left side, growths in the third frontal or Broca’s convolution may cause motor aphasia. (b) Prefontal Region.— Neither motor nor sensory disturbance may be present. The general symptoms are often well marked. The most striking feature of growths in this region is mental torpor and gradual imbecility. In its extension downward the tumor may involve on the left side the lower frontal convolution and produce aphasia, or in its progress backward cause irritative or destructive lesions of the motor area. (c) Tumors in the parieto-occipital lobe may grow to large size with- out causing any symptoms. There may be word-blindness and mind- blindness when the angular gyrus is involved, and paraphasia. (d) Tumors of the occipital lobe produce hemianopia, and a bilateral lesion may produce blindness. Tumors in this region on the left hemi- sphere may be associated with word-blindness and mind-blindness. (e) Tumors in the temporal lobe may attain a large size without pro- ducing symptoms. In their growth they involve the lower motor centres. On the left side involvement of the first and second gyri may be associated with word-deafness. (/) Tumors growing in the neighborhood of the basal ganglia produce hemiplegia from involvement of the internal capsule. Limited growths in either nucleus of the corpus striatum do not necessarily cause paralysis. Tumors in the thalamus opticus may also, when small, cause no symptoms, but increasing they may involve the fibres of the optic radiation, produc- ing hemianopia and sometimes hemiansesthesia. Growths in this situation are apt to cause early optic neuritis, and, growing into the third ventricle, may cause a distention of the lateral ventricles. In fact, pressure symp- toms from this cause and paralysis due to involvement of the internal capsule are the chief symptoms of tumor in and about these ganglia. TUMORS OF THE BRAIN. 973 Growths in the corpora quadrigemina are rarely limited, but most commonly involve the crura cerebri as well. Ocular symptoms are marked. The pupil reflex is lost and there is nystagmus. In the gradual growth the third nerve is involved as it passes through the crus, in which case there will be motor oculi paralysis on one side and hemiplegia on the other, a combination almost characteristic of unilateral crus disease. (g) Tumors of the pons and medulla. The symptoms are chiefly those of pressure upon the nerves emerging in this region. In disease of the pons the nerves may be involved alone -or with the tract. Of 52 cases analyzed by Mary Putnam Jacobi, there were 13 in which the cranial nerves were involved alone, 13 in which the limbs were affected, and 26 in which there was hemiplegia and involvement of the nerves. Twenty-two of the latter had what is known as alternate paralysis—i. e., involvement of the nerves on one side and the limbs on the opposite side. In four cases there were no motor symptoms. In tuberculosis (or syphilis) a growth at the inferior and inner aspects of the crus may cause paralysis of the third nerve on one side, and of the face, hypoglossal, and limbs on the opposite (syndrome of Weber). A tumor growing in the lower part of the pons usually involves the sixth nerve, producing internal strabis- mus ; the seventh nerve, producing facial paralysis; and the auditory nerve, causing deafness. Conjugate deviation of the eyes to the side opposite that on which there is facial paralysis also occurs. Tumors of the medulla may involve the cranial nerves alone or cause in some instances a combination of hemiplegia with paralysis of the nerves. Signs of irritation in the ninth, tenth, and eleventh nerves are usually present, and produce difficulty in swallowing, irregular action of the heart, irregular respiration, vomiting, and sometimes retraction of the head and neck. The gait may be unsteady or, if there is pressure on the cerebellum, ataxic. Occasionally there are sensory symptoms, numbness, and tingling, Toward the end convulsions may occur. Diagnosis.—From the general symptoms alone the existence of tumor may be determined, for the combination of headache, optic neuri- tis, and vomiting is distinctive. The localization must be gathered from the consideration of the symptoms above detailed. Mistakes are most likely to occur in connection with uraemia, hysteria, and general paralysis; but careful consideration of all the circumstances of the case usually en- ables the practitioner to avoid error. Prognosis.—Syphilitic tumors alone are amenable to treatment. Tuberculous growths occasionally cease to grow and become calcified. The gliomata and fibromata, particularly wdren the latter grow from the membranes, may last for years. I have described a case of small, hard glioma, in which the Jacksonian epilepsy persisted for fourteen years. Hughlings Jackson has reported cases of glioma in which the symptoms lasted for over ten years. The more rapidly growing sarcomata usually prove fatal in from six to eighteen months. Death may be sudden, par- 9 74 DISEASES OF THE NERVOUS SYSTEM. ticularly in growths near the medulla; more commonly it is due to coma in consequence of gradual increase in the intracranial pressure. Treatment.—(a) Medical.—If there is a suspicion of syphilis the iodide of potassium and mercury should be given. Nowhere do we see more brilliant therapeutical effects than in certain cases of cerebral gum- mata. The iodide should be given in increasing doses. In tuberculous tumors the outlook is less favorable, though instances of cure are reported, and there is post-mortem evidence to show that the solitary tuberculous tumors may undergo changes and become obsolete. A general tonic treat- ment is indicated in these cases. The headache usually demands prompt treatment. The iodide of potassium in full doses sometimes gives marked relief. An ice-cap for the head or, in the occipital headache, the applica- tion of the Paquelin cautery may be tried. The bromides are not of much use in the headache from this cause, and, as the last resort, morphia must be given. For the convulsions bromide of potassium is of little service. (&) Surgical.—Tumors of the brain have been successfully removed by Macewen, Horsley, Keen, and others. The number of cases for operation, however, is small. Four fifths at least of all the cases are probably un- successful, or of such a nature as to render an operation fatal. The most advantageous cases are the localized fibromata growing from the dura and only compressing the brain substance, as in Keen’s remarkable case. The safety with which the exploratory operation can be made warrants it in all doubtful cases. For all the recent details and cases consult Starr’s Brain Surgery and vol. i of Chipault’s larger work (Paris, 1894). IX. INFLAMMATION OF THE BRAIN (Suppurative Encephalitis; Abscess). Etiology.—Suppuration of the brain substance is rarely if ever pri- mary, but results, as a rule, from extension of inflammation from neigh- boring parts or infection from a distance through the blood. The question of idiopathic brain abscess need scarcely be considered, though occasion- ally instances occur in which it is extremely difficult to assign a cause. There are three important etiological factors : (1) Trauma. Falls upon the head or blows, with or without abra- sion of the skin. More commonly it follows fracture or punctured wounds. In this group meningitis is frequently associated with the abscess. (2) By far the most important infective foci are those which arise in direct extension from disease of the middle ear or of the mastoid cells. From the roof of the mastoid antrum the infection readily passes to the sigmoid sinus and induces an infective thrombosis. In other instances the dura becomes involved, and a sub-dural abscess is formed, which may readily involve the arachnoid or the pia mater. In another group the INFLAMMATION OF TIIE BRAIN. 975 inflammation extends along the lymph spaces, or the thrombosed veins, into the substance of the brain and causes suppuration. Macevven thinks that without local areas of meningitis the infective agents may be carried through the lymph and blood channels into the cerebral substance. In- fection which extends from the roof of the mastoid process is most likely to be followed by abscess in the temporo-sphenoidal lobe, while infection extending from the posterior wall causes most frequently sinus thrombosis and cerebellar abscess. (3) In septic processes. Abscess of the brain is not often found in pyaemia. In ulcerative endocarditis multiple foci of suppuration are common. Localized bone-disease and suppuration in the liver are occa- sional causes. Certain inflammations in the lungs, particularly bronchi- ectasis, which was present in 17 of 38 cases of these so-called “ pulmonal cerebral abscesses” collected by R. T. Williamson, are liable to be fol- lowed by abscess. It is an occasional complication of empyema. Abscess of the brain may follow the specific fevers. Bristowe has called attention to its occurrence as a sequel of influenza. The largest number of cases occur between the twentieth and fortieth years, and the condition is more frequent in men than in women. Morbid Anatomy.—The abscess may be solitary or multiple, dif- fuse or circumscribed. In the acute, rapidly fatal cases following injury the suppuration is not limited; but in long-standing cases the abscess is enclosed in a definite capsule, which may have a thickness of from two to five millimetres. The pus varies much in appearance, depending upon the age of the abscess. In early cases it may be mixed with reddish debris and softened brain matter, but in the solitary encapsulated abscess the pus is distinctive, having a greenish tint, an acid reaction, and a pe- culiar odor, sometimes like sulphuretted hydrogen. The brain substance surrounding the abscess is usually oedematous and infiltrated. The size varies from that of a walnut to that of a large orange. There are cases on record in which the cavity has occupied the greater portion of a hemi- sphere. Multiple abscesses are usually small. In four fifths of all cases the abscess is solitary. Suppuration occurs most frequently in the cere- brum, and the temporo-sphenoidal lobe is more often involved than other parts. The cerebellum is the next most common seat, particularly in con- nection with ear-disease. Symptoms.—Following injury or operation the disease may run an acute course, with fever, headache, delirium, vomiting, and rigors. The symptoms are those of an acute meningo-encephalitis, and it may be very difficult to determine, unless there are localizing symptoms, whether there is really suppuration in the brain substance. In the cases following ear dis- ease the symptoms may at first be those of meningeal irritation. There may be irritability, restlessness, severe headache, and aggravated earache. Other striking symptoms, particularly in the more prolonged cases, are drowsiness, slow cerebration, vomiting, and optic neuritis. In the chronic DISEASES OF THE NERVOUS SYSTEM. 976 form of brain abscess which may follow injury, otorrhoea, or local lung trouble, there may be a latent period ranging from one or two weeks to several months, or even a year or more. In the “ silent ” regions, when the abscess becomes encapsulated there may be no symptoms whatever during the latent period. During all this time the patient may be under careful observation and no suspicion be aroused of the existence of sup- puration. Then severe headache, vomiting, fever, set in, perhaps with a chill. An Arab was admitted to my wards at the University Hos- pital in a condition of profound anaemia, having been picked up by tbe police in the street, covered with blood. There was a small localized area of dulness in the third and fourth interspaces on the right side close to the sternum, and although no tubercle bacilli were found, it was thought to be probably a localized tuberculosis. He recovered rapidly from the anae- mia, and within three months was strong and well. A few days before his intended discharge he began to complain of headache, which became aggravated. He had vomiting, fever, and gradually increasing coma. A large, solitary encapsulated abscess was found in the parieto-occipital region of the left hemisphere, and in the middle lobe of the right lung a circum- scribed cavity, probably bronchiectatic, surrounded by fibroid tissue and containing a very offensive pus. So, too, after a blow upon the head or a fracture the symptoms of the lesion may be transient, and months after- ward cerebral symptoms of the most aggravated character may develop. The localization of the lesion is often difficult. In or near the motor region there may be convulsions or paralysis, and it is to be remembered that an abscess in the temporo-sphenoidal lobe may compress the lower motor centres and produce paralysis of the arm and face and on the left side cause aphasia. A large abscess may exist in the frontal lobe without caus- ing paralysis, but in these cases there is almost always some mental dulness. In the temporo-sphenoidal lobe, the common seat, there may be no focaliz- ing symptoms. So also in the parieto-occipital region ; though here early examination may lead to the detection of hemianopia. In abscess of the cerebellum vomiting is common. If the middle lobe is affected there may be staggering—cerebellar incoordination. Localizing symptoms in the pons and other parts are still more uncertain. Diagnosis.—In the acute cases there is rarely any doubt. The his- tory of injury followed by fever, marked cerebral symptoms, the develop- ment of optic neuritis and rigors, delirium, and perhaps paralysis, make the diagnosis certain. In chronic ear-disease, such cerebral symptoms as drowsiness and torpor, with irregular fever, supervening upon the cessation of a discharge should excite the suspicion of abscess. It is particularly in the chronic cases that difficulties arise. The symptoms resemble those of tumor of the brain ; indeed, they are those of tumor plus fever. In a patient with a history of trauma or with localized lung or pleural trouble, who for weeks or months has had slight headache or dizziness, the onset of a rapid fever, intense headache, and vomiting point strongly to abscess. CHRONIC HYDROCEPHALUS. 977 Macewen lays stress upon the value of percussion of the skull as an aid in diagnosis. The note, which is uniformly dull, becomes much more reso- nant when the lateral ventricles are distended in cerebellar abscess and in conditions in which the venae Galeni are compressed. It is not always easy to determine whether the meninges are involved with the abscess. Often in ear-disease the condition is that of meningo- encephalitis. I have already referred to a condition sometimes associated with ear-disease, which may simulate closely cerebral meningitis or even abscess. Indeed, Gowers states that not only may these general symptoms be produced by ear-disease, but even distinct optic neuritis. Treatment.—A remarkable advance has been made of late years in dealing with these cases, owing to the impunity with which the brain can be explored. In ear-disease free discharge of the inflammatory products should be promoted and careful disinfection practised. The treatment of injuries and fractures comes within the scope of the surgeon. The acute symptoms, such as fever, headache, and delirium, must be treated by rest, an ice-cap, and, if necessary, local depletion. In all cases, when a reason- able suspicion exists of the occurrence of abscess, the trephine should be applied and the brain explored. The cases following ear-disease, in which the suppuration is in the temporo-sphenoidal lobe or in the cerebellum, offer the most favorable chances of recovery. The localization can rarely be made accurately in these cases, and the operator must be guided more by general anatomical and pathological knowledge. In cases of injury the trephine should be applied over the seat of the blow or the fracture. In ear-disease the suppuration is most frequent in the temporo-sphenoidal lobe or in the cerebellum, and the operation should be performed at the points most accessible to these regions. And lastly, a most important, one might almost say essential, factor in the successful treatment of intra- cranial suppuration is an intelligent knowledge on the part of the surgeon of the work and works of William Macewen. X. CHRONIC HYDROCEPHALUS. Definition.—A condition, congenital or acquired, in which there is a great accumulation of fluid within the ventricles of the brain. The term hydrocephalus has also been applied to the collection of fluid between the cortex of the brain and the skull, known in this situation as h. e«cternus or h. ex vacuo, a condition common in cases of atrophy of the brain substance, and perhaps caused also by meningeal cysts. A true dropsy, however, of the arachnoid sac probably does not occur. The cases may be divided into two groups, congenital or infantile, and secondary or acquired. (1) Congenital Hydrocephalus.—The enlarged head may obstruct labor; more frequently the condition is noticed some time after birth. 978 DISEASES OF THE NERVOUS SYSTEM. The cause is unknown. It has occurred in several members of the same family. The anatomical condition in these cases offers no clew to the nature of the trouble. The lateral ventricles are enormously distended, but the ependyma is usually clear, sohietiines a little thickened and granular, and the veins large. The choroid plexuses are vascular, sometimes sclerotic, but often natural-looking. The third ventricle is enlarged, the aqueduct of Sylvius dilated, and the .fourth ventricle may be distended. The quantity of fluid may reach several litres. It is limpid and contains a trace of albumin and salts. The changes in consequence of this enormous ven- tricular distention are remarkable. The cerebral cortex is greatly stretched, and over the middle region the thickness may amount to no more than a few millimetres without a trace of the sulci or convolutions. The basal ganglia are flattened. The skull enlarges, and the circumference of the head of a child of three or four years may reach twenty-five or even thirty inches. The sutures widen, Wormian bone develop in them, and the bones of the cranium become exceedingly thin. The veins are marked be- neath the skin. A fluctuation wave may sometimes be obtained, and Fisher’s brain murmur may be heard. The orbital plates of the frontal bone are depressed, causing exophthalmos, so that the eyeballs cannot be covered by the eyelids. Convulsions may occur. The reflexes are increased, the child learns to walk late, and ultimately in severe cases the legs become feeble and sometimes spastic. The mental condition is variable; the child may be bright, but, as a rule, there is some grade of imbecility. The congenital cases usually die within the first four or five years. The process may be arrested and the patient may reach adult life. Cases of this sort are not very uncommon. Even when extreme, the mental faculties may be retained, as in Bright’s celebrated patient, Cardinal, who lived to the age of twenty-nine, and whose head was translucent when the sun was shin- ing behind him. Care must be taken not to mistake the rachitic head for hydrocephalus. Meningitis serosa.—Quincke distinguishes a serous meningitis from ordinary leptomeningitis and from hydrocephalus. The affection may come on acutely in children, with pain in the head, retraction of the neck, and signs of increased intra-cranial pressure, choked disk, slow pulse, etc. Delirium, convulsions, and local paralyses may occur. Fever is absent. In other instances the onset is more insidious, the course more chronic, and the condition is mistaken usually for brain tumor. Anatomically a meningitis ventricularis, with distention of the ventricles (acute hydrocephalus) with a clear exudate is found. The diagnosis from tumor is very difficult. The lumbar puncture may be made. A fluid with a specific gravity of 1,009, with albumin above 2 per 1,000, is suggest- ive of hydrocephalus through blood stasis. (2) Acquired Chronic Hydrocephalus. —This is stated to be occasionally CHRONIC HYDROCEPHALUS. 979 primary (idiopathic)—that is to say, it comes on spontaneously in the adult without observable lesion. Dean Swift is said to have died of hydro- cephalus, but this seems very unlikely. It is based upon the statement that “ he (Mr. Whitewav) opened the skull and found much water in the brain,” a condition no doubt of h. ex vacuo, due to the wasting associated with his prolonged illness and paralysis. In nearly all cases there is either a tumor at the base of the brain or in the third ventricle, which compresses the venae Galeni. The passage from the third to the fourth ventricle may be closed, either by a tumor or by parasites. More rarely the foramen of Magendie, through which the ventricles communicate with the cerebro- spinal meninges, becomes closed by meningitis. These conditions, occur- ring in adults, may produce the most extreme hydrocephalus without any enlargement of the head. Even when the tumor begins early in life, there maybe no expansion of the skull. In the case of a girl aged sixteen, blind from her third year, the head was not unusually large, the ventricles were enormously distended, and in the Rolandic region the brain substance was only five millimetres in thickness. A tumor occupied the third ventricle. In a case of cholesteatoma of the floor of the third ventricle, in which the symptoms persisted at intervals for eight or nine years, the ventricles were enormously distended without enlargement of the skull. In other in- stances the sutures separate and the head gradually enlarges. The symptoms of hydrocephalus in the adult are curiously variable. In the first case mentioned there were early headaches and gradual blind- ness ; then a prolonged period in which she was able to attend to her studies. Headaches again supervened, the gait became irregular and somewhat ataxic. Death occurred suddenly. In the other case there were prolonged attacks of coma with a slow pulse, and on one occasion the patient remained unconscious for more than three months. Gradually progressing optic neuritis without focalizing symptoms, headache, and attacks of somnolence or coma are suggestive symptoms. Cases are rare as a result of meningitis. The only instances I have seen were two which corresponded to the posterior meningitis of Gee and Barlow, in which, with the distention, there was extensive chronic purulent ependymitis. Treatment.—Very little can be done to relieve hydrocephalus. Medicines are powerless to cause the absorption of the fluid. More rational is the system of gradual compression, with or without the with- drawal of small quantities of the fluid. The compression may be made by means of broad plasters, so applied as to cross each other on the vertex, and another may be placed round the circumference. Of late years puncture of the ventricles, an operation which had been abandoned, has been revived, but when pressure symptoms are marked Quincke’s procedure may be used. He recommends puncture of the sub- arachnoid sac betweeen the third and the fourth lumbar vertebrae. At this point the spinal cord cannot be touched. The advantages are a slower removal of fluid and less danger of collapse. Browning (William), who 980 DISEASES OF THE NERVOUS SYSTEM. lias practised the method, recommends the use of a smooth, firm, aspi- rating needle, No. 3, and to enter between the third and fourth lumbar vertebrae, a little to one side of the median line. In adult cases the depth inserted is about 5 centimetres; in children 2'5 centimetres. The quan- tity which has been removed at a sitting is from one to one and a half ounce. It has been used with success in tuberculous meningitis (p. 937), and is certainly worth trying as a means of relief in cases of greatly in- creased brain pressure. Y. GENERAL AND FUNCTIONAL DISEASES. I. ACUTE DELIRIUM (.Bell's Mania). Definition.—Acute delirium running a rapidly fatal course, with slight fever, and in which post mortem no lesions are found sufficient to account for the disease. Cases are reported by many old writers under the term brain fever or phrenitis. Bell, at the time Superintendent of the McLean Asylum, de- scribed it * accurately under the designation, “ a form of disease resembling some advanced stages of mania and fever.” The disease may set in abruptly or be preceded by a period of irrita- bility, restlessness, and insomnia. The mental symptoms develop with rapidity and may quickly reach a grade of the most intense frenzy. There are the wildest hallucinations and outbreaks of great violence. The pa- tient talks incessantly, but incoherently and unintelligibly. No sleep is obtained, and at last, worn out with the intensity of the muscular move- ments, the patient becomes utterly prostrated and assumes the sitting or recumbent posture. There may sometimes be definite salaam movements, and in a case which I saw at Westphal’s clinic the patient incessantly made motions as if working a pump handle. After a period of intense bodily excitement, lasting for from twenty-four to thirty-six hours or longer, the patient can be examined, and presents the conditions which Bell described as typho-mania. The temperature ranges from 102° to 104°, or even higher. The tongue is dry, the pulse rapid and feeble, and sometimes there are seen on the skin bullse and pustules, and fre- quently sores from abrasion and self-inflicted injuries. Toward the close or, according to Spitzka, even during the development of the disease there may be lucid intervals. There may be petechise on the skin, and often there is marked congestion of the face and extremities. The duration of the disease is variable. Very acute cases may terminate within a week; others persist for two or even three weeks. The course of the disease is * American Journal of Insanity, 1849. ACUTE DELIRIUM. 981 almost uniformly fatal. The anatomical condition is practically nega- tive, or at any rate presents nothing distinctive. There is great venous engorgement of the vessels of the meninges and of the gray cortex. In two cases in which I made a careful microscopic examination of the gray matter there were perivascular exudation and leucocytes in the lymph sheaths and perigangliar spaces. In the inspection of fatal cases of acute delirium careful examination should be made of the lungs and ileum. It should be borne in mind that in a majority of the cases dying in this manner, there is engorgement of the bases of the lungs or even deglutition pneumonia. The nature of the disease is quite unknown. Some of the cases sug- gest acute infection. Spitzka thinks that it is due to an autochthonous nerve poison. Diagnosis.—There are several diseases which may present identical symptoms. As Bell remarks in his paper, the first glance in many cases suggests typhoid fever, particularly when the patient is seen after the vio- lence of the mania subsides. He gives two instances of this which were ad- mitted from a general hospital. Enlargement of the spleen, the occur- rence of spots, and the history give clews for the separation of the cases; but there are instances in which it is at first impossible to decide. More- over, typhoid fever may set in with the most intense delirium. The exist- ence of fever is the most deceptive symptom, and its combination with delirium and dry tongue so commonly means typhoid fever that it is very difficult to avoid error. Acute pneumonia may come on with violent maniacal delirium and the pulmonary symptoms may be entirely masked. Occasionally acute urtemia sets in suddenly with intense mania, and finally subsides into a fatal coma. The condition of the urine and the ab- sence of fever would be important diagnostic features. The character of the delirium is quite different from that of mania a potu. It may be extremely difficult to differentiate acute delirium from certain cases of cortical meningitis occurring in connection with pneu- monia or ulcerative endocarditis, tuberculosis, or due to extension from disease of the ear. This sets in more frequently with a chill, and there may be convulsions. Treatment.—Even though bodily prostration is apt to come on early and be profound, I would not hesitate to advise, in the case of a robust man, free venesection. It is not at all improbable that some of the many cases of mania in which Benjamin Bush let blood with such benefit belonged to this class of affections. Considering its remarkable calming influence in febrile delirium, the cold bath or the cold pack should be em- ployed. Morphia and chloroform may be administered and hyoscine and the bromides may be tried. Krafft-Ebing states that Solivetti has ob- tained good results by the use of ergotin. Unfortunately, as asylum re- ports show, the disease is almost uniformly fatal. DISEASES OF THE NERVOUS SYSTEM. II. PARALYSIS AGITANS {Parkinson's Disease ; Shaking Palsy). Definition.—A chronic affection of the nervous system, characterized by muscular weakness, tremors, and rigidity. Etiology.—Men are more frequently affected than women. It rarely occurs under forty, but instances have been reported in which the disease began about the twentieth year. It is by no means an uncommon affec- tion. Direct heredity is rare, but the patients often belong to families in which there are other nervous affections. Among exciting causes may be mentioned exposure to cold and wet, and business worries and anxieties. In some instances the disease has followed directly upon severe mental shock or trauma. Cases have been described after the specific fevers. Malaria is believed by some to be an important factor, hut of this there is no satisfactory evidence. Morbid Anatomy.—No constant lesions have been found. The similarity between certain of the features of Parkinson’s disease and those of old age suggest that the affection may depend upon a premature senil- ity of certain regions of the brain. Our organs do not age uniformly, but in some, owing to hereditary disposition, the process may be more rapid than in others. “ Parkinson’s disease has no characteristic lesions, but on the other hand it is not a neurosis. It has for an anatomical basis the lesions of cerebro-spinal senility, and which only differ from those of true senility, in their early onset and greater intensity.” (Dubief.) The im- portant changes are doubtless in the cerebral cortex. Symptoms.—The disease begins gradually, usually in one or other hand, and the tremor may. be either constant or intermittent. With this may be associated weakness or stiffness. At first these symptoms may be present only after exertion. Although the onset is slow and gradual in nearly all cases, there are instances in which it sets in abruptly after fright or trauma. When well established the disease is very characteristic, and the diagnosis can be made at a glance. The four prominent symptoms are tremor, weakness, rigidity, and the attitude. Tremor.—This may be in the four extremities or confined to hands or feet; the head is not so commonly affected. The tremor is usually marked in the hands, and the thumb and forefinger display the motion made in the act of rolling a pill. At the wrist there are movements of pronation and supination, and less marked of flexion and extension. The upper-arm muscles are rarely involved. In the legs the movement is most evident at the ankle-joint, and less in the toes than in the fingers. Shaking of the head is less frequent, but does occur, and is usually vertical, not rotatory. The rate of oscillation is about five per second. Any emotion exaggerates the movement. The attempt at a voluntary movement may check the tremor (the patient may be able to thread a needle), but it returns with PARALYSIS AGITANS. 983 increased intensity. The tremors cease, as a rule, during sleep, but persist when the muscles are at repose. The writing of the patient is tremulous and zigzag. Weakness.—Loss of power is present in all cases, and may occur even before the tremor, but is not very striking, as tested by the dynamometer, until the late stages. The weakness is greatest where the tremor is most developed. The movements, too, are remarkably slow. There is rarely complete loss of power. Rigidity may early be in a slowness and stillness in the vol- untary movements, which are performed with some effort and difficulty, and all the actions of the patient are deliberate. This rigidity is in all the muscles, and leads ultimately to the characteristic Attitude and Gait.—The head is bent forward, the back is bowed, and the arms are held away from the body and are somewhat flexed at the elbow-joints. The face is expressionless, and the movements of the lips are slow. The eyebrows are elevated, and the whole expresion is immobile or mask-like, the so-called Parkinson’s mask. The voice, as pointed out by Buzzard, is apt to be shrill and piping, and there is often a hesitancy in beginning a sentence; then the words are uttered with rapidity, as if the patient was in a hurry. This is sometimes in striking contrast to the scan- ning speech of insular sclerosis. The fingers are flexed and in the position assumed when the hand is at rest; in the late stages they cannot be ex- tended. Occasionally there is overextension of the terminal phalanges. The hand is usually turned toward the ulnar side, and the attitude some- what resembles that of advanced cases of rheumatoid arthritis. In the late stages there are contractures at the elbows, knees, and ankles. The movements of the patient are characterized by great deliberation. He rises from the chair slowly in the stooping attitude, with the head project- ing forward. In attempting to walk the steps are short and hurried, and, as Trousseau remarks, he appears to be running after his centre of gravity. This is termed festination or propulsion, in contradistinction to a peculiar gait observed when the patient is pulled backward, when he makes a num- ber of steps and would fall over if not prevented—retropulsion. The reflexes are normal in most cases, but in a few they are exag- gerated. Of sensory disturbances Charcot has noted abnormal alterations in the temperature sense. The patient may complain of subjective sensations of heat, either general or local—a phenomenon which may be present on one side only and associated with an actual increase of the surface tempera- ture, as much as 6° F. (Gowers). In other instances, patients complain of cold. Localized sweating may be present. The mental condition rarely shows any change. Variations in the Symptoms.—The tremor may be absent, but the rigidity, weakness, and attitude are sufficient to make the diagnosis. The disease may be hemiplegic in character, involving only one side or even one limb. Usually these are but stages of the disease. DISEASES OF THE NERVOUS SYSTEM. Diagnosis.—In well-developed cases the disease is recognized at a glance. The attitude, gait, stiffness, and mask-like expression are points of as much importance as the oscillations, and usually serve to separate the cases from senile and other forms of tremor. Disseminated sclerosis develops earlier, and is characterized by the nystagmus, and the scanning speech, and does not present the attitude so constant in paralysis agitans. The hemiplegic form might be confounded with post-hemiplegic tremor, but the history, the mode of onset, and the greatly in creased reflexes would be sufficient to distinguish the two. The Parkinsonian face is of great importance in the diagnosis of the obscure and anomalous forms. The disease is incurable. Periods of improvement may occur, but the tendency is for the affection to proceed progressively downward. It is a slow, degenerative process and the cases last for years. Treatment.—There is no method which can be recommended as satisfactory in any respect. Arsenic, opium, and hyoscyamia may be tried, but the friends of the patient should be told frankly that the disease is incurable, and that nothing can be done except to attend to the physical comforts of the patient. Other Forms of Tremor. (a) Simple Tremor.—This is occasionally found in persons in whom it is impossible to assign any cause. It may be transient or persist for an indefinite time. It is often extremely slight, and is aggravated by all causes which lower the vitality. (b) Hereditary Tremor.—C. L. Dana has reported remarkable cases of hereditary tremor. It occurred in all th£ members of one family, and beginning in infancy continued without producing any serious changes. (c) Senile Tremor.—With advancing age tremulousness during mus- cular movements is extremely common, but is rarely seen under seventy. It is always a fine tremor, which begins in the hands and often extends to the muscles of the neck, causing slight movement of the head. (d) Toxic tremor is seen chiefly as an effect of tobacco, alcohol, lead, or mercury; more rarely in arsenical or opium poisoning. In elderly men who smoke much it may be entirely due to the tobacco. One of the com- monest forms of this is the alcoholic tremor, which occurs only on move- ment and has considerable range. Lead tremor will be considered in speaking of lead poisoning, of which it constitutes a very important symptom. (e) Hysterical tremor, which usually occurs under circumstances which make the diagnosis easy, will be considered in the section on hysteria. ACUTE CHOREA. 985 III. ACUTE CHOREA {Sydenham's Chorea ; St. Vitus's Dance). Definition.—A disease cliiefly affecting children, characterized by irregular, involuntary contraction of the muscles, a variable amount of psychical disturbance, and a remarkable liability to acute endocarditis. We shall speak here only of Sydenham’s chorea. Senile chorea, chronic chorea, the prehemiplegic and post-hemiplegic forms, and rhythmic chorea are totally different affections. Etiology.—Sex.—Of 554 cases which I have analyzed from the Philadelphia Infirmary for Diseases of the Nervous System, seventy-one per cent were in females and twenty-nine per cent in males. After pu- berty the percentage in females increases. Age.—The age incidence in 522 cases was as follows: In the first decade, 201 ; in the second decade, 248; in the third decade, 10; in the fourth decade, 1; above the fourth decade, 2. In the cases under twenty years the following is the age incidence in the hemidecades: In the first hemidecade, 33; in the second hemidecade, 168 ; in the third hemi- decade, 212; in the fourth hemidecade, 52. Station.—While the disease affects children of all grades of society, it is more common among the lower classes. Race.—Chorea is rare in the negro, and is almost unknown in the na- tive races of this continent. Seasonal Relations.—Morris J. Lewis has analyzed 437 separate attacks with reference to this point. Throughout December, January, and Feb- ruary the cases increase. There is a fall in April, a rise through May and July, and then a steady fall until October. The cases are most numerous when the mean relative humidity and barometric pressure are low. Rheumatism.—A causal relationship between rheumatism and chorea has been claimed by many since the time of Bright. The English and French writers maintain the closeness of this connection, and Roger goes so far as to regard the disease in all cases as a manifestation of rheuma- tism. On the other hand, German authors, as a rule, regard the connec- tion as by no means very close. Of 554 cases which I have analyzed, in 15‘5 per cent there was a history of rheumatism in the family. In 88 cases, 15’8 per cent, there was a history of articular swelling, acute or sub- acute. In 33 cases there were pains, sometimes described as rheumatic, in various parts, but not associated with joint trouble. If we regard all such cases as rheumatic and add them to those with manifest articular trouble, the percentage is raised to nearly twenty-one. We find two groups of cases in which acute arthritis is present in chorea. In one, the arthritis antedates by some months or years the onset of the chorea, and does not recur before or during the attack. In the other group, the chorea sets in with or follows immediately upon the acute 986 DISEASES OF THE NERVOUS SYSTEM. arthritis. In some instances it is impossible to decide whether the joint trouble or the movements come first. It is difficult to differentiate the cases of irregular pains without definite joint affection. It is probable that many of them are rheumatic, and yet I think it would be a mistake to regard as such all cases in children in which there are complaints of vague pains in the bones or muscles—so-called growing pains. It should never be forgotten, however, that a slight articular swelling may be the sole manifestation of rheumatism in a child—so slight, indeed, that the disease may be entirely overlooked. The statistics of the Collective In- vestigation Committee of the British Medical Association, based upon 439 cases, give twenty-six per cent of antecedent joint affection, and if the cases of vague pains believed to be rheumatic are added, the percentage is raised to thirty-two. In this country rheumatism is not so common in children as in England. Of the last 144 cases of the Infirmary series, almost every one of which I saw personally, and in which the most minute inquiries were made about rheumatism, there were only 25 cases with articular pains or swelling, and in only 6 had there been acute inflamma- tory rheumatism. The question may reasonably be asked, Do these ar- ticular affections of chorea belong to true rheumatism? Are they not analogous to the joint troubles of scarlet fever, puerperal fever, and gon- orrhoea, which no one now regards as truly rheumatic? They have been spoken of by French writers as choreic arthropathies. Heart-disease.—Endocarditis is believed by some writers to be the cause of the disease. The particles of fibrin and vegetations from the valves pass as emboli to the cerebral vessels. On this view, which we shall discuss later, chorea is the result of an embolic process occurring in the course of a rheumatic endocarditis. Infectious Diseases.—Scarlet fever with arthritic manifestations may be a direct antecedent. It may be mentioned that a history of this disease occurred in 141 cases, or about twenty-five per cent. Sturges states that a history of previous whooping-cough occurs more frequently in choreic than in other children, but I find no evidence of this in the Infirmary records. With the exception of rheumatic fever, there is no intimate relationship between chorea and the acute diseases incident to childhood. It may be noted in contrast to this that the so-called canine chorea is a common sequel of distemper. Chorea has been known to develop in the course of an acute pyaemia, and to follow gonorrhoea and puerperal fever. Kinnicutt and others have reported cases of chorea in malarial fevers, but the association was probably accidental, not causal. Anaemia is less often an antecedent than a sequence of chorea, and though cases develop in children who are anaemic and in poor health, this is by no means the rule. Chorea may develop in chlorotic girls at puberty. Pregnancy.—Chorea may occur during pregnancy—most often during the first five months. It is more common in a first pregnancy, and is rare ACUTE CHOREA. 987 in women over twenty-five years of age. The disease is usually severe, and maniacal symptoms may develop. Occasionally it comes on after an abortion or after delivery at term. A tendency to the disease is found in certain families. In eighty cases there was a history of attacks of chorea in other members. In one instance both mother and grandmother had been affected. High-strung, excitable, nervous children are especially liable to the disease. Fright is considered a frequent cause, but in a large majority of the cases no close connection exists between the fright and the onset of the disease. Occasionally the attack sets in at once. Mental worry, trouble, a sudden grief, or a scold- ing may apparently be the exciting cause. The strain of education, par- ticularly in girls during the third hemidecade, is a most important factor in the etiology of the disease. Bright, intelligent, active-minded girls from ten to fourteen, ambitious to do well at school, often stimulated in their efforts by teachers and parents, form a large contingent of the cases of chorea in hospital and private practice. Sturges has called special attention to this school-made chorea as one serious evil in our modern method of forced education. Imitation, which is mentioned as an exciting cause, is extremely rare, and does not appear to have influ- enced the onset in a single case in the Infirmary records. The disease may rapidly follow an injury or a slight surgical opera- tion. Beflex irritation was believed to play an important role in the disease, particularly the presence of worms or genital irritation ; but I have met with no instance in which the disease could be attributed to either of these causes. Local spasm, particularly of the face—the habit chorea of Mitchell—may be associated with irritation in the nostrils and adenoid growths in the vault of the pharynx, as pointed out by Jacobi. It has been claimed by Stevens that ocular defects lie at the basis of many cases of chorea, and that with the correction of these the irregular movements disappear. The investigations of De Scliweinitz show that ocular defects do not occur in greater proportion in choreic than in other children. A majority of the cases in which operation has been followed by relief have been instances of tic, local or general. Morbid Anatomy and Pathology.—No constant lesions have been found in the nervous system in acute chorea. Vascular changes, such as hyaline transformation, exudation of leucocytes, minute haemor- rhages, and thrombosis of the smaller arteries, have been described. Embolism of the smaller cerebral vessels has been found, as might be expected in a disease with which endocarditis is so frequently associated ; and, based upon this fact, Kirkes and others have supported what is known as the embolic theory of the disease. Endocarditis is by far the most frequent lesion in Sydenham’s chorea. With no disease, not except- ing rheumatism, is it so constantly associated. I have collected from recent literature (to July, 1894) the records of 73 autopsies; there were 988 DISEASES OF THE NERVOUS SYSTEM. G2 with endocarditis.* The endocarditis is usually of the simple variety, but the ulcerative form has occasionally been described. We are still far from a solution of all the problems connected with chorea. Unfortunately, the word has been used to cover a series of totally diverse disorders of movement, so that there are still excellent observers who hold that chorea is only a symptom, and is not to be regarded as an etiological unit. The chorea of childhood, the disease which Sydenham described, presents, however, characteristics so unmistakable that it must be regarded as a definite, substantive affection. We cannot discuss fully, but only indicate briefly, certain of the theories which have been advanced with regard to it. The most generally accepted view is that it is a func- tional brain disorder affecting the nerve-centres controlling the motor apparatus, an instability of the nerve-cells, brought about, one supposes by hyperaemia, another by anaemia, a third by psychical influences, a fourth by irritation, centric or peripheric. Of the actual nature of this derange- ment we know nothing, nor, indeed, whether the changes are primary and the result of a faulty action of the cortical cells or whether the impulses are secondarily disturbed in their course down the motor path. The pre- dominance of the disease in females, and its onset at a time when the education of the brain is rapidly developing, are etiological facts which Sturges has urged in favor of the view that chorea is an expression of functional instability of the nerve-centres. The embolic theory originally advanced by Kirkes has a solid basis of fact, but it is not comprehensive enough, as all of the cases cannot be brought within its limits. There are instances without endocarditis and without, so far as can be ascertained, plugging of cerebral vessels; and there are also cases with extensive endocarditis in which the histological examination of the brain, so far as embolism is concerned, negative. In favor of the embolic view is the experimental production in animals of chorea by Rosenthal, and later by Money, by injecting fine particles into the carotids of animals. Lately, as indeed might be expected, a microbic origin has been sought for, and, however improbable such a theory looks at first sight, the case of tetanus gives a warrant, at least, to speculation and investigation in this direction. Nothing definite has yet been determined. In favor of this view it has been urged, as it is impossible to refer the chorea to endo- carditis or the endocarditis in all cases to rheumatism, that both have their origin in a common cause, some infectious agent, which is capable also, in persons predisposed, of exciting articular disease. Cases have been reported in scarlet fever with arthritic manifestations, in puerperal fever, and rheumatism, also after gonorrhoea, and such facts are suggestive at least of the association of the disease with infective processes. Possibly, as has been suggested by some writers, the paralytic conditions associated * Osier, Chorea and Choreiform Affections, 1894. ACUTE CIIOREA. 989 with chorea may be analogous to those which occur in typhoid and cer- tain of the infectious diseases. On the other hand, there are conditions extremely difficult to harmonize with this view. The prominent psychical element is certainly one of the most serious objections, since there can be no doubt that ordinary chorea may rapidly follow a fright or a sudden emotion. Symptoms.—Three groups of cases may be recognized—the mild, severe, and maniacal chorea. Mild Chorea.—In this the affection of the muscles is slight, the speech is not seriously disturbed, and the general health not impaired. Premonitory symptoms are shown in restlessness and inability to sit still, a condition well characterized by the term “ fidgets.” There are emo- tional disturbances, such as crying spells, or sometimes night-terrors. There may be pains in the limbs and headache. Digestive disturbances and anaemia may be present. A change in the temperament is frequently noticed, and a docile, quiet child may become cross and irritable. After these symptoms have persisted for a week or more the characteristic in- voluntary movements begin, and are often first noticed at the table, when the child spills a tumbler of water or upsets a plate. There may be only awkwardness or slight incoordination of voluntary movements, or constant irregular clonic spasms. The jerky, irregular character of the movements differentiates them from almost every other disorder of motion. In the mild cases only one hand, or the hand and face, are affected, and it may not spread to the other side. In the second grade, the severe form, the movements become general and the patient may be unable to get about or to feed or undress herself, owing to the constant, irregular, clonic contractions of the various muscle groups. The speech is also affected, and for days the child may not be able to talk. Often with the onset of the severer symptoms there is loss of power on one side or in the limb most affected. The third and most extreme form, the so-called maniacal chorea, or chorea insaniens, is truly a terrible disease, and may develop out of the ordinary form. These cases are more common in adult women and may develop during pregnancy. Chorea begins, as a rule, in the hands and arms, then involves the face, and subsequently the legs. The movements may be confined to one side —hemichorea. The attack begins oftenest on the right side, though oc- casionally it is general from the outset. One arm and the opposite leg may be involved. In nearly one fourth of the cases speech is affected; when slight this is only an embarrassment or hesitancy, but in other in- stances it becomes an incoherent jumble. In very severe cases the child will make no attempt to speak. The inability is in articulation rather than in phonation. The lips and tongue are concerned in the defect. Occasionally the inspiratory muscles are involved, even when the speech is not at all affected, and sobbing and sighing may result. Paroxysms of DISEASES OF THE NERVOUS SYSTEM. 990 panting and of hard expiration may occur, or odd sounds may be pro- duced. As a rule the movements cease during sleep. A prominent symptom is muscular weakness, usually no more than a condition of paresis. The loss of power is slight, but the weakness may be shown by an enfeebled grip or by a dragging of the leg or limping. In his original account Sydenham refers to the “ unsteady movements of one of the legs, which the patient drags.” There may be extreme paresis with but few movements—the paralytic chorea of Todd. Occasionally a local paralysis or weakness remains after the attack. It is doubtful whether choreic spasms extend to the muscles of organic life. The rapid action and disturbed rhythm of the heart present nothing peculiar to the disease, and there is no support for the view that irregular contractions occur in the papillary muscles. Heart Symptoms.—Neurotic.—As so many of the subjects of chorea are nervous girls, it is not surprising that a common symptom is rapidly acting heart. Irregularity, however, is not so special a feature in chorea as rapidity. The patients seldom complain of pain about the heart. Hcemic Murmurs.—With anaemia and debility, not uncommon asso- ciates of chorea in the third and fourth week, we find a corresponding cardiac condition. The impulse is diffuse, perhaps wavy in thin children. The carotids throb visibly, and in the recumbent posture there may be pulsation in the cervical veins. On auscultation a systolic murmur is heard at the base, perhaps, too, at the apex, soft and blowing in quality. Endocarditis.—As in rheumatism, so in chorea, acute valvulitis rarely gives evidence of its presence by symptoms. It must be sought, and clin- ical experience has shown that it is usually associated with murmurs at one or other of the cardiac orifices. For the guidance of the practitioner the following statements may be made: (1) In thin, nervous children a systolic murmur of soft quality is ex- tremely common at the base, particularly at the second left costal cartilage, and is probably of no moment. (2) A systolic murmur of maximum intensity at the apex, and heard also along the left sternal margin, is not uncommon in ansemic, enfeebled states, and does not necessarily indicate either endocarditis or insuffi- ciency. (3) A murmur of maximum intensity at apex, with rough quality, and transmitted to axilla or angle of scapula, indicates an organic lesion of the mitral valve, and is usually associated with signs of enlargement of the heart. (4) When in doubt it is much safer to trust to the evidence of eye and hand than to that of the ear. If the apex beat is in the normal posi- tion, and the area of dulness not increased vertically or to the right of the sternum, there is probably no serious valvular disease. (5) The endocarditis of chorea is almost invariably of the simple or ACUTE CHOREA. 991 warty form, and in itself is not dangerous; but it is apt to lead to those sclerotic changes in the valve which produce incompetency. Of 140 pa- tients examined more than two years after the attack,* I found the heart normal in 51; in 17 there was functional disturbance, and 72 presented signs of organic heart-disease. (6) Pericarditis is an occasional complication of chorea, usually in cases with well-marked rheumatism. Sensory Disturbances.—Pain in the affected limbs is not common. Occasionally there is soreness on pressure. There are cases, usually of hemichorea, in which pain in the limbs is a marked symptom. Weir Mitchell has spoken of these as 'painful choreas. The pain may be quite apart from any arthritic complications. Tingling and pricking sensations and numbness are found occasionally. Anaesthesia is very uncommon. Tender points along the lines of emergence of the spinal nerves or along the course of the nerves of the limbs are rare. The French writers have compared these to the hysterogenic points in hysteria, and have also described in certain cases ovarian tenderness. Headache may be a very troublesome symptom. Psychical disturbances are common, though in a majority of the cases slight in degree. Irritability of temper, marked wilfulness, and emotional outbreaks may indicate a complete change in the character of the child. There is deficiency in the powers of concentration, the memory is en- feebled, and the aptitude for study is lost. Rarely there is progressive impairment of the intellect with termination in actual dementia. Acute melancholia has been described (Edes). Hallucinations of sight and hear- ing may occur. Patients may behave in an odd and strange manner and do all sorts of meaningless acts. By far the most serious manifestation of this character is the maniacal delirium, occasionally associated with the very severe cases—chorea insaniens. Usually the motor disturbance in these cases is aggravated, but it has been overlooked and patients have been sent to an asylum. The psychical element in chorea is apt to be neglected by the practi- tioner. It is always a good plan to tell the parents that it is not the muscles alone of the child which are affected, but that the general irrita- bility and change of disposition, so often found, really form part of the disease. The condition of the reflexes in chorea is usually normal. Sinkler made observations at the Philadelphia Infirmary in 50 cases with the fol- lowing results: In 26 the knee-jerk was normal, in 15 it was diminished in degree, and in 9 it could not be obtained. Trophic lesions rarely occur in chorea unless, as some writers have done, we regard the joint troubles as arthropathies occurring in the course of a cerebro-spinal disease. Fever is not, as a rule, present in chorea unless complications exist. * Monograph on Chorea, 1894. 992 DISEASES OF THE NERVOUS SYSTEM. There may be the most intense and violent movements without any rise of temperature. I have seen instances, however, in which without appar- ently any visceral or articular disturbances there was slight daily fever. II. A. Hare states that in monochorea the temperature on the affected side may be elevated ; but this is not an invariable rule. Fever is found with an acute arthritis, when there is marked endocarditis or pericarditis, though the former may certainly occur with little if any rise in tempera- ture, and in the cases of maniacal chorea, in which the fever may range from 102° to 104°. Cutaneous Affections.—The pigmentation, which is not uncommon, is due to the arsenic. Herpes zoster occasionally occurs. Certain skin erup- tions, usually regarded as rheumatic in character, are not uncommon. Erythema nodosum has been described and I have seen several cases with a purpuric urticaria. There may, indeed, be the more aggravated condi- tion of rheumatic purpura, known as Schonlein’s peliosis rlieumatica. Subcutaneous fibrous nodules, which have been noted by English observers in many cases of chorea, associated with rheumatism, are extremely rare in this country. Duration and Termination.—From eight to ten weeks is the average duration of an attack of moderate severity. Cases may be so mild as to get well in two or three weeks; on the other hand, there may be found at every clinic for diseases of the nervous system choreic patients who have been under treatment for three, four, or even six months. Chronic chorea rarely follows the minor disease which we have been con- sidering. The cases described under this designation in children are usually instances 6f cerebral sclerosis or Friedreich’s ataxia; but occa- sionally an attack which has come on in the ordinary way persists for months or years, and recovery ultimately takes place. A slight grade of chorea, particularly noticeable under excitement, may persist for months in nervous children. The tendency of chorea to recur has been noticed by all writers since Sydenham first made the observation. Of 410 cases analyzed for this pur- pose, 240 had one attack, 110 had two attacks, 35 three attacks, 10 four attacks, 12 five attacks, and 3 six attacks. The recurrence is apt to be vernal. Rheumatism seems to favor this tendency ; of 60 cases in which there were three or more attacks, there was a history of articular disease in 11, a much higher percentage than in cases with only one or two at- tacks. The occurrence of heart-disease lias been thought to increase this liability, but I think it is the other way—recurrences tend to induce endo- carditis and valvular disease. Recovery is the rule in children. The statistics of out-patients’ depart- ments are not favorable for determining the mortality. A reliable esti- mate is that of the Collective Investigation Committee of the British Medioal Association, in which 9 deaths were reported among 439 cases, about two per cent. ACUTE CHOREA. 993 The paralysis rarely persists. Mental dulness may be present for a time, but usually passes away; permanent impairment of the mind is an exceptional sequence. Diagnosis.—There are few diseases which present more character- istic features, and in a majority of instances the nature of the trouble is recognized at a glance; but there are several affections in children which may simulate and be mistaken for it. (a) Multiple and diffuse cerebral sclerosis. The cases are often mis- taken for ordinary chorea, and have been described in literature as chorea spastica. There are doubtless chronic changes in the cortex. As a rule, the movements are readily distinguishable from those of true chorea, but the simulation is sometimes very close; the onset in infancy, the impaired intelligence, increased reflexes, and in some instances rigidity and the chronic course of the disease, separate them sharply from true chorea. (&) Friedreich’s ataxia. Cases of this well-characterized disease were formerly classed as chorea. The slow, irregular, incoordinate movements, the scoliosis, scanning speech, the early talipes, the nystagmus, and the family character of the disease are points which should render the diag- nosis easy. (c) In rare cases the paralytic form of chorea may be mistaken for polio-myelitis or, when both legs are affected, for paraplegia of spinal origin ; but this can only be the case when the choreic movements are very slight. (d) Hysteria may simulate chorea minor most closely, and unless there are other manifestations it may be impossible to make a diagnosis. Most commonly, however, the movements in the so-called hysterical chorea are rhythmic and differ entirely from those of ordinary chorea. (e) As mentioned above, the mental symptoms in maniacal chorea may mask the true nature of the disease and patients have even been sent to the asylum. Treatment.—Abnormally bright, active-minded children belonging to families with pronounced neurotic taint should be carefully watched from the ages of eight to fifteen and not allowed to overtax their mental powers. So frequently in children of this class does the attack of chorea date from the worry and stress incident to school examinations that the competition for prizes or places should be emphatically forbidden. The treatment of the attack consists largely in attention to hygienic measures, with which alone, in time, a majority of the cases recoyer. Par- ents should be told to scan gently the faults and waywardness of choreic children. The psychical element, strongly developed in so many cases,- is best treated by quiet and seclusion. The child should be confined to bed in the recumbent posture and mental as well as bodily quiet enjoined. In private practice this is often impossible, but with well-to-do patients the disease is always serious enough to demand the assistance of a skilled 994 DISEASES OF THE NERVOUS SYSTEM. nurse. Toys and dolls should not be allowed at first, for the child should be kept amused without excitement. The rest allays the hyper-excitabil- ity and reduces to a minimum the possibility of damage to the valve seg- ments should endocarditis exist. Time and again have I seen very severe cases which had resisted treatment for weeks outside a hospital become quiet and the movements subside after two or three days of absolute rest in bed. The child should be kept apart from other children and, if possible, from other members of the family, and should see only those persons directly concerned with the nursing of the case. Though irksome and troublesome to carry out, this is an important part of the treatment. In the latter period of the disease daily rubbings may be resorted to with great benefit. The medicinal treatment of the disease is unsatisfactory; with the exception of arsenic, no remedy seems to have any influence in con- trolling the progress of the affection. Without any specific action, it certainly does good in many cases, probably by improving the general nutrition. It is conveniently given in the form of Fowler’s solution, and the good effects are rarely seen until maximum doses are taken. It may be given as Martin originally advised (1813); he began “ with five drops and increased one drop every day, until it might begin to disagree with the stomach or bowels.” When the dose of fifteen minims is reached, it may be continued for a week, and then again increased, if necessary, every day or two, until physiological effects are manifest. On the occurrence of these the drug should be stopped for three or four days. The practice of resuming the administration with smaller doses is rarely necessary, as tolerance is usually established and we can begin with the dose which the child was taking when the symptoms of saturation occurred. I have frequently given as much as twenty-five minims three times a day. Usu- ally the signs of saturation are trivial but plain, and I have never seen any ill effects from the large doses, but I have heard recently of a case of arsenical neuritis due to the administration of Fowler’s solution in chorea. Of other medicines, strychnine, the zinc compounds, nitrate of silver, bromide of potassium, belladonna, chloral, and especially cimicifuga, have been recommended, and may be tried in obstinate cases. For its tonic effect electricity is sometimes useful; but it is not neces- sary as a routine treatment. The question of gymnastics is an important one. Early in the disease, when the movements are active, it is not ad- visable ; but during convalescence carefully graduated exercises are un- doubtedly beneficial. It is not well, however, to send a choreic child to a school gymnasium, as the stimulus of the other children and the excite- ment of the romping, violent play is very prejudicial. Other points in treatment may be mentioned. It is important to regu- late the bowels and to attend carefully to the digestive functions. For the ansemia so often present preparations of iron are indicated. ACUTE CHOREA. 995 In the severe cases with incessant movements, sleeplessness, dry tongue, and delirium, the important indication is to procure rest, for which pur- pose chloral may be freely given, and, if necessary, morphia. Chloroform inhalations may be necessary to subdue the intensity of the paroxysms, but the high rate of mortality in this class of cases illustrates how often our best endeavors are fruitless. The wet pack is sometimes very sooth- ing and should be tried. As these patients are apt to sink rapidly into a low typhoid state with heart weakness, a supporting treatment is required from the outset. Cases are found now and then which drag on from month to month without getting either better or worse and resist all modes of treatment. Change of air and scene is sometimes followed by rapid improvement, and in these cases the treatment by rest and seclusion should always be given a full trial. In all cases care should be taken to examine the nostrils, and glaring ocular defects should be properly corrected either by glasses or, if neces- sary, by operation. After the child has recovered from the attack, the parents should be warned that return of the disease is by no means infrequent, and is par- ticularly liable to follow overwork at school or debilitating influences of any kind. These relapses are apt to occur in the spring. Sydenham ad- vised purging in order to prevent the vernal recurrence of the disease. 996 DISEASES OF THE NERVOUS SYSTEM. IV. OTHER AFFECTIONS DESCRIBED AS CHOREA. (a) Chorea Major; Pandemic Chorea.—The common name, St. Vitus’s dance, applied to chorea has come to us from the middle ages, when under the influence of religious fervor there were epidemics characterized by great excitement, gesticulations, and dancing. For the relief of these symptoms, when excessive, pilgrimages were made, and in the Rhenish provinces, particularly to the Chapel of St. Vitus in Zebern. Epidemics of this sort have occurred also during this century, and descriptions of them among the early settlers in Kentucky have been given by Robertson and Yandell. It was unfortunate that Sydenham applied the term chorea to an affection in children totally distinct from this chorea major, which is in reality an hysterical manifestation under the influence of religious excitement. (b) Habit Spasm (Habit Chorea); Convulsive Tic (of the French). Two groups of cases may be recognized under the designation of habit spasm—one in which there are simply localized spasmodic movements, and the other in which, in addition to this, there are explosive utterances and psychical symptoms, a condition to which French writers have given the name tic convulsif. (1) Habit Spasm.—This is found chiefly in childhood, most frequently in girls from seven to fourteen years of age (Mitchell). In its simplest form there is a sudden, quick contraction of certain of the facial muscles, such as rapid winking or drawing of the mouth to one side, or the neck muscles are involved and there are unilateral movements of the head. The head is given a sudden, quick shake, and at the same time the eyes wink. A not infrequent form is the shrugging of one shoulder. The grimace or movement is repeated at irregular intervals, and is much aggra- vated by emotion. A short inspiratory sniff is not an uncommon symp- tom. The cases are found most frequently in children who are “ out of sorts,” or who have been growing rapidly, or who have inherited a tend- ency to neurotic disorders. Allied to or associated with this are some of the curious tricks of children. A boy at my clinic was in the habit every few moments of putting the middle finger into the mouth, biting it, and at the same time pressing his nose with the forefinger. Hartley Cole- ridge is said to have had a somewhat similar trick, only he bit his arm. In all these cases the habits of the child should be examined carefully, the nose and vault of the pharynx thoroughly inspected, and the eyes accurately OTHER AFFECTIONS DESCRIBED AS CHOREA. 997 tested. As a rule the condition is transient, and after persisting for a few months or longer gradually disappears. Occasionally a local spasm persists —twitching of the eyelids, or the facial grimace. (2) Tic Convulsif (Gilles cle la Tourette’s Disease).—This remarkable affection, often mistaken for chorea, more frequently for habit spasm, is really a psychosis allied to hysteria, though in certain of its aspects it has the features of monomania. The disease begins, as a rule, in young children, occurring as early as the sixth year, though it may develop after puberty. There is usually a markedly neurotic family history. The special features of the complaint are: (a) Involuntary muscular movements, usually affecting the facial or brachial muscles, but in aggravated cases all the muscles of the body may be involved and the movements may be extremely irregular and violent. (b) Explosive utterances, which may resemble a bark or an inarticulate cry. A word heard may be mimicked at once and repeated over and over again, usually with the involuntary movements. To this the term echo- lalia has been applied. A much more distressing disturbance in these cases is coprolalia, or the use of bad language. A child of eight or ten may shock its mother and friends by constantly using the word damn when making the involuntary movements, or by uttering all sorts of ob- scene words. Occasionally actions are mimicked—echolcinesis. (c) Associated with some of these cases are curious mental disturb- ances ; the patient becomes the subject of a form of obsession or a fixed idea. I was consulted recently about a young girl in whom the spasms were very slight, amounting only to twitching of the eyes and slight jerk- ing of the shoulder, but who had a most pronounced grade of the fixed idea known as arithmomania. Almost every action, even the most trifling, was preceded by the counting of a certain number of figures. Before she went to bed she had to tap her heel upon the side of the bedstead a cer- tain number of times; before drinking the tumbler had to be rotated eight or ten times, and then when set down again the same act was re- peated. Before opening the door a certain number of knocks had to be given. The greatest difficulty was experienced in getting her to brush her hair, as it took her so long to count the necessary number of figures before she began. In other cases the fixed idea takes the form of the im- pulse to touch objects, or it is a fixed idea about words—onomatomania. Aecording to Guinon, who has written an exhaustive article upon it in the Dictionnaire Encyclopedique, the prognosis is bad. The disease is well marked and readily distinguished from ordinary chorea. The movements have a larger range and are explosive in charac- ter. Tourette regards the coprolalia as the most distinctive feature of the disease. (c) Saltatoric Spasm {Latah; Myriachit; Jumpers).—Bamberger has described a disease in which when the patient attempted to stand there were strong contractions in the leg muscles, which caused a jumping or 998 DISEASES OF THE NERVOUS SYSTEM. springing motion. This occurs only when the patient attempts to stand. The affection has occurred in both men and women, more frequently in the former, and the subjects have usually shown marked neurotic tendencies. In many cases the condition has been transitory; in others it has per- sisted for years. Remarkable affections similar to this in certain points occur as a sort of endemic neurosis. One of the most striking of these occurs among the u jumping Frenchmen ” of Maine and Canada. As de- scribed by Beard and Thornton, the subjects are liable on any sudden emo- tion to jump violently and utter a loud cry or sound, and will obey any command or imitate any action without regard to its nature. The con- dition of echolalia is present in a marked degree. The “ jumping ” pre- vails in certain families. A very similar disease prevails in parts of Russia and in Java, where it is known by the names of myriachit and latah, the chief feature of which is mimicry by the patient of everything he sees or hears. (d) Chronic Chorea (Huntingdon’s Chorea).—An affection character- ized by irregular movements, disturbance of speech, and gradual dementia. It is frequently hereditary. The disease has no connection with Sydenham’s chorea, and it is unfortunate that the term was applied to it. It was de- scribed by Huntingdon, of Pomeroy, Ohio, at the time a practitioner on Long Island, and he gave in three brief paragraphs the salient points in connection with the disease—namely, the hereditary nature, the associa- tion with psychical troubles, and the late onset—between the thirtieth and fortieth years. The disease seems common in this country, and many cases have been reported by Clarence King, Sinkler, and others.* I have seen it in two Maryland families within the past two years. Under the term chronic chorea may be grouped the hereditary form and the cases which come on without family disposition, either at middle life or, more commonly, in the aged—senile chorea. It is doubtful whether the cases in children with chronic choreiform movements, often with mental weakness and spastic condition of the legs, should go into this category. The hereditary character of the disease is very striking, and it has been traced through four or five generations. Huntingdon’s father and grand- father, also physicians, had treated the disease in the family which he de- scribed. An identical affection occurs without any hereditary disposition. The age of onset is late, rarely before the thirtieth or the thirty-fifth year. The symptoms are very characteristic. The irregular movements are usually first seen in the hands, and the patient has slight difficulty in per- forming delicate manipulations or in writing. When well established the movements are disorderly, irregular, incoordinate rather than choreic, and have not the sharp, brusque motion of Sydenham’s chorea. In the face there are slow, involuntary grimaces. In a well-developed case the gait is irregular, swaying, and somewhat like that of a drunken man. The speech * For complete literature, see Huet, de la Choree Chronique, Paris, 1889. INFANTILE CONVULSIONS. 999 is sIoav and difficult, the syllables are badly pronounced and indistinct, hut not definitely staccato. The mental impairment leads finally to dementia. Very few post-mortems have been made. No characteristic lesions have been found. Atrophy of the convolutions, chronic meningo-encephalitis, and vascular changes have usually been present, the conditions Avhich one would expect to find in a chronic dementia. These existed in an autopsy Avhich I had on one of my cases. Oppenheim and Hoppe have described in two cases a miliary disseminated encephalitis of the cortical and sub- cortical regions, particularly of the motor zone. The affection is evi- dently a neuro-degenerative disorder, and has no connection with the simple chorea of childhood. (e) Rhythmic or Hysterical Chorea.—This is readily recognized by the rhythmical character of the movements. It may affect the muscles of the abdomen, producing the salaam convulsion, or involve the sterno-mastoid, producing a rhythmical movement of the head, or the psoas, or any group of muscles. In its orderly rhythm it resembles the canine chorea. V. INFANTILE CONVULSIONS (Eclampsia). Convulsive seizures similar to those of epilepsy are not infrequent in children and in adults. The fit may indeed be identical with epilepsy, from which the condition differs in that when the cause is removed there is no tendency for the fits to recur. Occasionally, however, the convul- sions in children continue and develop into true epilepsy. Etiology.—A convulsion in a child may be due to many causes, all of which lead to an unstable condition of the nerve-centres, permitting of sudden, excessive and temporary nervous discharges. The following are the most important of them : (1) Debility, resulting usually from gastro-intestinal disturbance. Con- vulsions frequently supervene toward the close of an attack of entero- colitis and recur, sometimes proving fatal. Morris J. Lewis has shown that the death rate in children from eclampsia rises steadily Avith that of gastro-intestinal disorders. (2) Peripheral irritation. Dentition alone is rarely a cause of cornuil- sions, but is often one of several factors in a feeble, unhealthy infant. The greatest mortality from convulsions is during the first six months, be- fore the teeth really cut through the gums. Other irritative causes are the overloading of the stomach Avith indigestible food. It has been sug- gested that some of these cases are toxic, OAving to the absorption of poi- sonous ptomaines. Worms, to Avhich convulsions are so frequently attrib- uted, probably have little influence. Among other sources possible are phimosis and otitis. (3) Pickets. The observation of Sir William Jenner upon the associa- tion of rickets and convulsions has been amply confirmed. The spasms may be laryngeal, the so-called child-croAving, Avhich, though convulsive in 1000 DISEASES OF THE NERVOUS SYSTEM. nature, can scarcely be considered with eclampsia. The influence of this condition is more apparent in Europe than in this country, although rickets is a common disease, particularly among the colored people. Spasms, local or general, in rickets are probably associated with the con- dition of debility and malnutrition and with cranio-tabes. (4) Fever. In young children the onset of the infectious diseases is frequently with convulsions, which often take the place of a chill in the adult. It is not known upon what they depend. Scarlet fever, measles, and pneumonia are most often preceded by convulsions. (5) Congestion of the brain. That extreme engorgement of the blood- vessels may produce convulsions is shown by their occasional occurrence in severe whooping-cough, but their rarity in this disease really indi- cates how small a part mechanical congestion plays in the production of fits. (6) Severe convulsions usher in or accompany many of the serious dis- eases of the nervous system in children. In more than fifty per cent of the cases of infantile hemiplegia the affection follows severe convulsions. They less frequently precede a spinal paralysis. They occur with menin- gitis, tuberculous or simple, and with tumors and other lesions of the brain. And, lastly, convulsions may occur immediately after birth and per- sist for weeks or months. In such instances there has probably been meningeal haemorrhage or serious injury to the cortex. The most important question is the relation of convulsions in children to true epilepsy. In Gowers'’s figures of 1,450 cases of epilepsy, the attacks began in 180 during the first three years of life. Of 460 cases of epilepsy in children which I have analyzed, in 187 the fits began within the first three years. Of the total list the greatest number, 74, was in the first year. In nearly all these instances there was no interruption in the con- vulsions. That convulsions in early infancy are necessarily followed by epilepsy in after life is certainly a mistake. Symptoms.—The attack may come on suddenly without any warn- ing ; more commonly it is preceded by a stage of restlessness, accompanied by twitching and perhaps grinding of the teeth. It is rarely so complete in its stages as true epilepsy. The spasm begins usually in the hands, most commonly in the right hand. The eyes are fixed and staring or are rolled up. The body becomes stiff and breathing is suspended for a moment or two by tonic spasm of the respiratory muscles, in consequence of which the face becomes congested. Clonic convulsions follow", the eyes are rolled about, the hands and arms twitch, or are flexed and extended in rhythmical movements, the face is contorted, and the head is retracted. The attack gradually subsides and the child sleeps or passes into a state of stupor. Following indigestion the attack may be single, but in rickets and intestinal disorders it is apt to be repeated. Sometimes the attacks fol- low each other with great rapidity, so that the child never rouses but dies INFANTILE CONVULSIONS. 1001 in a deep coma. If the convulsion has been limited chiefly to one side there may be slight paresis after recovery, or in instances in which the convulsions usher in infantile hemiplegia, when the child arouses one side is completely paralyzed. During the fit the temperature is often raised. Death rarely occurs from the convulsion itself, except in debilitated chil- dren or when the attacks recur with great frequency. In the so-called hydrocephaloid state in connection with protracted diarrhoea convulsions may close the scene. Diagnosis.—Coming on when the subject is in full health, the at- tack is probably due either to overloaded stomach, to some peripheral irritation, or occasionally to trauma. Setting in with high fever and vomiting, it may indicate the onset of an exanthem, or occasionally be the primary symptom of encephalitis, or whatever the condition is which causes infantile hemiplegia. When the attack is associated with debility and with rickets the diagnosis is easily made. The carpopedal spasms and pseudo-paralytic rigidity which are often associated with rickets, laryngismus stridulus, and the hydrocephaloid state are usually confined to the hands and arms and are intermittent and usually tonic. The con- vulsions associated with tumor or which follow infantile hemiplegia are usually at first Jacksonian in character. After the second year convulsive seizures which come on irregularly without apparent cause and recur while the child is apparently in good health are likely to prove true epi- lepsy. Prognosis.—Convulsions play an important part in infantile mor- tality. In Morris J. Lewis’s table of deaths in children under ten, 8'5 per cent were ascribed to convulsions. West states that 22'35 per cent of deaths under one year are caused by convulsions, but this is too high an estimate for this country. In chronic diarrhoea convulsions are usually of ill omen. Those ushering in fevers are rarely serious, and the same may be said of the fits associated with indigestion and peripheral irrita- tion. Treatment.—Every source of irritation should be removed. If as- sociated with indigestible food, a prompt emetic should be given, followed by an enema. The teeth should be examined, and if the gum is swollen, hot, and tense, it may be lanced; but never if it looks normal. When seen at first, if the paroxysm is severe, no time should be lost by giving a hot bath, but chloroform should be given at once, and repeated if neces- sary. A child is so readily put under chloroform and with such a small quantity that this precedure is quite harmless and saves much valuable time. The practice is almost universal of putting the child into a warm bath, and if there is fever the head may be douched with cold water. The temperature of the bath should not be above 95° or 96°. The very hot bath is not suitable, particularly if the fits are due to indigestion. After the attack an ice-cap may be placed upon the head. If there is much irri- tability, particularly in rickets and in severe diarrhoea, small doses of 1002 DISEASES OF THE NERYOUS SYSTEM. opium will be found efficacious. When the convulsions recur after the child comes from under the influence of chloroform it is best to place it rapidly under the influence of opium, which may be given as morphia hypodermically, in doses of from one twenty-fifth to one thirtieth of a grain for a child of one year. Other remedies recommended are chloral by enema, in five-grain doses, and nitrite of amyl. After the attack has passed the bromides are useful, of which five to eight grains may be given in a day to a child a year old. Recurring convulsions, particularly if they come on without special cause, should receive the most thorough and careful treat- ment with bromides. When associated with rickets the treatment should be directed to improving the general condition. VI. EPILEPSY. Definition.—An affection of the nervous system characterized by attacks of unconsciousness, with or without convulsions. The transient loss of consciousness without convulsive seizures is known as petit mat; the loss of consciousness with general convulsive seizures is known as grand mal. Localized convulsions, occurring usually without loss of consciousness, are known as epileptiform, or more frequently as Jacksonian or cortical epilepsy. Etiology.—Age.—In a large proportion of all cases the disease begins before puberty. Of the 1,450 cases observed by Gowers, in 422 the disease began before the tenth year, and three fourths of the cases began before the twentieth year. Of 460 cases of epilepsy in children which I have analyzed * the age of onset in 427 was as follows: First year, 74; second year, 62 ; third year, 51; fourth year, 24; fifth year, 17; sixth year, 18; seventh year, 19 ; eighth year, 23; ninth year, 17 ; tenth year, 27 ; eleventh year, 17; twelfth year, 18; thirteenth year, 15; fourteenth year, 21; fif- teenth year, 34. Arranged in hemidecades the figures are as follows: From the first to the fifth year, 229 ; from the fifth to the tenth'year, 104; from the tenth to the fifteenth year, 95. These figures illustrate in a striking manner the early onset of the disease in a large proportion of the cases. It is well always to be suspicious of epilepsy developing in the adult, for in a majority of such cases the convulsions are due to a local lesion. Sex.—No special influence appears to be discoverable in this relation, certainly not in children. Of 433 cases in my tables, 232 were males and 203 were females, showing a slight predominance of the male sex. After puberty unquestionably, if a large number of cases are taken, the males * Three hundred and nine cases from the records from the Philadelphia Infirmary for Diseases of the Nervous System, 126 cases at the Elwyn Institution for Feeble-minded Children, and 25 from the records of my neurological clinic at the Johns Hopkins Hospital. EPILEPSY. 1003 are in excess. The figures of Sieveking and Eeynolds show that the dis- ease is rather more prevalent in females than in males. Heredity.—Much stress has been laid upon this by many authors as an important predisposing cause, and the statistics collected give from nine to over forty per cent. Gowers gives thirty-five per cent for his cases, which have special value apart from other statistics embracing large numbers of epileptics in that they were collected by him in his own practice. In our figures it appears to play a minor role. In the Infirmary list there were only 31 cases in which there was a history of marked neurotic taint, and only three in which the mother herself had been epileptic. In the Elwyn cases, as might be expected, the percentage is larger. Of the 126 there was in 32 a family history of nervous derangement of some sort, either paralysis, epilepsy, marked hysteria, or insanity. It is interesting to note that in this group, in which the question of heredity is carefully looked into, there were only two in which the mother had had epilepsy, and not one in which the father had been affected. Indeed, I was not a little surprised to find in the list of my cases that hereditary influences played so small a part. I have heard this opinion expressed by certain French physicians, notably Marie, who in writing also upon the question takes strong grounds against heredity as an important factor in epilepsy. While, then, it may be said that direct inheritance is comparatively un- common, the children of neurotic families in which neuralgia, insanity, and hysteria prevail are more liable to fall victim to the disease. Chronic alcoholism in the parents is regarded by many as a potent pre- disposing factor in the production of epilepsy. Echeverria has analyzed 572 cases bearing upon this point and divided them into three classes, of which 257 cases could be traced directly to alcohol as a cause; 126 cases in which there were associated conditions, such as syphilis and trauma- tism ; 189 cases in which the alcoholism was probably the result of the epilepsy. Figures equally strong are given by Martin,* who found in 150 insane epileptics 83 with a marked history of parental intemperance. Of the 126 Elwyn cases, in which the family history on this point was care- fully investigated, a definite statement was found in only four of the cases. Syphilis.—This in the parents is probably less a predisposing than an actual cause of epilepsy, which is the direct outcome of local cerebral manifestations. There is no reason for recognizing a special form of syphilitic epilepsy. On the other hand, convulsive seizures due to acquired syphilitic disease of the brain are very common. Alcohol.—Severe epileptic convulsions may occur in steady drinkers. Of exciting causes fright is believed to be important, but is less so, I think, than is usually stated. Trauma is present in a certain number of instances. An important group depends upon a local disease of the brain * Annales Medicales Psychologiques, 1879. 1004 DISEASES OF TIIE NERVOUS SYSTEM. existing from childhood, as seen in the post-hemiplegic epilepsy. Occa- sionally cases follow the infectious fevers. Masturbation has been stated to be a special cause, but its influence is probably overrated. A large group of convulsive seizures allied to epilepsy are due to some toxic agent, as in lead-poisoning and in uraemia. Great stress was laid upon reflex causes, such as dentition and worms, the irritation of a cicatrix, some local affection, such as adherent prepuce, or a foreign body in the ear or the nose. In many of these cases the fits cease after the removal of the cause, so that there can be no question of the association between the two. In others the attacks persist. Genuine cases of reflex epilepsy are, I believe, rare. A remarkable instance of it occurred at the Philadelphia Infirmary for Diseases of the Nervous System in the case of a man with a testis in the inguinal canal, pressure upon which would cause a typical fit. Removal of the organ was followed by cure. Epilepsy has been thought to be associated with disturbance of the heart’s action, and some have spoken of a special cardiac epilepsy, par- ticularly in cases in which there is palpitation or slowing of the action prior to the onset. Epileptic seizures may occur during the passage of a gall-stone or occasionally during the removal of pleuritic fluid. Indiges- tion and gastric troubles are extremely common in epilepsy, and in many instances the eating of indigestible articles seems to precipitate an attack. An attempt to associate genuine epilepsy with eye-strain has signally failed. Symptoms.—(1) Grand Mai.—Preceding the fits there is usually a localized sensation, known as an aura, in some part of the body. This may be somatic, in which the feeling comes from some particular region in the periphery, as from the finger or hand, or is a sensation felt in the stomach or about the heart. The peripheral sensations preceding the fit are of great value, particularly those in which the aura always occurs in a definite region, as in one finger or toe. It is the equivalent of the signal symptom in a fit from a brain tumor. The varieties of these sensations are numerous. The epigastric sensations are most common. In these the patient complains of an uneasy sensation in the epigastrium or distress in the intestines, or the sensation may not be unlike that of heart-burn and may be associated with palpitation. These groups are sometimes known as pneumogastric aurae or warnings. Of psychical aurae one of the most common, as described by Hughlings Jackson, is the vague, dreamy state, a sensation of strangeness or some- times of terror. The aurae may be associated with special senses, of which the visual are the most common, consisting of flashes of light or sensa- tions of color; less commonly, distinct objects are seen. The auditory aurae consist of noises in the ear, odd sounds, musical tunes, or occasionally voices. Olfactory and gustatory aurae, unpleasant tastes and odors, are rare. Occasionally the fit may be preceded not by an aura, but by certain EPILEPSY. 1005 movements; the patient may turn round rapidly or run with great speed for a few minutes, the so-called epilepsia procursiva. Iu one of the Elwyn cases the lad stood on his toes and twirled with extraordinary rapidity, so that his features were scarcely recognizable. At the onset of the attack the patient may give a loud scream or yell, the so-called epileptic cry. The patient drops as if shot, making no effort to guard the fall. In consequence of this, epileptics frequently injure themselves, cutting the face or head or burning themselves. In the attack, as described by Hippocrates, “ the patient loses his speech and chokes, and foam issues from the mouth, the teeth are fixed, the hands are contracted, the eyes distorted, he becomes insensible, and in some cases the bowels are affected. And these symptoms occur sometimes on the left side, sometimes on the right, and sometimes on both.” The fit may be described in three stages: {a) Tonic Spasm.—The head is drawn back or to the right, and the jaws are fixed. The hands are clinched and the legs extended. This tonic contraction affects the muscles of the chest, so that respiration is impeded and the initial pallor of the face changes to a dusky or livid hue. The muscles of the two sides are unequally affected, so that the head and neck are rotated or the spine is twisted. The feet are extended and the knees and hip-joint are flexed. The arms are usually flexed at the elbows, the hand at the wrist, and the fingers are tightly clinched in the palm. This stage lasts only a few seconds, and then the (b) Clonic stage begins. The muscular contractions become inter- mittent; at first tremulous or vibratory, they gradually become more rapid and the limbs are jerked and tossed about violently. The mus- cles of the face are in constant clonic spasm, the eyes roll, the eyelids are opened and closed convulsively. The movements of the muscles of the jaw are very forcible and strong, and it is at this time that the tongue is apt to be caught between the teeth and lacerated. The cyan- osis, marked at the end of the tonic stage, gradually lessens. A frothy saliva, which may be blood-stained, escapes from the mouth. The fasces and urine may be discharged involuntarily. The duration of this stage is variable. It rarely lasts more than one or two minutes. The contrac- tions become less violent and the patient gradually sinks into the con- dition of (c) Coma. The breathing is noisy or even stertorous, the face con- gested, but no longer intensely cyanotic. The limbs are relaxed and the unconsciousness is profound. After a variable time the patient can be aroused, but if left alone he sleeps for some hours and then awakes, com- plaining only of slight headache or mental confusion. In some cases one attack follows the other with great rapidity and con- sciousness is not regained. This is termed the status epilepticus, an ex- ceptional condition, in which the patient may die of exhaustion consequent 1006 DISEASES OF THE NERVOUS SYSTEM. upon the repeated attacks. In it the temperature is usually elevated. After the attack the reflexes are sometimes absent; more frequently they are increased and the ankle clonus can usually he obtained. The state of the urine is variable, particularly as regards the solids. The quantity is usually increased after the attack, and albumen is not in- frequently present. Post-epileptic symptoms are of great importance. The patient may be in a trance-like condition, in which he performs actions of which subse- quently he has no recollection. More serious are the attacks of mania, in which the patient is often dangerous and sometimes homicidal. It is held by good authorities that an outbreak of mania may be substituted for the fit. And, lastly, the mental condition of an epileptic patient is often seri- ously impaired, and profound defects are common. Paralysis, which rarely follows the epileptic fit, is usually hemiplegic and transient. Slight disturbances of speech also may occur; in some instances forms of sensory aphasia. The attacks may occur at night, and a person may he epileptic for years without knowing it. As Trousseau truly remarks, when a person tells us that in the night he has incontinence of urine and awakes in the morning with headache and mental confusion, and complains of difficulty in speech owing to the fact that he has bitten his tongue; if, also, there are on the skin of the face and neck purpuric spots, the probability is very strong indeed that he is subject to nocturnal epilepsy. (2) Petit Mai.—This is epilepsy without the convulsions. The attack consists of transient unconsciousness, which may come on at any time, accompanied or unaccompanied by a feeling of faintness and vertigo. Suddenly, for example, at the dinner table, the subject stops talking and eating, the eyes become fixed, and the face slightly pale. Anything which may have been in the hand is usually dropped. In a moment or two con- sciousness is regained and the patient resumes conversation as if nothing had happened. In other instances there is slight incoherency or the pa- tient performs some almost automatic action. He may begin to undress himself and on returning to consciousness find that he has partially dis- robed. In other attacks the patient may fall without convulsive seizures. A definite aura is rare. Though transient, unconsciousness and giddiness are the most constant manifestations of petit mal; there are many other equivalent manifestations, such as sudden jerkings in the limbs, sudden tremor, or a sudden visual sensation. Gowers mentions no less than seven- teen different manifestations of petit mal. After the attack the patient may be dazed for a few seconds and per- form certain automatic actions, which may seem to be volitional. As men- tioned, undressing is a common action, but all sorts of odd actions may be performed, some of which are awkward or even serious. One of my pa- tients after an attack was in the habit of tearing anything he could lay EPILEPSY. 1007 hands on, particularly books. Violent actions have been committed and assaults made, frequently giving rise to questions which come before the courts. This condition has been termed masked epilepsy, or epilepsia larvata. In a majority of the cases of petit mat convulsions finally occur, at first slight, but ultimately the grand mat becomes well developed, and the attacks may then alternate. (3) Jacksonian Epilepsy.—This is also known as cortical, symptomatic, or partial epilepsy. It is distinguished from the ordinary epilepsy by the important fact that consciousness is retained. The attacks are usually the result of irritative lesions in the motor zone, though there are probably also sensory equivalents of this motor form. In a typical attack the spasm begins in a limited muscle group of the face, arm, or leg. The zygomatic muscles, for instance, or the thumb may twitch, or the toes may first be moved. Prior to the twitching the patient may feel a sensation of numbness or tingling in the part affected. The spasm extends and may involve the muscles of one limb only or of the face. The patient is conscious throughout and watches, often with interest, the march of the spasm. The onset may be slow, and there may be time, as in a case which I have reported, for the patient to place a pillow on the floor, so as to be as comfortable as possible during the attack. The spasms may be local- ized for years, but there is a great risk that the partial epilepsy may become general. The condition is due, as a rule, to an irritative lesion in the motor zone. Thus of 107 cases analyzed by Roland, there were 48 of tumor, 21 instances of inflammatory softening, 14 instances of acute and chronic meningitis, and 8 cases of trauma. The remaining instances were due to haemorrhage or abscess, or were associated with sclerosis cerebri. Two other conditions may be mentioned, which may cause typical Jacksonian epilepsy—namely, uraemia and progressive pa- ralysis of the insane. A considerable number of the cases of Jackso- nian epilepsy are found in children following hemiplegia, the so-called post-hemiplegic epilepsy. The convulsions usually begin on the affected side, either in the arm or leg, and the fit may be unilateral and with- out loss of consciousness. Illtimately they become more severe and general. Diagnosis.—In major epilepsy the suddenness of the attack, the abrupt loss of consciousness, the order of the tonic and clonic spasm, and the relaxation of the sphincters at the height of the attack are distinctive features. The convulsive seizures due to ursemia are epileptic in character and usually readily recognized by the existence of greatly increased ten- sion and the condition of the urine. Practically in young adults hysteria causes the greatest difficulty, and may closely simulate true epilepsy. The following table from Gowers’s work draws clearly the chief differences between them : 1008 DISEASES OF THE NERVOUS SYSTEM. Epileptic. Hysteroid. Apparent cause Warning none. emotion. any, but especially unilat- eral or epigastric auras. palpitation, malaise, choking, bi- lateral foot aura. Onset always sudden. often gradual. Scream at onset. during course. Convulsion rigidity followed by “jerk- ing,” rarely rigidity alone. rigidity or “struggling,” throwing about of limbs or head, arching of back. Biting tongue. lips, hands, or other people and things. Micturition frequent. never. Defecation occasional. never. Talking never. frequent. Duration a few minutes. more than ten minutes, often much longer. Restraint necessary.. to prevent accident. to control violence. Termination spontaneous. spontaneous or induced (water, etc.). Recurring epileptic seizures in a person over thirty who has not had previous attacks is always suggestive of organic disease. According to II. C. Wood, whose opinion is supported hy that of Fournier, in nine cases out of ten the condition is due to syphilis. Petit mat must be distinguished from attacks of syncope, and the ver- tigo of Meniere’s disease, of a cardiac lesion, and of indigestion. In these cases there is no actual loss of consciousness, which forms a characteristic though not an invariable feature of petit mat. Jacksonian epilepsy has features so distinctive and peculiar that it is at once recognized. It is by no means easy, however, always to deter- mine upon what the spasm depends. Irritation in the motor centres may be due to a great variety of causes, among which tumors and local- ized meningo-encephalitis are the most frequent; but it must not be forgotten that in ursemia localized epilepsy may occur. The most typi- cal Jacksonian spasms also are not infrequent in general paresis of the insane. Prognosis.—This may be given to-day in the words of Hippocrates: “ The prognosis in epilepsy is unfavorable when the disease is congenital, and when it endures to manhood, and when it occurs in a grown person without any previous cause. . . . The cure may be attempted in young persons, but not in old.” Death during the fit rarely occurs, but it may happen if the patient falls into the water or if the fit comes on while he is eating. Occasionally the fits seem to stop spontaneously. This is particularly the case in the epilepsy in children which has followed the convulsions of teething or of the fevers. Frequency of the attacks and marked mental disturbance are unfavorable indications. Hereditary predisposition is apparently of no moment in the prognosis. The outlook is better in males than in females. The post-hemiplegic epilepsy is rarely arrested. Of the cases coming on EPILEPSY. 1009 in adults, those due to syphilis and to local affections of the brain allow a more favorable prognosis. Treatment. — General.—In the case of children the parents should be made to understand from the outset that epilepsy in the great majority of cases is an incurable affection, so that the disease may interfere as little as possible with the education of the child. The subjects need firm but kind treatment. Indulgence and yielding to caprices and whims are followed by weakening of the moral control, which is so necessary in these cases. The disease does not incapacitate a person for all occupation. It is much better for epileptics to have some definite pursuit. There are many instances in which they have been persons of extraordinary mental and bodily vigor; as, for example, Julius Caesar and Napoleon. One of the most distressing features in epilepsy is the gradual mental impairment which follows in a certain number of cases. If such patients become ex- tremely irritable or show signs of violence they should be placed under supervision in an asylum. Marriage should be forbidden to epileptics. During the attack a cork or bit of rubber should be placed between the teeth and the clothes should be loosened. The patient should be in the recumbent posture. As the attack usually passes off with rapidity, no special treatment is necessary, but in cases in which the convulsion is pro- longed a few whiffs of chloroform or nitrite of amyl or a hypodermic of a quarter of a grain of morphia may be given. Dietetic.—The old authors laid great stress upon regimen in epilepsy. The important point is to give the patient a light diet at fixed hours, and on no account to permit overloading of the stomach. Meat should not be given more than once a day. There are cases in which animal food seems injurious. A strict vegetable diet has been warmly recom- mended. The patient should not go to sleep until the completion of gastric digestion. Medicinal.—The bromides are the only remedies which have a special influence upon the disease. Either the sodium or potassium salt may be given. Sodium bromide is probably less irritating and is better borne for a long period. It may be given in milk, in which it is scarcely tasted. In all instances the dilution should be considerable. In adults it is well taken in soda water or in some mineral water. The dose for an adult should be from half a drachm to a drachm and a half daily. As Seguin recommends, it is often best to give but a single dose daily, about four to six hours before the attacks are most likely to occur. For instance, in the case of nocturnal epilepsy a drachm should be given an hour or two after the evening meal. If the attack occurs early in the morning, the patient should take a full dose when he awakes. When given three times a day it is best given after meals. Each case should be carefully studied to determine how much bromide should be used. The individual suscepti- bility varies and some patients require more than others. Fortunately, children take the drug well and stand proportionately larger doses than 1010 DISEASES OF THE NERVOUS SYSTEM. adults. Saturation is indicated by certain unpleasant effects, particu- larly drowsiness, mental torpor, and gastric and cardiac distress. Loss of palate reflex is one of the earliest indications that the system is under the influence of the bromides, and is a condition which should be attained. A very unpleasant feature is the development of acne, which, however, is no indication of bromism. Seguin states that the tendency to this is much diminished by giving the drug largely diluted in alkaline waters and ad- ministering from time to time full doses of arsenic. To be effectual the treatment should be continued for a prolonged period and the cases should be incessantly watched in order to prevent bromism. The medi- cine should be continued for at least two years after the cessation of the fits; indeed, Seguin recommends that the reduction of the bromides should not be begun until the patient has been three years without any mani- festations. Written directions should be given to the mother or to the friends of the patient, and he should not himself be held responsible for the administration of the medicine. A book should be provided in which the daily number of attacks and the amount of medicine taken should be noted. The addition of belladonna to the bromide is warmly recom- mended by Black, of Glasgow. Among other remedies which have been recommended as controlling epilepsy are chloral, cannabis indica, zinc, nitroglycerin, and borax. Nitro- glycerin is sometimes advantageous in petit mat, but is not of much serv- ice in the major form. To be beneficial it must be given in full doses, from two to five minims of the one per cent solution, and increased until the physiological effects are produced. Counter-irritation is rarely advisable. When the aura is very definite and constant in its onset, as from the hand or from the toe, a blister about the part or a ligature tightly applied may stop the oncoming fit. In children, care should be taken that there is no source of peripheral irritation. In boys, adherent prepuce may occasionally be the cause. The irritation of teething, the presence of worms, and foreign bodies in the ears or nose have been asso- ciated with epileptic seizures. The subjects of a chronic and, in most cases, a hopelessly incurable disease, epileptic patients form no small portion of the unfortunate victims of charlatans and quacks, who prescribe to-day, as in the time of the father of medicine, “ purifications and spells and other illiberal practices of like kind.” Surgical.—In Jacksonian epilepsy the propriety of surgical inter- ference is universally granted. It is questionable, however, whether in the epilepsy folloAving hemiplegia, considering the anatomical condition, it is likely to be of any benefit. In idiopathic epilepsy, when the fit starts in a certain region—the thumb, for instance—and the signal symptom is in- variable, the centre controlling this part may be removed. This procedure has been practised by Macewen, Horsley, Keen, and others, but time alone can determine its value. The traumatic epilepsy, in which the fit follows fracture, is much more hopeful. MIGRAINE. 1011 The operation, per se, appears in seme cases to have' a curative effect. Thus of 50 cases of trephining for epilepsy in which nothing abnormal was found to account for the symptoms, 25 were reported as cured and 18 as im- proved.* The operations have not been always on the skull,, and White has collected an interesting series in which various surgical procedures have been resorted to, often with curative effect, such as ligation of the carotid artery, castration, tracheotomy, excision of the superior cervical ganglia, incision of the scalp, circumcision, etc. VII. MIGRAINE (Ilemicrania; Side Headache). Definition.—A paroxysmal affection characterized by severe head- ache, usually unilateral, and often associated with disorders of vision. Etiology.—The disease is frequently hereditary and has occurred through several generations. "Women and the members of neurotic fami- lies are most frequently attacked. It is an affection from which many dis- tinguished men have suffered and have left on record an account of the dis- ease, notably the astronomer Airy. Edward Liveing’s work is the standard authority upon which most of the subsequent articles have been based. A gouty or rheumatic taint is present in many instances. Sinkler has called special attention to the frequency of reflex causes. Migraine has long been known to be associated with uterine and menstrual disorders. Many of the headaches from eye-strain are of the hemicranial type. Brunton refers to caries of the teeth as a cause of these headaches, even when not associ- ated with toothache. Cases have been described in connection with ade- noid growths in the pharynx, and particularly with abnormal conditions of the nose. Many of the attacks of severe headaches in children are of this nature, and the eyes and nostrils should be examined with great care. Sinkler refers to a case in a child of two years, and Gowers states that a third of all the cases begin between the fifth and tenth years of age. The direct influences inducing the attack are very varied. Powerful emotions of all sorts are the most potent. Mental or bodily fatigue, digestive dis- turbances, or the eating of some particular article of food may be followed by the headache. The paroxysmal character is one of the most striking features, and the attacks may recur on the same day every week, every fortnight, or every month. Symptoms.—Premonitory signs are present in many cases, and the patient can tell when an attack is coming on. Remarkable prodromata have been described, particularly in connection with vision. Apparitions may appear—visions of animals, such as mice, dogs, etc. Transient he- mianopia or scotoma may be present. In other instances there is spas- modic action of the pupil on the affected side, which dilates and contracts * J. William White, Curative Effects of Operations per se, Annals of Surgery, 1891. 1012 DISEASES OF THE NERVOUS SYSTEM. alternately, the condition known as liippus. Frequently the disturbance of vision is only a blurring, or there are balls of light, or zigzag lines, or the so-called fortification spectra (teichopsia), which may be illuminated with gorgeous colors. Disturbances of the other senses are rare. Numb- ness of the tongue and face and occasionally of the hand may occur with tingling. More rarely there are cramps or spasms in the muscles of the affected side. Transient aphasia has also been noted. Some patients show marked psychical disturbance, either excitement or, more commonly, mental confusion or great depression. Dizziness occurs in some cases. The headache follows a short time after the prodromal symptoms have appeared. It is cumulative and expansile in character, beginning as a localized small spot, which is generally constant either on the temple or forehead or in the eyeball. It is usually described as of a penetrating, sharp, boring character. At first unilateral, it gradually spreads and in- volves the side of the head, sometimes the neck, and the pains may pass into the arm. In other cases both sides are affected. Nausea and vomit- ing are common symptoms. If the attack comes on when the stomach is full, vomiting usually gives relief. Vaso-motor symptoms may be pres- ent. The face, for instance, may be pale, and there may be a marked difference between the two sides. Subsequently the face and ear on the affected side may become a burning red from the vaso-dilator influences. The pulse may be slow. The temporal artery on the affected side may be firm and hard, and in a condition of arterio-sclerosis—a fact which has been confirmed anatomically by Thoma. Few affections are more pros- trating than migraine, and during the paroxysm the patient may scarcely be able to raise the head from the pillow. The slightest noise or light aggravates the condition. The duration of the entire attack is variable. The severer forms usually incapacitate the person for at least three days. In other instances the en- tire attack is over in a day. The disease recurs for years, and in cases with a marked hereditary tendency may persist throughout life. In women the attacks often cease after 'the climacteric, and in men after the age of fifty. Two of the greatest sufferers I have known, who had recurring attacks every few weeks from early boyhood, now have complete freedom. The nature of the disease is unknown. Liveing’s view, that it is a nerve storm or form of periodic discharge from certain sensory centres and is related to epilepsy, has found much favor. According to this view, it is the sensory equivalent of a true epileptic attack. Mollendorf, Latham, and others regard it as a vaso-motor neurosis, and hold that the early symptoms are due to vaso-constrictor and the later symptoms to vaso-dila- tor influences. The fact of the development of arterio-sclerosis in the arteries of the affected side is a point of interest bearing upon this view. Treatment.—The patient is fully aware of the causes which precipi- tate an attack. Avoidance of excitement, regularity in the meals, and moderation in diet are important rules. The treatment should be directed NEURALGIA. 1013 toward the removal of the conditions upon which the attacks depend. In children much may be done by watchfulness and care on the part of the mother in regulating the bowels and watching the diet of the child. Errors of refraction should be adjusted. On no account should such chil- dren be allowed to compete in school for prizes. A prolonged course of bromides sometimes proves successful. If anaemia is present, iron and arsenic should be given. When the arterial tension is increased a course of nitroglycerin may be tried. Not too much, however, should be expect- ed of the preventive treatment of migraine. It must be confessed that in a very large proportion of the cases the headaches recur in spite of all we can do. During the paroxysm the patient should be kept in bed and ab- solutely quiet. If the patient feels faint and nauseated, a small cup of hot, strong coffee or twenty drops of chloroform give relief. Cannabis indica is probably the most satisfactory remedy. Seguin recommends a prolonged course of the drug. Antipyrin, antifebrin, and phenacetin have been much used of late. When given early, at the very outset of the paroxysm, they are sometimes effective. The doses which have been rec- ommended of antifebrin and antipyrin are often dangerous, and I have seen in a case of migraine unpleasant collapse symptoms follow a twenty- five-grain dose of antipyrin which the patient had taken on her own re- sponsibility. Smaller, repeated doses are more satisfactory. Of other remedies, caffeine, in five-grain doses of the citrate, nux vomica, and ergot have been recommended. Electricity does not appear to be of much service. VIII. NEURALGIA. Definition.—A painful affection of the nerves, due either to func- tional disturbance of their central or peripheral extremities or to neuritis in their course. Etiology.—Members of neuropathic families are most subject to the disease. It affects women more than men. Children are rarely attacked. Of all causes, debility is the most frequent. It is often the first indication of an enfeebled nervous system. The various forms of anaemia are fre- quently associated with neuralgia. It may be a prominent feature at the onset of certain acute diseases, particularly typhoid fever. Malaria is be- lieved to he a potent cause, but it has not been shown that neuralgia is more frequent in malarial districts, and the error has probably arisen from regarding periodicity as a special manifestation of paludism. It occasion- ally occurs in malarial cachexia. Exposure to cold is a cause in very sus- ceptible persons. Reflex irritation, particularly from carious teeth, may in- duce neuralgia of the fifth nerve. The disease occurs sometimes in rheumatism, gout, lead poisoning, and diabetes. Symptoms.—Before the onset of the pain there may be uneasy sen- sations, sometimes tingling in the part which will be affected. The pain 1014 DISEASES OF THE NERVOUS SYSTEM. is localized to a certain group or division of nerves, usually affecting one .side. The pain is not constant, hut paroxysmal, and is described as stab- bing, burning, or darting in character. The skin may be exquisitely ten- der in the affected region, particularly in certain points along the course of the nerve, the so-called tender points. Movements, as a rule, are pain- ful. Trophic and vaso-motor changes may accompany the paroxysm; the skin may be cool, and subsequently hot and burning, occasionally local oedema or erythema occurs. More remarkable still are the changes in the hair, which may become blanched (canities), or even fall out. Fortunate- ly, such alterations are rare. Twitchings of the muscles, or even spasms, may be present during the paroxysm. After lasting a variable time—from a few minutes to many hours—the attack subsides. Recurrence may be at definite intervals—every day at the same hour, or at intervals of two, three, or even seven days. Occasionally the paroxysms develop only at the catamenia. This periodicity is quite as marked in non-malarial as in malarial regions. Clinical Varieties, depending on the Nerve Groups affected.—(1) Tri- facial Neuralgia ; Tic Douloureux ; Prosopalgia.—All the branches are rarely involved together. The ophthalmic is most often affected, but in severe attacks the pains, though more intense in one division, radiate over the other branches. At the outset there may be hyperaesthesia of the skin and sensitiveness of the mucous membrane. Pressure is painful at the points of emergence of the nerve trunk, and where the nerves enter the muscles. Sometimes in addition, as Trousseau pointed out, there are pains at the occipital protuberance and in the upper cervical spines. When the ophthalmic division is affected the eye may weep and the con- junctivae are injected and painful. In the upper maxillary division there is a tender point where the nerve leaves the infraorbital canal, and the pain is specially marked along the upper teeth. In the lower branches, which are more frequently involved, there are painful points along the auriculo-temporal nerve and the pain radiates in the region of the ear along the lower jaw and teeth. The movements of mastication and speak- ing may be painful. Salivation is not uncommon. Herpes may occur about the eye or the lips. In protracted cases there may be atrophy or induration of the skin. Some of the forms of facial neuralgia are of frightful intensity and the recurring attacks render the patient’s life almost insupportable. (2) Cervico-occipital neuralgia involves the posterior branches of the first four cervical nerves, particularly the inferior occipital, at the emer- gence of which there is a painful point about half-way between the mastoid process and the first cervical vertebra. It may be caused by cold, and these nerves arse often affected in cervical caries. (3) Cervico-brachial neuralgia involves the sensory nerves of the brachial plexus, particularly in the cubital division. When the circumflex nerve is involved the pain is in the deltoid. The pain is most commonly NEURALGIA. 1015 about the shoulder and down the course of the ulnar nerve. There is usually a marked tender point upon this nerve at the elbow. This form rarely follows cold, but more frequently results from rheumatic affections of the joints, and trauma. (4) Neuralgia of the 'phrenic nerve is rare. It is sometimes found in pleurisy and in pericarditis. The pain is chiefly at the lower part of the thorax on* a line with the insertion of the diaphragm, and here may be painful points on deep pressure. Full inspiration is painful, and there is great sensitiveness on coughing or in the performance of any movement by which the diaphragm is suddenly depressed. (5) Intercostal Neuralgia.—Next to the tic douloureux this is the most important form. It is most frequent in women and very common in hysteria and anaemia. The pain in caries and aneurism is felt in the in- tercostal nerves. They are also the seat of the intense pain in inflammation of the pleura. The pain is often constant and exaggerated by movements. Pleurodynia is supposed by some to be local intercostal neuralgia, con- fined to one spot, usually along the course or at the exit of the nerves. Herpes zoster or zona occurs with the most aggravated form of intercostal neuralgia. The pain usually precedes the eruption, which consists of a series of pearly vesicles, wdiich take two or three days to develop and gradually disappear. The eruption may occur without much pain. The most distressing feature in the complaint is the persistence in the pain after the eruption has subsided. The eruption and the neuralgia are in reality manifestations of neuritis. Changes have been found in the nerves and in the ganglia of the posterior roots. The pain of zona may persist indefinitely, and it has been known to be so intractable that in despair the person has committed suicide. (6) Lumbar Neuralgia.—The affected nerves are the posterior fibres of the lumbar plexus, particularly the ilio-scrotal branch. The pain is in the region of the iliac crest, along the inguinal canal, in the spermatic cord, and in the scrotum or labium majus. The affection known as irri- table testis, probably a neuralgia of this nerve, may be very severe and accompanied by syncopal sensations. (7) Coccydynia.—This is regarded as a neuralgia of the coccygeal plexus. It is most common in women, and is aggravated by the sitting posture. It is very intractable, and may necessitate the removal of the coccyx, an operation, however, which is not always successful. Neuralgias of the nerves of the leg have already been considered. (8) Neuralgias of the Nerves of the Feet. Painful Heel.—Both in women and men there may be about the heel severe pains which interfere seriously with walking—the pododynia of S. D. Gross. There may be little or no swelling, no discoloration, and no affection of the joints. Plantar Neuralgia.—This is often associated with a definite neuritis, such as follows typhoid fever, and has been seen in an aggravated form 1016 DISEASES OF THE NERVOUS SYSTEM. in caisson disease (Hughes). The pain may be limited to the tips of the toes or to the ball of the great toe. Numbness, tingling, and hyper- esthesia or sweating may occur with it. Following the cold-bath treat- ment in typhoid fever it is not uncommon for patients to complain of great sensitiveness in the toes. Metatarsalgia.—Morton’s (Thomas G.) “painful affection of the fourth metatarso-phalangeal articulation ” is a peculiar and very trying disorder, seen most frequently in women, and usually in one foot. Morton regards it as due to a pinching of the metatarsal nerve. The disease rarely gets well without operation. Erytliromelalgia.—Under this term Weir Mitchell described a con- dition which is associated with great pain in the heel or in the sole of the foot, with vascular changes, either an acute hypersemia or cyanosis. Some of the cases should unquestionably be regarded as Raynaud’s disease. (9) Visceral Neuralgias.—The more important of these have already been referred to in connection with the cardiac and the gastric neuroses. They are most frequent in women, and are constant accompaniments of neu- rasthenia and hysteria. The pains are most common in the pelvic region, particularly about the ovaries. Nephralgia is of great interest, for, as has already been mentioned, the symptoms may closely simulate those of stone. Treatment.—Causes of reflex irritation should be carefully removed. The neuralgia, as a rule, recurs unless the general health improves; so that tonic and hygienic measures of all sorts should be employed. Often a change of air or surroundings will relieve a severe neuralgia. I have known obstinate cases to be cured by a prolonged residence in the mount- ains, with an out-of-door life and plenty of exercise. A strict vegetable diet will sometimes relieve the neuralgia or headache of a gouty person. Of general remedies, iron is often a specific in the cases associated with chlorosis and antemia. Arsenic, too, is very beneficial in these forms, and should be given in ascending doses. The value of quinine has been much overrated. It probably has no more influence than any other bitter tonic, except in the rare instances in which the neuralgia is definitely associated with malarial poisoning. Strychnine, cod-liver oil, and phosphorus are also advantageous. Of remedies for the pain, the new analgesics should first be tried—antipyrin, antifebrin, and phenacetin—for they are some- times of service. Morphia should be given with great caution, and only after other remedies have been tried in vain. On no consideration should the patient be allowed to use the hypodermic syringe. Gelsemium is highly recommended. Of nervine stimulants, valerian and ether, which often act well together, may be given. Alcohol is a valuable though dangerous remedy, and should not be ordered for women. In the trifa- cial neuralgia nitro-glycerin in large doses may be tried. Aconitia in doses of from one two-hundredth to one one-hundred-and-fiftieth of a grain may be tried. In gouty and rheumatic subjects cannabis indica and cimicifuga are recommended with the lithium salts. PROFESSIONAL SPASMS; OCCUPATION NEUROSES. 1017 Of local applications, the thermo-cautery is invaluable, particularly in zona and the more chronic forms of neuralgia. Acupuncture may be used, or aquapuncture, the injection of distilled water beneath the skin. Chloroform liniment, camphor and chloral, menthol, the oleates of mor- phia, atropia, and belladonna used with lanolin may be tried. Freezing over the tender point with ether spray is sometimes successful. The con- tinuous current may be used. The sponges should be warm, and the posi- tive pole should be placed near the seat of the pain. The strength of the current should be such as to cause a slight tingling or burning, but not pain. The surgical treatment of intractable neuralgia embraces nerve stretch- ing and excision. The latter is the most satisfactory, but too often the pain returns. IX. PROFESSIONAL SPASMS; OCCUPATION NEUROSES. The continuous and excessive use of the muscles in performing a certain movement may be followed by an irregular, involuntary spasm or cramp, which may completely check the performance of the action. The condi- tion is found most frequently in writers, hence the term writer’s cramp or scrivener’s palsy; but it is also common in piano and violin players and in telegraph operators. The spasms occur in many other persons, such as milkmaids, weavers, and cigarette-rollers. The most common form is writer’s cramp, which is much more fre- quent in men than in women. Of 75 cases of impaired writing power re- ported by Poore, all of the instances of undoubted writer’s cramp were in men. Morris J. Lewis states that in this country, in the telegrapher’s cramp, women, who are employed a great deal in telegraphy, are much less frequently affected (only 4 out of 43 cases). Persons of a nervous temperament are more liable to the disease. Occasionally it follows slight injury. Gowers states that in a majority of the cases a faulty method of writing has been employed, using either the little finger or the wrist as the fixed point Persons who write from the middle of the forearm or from the elbow are rarely affected. No anatomical changes have been found. The most reasonable ex- planation of the disease is that it results from a deranged action of the nerve centres presiding over the muscular movements involved in the act of writing, a condition which has been termed irritable weakness. “ The education of centres which may be widely separated from each other for the performance of any delicate movement is mainly accomplished by less- ening the lines of resistance between them, so that the movement, which was at first produced by a considerable mental effort, is at last executed almost unconsciously. If, therefore, through prolonged excitation, this 1018 DISEASES OF THE NERVOUS SYSTEM. lessened resistance be carried too far, there is an increase and irregular discharge of nerve energy, which gives rise to spasm and disordered move- ment. According to this view, the muscular weakness is explained by an impairment of nutrition accompanying that of function, and the dimin- ished faradic excitability by the nutritional disturbance descending the motor nerves.” (Gray.) Symptoms.—These may be described under five heads (Lewis). (a) Cramp or Spasm.—This is often an early symptom and most com- monly affects the forefinger and thumb ; or there may be a combined move- ment of flexion and adduction of the thumb, so that the pen may be twisted from the grasp and thrown to some distance. Weir Mitchell has described a lock-spasm, in which the fingers become so firmly contracted upon the pen that it cannot be removed. (b) Paresis and Paralysis.—This may occur with the spasm or alone. The patient feels a sense of weakness and debility in the muscles of the hand and arm and holds the pen feebly. Yet in these circumstances the grasp of the hand may be strong and there may be no paralysis for ordi- nary acts. (c) Tremor.—This is most commonly seen in the forefinger and may be a premonitory symptom of atrophy. It is not an important symptom, and is rarely sufficient to produce disability. (d) Pain.—Abnormal sensations, particularly a tired feeling in the muscles, are very constantly present. Actual pain is rare, but there may be irregular shooting pains in the arm. Numbness or soreness may exist. If, as sometimes happens, a subacute neuritis develops, there may be pain over the nerves and numbness or tingling in the fingers. {e) Vasomotor Disturbances.—These may occur in severe cases. There may be liyperaesthesia. Occasionally the skin becomes glossy, or there is a condition of local asphyxia resembling chilblains. In attempting to write, the hand and arm may become flushed and hot and the veins increased in size. Early in the disease the electrical reactions are normal, but in ad- vanced cases there may be diminution of faradic and sometimes increase in the galvanic irritability. Diagnosis.—A well-marked case of writer’s cramp or palsy could scarcely be mistaken for any other affection. Care must be taken to ex- clude the existence of any cerebro-spinal disease, such as progressive mus- cular atrophy or hemiplegia. The physician is sometimes consulted by nervous persons who fancy they are becoming subject to the disease and complain of stiffness or weakness without displaying any characteristic features. Prognosis.—The course of the disease is usually chronic. If taken in time and if the hand is allowed perfect rest, the condition may im- prove rapidly, but too often there is a strong tendency to recurrence. The patient may learn to write with the left hand, but this also may after a time be attacked. TETANY. 1019 Treatment.—Various prophylactic measures have been advised. As mentioned, it is important that a proper method of writing be adopted. Gowers suggests that if all persons wrote from the shoulder writer’s cramp would practically not occur. Various devices have been invented for re- lieving the fatigue, but none of them are very satisfactory. The use of the type-writer has diminished very much the frequency of scrivener’s palsy. Rest is essential. No measures are of value without this. Massage and manipulation, when combined with systematic gymnastics, give the best results. Poore recommends the galvanic current applied to the muscles, which are at the same time rhythmically exercised. The nutrition of the patients is apt to be much impaired, and cod-liver oil, strychnia, and other tonics will be found advantageous. Local appli- cations are of little benefit. Tenotomy and nerve-stretching have been abandoned. X. TETANY. Definition.—An affection characterized by peculiar bilateral tonic spasms, either paroxysmal or continued, of the extremities. Etiology.—The disease occurs under very different conditions, of which the following may be recognized : (a) Epidemic tetany, also known as rheumatic tetany. In certain parts of the continent of Europe the disease has prevailed widely, particu- larly in the winter season. Von Jaksch, who has described an epidemic form occurring in young men of the working classes, sometimes with slight fever, regards the disease as infectious. This form is acute, lasting only two or three weeks and rarely proving fatal. (b) A majority of the cases are found in association with debility fol- lowing lactation and chronic diarrhoea, or in the malnutrition of rickets. From its occurrence in nursing women Trousseau called it nurse’s con- tracture. It may also occur during pregnancy. It has been found as a sequence of the acute fevers, and in some typhoid epidemics many cases have occurred. (c) Tetany may follow removal of the thyroid gland. Thirteen cases, for example, followed seventy-eight operations on enlarged thyroid in Bill- roth’s clinic, and six of them proved fatal. James Stewart has reported an instance in which with the tetany there were symptoms of myxcedema, and no trace of the thyroid gland. Removal of the thyroid in dogs is fol- lowed by tetany. (d) And, lastly, there is a form of tetany which is associated with dila- tation of the stomach, particularly after the organ has been washed out. On this continent true tetany is an extremely rare disease. Griffith has collected 72 cases, among which, however, cases of carpo-pedal spasm are included. The nature of the disease is unknown ; certain forms depend undoubt- edly on loss of the function of the thyroid gland. 1020 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—In cases associated with general debility or in children with rickets the spasm is limited to the hands and feet. The fingers are bent at the metacarpo-phalangeal joint, extended at the terminal joints, pressed close together, and the thumb is contracted in the palm of the hand. The wrist is flexed, the elbows are bent, and the arms are folded over the chest. In the lower limbs the feet are extended and the toes ad- ducted. The muscles of the face and neck are less commonly involved, but in severe cases there may be trismus, and the angles of the mouth are drawn out. The skin of the hands and feet is sometimes tense and oedem- atous. The spasms are usually paroxysmal and last for a variable time. In children the attack may pass off in a few hours. In some of the severer chronic cases in adults the stiffness and contracture may continue or even increase for many days, and the attack may last as long as two weeks. In the acute cases the temperature may be elevated and the pulse quickened. In the severe paroxysms there may be involvement of the muscles of the back and of the thorax, inducing dyspnoea and cyanosis. Certain additional features, valuable in diagnosis, are present. Trousseau’s symptom: “ So long as the attack is not over, the paroxysms may be reproduced at will. This is effected by simply compressing the affected parts, either in the direction of their principal nerve trunks or over their blood-vessels, so as to impede the venous or arterial circulation.” Chovestek’s symptom is shown in the remarkable increase in the me- chanical excitability of the motor nerves. A slight tap, for example, in the course of the facial nerve will throw the muscles to which it is dis- tributed into active contraction. Erb has shown that the electrical irrita- bility of the nerves is also greatly increased, and Hofmann has demon- strated the heightened excitability of the sensory nerves, the slightest pressure on which may cause pargesthesia in the region of distribution. Diagnosis.—The disease is readily recognized. It is a mistake to call instances of carpo-pedal spasm of children true tetany. It is com- mon to find in rickety children or in cases of severe gastro-intestinal catarrh a transient spasm of the fingers or even of the arms. By many authors these are considered cases of mild tetany, and there are all grades in rickety children between the simple carpo-pedal spasm and the con- dition in which the four extremities are involved; but it is well, I think, to limit the term tetany to the severer affection. With true tetanus the disease is scarcely ever confounded, as the com- mencement of the spasm in the extremities, the attitude of the hands, and the etiological factors are very different. Hysterical contractures are usually unilateral. Treatment.—In the case of children the condition with which the tetany is associated should be treated. Baths and cold sponging are rec- ommended and often relieve the spasm as promptly as in child-crowing. Bromide of potassium may be tried. In severe cases chloroform inhala- tions may be given. Massage, electricity, and the spinal ice-bag have also HYSTERIA. 1021 been used with success. Cases, however, may resist all treatment, and the spasms recur for many years. The thyroid extract should be tried. Gott- stein reports relief in a case of long standing, and Bramwell reports one case of operative tetany and one of the idiopathic form successfully treated in this way. XI. HYSTERIA. Definition.—A state in which ideas control the body and produce morbid changes in its functions (Mobius). Etiology.—The affection is most common in women, and usually ap- pears first about the time of puberty, but the manifestations may continue until the menopause, or even until old age. Men and boys, however, are by no means exempt, and of late years hysteria in the male has attracted much attention. It occurs in all races, but is much more prevalent, par- ticularly in its severer forms, in members of the Latin race. In this country the milder grades are common, but the graver forms are rare in comparison with the frequency with which they are seen in France. Of predisposing causes, two are important—heredity and education. The former acts by endowing the child with a mobile, abnormally sensi- tive nervous organization. We see cases most frequently in families with marked neuropathic tendencies, the members of which have suffered from neuroses of various sorts. Education at home too often fails to inculcate habits of self-control. A child grows to girlhood with an entirely errone- ous idea of her relations to others, and accustomed to have every whim gratified and abundant sympathy lavished on every woe, however trifling, she reaches womanhood with a moral organization unfitted to withstand the cares and worries of every-day life. At school, between the ages of twelve and fifteen, the most important period in her life, when the vital energies are absorbed in the rapid development of the body, she is often cramming for examinations and cooped in close school-rooms for six or eight hours daily. The result too frequently is an active, bright mind in an enfeebled body, ill adapted to subserve the functions for which it was framed, easily disordered, and prone to react abnormally to the ordinary stimuli of life. Among the more direct influences are emotions of various kinds, fright occasionally, more frequently love affairs, grief, and domestic worries. Physical causes less often bring on hysterical outbreaks, but they may follow directly upon an injury or develop during the convalescence from an acute illness or be associated with disease of the generative organs. The name hysteria indicates how important was believed to be the part played by the uterus in the causation of the disease. Opinions differ a good deal on this question, but undoubtedly in many cases there are ova- rian and uterine disorders the rectification of which sometimes cures the disease. Sexual excess, particularly masturbation, is an important factor, both in girls and boys. 1022 DISEASES OF THE NERVOUS SYSTEM. Symptoms.—A useful division is into the convulsive and non-con- vulsive varieties. Convulsive Hysteria.—(a) Minor Forms.—The attack most commonly follows emotional disturbance. It may set in suddenly or be preceded by symptoms, called by the laity “ hysterical,” such as laughing and crying alternately, or a sensation of constriction in the neck, or of a ball rising in the throat—the globus hystericus. Sometimes, preceding the convulsive movements, there may be painful sensations arising from the pelvic, ab- dominal, or thoracic regions. From the description these sensations resemble aurae. They become more intense with the rising sensation of choking in the neck and difficulty in getting breath, and the patient falls into a more or less violent convulsion. It will be noticed that the fall is not sudden, as in epilepsy, but the subject falls, as a rule, easily, often picking a soft spot, like a sofa or an easy chair, and in the movements apparently exercises care to do herself no injury. Yet at the same time she appears to be quite unconscious. The movements are clonic and disorderly, consisting of to-and-fro motion of the trunk or pelvic mus- cles, and the head and arms are thrown about in an irregular manner. The paroxysm after a few minutes slowly subsides, then the patient becomes emotional, and gradually regains consciousness. When ques- tioned the patient may confess to having some knowledge of the events which have taken place, but, as a rule, has no accurate recollection. Dur- ing the attack the abdomen may be much distended with flatus, and sub- sequently a large amount of clear urine may be passed. These attacks vary greatly in character. There may be scarcely any movements of the limbs, but after a nerve storm the patient sinks into a torpid, semi-uncon- scious condition, from which she is roused with great difficulty. In some cases from this state the patient passes into a condition of catalepsy. (b) Major Forms ; Hystero-epilepsy.—This condition has been specially studied by Charcot and his pupils. Typical instances passing through the various phases are very rare in this country. The attack is initiated by certain prodromata, chiefly minor hysterical manifestations, either foolish or unseemly behavior, excitement, sometimes dyspeptic symptoms with tympanites, or frequent micturition. Areas of hyperaesthesia may at this time be marked, the so-called hysterogenic spots so elaborately described by Richet. These are usually symmetrical and situated over the upper dorsal vertebra, and in front in a series of symmetrically placed spots on the chest and abdomen, the most marked being those in the inguinal regions over the ovaries. Painful sensations or a feeling of oppression and a globus- rising in the throat may be complained of prior to the onset of the convulsion, which, according to French writers, has four distinct stages: (1) Epileptoid condition, which closely simulates a true epileptic attack with tonic spasm (often leading to opisthotonos), grinding of the teeth, congestion of the face, followed by clonic convulsions, gradual relaxation, and coma. This attack lasts rather longer than a true epi- HYSTERIA. 1023 leptic attack. (2) Succeeding this is a period which Charcot has termed clownism, in which there is an emotional display and a remarkable series of contortions or of cataleptic poses. (3) Then in typical cases there is a stage in which the patient assumes certain attitudes expressive of the various passions—ecstasy, fear, beatitude, or erotism. (4) Finally con- sciousness returns and the patient enters upon a stage in which she may display very varied symptoms, chiefly manifestations of a delirium with the most extraordinary hallucinations. Visions are seen, voices heard, and conversations held with imaginary persons. In this stage patients will relate with the utmost solemnity imaginary events, and make ex- traordinary and serious charges against individuals. This sometimes gives a grave aspect to these seizures, for not only will the patient at this stage make and believe the statements, but when recovery is complete the hal- lucination sometimes persists. We seldom see in this country attacks having this orderly sequence. Much more commonly the convulsions succeed each other at intervals for several days in succession. Here is a striking difference between hystero-epilepsy and true epilepsy. In the latter the status epilepticus, if persistent, is always serious, associated with fever, and frequently fatal, while in hystero-epilepsy attacks may recur for days without special danger to life. After an attack of hystero- epilepsy the patient may sink into a state of trance or lethargy, in which she may remain for days. Non-convulsive Forms.—So complex and varied is the clinical picture of hysteria that various manifestations are best considered according to the systems which are involved. (1) Disorders of Motion.—(a) Paralyses.—These may be hemiplegic, paraplegic, or monoplegic. Hysterical diplegia is extremely rare. The paralysis either sets in abruptly or gradually, and may take weeks to attain its full development. There is no type or form of organic paralysis which may not he simulated in hysteria. According to Weir Mitchell, the hemi- plegias are most frequent in the ratio of four on the left to one on the right side. The face is not affected; the neck may be involved, but the leg suffers most. Sensation is either lessened or lost on the affected side. The hysterical paraplegia is more common than hemiplegia. The loss of power is not absolute ; the legs can usually be moved, but do not support the patient. The reflexes may be increased, though the knee-jerk is often normal. A spurious ankle clonus may sometimes be present. The feet are usually extended and turned inward in the equino-varus position. The muscles do not waste and the electrical reactions are normal. Other mani- festations, such as paralysis of the bladder or aphonia, are usually associ- ated with the hysterical paraplegia. Hysterical monoplegias may be facial, crural, or brachial. A condition of ataxia sometimes occurs with paresis. The incoordination may be a marked feature, and there are usually sen- sory manifestations. (h) Contractures and Spasms.—An extraordinary variety of spas- DISEASES OF THE NERVOUS SYSTEM. modic affections occurs in hysteria, of which the most common are the following: The hysterical contractures may attack almost any group of voluntary muscles and be of the hemiplegic, paraplegic, or monoplegic type. They may come on suddenly or slowly, persist for months or years, and disappear rapidly. The contracture is most commonly seen in the arm, which is flexed at the elbow and wrist, and the fingers tightly grasp the thumb in the palm of the hand; more rarely the terminal phalanges are hyperextended as in athetosis. It may occur in one or in both legs, more commonly the former. The ankle clonus is present; the foot is inverted and the toes are strongly flexed. These cases may be mistaken for lateral sclerosis and the difficulty in diagnosis may really be very great. The spastic gait is very typical, and with the exaggerated knee-jerk and ankle clonus the picture may be characteristic. In 1879 I frequently showed such a case at the Montreal General Hospital as a typical example of lateral sclerosis. The condition persisted for more than eighteen months and then disappeared completely. Other forms of contracture may be in the muscles of the hip, shoulder, or neck; more rarely in those of the jaws —hysterical trismus—or in the tongue. Remarkable indeed are the local contractures in the diaphragm and abdominal muscles, producing a phan- tom tumor, in which just below and in the neighborhood of the umbilicus is a firm, apparently solid growth. According to Gowers, this is produced by relaxation of the recti and a spasmodic contraction of the diaphragm, together with inflation of the intestines with gas and an arching forward of the vertebral column. They are apt to occur in middle-aged women about the menopause, and are frequently associated with the symptoms of spurious pregnancy—pseudo-cyesis. The resemblance to a tumor may be striking, and I have known skilful diagnosticians to be deceived. The only safeguard is to be found in complete anaesthesia, when the tumor entirely disappears. Some years ago I went by chance into the operating- room of a hospital and found a patient on the table under chloroform and the surgeon prepared to perform ovariotomy. The tumor, however, had completely disappeared with full anassthesia. Mitchell has reported an instance of a phantom tumor in the left pectoral region just above the breast, which was tender, hard, and dense. Clonic spasms are more common in hysteria in this country than contractures. The following are the important forms : Rhythmic hyster- ical spasm. This, unfortunately, is sometimes known as rhythmic chorea or hysterical chorea. The movements may be of the arm, either flexion and extension, or, more rarely, pronation and supination. Clonic contrac- tions of the sterno-cleido-mastoid or of the muscles of the jaws or of the rotatory muscles of the head may produce rhythmic movements of these parts. The spasm may be in one or both psoas muscles, lifting the leg in a rhythmic manner eight or ten times in a minute. In other instances the muscles of the trunk are affected, and every few moments there is a bowing movement—salaam convulsions—or the muscles of the back may HYSTERIA. 1025 contract, causing strong arching of the vertebral column and retraction of the head. These movements may often alternate, as in a case in my wards, in which the patient on fine days had regular salaam convulsions, while on wet days the rhythmic spasm was in the muscles of the back and neck. Mitchell has described a rotatory spasm in which the patient ro- tated involuntarily, usually to the left. More unusual cases are those in which the contractions closely simulate paramyoclonus multiplex. Hys- terical athetosis is a rare form of spasm. Tremor may be a pure hysterical manifestation, occurring either alone or with paralysis and contracture. It most commonly involves the hands and arms; more rarely the head and legs. The movements are small and quick. In the type Rendu the tremor may or may not persist during repose, but it is increased or pro- voked by volitional movements. Volitional or intentional tremor may ex- ist, simulating closely the movements of insular sclerosis. Buzzard states that many instances of this disease in young girls are mistaken for hysteria. (2) Disorders of Sensation.—Ancesthesia is most common, and usually confined to one half of the body. It may not be noticed by the patient. Usually it is accurately limited to the middle line and involves the mucous surfaces and deeper parts. The conjunctiva, however, is often spared. There may be hemianopia. This symptom may come on slowly or follow a convulsive attack. Sometimes the various sensations are dissociated and the anaesthesia may be only to pain and to touch. The skin of the affected side is usually pale and cool, and a pin-prick may not be followed by blood. With the loss of feeling there may be loss of muscular power. Curious trophic changes may be present, as in an interesting case of Weir Mitch- ell’s, in which there was unilateral swelling of the hemiplegic side. A phenomenon to which much attention has been paid is that of trans- ference. By metallotherapy, the application of certain metals, the anaes- thesia or analgesia can be transferred to the other side of the body. It has been shown, however, that this phenomenon may be caused by the electro-magnet and by wood and various other agents, and is probably entirely a mental effect. The subject has no practical importance, but it remains an interesting and instructive chapter in Gallic medical history. Hypercesthesia.—Increased sensitiveness and pains occur in various parts of the body. One of the most frequent complaints is of pain in the head, usually over the sagittal suture, less frequently in the occiput. This is described as agonizing, and is compared to the driving of a nail into the part; hence the name clavus hystericus. Neuralgias are common. Hy- pertesthetic areas, the hysterogenic points, exist on the skin of the thorax and abdomen, pressure upon which may cause minor manifestations or even a convulsive attack. Increased sensitiveness exists in the ovarian region, but is not peculiar to hysteria. Pain in the back is an almost con- stant complaint of hysterical patients. The sensitiveness may be limited to certain spinous processes, or it may be diffuse. In hysterical women the pains in the abdomen may simulate those of gastralgia and of gastric 1026 DISEASES OF THE NERVOUS SYSTEM. ulcer, or the condition may be almost identical with that of peritonitis; more rarely the abdominal pains closely resemble those of appendix disease. Special Senses.—Disturbances of taste and smell are not uncommon and may cause a good deal of distress. Of ocular symptoms, retinal hy- peraesthesia is the most common, and the patients always prefer to be in a darkened room. Retraction of the field of vision is common and usually follows a convulsive seizure. It may persist for years. The color percep- tion may be normal even with complete anaesthesia, and in this country the achromatopsia does not seem to be nearly so common an hysterical manifestation as in Europe. Hysterical deafness may be complete and may alternate or come on at the same time with hysterical blindness. Hysterical amaurosis may occur in children. One must carefully distin- guish between functional loss of power and simulation. (3) Visceral Manifestations.—Respiratory Apparatus.—Of disturb- ances in the respiratory rhythm, the most frequent, perhaps, is an exaggera- tion of the deeper breath, which is taken normally every fifth or sixth inspiration, or there may be a “ catching ” breathing, such as is seen wrhen cold water is poured over a person. Hysterical dyspnoea is readily recog- nized, as there is no special distress and the pulse is usually normal. I have met with a remarkable case following trauma in which the respira- tions rose above one hundred and thirty in the minute. Among laryngeal manifestations aphonia is the most frequent and may persist for months or even years without other special symptoms of the disease. Spasm of the muscles may occur with violent inspiratory efforts and great distress, and may even lead to cyanosis. Hiccough, or sounds resembling it, may be present for weeks or months at a time. Among the most remarkable of the respiratory manifestations are the hysterical cries. These may mimic the sounds produced by animals, such as barking, mewing, or grunting, and in France epidemics of them have been repeatedly observed. Extraor- dinary cries may be produced, either inspiratory or expiratory. I saw at Wagner’s clinic at Leipsic a girl of thirteen or fourteen, who had for many weeks given utterance to a remarkable inspiratory cry somewhat like the whoop of whooping-cough, but so intense that it was heard at a long distance. It was incessant, and the girl was worn to a skeleton. Attacks of gaping, yawning, and sneezing may also occur. The hysterical cough is a frequent symptom, particularly in young girls. It may occur in paroxysms, but is often a dry, persistent, croaking cough, extremely monotonous and unpleasant to hear. Sir Andrew Clark has called attention to a loud, barking cough (cynobex hebetica) occurring about the time of puberty, chiefly in boys belonging to neurotic families. The attacks, which last about a minute, recur frequently. There is a peculiar form of haemoptysis which may be very deceptive and lead to the diagnosis of pulmonary disorders. Wagner describes the sputum as a pale-red fluid—not so bright in color as in ordinary haemop- tysis, and on settling presents a reddish-brown sediment. It contains par- ticles of food, pavement epithelium, red corpuscles, and micrococci, but HYSTERIA. 1027 no cylindrical or ciliated epithelium. It probably comes from the mouth or pharynx. Digestive System.—Disturbed or depraved appetite, dyspepsia, and gastric pains are common in hysterical patients. The patient may have difficulty in swallowing the food, apparently from spasm of the gullet. There are instances in which the food seems to be expelled before it reaches the stomach. In other cases there is incessant gagging. In the hysterical vomiting the food is regurgitated without much effort and without nausea. This feature may persist for years without great disturbance of nutrition. The most striking and remarkable digestive disturbance in hysteria is the anorexia nervosa described by Sir William Gull. “ To call it loss of appe- tite—anorexia—but feebly characterizes the symptom. It is rather an annihilation of appetite, so complete that it seems in some cases impossible ever to eat again. Out of it grows an antagonism to food which results at last and in its worst forms in spasm on the approach of food, and this in turn gives rise to some of those remarkable cases of survival for long periods without food ” (Mitchell). As this goes on there may be an extreme degree of muscular restlessness, so that the patients wander about until exhausted. This feature has not been present in the cases which have come under my observation. Nothing more pitiable is to be seen in practice than an advanced case of this sort. It is usually in a young girl, sometimes as early as the eleventh or twelfth, more commonly between the fifteenth and twentieth years. The emaciation is frightful, and scarcely exceeded by that of cancer of the oesophagus. The patient finally takes to bed, and in extreme cases lies upon one side with the thighs and legs flexed, and con- tractures may occur. Food is either not taken at all or only upon urgent compulsion. The skin becomes wasted, dry, and covered with bran-like scales. No food may be taken for several weeks at a time, and attempts to feed may be followed by severe spasms. Although the condition looks so alarming, these cases, when removed from their home surroundings and treated by Weir Mitchell’s method, sometimes recover in a remarkable way. Death, however, may follow with extreme emaciation. In a fatal case recently under my care the girl weighed only forty-nine pounds. No lesions were found post mortem. Among intestinal symptoms flatulency is one of the most distressing, and is usually associated with the condition of peristaltic unrest (Kuss- maul). Frequent discharges of faeces may be due to disturbance in either the small or large bowel. An obstinate form of diarrhoea is found in some hysterical patients, which proves very intractable and is associated espe- cially with the taking of food. It seems an aggravated form of the loose- ness of bowels to which so many nervous people are subject on emotion or the tendency which some have to diarrhoea immediately after eating. An entirely different form is that produced by what Mitchell calls the irritable rectum, in which scybala are passed frequently during the day, sometimes with great violence. Constipation is more frequent, however, and may be 1028 DISEASES OF THE NERVOUS SYSTEM. due to a loss of power in the muscles of the bowel, or in the abdominal muscles. In extreme cases the bowels may not be moved for two or three weeks, leading to great accumulation of faeces. Other disturbances are ano-spasm or intense pain in the rectum apart from any fissure. Cardio-vascular.—Kapid action of the heart on the slightest emotion, with or without the subjective sensation of palpitation, is often a source of great distress. A slow pulse is less frequent. Pains about the heart may simulate angina, the so-called hysterical or pseudo-angina, which has already been considered. Flushes in various parts are among the most common symptoms. Sweating occasionally occurs. Among the more remarkable vaso-motor phenomena are the so-called stigmata or hsemorrhages in the skin, such as were present in the cele- brated case of Louise Lateau. In many cases these are undoubtedly fraudulent, but if, as appears credible, such bleeding may exist in the hypnotic trance, there seems no reason to doubt its occurrence in the .trance of prolonged religious ecstasy. Joint Affections.—To Sir Benjamin Brodie and Sir James Paget we owe the recognition of these extraordinary manifestations of hysteria. Perhaps no single affection has brought more discredit upon the profes- sion, for the cases are very refractory, and finally fall into the hands of a charlatan or faith-healer, under whose touch the disease may disappear at once. Usually it affects the knee or the hip, and may follow a trifling injury. The joint is usually fixed, sensitive, and swollen. The surface may be cool, but sometimes the local temperature is increased. To the touch it is very sensitive and movement causes great pain. In protracted cases the muscles about the joint are somewhat wasted, and in conse- quence it looks larger. The pains are often nocturnal, at which time the local temperature may be much increased. While, as a rule, neuromimetic joints yield to proper management, there are interesting instances in the literature in which organic change has succeeded the functional disturb- ance. In the remarkable case reported in Weir Mitchell’s lectures, the hysterical features were pronounced, and, on account of the chronicity, the disease of the knee-joint was considered organic by such an authority as Billroth. Sands found the joint surfaces normal, and the thickening to be due to inflammatory products outside the capsule. Intermittent hydrarthrosis may be a manifestation of hysteria, occur- ring in the knee or other joints, sometimes with transient paresis. Mental Symptoms.—The psychical condition of an hysterical patient is always abnormal, and the disease occupies the ill-defined territory be- tween sanity and insanity. In a large number of cases the patients are really insane, particularly in the perversion witnessed in the moral sphere. Not the slightest dependence can be placed upon their statements, and they will for months or years deceive friends, relatives, and physician. This appears to result partly, but not wholly, from a morbid craving for sympathy. It is really due to an entire unhinging of the moral nature. HYSTERIA. 1029 Hysterical patients may become insane and display persistent hallu- cinations and delirium, alternating perhaps with emotional outbursts of an aggravated character. For weeks or months they may be confined to bed, entirely oblivious to their surroundings, with a delirium which may simulate that of delirium tremens, particularly in being associated with loathsome and unpleasant animals. The nutrition may be maintained, but in these cases there is always a very heavy, foul breath. With seclu- sion and care recovery usually takes place within three or four months. At the onset of these attacks and during convalescence the patients must be incessantly watched, as a suicidal tendency is by no means uncommon. I have been accustomed to speak of this condition as the status hystericus. Of hysterical manifestations in the higher centres that of trance is the most remarkable. This may develop spontaneously without any convul- sive seizure, but more frequently, in this country at least, it follows hys- teroid attacks. Catalepsy, a condition in which the limbs are plastic and remain in any position in which they are placed, may be present. The Metabolism in Hysteria.—The studies of Gilles de la Tourette and Cathelineau, under Charcot’s direction, have shown that in the ordi- nary forms of hysteria the urine does not show quantitative or qualitative changes, but in the severe types, characterized by convulsions, etc., there are important modifications : reduction in the urates and phosphates ; the ratio of the earthy to the alkaline phosphates, normally 1:3, is 1:2, or even 1:1. The urine is also reduced in amount. They think that these changes might sometimes serve to differentiate convulsive hysteria from epilepsy, in which there is always an increase in the solid constituents after a seizure. . Hysterical Fever.—In hysteria the temperature, as a rule, is normal. The cases with fever may be grouped as follows : (a) Instances in which the fever is the sole manifestation. These are rare, but I have seen at least two cases in which the chronic course, the retention of the nutrition, and the entirely negative condition of the organs left no other diagnosis possible. In a case recently under observation the patient has had for four or five years an afternoon rise of temperature, reaching usually to 102 or 103°. She was well nourished and presented no pronounced hysterical symptoms, but there was a marked neurotic history on one side and a form of interrupted sighing respiration so often seen in hysteria. (b) Cases of hysterical fever with spurious local manifestations. These are very troublesome and deceptive cases. The patient may be suddenly taken ill with pain in various regions and elevation of temperature. The case may simulate meningitis. There may be pain in the head, vomiting, contracted pupils, and retraction of the neck—symptoms which may per- sist for weeks—and some anomalous manifestation during convalescence may alone indicate to the physician that he has had to deal with a case of hysteria, and has not, as he perhaps flattered himself, cured a case of men- ingitis. Mary Putnam Jacobi, in a recent article on hysterical fever, 1030 DISEASES OF THE NERVOUS SYSTEM. mentions a case in the service of Cornil which was admitted with dyspnoea, slight cyanosis, and a temperature of 39° C. The condition proved to be hysterical. There is also an hysterical pseudo-phthisis with pain in the chest, slight fever, and the expectoration of a blood-stained mucus. The cases of hysterical peritonitis may also show fever. (c) Hysterical Hyperpyrexia.—It is a suggestive fact that the cases of paradoxical temperatures reported of late years, in which the thermometer has registered 112° to 120° or more, have been in women. Fraud has been practised in some of these, but others have to be accepted, though their explanation is impossible under our known laws. Jacobi has re- cently reported a case in which the temperature rose to 148° F. (65-5° C.). The Omaha case, in.which the temperature was recorded at 170° F., has, I am informed on good authority, proved a fraud. Diagnosis.—Inquiry into the occurrence of previous manifestations and the mental conditions may give important information. These ques- tions, as a rule, should not be asked the mother, who of all others is least likely to give satisfactory information about the patient’s condition. The occurrence of the globus hystericus, of emotional attacks, of weeping and crying, are always suggestive. The points of difference between the con- vulsive attacks and true epilepsy were referred to in their description, and as a rule little difficulty is experienced in distinguishing between the two conditions. The hysterical paralyses are very variable and apt to be associated with anaesthesia. The contractures may at times be very decep- tive, but the occurrence of areas of anaesthesia, of retraction of the visual held, and the development of minor hysterical manifestations, give valua- ble indications. The contractures disappear under full anaesthesia. Spe- cial care must be taken not to confound the spastic paraplegia of hysteria with lateral sclerosis. The visceral manifestations are usually recognized without much diffi- culty. The practitioner has constantly to bear in mind the strong tend- ency in hysterical patients to practise deception. Treatment.—The prophylaxis in hysteria may be gathered from the remarks on the relation of education to the disease. The successful treat- ment of hysteria demands qualities possessed by few physicians. The first element is a due appreciation of the nature of the disease on the part of the physician and friends. It is pitiable to think of the misery which has been inflicted on these unhappy victims by the harsh and unjust treat- ment which has resulted from false views of the nature of the trouble; on the other hand, worry and ill-health, often the wrecking of mind, body, and estate, are entailed upon the near relatives in the nursing of a protracted case of hysteria. The minor manifestations, attacks of the vapors, the crying and weeping spells, are not of much moment and rarely require treatment. The physical condition should be carefully looked into and the mode of life regulated so as to insure system and order in everything. A congenial occupation offers the best remedy for many of these manifestations. Any functional disturbance should be at- HYSTERIA. 1031 tended to and a course of tonics prescribed. Special attention should ‘be paid to the action of the bowels. Valerian and asafcetida are often of service. For the pains in various parts, particularly in the back, the therino-cautery and static electricity will be found invaluable. Morphia should be withheld. In the convulsive seizures, particularly in the minor forms, it is often best, after settling the patient comfortably, to leave her. When she comes to, and finds her- self alone and without sympathy, the attacks are less likely to be repeated. There is, as a rule, no cure for the hysterical manifestations of women, otherwise in good health, who are, as Mitchell says, “ fat and ruddy, with sound organs and good appetites, but ever complain of pains and aches, and ever liable on the least emotional disturbance to exhibit a quaint variety of hysterical phenomena.” To treat hysteria as a physical disorder is, after all, radically wrong. It is essentially a mental and emotional anomaly, and the important ele- ment in the treatment is moral control. At home, surrounded by loving relatives who misinterpret entirely the symptoms and have no appreciation of the nature of the disease, the severer forms of hysteria can rarely be cured. The necessary control is impossible; hence the special value of the method introduced by Weir Mitchell, which is particularly applicable to the advanced cases which have become chronic and bedridden. The treatment consists in isolation, rest, diet, massage, and electricity. Sepa- ration from friends and sympathetic relatives must be absolute, and can rarely, if ever, be obtained in the individual’s home. An essential element in the treatment is an intelligent nurse. No small share of the success which has attended the author of this plan has been due to the fact that he has persistently chosen as his allies bright, intelligent women. The details of the plan are as follows: The patient is confined to bed and not allowed to get up, nor, at first, in aggravated cases, to read, write, or even to feed herself. Massage is used daily, at first for twenty minutes or half an hour, subsequently for a longer period. It is essential as a substitute for exercise. The induction current is applied to the various muscles and to the spine. Its use, however, is not so essential as that of massage. The diet may at first be entirely of milk, four ounces every two hours. It is better to give skimmed milk, and it may be diluted with soda water or barley water and, if necessary, peptonized. After a week or ten days the diet may be increased, the amount of milk still being kept up. A chop may be given at midday, a cup of coffee or cocoa Avith toast or bread and butter or a biscuit with the milk. The patients usually fatten rapidly as the solid food is added, and with the gain there is, as a rule, a diminution or cessation of the nervous symptoms. The milk is the essential element in the diet, and is itself amply sufficient. The remarkable results obtained by this method are now universally recognized. The plan is more applicable to the lean than to fat, flabby hysterical patients. Not only is it suitable for the more obstinate varie- 1032 DISEASES OF THE NERVOUS SYSTEM. ties of hysteria with bodily manifestations, but in the cases with mental symptoms the seclusion and separation from relatives and friends are par- ticularly advantageous. In the hysterical vomiting Debove’s method of forced feeding may be used with benefit. For the innumerable minor manifestations of hysteria and for the simulations the indications for treat- ment are usually clear. Of late, hypnotism has been extensively used in the treatment of hysteria. Occasionally in cases of hysterical contractions or paralysis it is of benefit, but any one who has seen the development of this method as practised at present in France must feel that it is a two- edged sword and that the constant repetition in the same patient is fraught with danger. In the cases which we have tried here the success has not been marked. XII. NEURASTHENIA. Definition.—A condition of weakness or exhaustion of the nervous system. The term, invented by Beard, covers an ill-defined, motley group of symptoms, which may be either general and the expression of derange- ment of the entire system, or local, limited to certain organs; hence the terms cerebral, spinal, cardiac, and gastric neurasthenia. In certain re- spects it is the physical counterpart of insanity. As the essential feature in the latter condition is the abnormal response to stimuli, from within or without, upon the higher centres presiding over the mind, so neurasthenia appears to be the expression of a morbid, unhealthy reaction to stimuli acting on the nervous centres which preside over the functions of organic life. No hard and fast line can be drawn between neurasthenia and cer- tain mental states, particularly hysteria and hypochondria. Etiology.—Although the causes are apparently varied, they may be grouped as hereditary and acquired. (a) Hereditary.—We do not all start in life with the same amount of nerve capital. Parents who have been the subjects of nervous complaints or of mental troubles transmit to their children an organization which is defective in what, for want of a better term, we must call “ nerve force.” Such individuals start handicapped, and furnish a considerable proportion of our neurasthenic patients. So long as they are content to transact a moderate business with their life capital, all may go well, but there is no reserve, and in the emergencies which constantly arise in the exigencies of modern life these small capitalists go under and come to us as bank- rupts. (b) Acquired.—The functions, though perverted most readily in per- sons who have inherited a feeble organization, may also be damaged by exercise which is excessive in proportion to the strength—i. e., by strain. The cares and anxieties attendant upon the gaining of a livelihood may be borne without distress, but in many persons the strain becomes excess- NEURASTHENIA. 1033 ive and is first manifested as worry. The individual loses the distinction between essentials and non-essentials, trifles cause annoyance, and the entire organism reacts with unnecessary readiness to slight stimuli, and is in a state which the older writers called irritable weakness. If such a condition be taken early and the patient given rest, the balance is quickly restored. In this group may be placed a large proportion of the neuras- thenics which we see in this country, particularly among business men. Other causes more subtle, yet potent, and less easily dealt with, are the worries attendant upon love affairs, religious doubts, and the sexual pas- sion. Symptoms.—These are extremely varied, and may be general or localized; more often a combination of both. The appearance of the patient is suggestive, sometimes characteristic, but difficult to describe. Loss of weight and slight anaemia may be present. The physical debility may reach a high grade and the patient may be confined to bed. Men- tally the patients are usually low-spirited and despondent, in women fre- quently emotional. The local symptoms may dominate the situation, in which case the clinical picture is of the so-called cerebral or spinal neurasthenia. Other local forms are cardio-vascular, gastric, and sexual. In the cerebral form the symptoms are chiefly connected with an inability to perform the ordinary mental work. Thus a row of figures cannot be correctly added, the dictation or the writing of a few letters is a source of the greatest worry, the transaction of petty details in business is a painful effort, and there is loss of power of fixed attention. With this condition there may be no headache, the appetite may be good, and the patient may sleep well. As a rule, however, there are sensations of fulness and weight or flushes, if not actual headache. Sleeplessness is a frequent concomitant, and may be the first manifestation. Some of these patients are good-tempered and cheerful, but a majority are moody, irritable, and depressed.* The special senses may be disturbed, particularly vision. An aching or weariness of the eyeballs after reading a few minutes or flashes of light are common symptoms. A difference between the pupils may be present. When the spinal symptoms predominate—spinal irritation or spinal neurasthenia—in addition to many of the features just mentioned, the patients complain of weariness on the least exertion, of weakness, pain in the back, and of aching pains in the legs. There may be spots of local tenderness on the spine. Occasionally there may be disturbances of sen- sation, particularly a feeling of numbness and tingling, and the reflexes may be increased. The aching pain in the back or in the back of the neck is the most constant complaint in these cases. In women it is often * For an exhaustive consideration of the mental symptoms of neurasthenia, see the Shattuck Lecture, by Cowles. Boston Medical and Surgical Journal, 1891. 1034 DISEASES OF THE NERVOUS SYSTEM. impossible to say whether this condition is one of neurasthenia or hys- teria. In other cases the cardio-vascular symptoms are the most distressing, and may occur with only slight disturbance of the cerebro-spinal functions, though the conditions may be combined. Palpitation of the heart, irregu- lar and very rapid action, and pains in the'-cardiac region are the most common symptoms. The slightest excitement may be followed by in- creased action of the heart, and the patients frequently have the idea that they sutler from serious disease of this organ. Vaso-motor disturbances constitute a special feature of many cases. Flushes of heat and transient hyperaemia of the skin may be very distress- ing symptoms. Profuse sweating may occur, either local or general, and sometimes nocturnal. The pulse may show interesting features, owing to the extreme relaxation of the peripheral arterioles. The arterial throb- bing may be everywhere visible, almost as much as in aortic insufficiency. The pulse, too, may under these circumstances have a somewhat water- hammer quality. The capillary pulse may be seen in the nails, on the lips, or on the margins of a line drawn upon the forehead, and I have on several occasions seen pulsation in the veins of the back of the hand. A characteristic symptom in some cases is the throbbing aorta. This “ preternatural pulsation in epigastrium,” as Allan Burns calls it, may be extremely forcible and suggest the existence of abdominal aneurism. The subjective sensations associated with it may be very unpleasant, particu- larly when the stomach is empty. The general features of gastro-intestinal neurasthenia have been dealt with under the section of nervous dyspepsia. The connection of these cases with dilatation of the stomach, floating kidney, and the condition which Grlenard calls enteroptosis has already been mentioned. Sexual neurasthenia is a condition in which there is an irritable weak- ness of the sexual organs manifested by nocturnal emissions, unusual de- pression after intercourse, and often by a distressing dread of impotence. The mental condition of these patients is most pitiable, and they fall an easy prey to quacks and charlatans of all kinds. In all forms of neurasthenia the condition of the urine is important. Many cases are complicated with the symptoms of the condition known as lithaemia, and so marked may -this be that some have indeed made a special form of lithaemic neurasthenia. Polyuria may be present, but is more common in hysteria. With disturbed digestion the urates and oxa- lates may be in excess. The diagnosis is readily made. It is sometimes difficult to distinguish the cases from hysteria, and this is not surprising, as we cannot always differentiate the two conditions. Neurasthenia occurs chiefly in men; in fact, it is in many ways in them the equivalent of hysteria. THE TRAUMATIC NEUROSES. 1035 XIII. THE TRAUMATIC NEUROSES (Railway Brain and Railway Spine; Traumatic Hysteria). Definition.—A morbid condition following shock which presents the symptoms of neurasthenia or hysteria or of both. The condition is known as “ railway brain ” and “ railway spine.” Erichsen regarded the condition as the result of inflammation of the meninges and cord, and gave it the name railway spine. AValton and J.. J. Putnam, of Boston, were the first to recognize the hysterical nature of many of the cases,* and to Westphal’s pupils we owe the name traumatic neurosis. Etiology.—The condition follows an accident, often in a railway train, in which injury has been sustained, or succeeds a shock or concus- sion, from which the patient may apparently not have suffered in his body. A man may appear perfectly well for several days, or even a week or more, and then develop the symptoms of the neurosis. Bodily shock or concussion is not necessary. The affection may follow a profound mental impression; thus, an engine driver ran over a child, and received thereby a very severe shock, subsequent to which the most pronounced symptoms of neurasthenia developed. Severe mental strain combined with bodily exposure may cause it, as in a case of a naval officer who was wrecked in a violent storm and exposed for more than a day in the rig- ging before he was rescued. A slight blow, a fall from a carriage or on the stairs may suffice. Symptoms.—The cases may be divided into three groups: simple neurasthenia, cases with marked hysterical manifestations, and cases with severe symptoms indicating or simulating organic disease. (a) Simple Traumatic Neurasthenia.—The first symptoms usually de- velop a few weeks after the accident, which may or may not have been associated with an actual trauma. The patient complains of headache and tired feelings. He is sleepless and finds himself unable to concentrate his attention properly upon his work. A condition of nervous irritability develops, which may have a host of trivial manifestations, and the entire mental attitude of the person may for a time be changed. He dwells con- stantly upon his condition, gets very despondent and low-spirited, and in extreme cases melancholia may develop. lie may complain of numbness and tingling in the extremities, and in some cases of much pain in the back. The bodily functions may be well performed, though such patients usually have, for a time at least, disturbed digestion and loss in weight. The physical examination may be entirely negative. The reflexes are slightly increased, as in ordinary neurasthenia. The pupils may be un- equal ; the cardio-vascular changes already described in neurasthenia may be present in a marked degree. According as the symptoms are more * See La Neurasthenic, par L. Bouveret, Paris, 1891. 1036 DISEASES OF THE NERVOUS SYSTEM. spinal or more cerebral, the condition is known as railway brain or railway spine. (2) Cases with Marked Hysterical Features.—Following an injury of any sort, neurasthenic symptoms, like those described above, may develop, and in addition symptoms regarded as characteristic of hysteria. The emotional element is prominent, and there is but slight control over the feelings. The patients have headache, backache, and vertigo. A violent tremor may be present, and indeed constitutes the most striking feature of the case. I have recently seen an engineer who developed subsequent to an accident a series of nervous phenomena, but the most marked feature was an excessive tremor of the entire body, which was specially manifest during emotional excitement. The most pronounced hysterical symptoms are the sensory disturbances. As first noted by Putnam and Walton, hemianaesthesia may occur as a sequence of traumatism. This is a common symptom in France, but rare in England and in this country. Achromatopsia may exist on the anaesthetic side. A second, more com- mon, manifestation is limitation of the field of vision, similar to that which occurs in hysteria. Remarkable disturbances may develop in some of these cases. A few months ago I saw a man who had been struck by an electric car, whose chief symptom was an extraordinary increase in the number of respira- tions. He was a stout, powerfully built man, and presented practically no other symptom than dyspnoea of the most extreme grade. At the time of observation his respirations were over 130 per minute, and he stated that they had been counted at over 150. (3) Cases in which the Symptoms suggest Organic Disease of the Brain and Cord.—As a result of spinal concussion, without fracture or external injury, there may subsequently develop symptoms suggestive of organic disease, which may come on rapidly or at a late date. In a case reported by Leyden the symptoms following the concussion were at first slight and the patient was regarded as a simulator, but finally the condi- tion became aggravated and death resulted. The post-mortem showed a chronic pachymeningitis, which had doubtless resulted from the accident. The cases in this group about which there is so much discussion are those which display marked sensory and motor changes. Following an accident in which the patient has not received external injury a condition of ex- citement may develop within a week or ten days; he complains of head- ache and backache, and on examination sensory disturbances are found, either hemianaesthesia or areas on the skin in which the sensation is much benumbed ; or painful and tactile impressions may be distinctly felt in certain regions, and the temperature sense is absent. The distribution may be bilateral and symmetrical in limited regions or hemiplegic in type. Limitation of the field of vision is usually marked in these cases, and there may be disturbance of the senses of taste and smell. The superficial re- flexes may be diminished; usually the deep reflexes are exaggerated. The THE TRAUMATIC NEUROSES. 1037 pupils may be unequal; the motor disturbances are variable. The French writers describe cases of monoplegia with or without contracture, symp- toms upon which Charcot lays great stress as a manifestation of profound hysteria. The combination of sensory disturbances—anaesthesia or hyper- aesthesia—with paralysis, particularly if monoplegic, and the occurrence of contractures without atrophy and with normal electrical reactions, may be regarded as distinctive of hysteria. In rare cases following trauma and succeeding to symptoms which may have been regarded as neurasthenic or hysterical, there are organic changes which may prove fatal. That this sequence occurs is demonstrated clearly by recent post-mortem examinations. The features upon which the greatest reliance can be placed as indicating organic change are optic atrophy, bladder symptoms, particularly in combination with tremor, paresis, and exaggerated reflexes. The anatomical changes in this condition have not been very definite. When death follows spinal concussion within a few days there may be no apparent lesion, but in some instances the brain or cord has shown punc- tiform haemorrhages. Edes has reported four cases in which a gradual degeneration in the pyramidal tracts followed concussion or injury of the spine; but in all these cases there was marked tremor and the spinal symptoms developed early or followed immediately upon the accident. Post-mortems upon cases in which organic lesions have supervened upon a traumatic neurosis are extremely rare. Bernhardt reports an instance of a man, aged thirty-three, who in 1886 received a kick from a horse on the epigastrium and subsequently developed the symptom-complex of neurasthenia and hysteria with attacks of vertigo and great psychical de- pression. He afterward had more marked mental symptoms and attacks of unconsciousness. He committed suicide and the brain and cord showed a beginning multiple sclerosis in the white matter, which was possibly associated with an advanced grade of arterio-sclerosis. In a second case a man, aged forty-two, received a shock in a railway accident in July, 1884. He was rendered unconscious and had a slight injury in the but- tock region. In a few weeks symptoms of traumatic neurosis developed, particularly great depression of spirits, with headache and sensory disturb- ances in the feet and hands. Tremor and great weakness were com- plained of when he attempted to work. There was no increase in the reflexes. The case was regarded as an instance of simulation and a defect in objective symptoms favored this view. Subsequently this judgment was reversed, but he did not improve. He died in January, 1889, with symptoms of cardiac dyspnoea. Macroscopically the brain and cord ap- peared normal. There was extreme arterio-sclerosis, particularly of the vessels of the brain and cord. In the latter there were scattered areas of degeneration in the white substance, and degeneration in the sympathetic ganglia. I have entered somewhat fully into this question because of its extreme 1038 DISEASES OF THE NERVOUS SYSTEM. importance and on account of the paucity of the observations upon cases which have subsequently developed symptoms of organic disease. Exam- ples of it are extremely rare. So far as I know no case with autopsy has been reported in this country, nor have I seen an instance in which the clinical features pointed to an organic disease which had followed upon a traumatic neurosis. Diagnosis.—A condition of fright and excitement following an acci- dent may persist for days or even weeks, and then gradually pass away. The symptoms of neurasthenia or of hysteria which subsequently develop present nothing peculiar and are identical with those which occur under other circumstances. Care must be taken to avoid simulation, and, as in these cases the condition is largely subjective, this is sometimes extremely difficult. In a careful examination a simulator will often reveal himself by exaggeration of certain symptoms, particularly sensitiveness of the spine, and by increasing voluntarily the reflexes. It may require a careful study of the case to determine whether the individual is honestly suffering from the symptoms of which he complains. A still more important ques- tion in these cases is, Has the patient organic disease ? The symptoms given under the first two groups of cases may exist in a marked degree and may persist for several years without the slightest evidence of organic change. It must be noted that in the two autopsies above referred to the patients were the subjects of extreme arterio-sclerosis, with which, in all probability, the areas of multiple sclerosis were associated. Hemiansesthe- sia, limitation of the field of vision, monoplegia with contracture, may all be present as hysterical manifestations, from which recovery may be com- plete. In our present knowledge the diagnosis of an organic lesion should be limited to those cases in which optic atrophy, bladder troubles, and signs of sclerosis of the cord are well marked—indications either of degeneration of the lateral columns or of multiple sclerosis. Prognosis.—A majority of patients with traumatic hysteria recover. In railway cases, so long as litigation is pending and the patient is in the hands of lawyers the symptoms usually persist. Settlement is often the starting point of a speedy and perfect recovery. I have known return to health after the persistence of the most aggravated symptoms with com- plete disability of from three to five years’ duration. On the other hand, there are a few cases in which the symptoms persist even after the litiga- tion has been closed ; the patient goes from bad to worse and psychoses develop, such as melancholia, dementia, or occasionally progressive paresis. And, lastly, in extremely rare cases, organic lesions may develop as a sequence of the traumatic neurosis. The function of the physician acting as medical expert in these cases consists in determining (a) the existence of actual disease, and (b) its char- acter, whether simple neurasthenia, severe hysteria, or an organic lesion. The outlook for ultimate recovery is good except in cases which present the more serious symptoms above mentioned. Nevertheless, it must be borne OTHER FORMS OF FUNCTIONAL PARALYSIS. 1039 m mind that traumatic hysteria is one of the most intractable affections which we are called upon to treat. Treatment of Neurasthenia.—Many patients come under our care a generation too late for satisfactory treatment, and it may be impos- sible to restore the exhausted capital. In other instances, the recovery takes place rapidly, the patient remains well for a few months or a year, and then overwork, or even the ordinary wear and tear of life, again pros- trates him. Other persons drift into a condition of chronic invalidism or become slaves to morphia or chloral. In the case of business or profes- sional men, in whom the condition develops as a result of overwork or overstudy, it may be sufficient to enjoin absolute rest with change of scene and diet. A trip abroad, with a residence for a month or two in Switzer- land, or, if there are symptoms of nervous dyspepsia, a residence at one of the Spas, will usually prove sufficient. The excitement of the large cities abroad should be avoided. Better still for these cases, if they carry it out, is a life in the woods or on the plains. Three months of tent-life in the Adirondacks or the same length of tin\e in the Kocky Mountains will sometimes cure the most marked cases of this kind. Such a plan is not, however, within the circumstances of all. In a much larger class, includ- ing a large proportion of neurasthenic women, a systematic Weir Mitchell treatment rigidly carried out should be tried (see hysteria). For obstinate and protracted cases, particularly if combined with the chloral or morphia habit, no other plan is so satisfactory. The treatment of the gastric and intestinal symptoms so important in this condition has already been con- sidered. In milder grades of the condition massage alone will be found very useful. For the irregular pains, particularly in the back and neck, the thermo-cautery is invaluable. Medicines are of little avail. Strychnia in full doses is often beneficial. For the relief of sleeplessness all possible measures should be resorted to before the employment of drugs. XIV. OTHER FORMS OF FUNCTIONAL PARALYSIS. I. Periodical Paralysis. I have already referred to the remarkable periodical paralysis of the ocular muscles, which may recur at intervals for many years. There is a form of periodical paralysis involving the general muscles, which may recur with great regularity, and which is also a “ family ” affection. In WestpliaTs case, a boy of twelve, the attacks began in the eighth year, and at first recurred every four or six weeks, and lasted from a few hours to two days. Goldflam * has described a family in which twelve members were affected with this disease, the heredity being through the mother. * Zeitschrift fiir klinische Medicin, Bd. xix, 1891. 1040 DISEASES OF THE NERVOUS SYSTEM. Cousot has also met with a family in which the mother and four children were attacked. The disease occurs in youth, and the tendency to the attacks diminishes with age. The clinical picture is very much alike in all the recorded cases. The paralysis involves, as a rule, the arms and legs. It comes on when the patients are in full health, and without any .apparent cause, often during sleep. Sometimes it,begins with weakness in the limbs, a sensation of weariness and sleepiness, not often with sensory symptoms. The paralysis is usually complete within the first twenty-four hours, beginning in the legs, to which in rare instances it is confined. The muscles of the neck are sometimes involved, and occasionally those of the tongue and pharynx. The cerebral nerves and the special senses are, as a rule, uninvolved. The attacks are afebrile, sometimes with low temperatures and slow pulse. The deep reflexes are reduced, sometimes abolished, and the skin reflexes may be feeble. One of the most remarkable features is the extraordinary reduction or complete abolition of the faradic excitability, both of muscles and of nerves. Improvement begins sometimes in the course of a few hours or after a day or two, and the paralysis disappears completely, and the patient is perfectly well. As mentioned, the attacks may recur every few weeks, in some instances even daily; more commonly, an interval of one or two weeks elapses between the attacks. Hold flam suggests that the paralysis is due to an auto-intoxication, and that the poisonous material acts upon the nerve-endings in the muscles. He has made experiments with the urine of a case which showed that during the attacks the toxic properties of this secretion were materially increased. From the recurring, periodic char- acter of the attacks they have been supposed to be due to malaria, but of this there is no evidence. II. Astasia ; Abasia. These terms, indicating respectively inability to stand and inability to walk, have been applied by Charcot and Blocq to diseased conditions char- acterized by loss of the power of standing or of walking with retention of muscular power, coordination, and sensation. Blocq’s definition is as fol- lows : “ A morbid state in which the impossibility of standing erect and walking normally is in contrast with the integrity of sensation, of muscu- lar strength, and of the coordination of the other movements of the lower extremities.” The condition forms a symptom group, not a morbid entity, and is probably a functional neurosis. Knapp in a recent paper analyzes the 50 cases reported in the literature. Twenty-five of these were in men, 25 in women. In 21 cases hysteria was present; in 3, chorea; in 2, epi- lepsy ; and in 4, intention psychoses. As a rule, the patients, though able to move the feet and legs perfectly when in bed, are either unable to walk properly or cannot stand at all. The disturbances have been very varied, RAYNAUD’S DISEASE. 1041 and different forms have been recognized. The commonest, according to Knapp’s analysis of the recorded cases, is the paralytic, in which the legs give out as the patient attempts to walk and “ bend under him as if made of cotton.” “ There is no rigidity, no spasm, no incoordination. In bed, sitting, or even while suspended, the muscular strength is found to be good.” Other cases are associated with spasm or ataxia; thus there may be movements which stiffen the legs and give to the gait a somewhat spas- tic character. In other instances there are sudden flexions of the legs, or even of the arms, or a saltatory, spring-like spasm. In a majority of the cases it is a manifestation of a neurosis allied to hysteria. The cases, as a rule, recover, particularly in young persons. Relapses are not uncommon. The rest treatment and static electricity should be employed. VI. VASO-MOTOR AND TROPHIC DISORDERS. I. RAYNAUD’S DISEASE. Definition.—A vascular disorder, probably dependent upon vaso- motor influences, characterized by three grades of intensity: (a) Local syncope, (d) local asphyxia, and (c) local or symmetrical gangrene. Local Syncope.—This condition is seen most frequently in the extrem- ities, producing the condition known as dead fingers or dead toes. It is analogous to that produced by great cold. The entire hand may be af- fected with the fingers; more commonly only one or more of the fingers. This feature of the disease rarely occurs alone, but is generally associated with local asphyxia. The common sequence is as follows : On exposure to slight cold or in consequence of some emotional disturbance the fingers become white and cold, or both fingers and toes are affected. The pallor may continue for an indefinite time, though usually not more than an hour or so; then gradually a reaction follows and the fingers get burning hot and red. This does not necessarily occur in all the fingers together; one finger may be as white as marble, while the adjacent ones are of a deep red or plum color. Local Asphyxia.—Chilblains form the mildest grade of this condition. It usually follows the local syncope, but it may come on independently. The fingers and toes are oftenest affected, next in order the ears; more rarely portions of the skin on the arms and legs. During an attack the fingers alone, sometimes the hands, also swell and become intensely con- gested. In the most extreme grade the fingers are perfectly livid, and the capillary circulation is almost stagnant. The swelling causes stiff- ness and usually pain, not acute, but due to the tension and distention of the skin. Sometimes there is marked anaesthesia. Attacks of this sort 1042 DISEASES OF THE NERVOUS SYSTEM. may recur for years, and be brought on by the slightest exposure to cold or in consequence of disturbances, either mental or, in some instances, gastric. Apart from this unpleasant symptom the general health may be very good. The attacks may recur only at long intervals or during the winter time. Local or Symmetrical Gangrene.—The mildest grade of this condition follows the local asphyxia, in the chronic cases of which small necrotic areas are sometimes seen at the tips of the fingers. Sometimes the pads of the fingers and of the toes are quite cicatricial from repeated slight losses of this kind. So also when the ears are affected there may be super- ficial loss of substance at the edge. The severer cases, which terminate in extensive gangrene, are fortunately rare. In an attack the local asphyxia persists in the fingers. The terminal phalanges, or perhaps only one finger, become black, cold, and insensi- ble. The skin begins to necrose and superficial gangrenous blebs appear. Gradually a line of demarkation shows itself and a portion of one or more of the fingers sloughs away. The resulting loss of substance is much less than the appearance of the hand or foot would indicate, and a condition which looks as if the patient would lose all the fingers or half of a foot may result perhaps in only a slight superficial loss in the phalanges. In severer cases the greater portion of a finger or the tip of the nose may be lost. Occasionally the disease is not confined to the extremities, but affects symmetrical patches on the limbs or trunk, and may pass on to rapid gan- grene. These severe types of cases occur particularly in young children, and death may result within three or four days. The attacks are usually very painful, and the motion of the part is much impaired. In some cases numbness and tingling persist for a long time. The climax of this series of neuro-vascular changes is seen in the re- markable instances of extensive multiple gangrene. They are most com- mon in children, and may proceed with frightful rapidity. In the Medico-Chirurgical Society’s Transactions, vol. xxii, there is an extraordi- nary case reported, in which the child, aged three, lost in this way both arms above the elbow, and the left leg below the knee. There also had been a spot of local gangrene on the nose. Spontaneous amputation occurred, and the child made a complete recovery. The cases are more frequent than has been supposed, and an illustration is given by Weeks, of Marion, Ohio, in which the boy had rheumatic pains in the legs, and purpuric blotches developed before the gangrene began (Medico-Surgical Bulletin, July 1, 1894). There are remarkable concomitant symptoms in Raynaud’s disease to which a good deal of attention has been paid of late years. Haemoglobi- nuria may develop during an attack, or may take the place of an outbreak. In such instances the affection is usually brought on by cold weather. In a case reported by H. M. Thomas from my clinic, Raynaud’s disease occurred for three successive winters and always in association with hemo- globinuria. The attacks were sometimes preceded by a chill. Several ANGIO-NEUROTIC (EDEMA. 1043 cases of the kind are found in Barlow’s appendix to his translation of Raynaud’s paper for the New Sydenham Society. The onset with a chill, as in the case just mentioned, has doubtless given rise to the idea that the disease is in some way associated with ague. Cerebral symptoms, par- ticularly mental torpor and transient loss of consciousness, have also been noticed in some cases. The case just mentioned with haemoglobinuria had epilepsy with the attacks. Exposure on a cold day would bring on an epileptic seizure with the local asphyxia and bloody urine. Another pa- tient, the subject for years of Raynaud’s disease, has had many attacks of transient hemiplegia on one side or the other, when on the right side with aphasia. Occasionally joint affections develop, particularly anchylosis and thickening of the phalangeal articulations. Southey has reported a case in which mania developed, and Barlow an instance in which the woman had delusions. Peripheral neuritis has been found in several cases. The pathology of this remarkable disease is still obscure. Raynaud suggested that the local syncope was produced by contraction of the ves- sels, which seems likely. The asphyxia is dependent upon dilatation of the capillaries and small veins, probably with the persistence of some degree of spasm of the smaller arteries. There are two totally different forms of congestion, which may be shown in adjacent fingers; one may be swollen, of a vivid red color, extremely hot, the capillaries and all the vessels fully distended, and the anaemia produced by pressure may be in- stantaneously obliterated ; the adjacent finger may be equally swollen, absolutely cyanotic, stone cold, and the anaemia produced by pressure takes a long time to disappear. In the latter case the arterioles are prob- ably still in a condition of spasm. Treatment.—In many cases the attacks recur for years uninfluenced by treatment. Mild attacks require no treatment. In the severer forms of local asphyxia, if in the feet, the patient should be kept in bed with the legs elevated. The toes should be wrapped in cotton-wool. The pain is often very intense and may require morphia. Carefully applied, sys- tematic massage of the extremities is sometimes of benefit. Galvanism may be tried. Barlow advises immersing the affected limb in salt water and placing one electrode over the spine and the other in the water. Nitro-glycerine has been warmly recommended by Cates. II. ANGIO-NEUROTIC CEDEMA. Definition.—An affection characterized by the occurrence of local cedematous swellings, more or less limited in extent, and of transient duration. Severe colic is sometimes associated with the outbreak. There is a marked hereditary disposition in the disease. The affection has been specially studied by Quincke, Jamieson, J. E. Graham, and Matas. Symptoms.—The oedema appears suddenly and is usually circum- 1044 DISEASES OF THE NERVOUS SYSTEM. scribed. It may appear in the face; the eyelid is a common situation ; or it may involve the lips or cheek. The backs of the hands, the legs, or the throat may be attacked. Usually the condition is transient, associated perhaps with slight gastro-intestinal distress, and the affection is of little moment. There may be a remarkable periodicity in the outbreak of the oedema. In Matas’s case this periodicity was very striking; the attack came on every day at eleven or twelve o’clock. The disease may be hered- itary through many generations. In the family whose history I reported, five generations had been affected, including twenty-two members. The swellings appear in various parts; only rarely are they constant in one locality. The hands, face, and genitalia are the parts most frequently affected. Itching, heat, redness, or in some instances, urticaria may pre- cede the outbreak. Sudden oedema of the larynx may prove fatal. Two members of the family just referred to died of this complication. In one member of this family, whom I saw repeatedly in attacks, the swell- ings came on in different parts; for example, the under lip would be swollen to such a degree that the mouth could not be opened. The hands enlarge suddenly, so that the fingers cannot be bent. The attacks recur every three or four weeks. Accompanying them are usually gastro- intestinal attacks, severe colic, pain, nausea, and sometimes vomiting. The colic is of great intensity and usually requires morphia. Arthritis apparently does not occur. The disease has affinities with urticaria, the giant form of which is probably the same disease. There is a form of severe purpura, often with urticarial manifestations, which is also associated with marked gastro- intestinal crises. Quincke regards the condition as a vaso-motor neurosis, under the influence of which the permeability of the vessels is suddenly increased. Milroy, of Omaha, has described cases of hereditary oedema, twenty-two individuals in six generations, in which there existed from birth a solid oedema of one or of both legs, without any special inconven- ience or any progressive increase of the disease. The treatment is very unsatisfactory. In the cases associated with anaemia and general nervousness, tonics, particularly large doses of strych- nia, do good; but too often the disease resists all treatment. III. FACIAL HEMI-ATROPHY. An affection characterized by progressive wasting of the bones and soft tissues of one side of the face. The atrophy begins, as a rule, in childhood, but in a few cases has not come on until middle age. It begins diffusely, but in some instances has started at one spot on the skin and has gradually spread, involving at first the subcutaneous tissues, then the muscles and the bones, more particularly the upper jaw. The wasting is sharply limited at the middle line, and the appearance of the patient is ACROMEGALIA. 1045 very remarkable, the face looking as if made up of two halves from differ- ent persons. There is usually change in the color of the skin and the hair falls. Owing to the wasting of the alveolar processes the teeth be- come loose and ultimately fall out. The wasting involves the tissues of the orbit, and the eye on the affected side is sunken. In a majority of the cases the atrophy has been confined to one side of the face, but there are instances on record in which the disease was bilateral, and a few cases in which there were areas of atrophy on the back and on the arm of the same side. The disease is rare. Sachs has collected ninety-seven cases from the literature. Two autopsies have been made. In Mendel’s case there was the ter- minal stage of an interstitial neuritis in all the branches of the trigemi- nus, from its origin to the periphery, most marked in the superior maxil- lary branch. In Homen’s case, which came on rapidly and hardly belongs to the typical form of the disease, a tumor was found pressing upon the Gas- serian ganglion and the trigeminus nerve. The disease is recognized at a glance. The facial asymmetry asso- ciated with congenital wryneck must not be confounded with progressive facial hemi-atrophy. The precise nature of the disease is still doubtful. IV. ACROMEGALIA. Definition.—A dystrophy characterized by abnormal processes of growth, chiefly in the bones of the face and extremities. The term was introduced by Marie, and signifies large extremities. Etiology.—It occurs rather more frequently in women. Of the 38 cases analyzed in the monograph of Souza-Leite, 16 were in men and 22 in women. The disease usually begins about the twenty-fifth year, though in some instances as late as the fortieth. Kheumatism, syphilis, and the specific fevers have preceded the development of the disease, but probably have no special connection with it. In this country many cases have now been reported. Symptoms.—In a well-marked case the disease presents most char- acteristic features. The hands and feet are greatly enlarged, but are not deformed, and can be used freely. The hypertrophy is general, involving all the tissues, and gives a curious spade-like character to the hands. The wrists may be enlarged, but the arms are rarely affected. The feet are involved like the hands and are uniformly enlarged. The big toe may be much larger in proportion. The nails are usually broad and large. The head increases in volume, but not as much in proportion as the face, which becomes much elongated and enlarged in consequence of the in- crease in the size of the superior and inferior maxillary bones. The latter in particular increases greatly in size, and often projects below the upper jaw. The alveolar processes are widened and the teeth separated. The 1046 DISEASES OF THE NERVOUS SYSTEM. soft parts also increase in size, and the nostrils are large and broad. The eyelids are sometimes greatly thickened, and the ears enormously hyper- trophied. The tongue in some instances becomes greatly enlarged. Late in the disease the spine may be affected and the back bowed—kyphosis. The bones of the thorax may slowly and progressively enlarge. With this gradual increase in size the skin of the hands and face may appear nor- mal. Sometimes it is slightly altered in color, coarse, or flabby, but it has not the dry, harsh appearance of the skin in myxcedema. The muscles are sometimes wasted. Changes in the thyroid have been found, but are not constant. The gland has been normal in some, atrophied in others, and in a third group of cases enlarged. Erb, who has made an elaborate study of the disease, has noticed an area of dulness over the manubrium sterni, which he thought possibly due to the persistence or enlargement of the thymus. Headache is not uncommon. Somnolence has been noted in many cases. Menstrual disturbance may occur early, and there may be suppression. In some instances vision has been involved, owing to a gradual atrophy of the optic nerve. The disease may persist for fif- teen, twenty, or more years. The pathological anatomy has been studied in a few cases. In addi- tion to enlargement of the bones, which is a true hypertrophy, enormous enlargement of the hypophysis (pituitary body) has been found. Owing to the remarkable changes in this body in acromegaly, it has been suggested that the disease is a nutritional disturbance analogous to myxcedema, and caused directly by disturbance in the function of this organ. The evidence from comparative anatomy and embryology shows that the pituitary body is a very “ complex organ consisting of an anterior secreting glandular organ; a water vascular duct; a posterior, sensitive, nervous lobe, of which the last two—namely, the duct and the nervous lobe—were morphologically well developed and functioned in ancestral vertebrata, but have become obliterated and atrophied in struc- ture and function forever above larval acraniates ” (Andriezen, B. M. J.f 1894, i). The pituitary body continues active, but the duct is obliterated “ and the gland changed into a ductless gland ; the secretion becomes an ‘ internal secretion,’ ” which is absorbed by the lymphatics. It has been suggested by Massalongo and others that gigantism and acromegaly are one and the same disease, both due to the hyperfunction of the pituitary gland. Certain persons exhibited as giants have been acromegalic, and the skulls of some notable giants show enormous en- largement of the sella turcica. Less constant have been the changes in the thymus and in the thyroid. In some instances the peripheral nerves have been involved. As stated, the true nature of the disease is unknown. Marie regards it as a systemic dystrophy, analogous to myxcedema and due to the mor- bid condition of the pituitary body, just as myxcedema is associated with disease of the thyroid. ACROMEGALIA. 1047 Diagnosis.—There are several affections which are apt to be con- founded with acromegaly. The congenital, progressive hypertrophy of a single member, as of an arm or leg, or of one side of the body—the so- called giant growth—is readily recognized. In the osteitis deformans of Paget the shafts of the long bones are chiefly involved, and in the head the bones of the cranium, but not those of the face. As Marie states, in Paget’s disease the face is triangular with the base upward ; in acromegaly it is ovoid or egg-shaped with the large end downward ; while in inyxcedema it is round and full-moon-shaped. Marie has given the name hypertrophic pulmonary osteo-arthropathy to a remarkable disorder, characterized by enlargement of the hands and feet, and of the ends of the long bones, chiefly of the lower three fourths of the forearm and legs. Unlike acromegaly, the bones of the skull and of the face are not involved. The terminal phalanges are much spread with both transverse and longitudinal curves ; the nails, too, are large and much curved over the ends of the phalanges. Both scoliosis and kyphosis have been met with. The disease is very chronic, and in nearly all cases has been associated with some long-standing affection of the bronchi, lungs, or pleura (hence the name pulmonary osteo-arthropathy), of which sarcoma, chronic bronchitis, chronic tuberculosis, and empyema have been the most frequent. There are several instances in which disease has de- veloped in the subjects of syphilis. The disease occurs usually in adults and in the male sex. Thorburn (B. M. J., 1893, i) has collected about thirty cases. The essential pathology of the disease is very obscure. Marie suggests that the toxines of the pulmonary disease are absorbed into the circula- tion and exercise an irritant action on the bony and articular structures. Thorburn thinks that it is a chronic tuberculous affection of a large number of bones and joints of a benign type. Finally, in a remarkable condition known as leontiasis ossea, there is hyperostosis of the bones of the cranium, and sometimes those of the face. The description is largely based upon the skulls in museums, but Allen Starr has recently reported an instance in a woman, who presented a slowly progressing increase in the size of the head, face, and neck, the hard and soft tissues both being affected. He has applied to the condition the term megalo-cephalie. The treatment does not appear to have any influence upon the prog- ress of the disease. The thyroid extract has been tried in many cases, without, so far as my personal experience goes, any benefit. Extract of the pituitary gland has also been used. The lung extract has been em- ployed in some cases of pulmonary osteo-arthropathy. In a case of Caton’s, of Liverpool, an unsuccessful attempt was made to extirpate the pituitary body. 1048 DISEASES OF THE NERVOUS SYSTEM. V. SCLERODERMA. Definition.—A condition of localized or diffuse induration of the skin. Lewin and Heller (Die Sclerodermie, Berlin, 1895) have recently col- lected from the literature 508 cases. Two forms are recognized : the circumscribed, which corresponds to the keloid of Addison, and to morphoea; and the diffuse, in which large areas are involved. The disease affects females more frequently than males. The cases occur most commonly at the middle period of life. The sclerema neona- torum is a different affection, not to be confounded with it. A large majority of the patients have been French or German; among the col- lected cases only 32 are from North America, but this scarcely represents the incidence of the disease; four cases of the diffuse form have come under my observation within the past five years. In the circumscribed form there are patches, ranging from a few cen- timetres in diameter to the size of the hand or larger, in which the skin has a waxy or dead-white appearance, and to the touch is brawny, hard, and inelastic. Sometimes there is a preliminary hyperasmia of the skin, and subsequently there are changes in color, either areas of pigmentation or of complete atrophy of the pigment—leucoderma. The sensory changes are rarely marked. The secretion of sweat is diminished or entirely abol- ished. The disease is more common in women than in men, and is situ- ated most frequently about the breasts and neck, sometimes in the course of the nerves. The patches may develop with great rapidity, and may per- sist for months or years; sometimes they disappear in a few weeks. The diffuse form, though less common, is more serious. It develops first in the extremities or in the face, and the patient notices that the skin is unusually hard and firm, or that there is a sense of stiffness or tension in making accustomed movements. Gradually a diffuse, brawny indura- tion develops and the skin becomes firm and hard, and so united to the subcutaneous tissues that it cannot be picked up or pinched. The skin may look natural, but more commonly is glossy, drier than normal, and unusually smooth. With reference to the localization, in 66 observations the disease was universal; in 203, regions of the trunk were affected; in 193, parts of the head or face ; in 287, portions of one or other of the upper extremities; and in 122, portions of the lower extremities. In 80 cases there were disturbances of sensation. The disease may gradually extend and involve the skin of an entire limb. When universal, the face is ex- pressionless, the lips cannot be moved, mastication is hindered, and it may become extremely difficult to feed the patient. The hands become fixed, the fingers immobile, on account of the extreme induration of the skin over the joints. The disease is chronic, lasting for many months or many SCLERODERMA. years. There are instances on record of its persistence for more than twenty years. Recovery may occur, or the disease may be arrested. The patients are apt to succumb to pulmonary complaints or to nephritis. Rheumatic troubles have been noticed in some instances; in others, endo- carditis. Raynaud’s disease may be associated with it, as in two cases described by Stephen Mackenzie. I have seen an instance of the diffuse form in which the primary symptoms were those of local asphyxia of the fingers, and in which, with extensive scleroderma of the arms and hands and face, there were cyanosis and swelling of the skin of the feet without any brawny induration. The pathology of the disease is unknown. It is usually regarded as a tropho-neurosis, probably dependent upon changes in the arteries of the skin leading to connective-tissue overgrowth. The patients require to be warmly clad and to be guarded against ex- posure, as they are particularly sensitive to changes in the weather. Fric- tions with oil, and galvanism, are recommended. The remarkable dystrophy known as sclerodactylie belongs to this dis- order. There are symmetrical involvements of the fingers, which become deformed, shortened, and atrophied; the skin becomes thickened, of a waxy color, and is sometimes pigmented. Bullae and ulcerations have been met with in some instances, and a great deformity of the nails. The disease has usually followed exposure, and the patients are much worse during the winter, and are curiously sensitive to cold. There may be changes in the skin of the feet, but the deformity similar to that which occurs in the hand has not been noted. Some of the cases present in addi- tion diffuse sclerodermatous changes of the skin of other parts. In Lewin and Heller’s monograph there are 35 cases of isolated sclerodactylism, and 106 cases in which it was combined with scleroderma. AINHUM. Here a brief reference may be made to the remarkable trophic lesion described by Da Silva Lima, which is met with in negroes in Brazil, Africa, India, and occasionally in the Southern States. It is confined to the toes, usually the little toe, and begins as a furrow on the line of the digito-plantar fold. This gradually deepens, the end of the toe enlarges, and, usually without inflammation or pain, the toe falls off. The process may last some years. Oases have been reported in this country by Horna- day, Pittman, F. J. Shepherd, and Morrison. SECTION IX. DISEASES OF TIIE MUSCLES. I. MYOSITIS. Definition.—Inflammation of the voluntary muscles. A primary myositis occurs as an acute or subacute affection, and is probably dependent on some unknown infectious agent. Several charac- teristic cases have been described of late years. The case of E. Wagner may be taken as a typical example. A tuberculous but well-built woman entered the hospital, complaining of stiffness in the shoulders and a slight oedema of the back of the hands and forearms. There was paraes- thesia, the arms became swollen, the skin tense, and the muscles felt doughy. Gradually the thighs became affected. The disease lasted about three months. The post-mortem showed slight pulmonary tuberculosis; all the muscles except the glutei, the calf, and abdominal muscles were stiff and firm, but fragile, and there were serous infiltration, great pro- liferation of the interstitial tissue, and fatty degeneration. Similar cases have been reported by TTnverricht, Hepp, and Jacoby of New York. In the case reported by Jacoby the muscles were firm, hard, and tender, and there was slight oedema of the skin The duration of the cases is usually from one to three months, though there are instances in which it has been longer The swelling and tenderness of the muscles, the oedema, and the pain naturally suggest trichinosis, and indeed Hepp speaks of it as a pseudo-trichinosis. The nature of the disease is unknown. Senator’s case presented marked disorders of sensation, and there is a question whether the peripheral nerves are not involved with the muscles. Wagner suggests that some of these cases were examples of acute progressive muscular atro- phy. The separation from trichinosis can be made only by removing a portion of the muscle. There are septic cases in which a diffuse, purulent infiltration of the muscles of different regions occurs. Instances have been reported in which this has been described as the primary affection, the condition of the muscles even passing on to gangrene. A remarkable affection is myositis ossificans progressiva, in which portions of the muscles undergo a progressive calcification. THE MUSCULAR DYSTROPHIES. 1051 II. THE MUSCULAR DYSTROPHIES (Dystrophia muscularis progressiva, Erb). Definition.—Muscular wasting, with or without an initial hyper- trophy, beginning in various groups of muscles, usually progressive in character, and dependent on primary changes in the muscles themselves. A marked hereditary disposition is met with in the disease. Before considering the primary muscular atrophies it may be well to summarize briefly the chief conditions under which muscular atrophy occurs. These are: (1) Acute or chronic lesions of the nuclei of the motor path, which may be (a) cortical, as a direct result of a cerebral lesion; (&) bulbar, as in chronic bulbar paralysis; (c) spinal, either acute, as in poliomyelitis of children, or chronic, as in the progressive muscular atrophy of the simple or of the spastic type. (2) Neuritic muscular atrophy, following a local neuritis due to trauma, a multiple neuritis due to alcohol, lead, and the infectious diseases. In this same category probably may be placed the muscular atrophies asso- ciated with joint-disease, the progressive hemi-atrophy of the face, and the atrophy sometimes found in cases of hysteria. The peroneal type of mus- cular atrophy belongs in this division. (3) Conditions of the muscles themselves—muscular dystrophy. Etiology.—No etiological factors of any moment are known other than heredity. The influence may show itself by true heredity—that is, the disease occurring in two or more generations—or several members of the same generation may be affected, showing a family tendency. Many members of the same family may be attacked through several generations. Males, as a rule, are more frequently affected than females. The disease is usually transmitted through the mother, though she may not herself be the subject. As many as twenty or thirty cases have been described in five generations. In Erb’s cases 44 per cent showed no heredity. The disease usually sets in before puberty, but may be as late as the twentieth or twenty-fifth year, or in some instances even later. Symptoms.—The first symptom noticed is, as a rule, clumsiness in the movements of the child, and on examination certain muscles or groups of muscles seem to be enlarged, particularly those of the calves. The extensors of the leg, the glutei, the lumbar muscles, the deltoid, triceps, and infraspinatus, are the next most frequently involved, and may stand out with great prominence. The muscles of the neck, face, and forearm rarely suffer. Sometimes only a portion of a muscle is involved. With this hypertrophy of some muscles there is wasting of others, particularly the lower portion of the pectorals and the latissimus dorsi. The attitude ■when standing is very characteristic. The legs are far apart, the shoulders DISEASES OF THE MUSCLES. 1052 thrown back, the spine is greatly curved, and the abdomen protrudes. The gait is waddling and awkward. In getting up from the floor the position assumed, as so well known now through Gowers’s figures, is pathognomonic. The patient first turns over in the all-fours position and raises the trunk with his arms; the hands are then moved along the ground until the knees are reached; then with one hand upon a knee he lifts himself up, grasps the other knee, and gradually pushes himself into the erect posture, as it has been expressed, by climbing up his legs. The striking contrast between the feebleness of the child and the powerful- looking pseudo-hypertrophic muscles is very characteristic. The enlarged muscles may, however, be relatively very strong. The course of the disease is slow, but progressive. Wasting proceeds and finally all traces of the enlarged condition of the muscles disappears. At this late period distortions and contractions are common. The muscles of the shoulder-girdle are nearly always affected early in the disease, causing a symptom upon which Erb lays great stress. With the hands under the arms, when one endeavors to lift the patient, the shoulders are raised to the level of the ears, and one gets the impression as though the child were slipping through. These “ loose shoulders ” are very characteristic. The abnormal mobility of the shoulder-blades gives them a winged appearance, and makes the arms seem much longer than usual when they are stretched out. The patients complain of no sensory symptoms. The atrophic mus- cles do not show the reaction of degeneration except in extremely rare instances. Clinical Forms.—A number of different types have been described, depending upon the age of the onset, the muscles first affected, the occur- rence of hypertrophy, the prominence of heredity, etc. But Erb has shown that there is no sharp division between these different forms, and classes them all under the name of dystrophia muscularis progressiva. For convenience of description he subdivides the disease into two large groups: I. Those cases which occur in childhood. II. The cases occurring in youth and adult life. The first division is subdivided into (1) the hypertrophic and (2) the atrophic forms. Under the hypertrophic form, which is the pseudo-hypertrophic mus- cular paralysis of authors, he thinks it is useful to distinguish between the cases in which (a) the enlarged muscles have undergone lipomatosis— i. e., pseudo-hypertrophy—from those (#) in which there is a real hyper- trophy. The atrophic form also includes two subclasses: (a) Those cases in which the muscles of the face are involved early ; this corresponds to the infantile form of Duchenne—the Landouzy-Dejerine type, (b) Those cases in which the face is not involved. THE MUSOULAR DYSTROPHIES. 1053 I. Dystrophia muscularis progressiva infantum. 1. Hypertrophic form. (a) With pseudo-hypertrophy. (b) With real hypertrophy. 2. Atrophic form. (a) With primary involvement of the face (infantile form of Duehenne). (b) Without involvement of the face. II. Dystrophia muscularis progressiva juvenum vel adultorum (Erb’s juvenile form). Morbid Anatomy.—According to Erb, the disease consists in a change in the muscles themselves. At first the muscle-fibres hyper- trophy, then become round, the nuclei increase, and the muscle-fibres may become fissured. At the same time there is a slight increase in the connective tissue. Sooner or later the muscle-fibres begin to atrophy, and the nuclei become greatly increased. Vacuoles and fissures appear, and they finally become completely atrophic, the connective tissue be- coming markedly increased. Fat may be deposited in the connective tissue to such an extent as to cause hypertrophic lipomatosis—pseudo- hypertrophy. The nervous system has very generally been found to be without demonstrable lesions. The different stages of these changes may be found in a single muscle at the same time. Diagnosis.—The primary myopathies can usually be readily distin- guished from the cerebral, myelopathic, and neuritic forms. {a) In the cerebral atrophy loss of power usually precedes the atrophy, which is either of a monoplegic or hemiplegic type. (b) In the myelopathic or spinal muscular atrophy the distinctions are clearly marked. Polio-myelitis anterior chronica begins in the small muscles of the hand, a situation rarely if ever affected by the primary myopathies, which involve first those of the calves, the trunk, the face, or the shoulder-girdle. In the myelopathic atrophy the reaction of degenera- tion is present and fibrillary twitchings occur in both the atrophied and non-atrophied muscles. In many cases, in addition to the wasting in the arms, there is a spastic condition in the legs and increase in the re- flexes. The myelopathic atrophies come on late in life; the myopathic forms develop, as a rule, early. In the primary muscular atrophies he- redity plays an important role, which in the myelopathic is quite sub- sidiary. (c) In the neuritic muscular atrophies, whether due to lead or to trauma, the general characters and the mode of onset are distinctive. In the cases of multiple neuritis seen for the first time at a period when the wasting is marked there is often difficulty, but the absence of family his- tory and the distribution are important features. Moreover, the paralysis is out of proportion to the atrophy. Sensory symptoms may be present, 1054 DISEASES OF THE MUSCLES. and in the cases in which the legs are chiefly involved there is usually the steppage gait so characteristic of peripheral neuritis. (d) Progressive neural muscular atrophy. Here heredity is also a factor, and the disease usually begins in early life, but the distribution of atrophy and paralysis, which in this affection is at first confined to the periphery of the extremities, helps to distinguish it from the dystrophies; while the occurrence of sensory symptoms, fibrillary contractions, and the marked decrease in the electrical excitability usually makes the distinc- tion clear. The outlook in the primary myopathies is bad. The wasting pro- gresses uniformly, uninfluenced by treatment. Erb holds that by elec- tricity and massage the progress is occasionally arrested. The general health should be carefully looked after, moderate exercise allowed, fric- tions with oil applied to the muscles, and when the patient becomes bed- fast, as is inevitable sooner or later, care should be taken to prevent con- tractures in awkward positions. Progressive Neural Muscular Atrophy.—This form, known also as the peroneal type, or by the names of the men who have described it most accurately of late—namely, Charcot, Marie, and Tooth—occurs either as a hereditary or as a family affection. It usually begins in early child- hood, affecting first the muscles of the feet and the peroneal group, and as a result of the weakening of these muscles, club-foot, either pes equinus or pes equino-varus occurs. In rare instances the disease may begin in the hands, but the upper limbs, as a rule, are not affected for some years after the legs are attacked, and the trouble then begins in the small mus- cles of the hands. Sensory disturbances are frequently present and form important diagnostic features. Fibrillary contractions and twitchings also occur. The electrical reactions are altered ; there is either a loss or a very great decrease of the excitability, which can be demonstrated not only in the atrophic muscles, but also in muscles and nerves which are apparently normal. There have been only two recent autopsies—that of Dubreuilh, who found changes in the peripheral nerves, and of Dejerine and Sottas, who found hypertrophy of the nerve-trunks and of the nerve-roots, with sec- ondary alterations of the posterior columns of the cord. They call the neuritis interstitial and hypertrophic; and in another case there was marked hypertrophy and hardness of the nerve-trunks of the limbs. III. THOMSEN’S DISEASE; MYOTONIA CONGENITA. Definition.—An hereditary disease characterized by tonic cramp of the muscles on attempting voluntary movements. The disease received its name from the physician who first described it, in whose family it has existed for five generations. PARAMYOCLONUS MULTIPLEX. 1055 Etiology.—All the typical cases have occurred in family groups; a few isolated instances have been described in which similar symptoms have been present. The disease is rare in this country and in England ; it seems more common in Germany and in Scandinavia. Symptoms.—The disease comes on in childhood. It is noticed that on account of the stiffness the children are not able to take part in ordi- nary games. The peculiarity is noticed only during voluntary movements. The contraction which the patient wills is slowly accomplished; the re- laxation which the patient wills is also slow. The contraction often per- sists for a little time after he has dropped an object he has picked up. In walking, the start is difficult; one leg is put forward slowly, it halts from stiffness for a second or two, and then after a few steps the legs become limber and he walks without any difficulty. The muscles of the arms and legs are those usually implicated; rarely facial, ocular, or laryngeal muscles. Emotion and cold aggravate the condition. In some instances there is mental weakness. The sensation and the reflexes are normal. The condition of the muscles is interesting. The patients ap- pear and are muscular, and there is sometimes a definite hypertrophy of the muscles. The force is scarcely proportionate to the size. Erb has described a characteristic reaction of the nerve and muscle to the elec- trical currents—the so-called myotonic reaction, the chief feature of which is that normally the contractions caused by either current attain their maximum slowly and relax slowly, and vermicular, wave-like contractions pass from the cathode to the anode. The disease is incurable, but it may be arrested temporarily. The nature of the affection is unknown. There is an extraordinary increase in the size of the voluntary fibres. In the only autopsy made Dejerine and Sottas have found hypertrophy of the primitive fibres with multiplication of the nuclei of all the muscles, including the diaphragm, but not the heart. The spinal cord and the nerves were intact. No treatment for the condition is known. IV. PARAMYOCLONUS MULTIPLEX (Myoclonia). An affection, described by Friederich, characterized by clonic contrac- tions, chiefly of the muscles of the extremities, occurring either constantly or in paroxysms. The cases have been chiefly in males, and the disease has followed emotional disturbance, fright, or straining. The contractions are usually bilateral and may vary from fifty to one hundred and fifty in the minute. Occasionally tonic spasms occur. It is not accompanied by any sensory or motor disturbances. In the intervals between the attacks there may be tremors of the muscles. In the severe spasms the movements may be very 1056 DISEASES OF THE MUSCLES. violent; the body is tossed about, and it is sometimes difficult to keep the patient in bed. Gucci has described a family in which the affection has occurred in three generations. Weiss has also noted heredity in four generations. According to this author the essential symptoms are continuous or paroxysmal muscular contractions, usually symmetrical and rhythmical, of muscles otherwise normal, which cease during sleep. There are neither psychical nor sen- sory disturbances. The condition is most common in young males, and is unaffected by treatment. Raymond groups this disease with fibrillary tremors, electric chorea (Henoch), tic non douloureux of the face, and the convulsive tic under the name of myoclonies, believing that it is only one link in a chain of pathological manifestations in the degenerate. SECTION X. THE INTOXICATIONS, SHN-STROKE, OBESITY. I. ALCOHOLISM. (1) Acute Alcoholism.—When a large quantity of alcohol is taken, its influence on the nervous system is manifested in muscular incoordina- tion, mental disturbance, and, finally, narcosis. The individual presents a flushed, sometimes slightly cyanosed face, a full pulse, with deep but rarely stertorous respirations. The pupils are dilated. The temperature is fre- quently below normal, particularly if the patient has been exposed to cold. Perhaps the lowest reported temperatures have been in cases of this sort. An instance is on record in which the patient on admission to hos- pital had a temperature of 24° C. (ca. 75° E.), and ten hours later the temperature had not risen to 91°. The unconsciousness is rarely so deep that the patient cannot be roused to some extent, and in reply to questions he mutters incoherently. Muscular twitchings may occur, but rarely con- vulsions. The breath has a heavy alcoholic odor. The diagnosis is not difficult, yet mistakes are frequently made. Per- sons are sometimes brought to hospital by the police supposed to be drunk when in reality they are dying from apoplexy. Too great care cannot be exercised, and the patient should receive the benefit of the doubt. In some instances the mistake has arisen from the fact that a person who has been drinking heavily has been stricken with apoplexy. In this condition the coma is usually deeper, stertor is present, and there may be evidence of hemiplegia in the greater flaccidity of the limbs on one side. The subject has already been considered in the section upon uraemic coma. (2) Chronic Alcoholism.—In moderation, wine, beer, and spirits may be taken throughout a long life without impairing the general health. According to Payne, the poisonous effects of alcohol are manifested (1) as a functional poison, as in acute narcosis; (2) as a tissue poison, in which its effects are seen on the parenchymatous elements, particularly epithe- lium and nerve, producing a slow degeneration, and on the blood-vessels, causing thickening and ultimately fibroid changes; and (3) as a checker 1058 THE INTOXICATIONS, SUN-STROKE, OBESITY. of tissue oxidation, since the alcohol is consumed in place of the fat. This leads to fatty changes and sometimes to a condition of general steatosis. The chief effects of chronic alcohol poisoning may be thus summa- rized : Nervous System.—Functional disturbance is common.—Unsteadiness of the muscles in performing any action is a constant feature. The tremor is best seen in the hands and in the tongue. The mental processes may be dull, particularly in the early morning hours, and the patient is unable to transact any business until he has had his accustomed stimu- lant. Irritability of temper, forgetfulness, and a change in the moral character of the individual gradually come on. The judgment is seri- ously impaired, the will enfeebled, and in the final stages dementia may supervene. The relation of chronic alcoholism to insanity has been much discussed. According to Savage, of 4,000 patients admitted to the Beth- lehem Hospital, 133 gave drink as the cause of their insanity. Chronic alcoholism is believed by many to be one of the special causes of dementia paralytica, but the opinions of experts on this question are still discordant. Savage states that not more than seven per cent are caused by alcohol alone. In many cases it is certainly one of the important elements in the strain which leads to this breakdown. No characteristic changes are found in the nervous system. Haemor- rhagic pachymeningitis is not very uncommon. Opacity and thickening of the pia-arachnoid membranes, with more or less wasting of the convo- lutions, generally occur. These are in no way peculiar to chronic alcohol- ism, but are found in old persons and in chronic wasting diseases. In the very protracted cases there may be chronic encephalo-meningitis with ad- hesions of the membranes. By far the most striking effect of alcohol on the nervous system is the production of the alcoholic neuritis, which has already been considered. Digestive System.—Catarrh of the stomach is the most common symp- tom. The toper has a furred tongue, heavy breath, and in the morning a sensation of sinking at the stomach until he has his dram. The appetite is usually impaired and the bowels are constipated. These features are associated with a chronic catarrh of the stomach. Alcohol produces definite changes on the liver, leading to the various forms of cirrhosis already described. The effect is probably a primary degenerative change in the liver-cells, although many good observers still hold that the poison acts first upon the connective-tissue elements. It is probable that a special vulnerability of the liver-cells is necessary in the etiology of alcoholic cirrhosis. There are cases in which comparatively moderate drinking for a few years has been followed by cirrhosis; on the other hand, the livers of persons who have been steady drinkers for thirty or forty years may show only a moderate grade of sclerosis. With the gas- tric and hepatic disorders the facies often becomes very characteristic. The venules of the cheeks and nose are dilated; the latter becomes enlarged, ALCOHOLISM. 1059 red, and may present the condition known as acne rosacea. The eyes are watery, the conjunctive hyperemic and sometimes bile-tinged. Kidneys.—The influence of chronic alcoholism upon these organs is by no means so marked. According to Dickinson the total of renal dis- ease is not greater in the drinking class, and he holds that the effect of alcohol on the kidneys has been much overrated. Formad has directed at- tention to the fact that in a large proportion of chronic alcoholics the kid- neys are increased in size. The Guy’s Hospital statistics support this statement, and Pitt notes that in forty-three per cent of the bodies of hard drinkers the kidneys were hypertrophied without showing morbid change. The typical granular kidney seems to result indirectly from alcohol through the arterial changes. It was formerly thought that alcohol was in some way antagonistic to tuberculous disease, but the observations of late years indicate clearly that the reverse is the case and that chronic drinkers are much more liable to both acute and pulmonary tuberculosis. It is probably altogether a question of altered tissue-soil, the alcohol lowering the vitality and enabling the bacilli more readily to develop and grow. (3) Delirium Tremens {mania a potu) is really only an incident in the history of chronic alcoholism, and results from the long-continued action of the poison on the brain. The condition was first accurately described early in this century by Sutton, of Greenwich, who had numerous oppor- tunities for studying the different forms among the sailors. One of the most thorough and careful studies of the disease was made by Ware, of Boston. A spree in a temperate person, no matter how prolonged, is rare- ly if ever followed by delirium tremens; but in the case of an habitual drinker a temporary excess is apt to bring on an attack. It sometimes develops in consequence of the sudden withdrawal of the alcohol. There are circumstances which in a heavy drinker determine, sometimes with abruptness, the onset of delirium. Such are an accident, a sudden fright or shock, and an acute inflammation, particularly pneumonia. At the outset of the attack the patient is restless and depressed and sleeps badly, symptoms which cause him to take alcohol more freely. After a day or two the characteristic delirium sets in. The patient talks constantly and incoherently; he is incessantly in motion, and desires to go out and attend to some imaginary business. Hallucinations of sight and hearing develop. He sees objects in the room, such as rats, mice, or snakes, and fancies that they are crawling over his body. The terror inspired by these imaginary objects is great, and has given the popular name “ horrors ” to the disease. The patients need to be watched constantly, for in their delusions they may jump out of the window or escape. Auditory hallucinations are not so common, but the patient may complain of hearing the roar of animals or the threats of imaginary enemies. There is much muscular tremor; the tongue is covered with a thick white fur, and when protruded is tremu- lous. The pulse is soft, rapid, and readily compressed. There is usually 1060 THE INTOXICATIONS, SUN-STROKE, OBESITY. fever, but the temperature rarely registers above 102° or 103°. In fatal cases it may be higher. Insomnia is a constant feature. On the third or fourth day in favorable cases the restlessness abates, the patient sleeps, and improvement gradually sets in. The tremor persists for some days, the hallucinations gradually disappear, and the appetite returns. In more serious cases the insomnia persists, the delirium is incessant, the pulse becomes more frequent and feeble, the tongue dry, the prostration ex- treme, and death takes place from gradual heart-failure. Diagnosis.—The clinical picture of the disease can scarcely be con- founded with any other. Cases with fever, however, may be mistaken for meningitis. By far the most common error is to overlook some local dis- ease, such as pneumonia or erysipelas, or an accident, as a fractured rib, which in a chronic drinker may precipitate an attack of delirium tremens. In every instance a careful examination should be made, particularly of the lungs. It is to be remembered that in the severer forms, particularly the febrile cases, congestion of the bases of the lungs is by no means un- common. Another point to be borne in mind is the fact that pneumonia of the apex is apt to be accompanied by delirium similar to mania a potu. Prognosis.—Recovery takes place in a large proportion of the cases in private practice. In hospital practice, particularly in the large city hospitals to which the debilitated patients are taken, the death rate is higher. Gerhard states that of 1,241 cases admitted to the Philadelphia Hospital 121 proved fatal. Recurrence is frequent, almost indeed the rule, if the drinking is kept up. Treatment.—Acute alcoholism rarely requires any special measures, as the patient sleeps off the effects of the debauch. In the case of pro- found alcoholic coma it may be advisable to wash out the stomach, and if collapse symptoms occur the limbs should be rubbed and hot applications made to the body. Should convulsions supervene, chloroform may be carefully administered. In the acute, violent alcoholic mania the hypo- dermic injection of apomorphia, one eighth or one sixth of a grain, is usually very effectual, causing nausea and vomiting, and rapid disappear- ance of the maniacal symptoms. Chronic alcoholism is a condition very difficult to treat, and once fully established the habit is rarely abandoned. The most obstinate cases are are those with marked hereditary tendency. Withdrawal of the alcohol is the first essential. This is most effectually accomplished by placing the patient in an institution, in which he can be carefully watched during the trying period of the first Aveek or ten days of abstention. The absence of temptation in institution life is of special advantage. For the sleep- lessness the bromides or hyoscine may be employed. Quinine and strych- nine in tonic doses may be given. Cocaine or the fluid extract of coca has been recommended as a substitute for alcohol, but it is not of much service. Prolonged seclusion in a suitable institution is in reality the only MORPHIA HABIT. 1061 effectual means of cure. When the hereditary tendency is strongly devel- oped a lapse into the drinking habits is almost inevitable. In delirium tremens the patient should be confined to bed and care- fully watched night and day. The danger of escape in these cases is very great, as the patient imagines himself pursued by enemies or demons. Flint mentions the case of a man who escaped in his night-clothes and ran barefooted for fifteen miles on the frozen ground before he was over- taken. The patient should not he strapped in bed, as this aggravates the delirium; sometimes, however, it may be necessary, in which case a sheet tied across the bed may be sufficient, and this is certainly better than vio- lent restraint by three or four men. Alcohol should be withdrawn at once unless the pulse is feeble. Delirium tremens is a disease which, in a large majority of cases, runs a course very slightly influenced by medicine. The indications for treat- ment are to procure sleep and to support the strength. In mild cases half a drachm of bromide of potassium combined with tincture of capsicum may be given every three hours. Chloral is often of great service, and may be given without hesitation unless the heart’s action is feeble. Good re- sults sometimes follow the hypodermic use of hyoscine, one one-hundredth of a grain. Opium must be used cautiously. A special merit of Ware’s work was the demonstration that on a rational or expectant plan of treat- ment the percentage of recovery was greater than with the indiscriminate use of sedatives, which had been in vogue for many years. When opium is indicated it should be given as morphia, hypodermically. The effect should be carefully watched, and if after three or four quarter-grain doses have been given the patient is still restless and excited, it is best not to push it farther. When fever is present the tranquillizing effects of a cold douche or cold bath may be tried, or the cold pack. The large doses of digitalis formerly employed are not advisable. Careful feeding is the most important element in the treatment of these cases. Milk and concentrated broths should be given at stated intervals. If the pulse becomes rapid and shows signs of flagging alcohol may be given in combination with the aromatic spirits of ammonia. II. MORPHIA HABIT (Morphiomania; Morphinism). This habit arises from the constant use of morphia—taken at first, as a rule, for the purpose of allaying pain. The craving is gradually engen- dered, and the habit in this way acquired. The injurious effects vary very much, and in the East, where opium-smoking is as common as tobacco- smoking with us, the ill effects are, according to good observers, not so striking. The habit is particularly prevalent among women and physicians who use the hypodermic syringe for the alleviation of pain, as in neuralgia or 1062 THE INTOXICATIONS, SUN-STROKE, OBESITY. sciatica. The acquisition of the habit as a pure luxury is rare in this country. The symptoms at first are slight, and moderate doses may be taken for months without serious injury and without disturbance of health. There are exceptional instances in which for a period of years excessive doses have been taken without determination of the mental or bodily functions. As a rule, the dose necessary to obtain the desired sensations has gradu- ally to be increased. As the effects wear off the victim experiences sensa- tions of lassitude and mental depression, accompanied often with slight nausea and epigastric distress, symptoms which are relieved by another dose of the drug. The confirmed opium-eater often presents a very char- acteristic appearance. There is a sallowness of the complexion which is almost pathognomonic, and he becomes emaciated, gray, and prematurely aged. He is restless, irritable, and unable to remain quiet for any time. Itching is a common symptom. The sleep is disturbed, the appetite and digestion are deranged, and except when directly under the influence of the drug the mental condition is one of depression. Occasionally there are profuse sweats, which may be preceded by chills. The pupils, except when under the direct influence of the drug, are dilated, sometimes un- equal. Persons addicted to morphia are inveterate liars, and no reliance whatever can be placed upon their statements. In many instances this is not confined to matters relating to the vice. In women the symptoms may be associated with those of pronounced hysteria or neurasthenia. The practice may be continued for an indefinite time, usually requiring increase in the dose until ultimately enormous quantities may be needed to obtain the desired effect. Finally a condition of asthenia is induced, in which the victim takes little or no food and dies from the extreme bodily debility. The treatment of the morphia habit is extremely difficult, and can rarely be successfully carried out by the general practitioner. Isolation, systematic feeding, and gradual withdrawal of the drug are the essential elements. As a rule, the patients must be under control in an institution and should be in bed for the first ten days. It is best in a majority of cases to reduce the morphia gradually. The diet should consist of beef- juices, milk, and egg-white, which should be given at short intervals. The sufferings of the patients are usually very great, more particularly the ab- dominal pains, sometimes nausea and vomiting, and the distressing rest- lessness. Usually within a week or ten days the opium may be entirely withdrawn. In all cases the pulse should be carefully watched and, if feeble, stimulants should be given, with the aromatic spirits of ammonia and digitalis. For the extreme restlessness a hot bath is serviceable. The sleeplessness is the most distressing symptom, and various drugs may have to be resorted to, particularly hyoscine and sulphonal and sometimes, if the insomnia persists, morphia itself. It is essential in the treatment of a case to be certain that the patient LEAD-POISONING 1063 has no means of obtaining morphia. Even under the favorable circum- stances of seclusion in an institution, and constant watching by a night and a day nurse, I have known a patient to practice deception for a period of three months. After an apparent cure the patients are only too apt to lapse into the habit. The condition is one which has become so common, and is so much on the increase, that physicians should exercise the utmost caution in pre- scribing morphia, particularly to female patients. Under no circumstances whatever should a patient with neuralgia or sciatica be allowed to use the hypodermic syringe, and it is even safer not to intrust this dangerous instrument to the hands of the nurse. III. LEAD-POISONING (Plumbism; Saturnism). Etiology.—The disease is wide-spread, particularly in lead-workers and among plumbers, painters, and glaziers. The metal is introduced into the system in many forms. Miners usually escape, but those engaged in the smelting of lead-ores are often attacked. Animals in the neighbor- hood of smelting furnaces have suffered with the disease, and even the birds that feed on the berries in the neighborhood may be affected. Men engaged in the white-lead factories are particularly prone to plumbism. Accidental contamination may come in many ways; most commonly by drinking water which has passed through lead pipes or been stored in lead-lined cisterns. Wines and cider which contain acids quickly become contaminated in contact with lead. It was the frequency of colic in cer- tain of the cider districts of Devonshire which gave the name Devonshire colic, as the frequency of it in Poitou gave the name colica Pictonum. Among the innumerable sources of accidental contamination may be men- tioned milk, various sorts of beverages, hair dyes, false teeth, and thread. A serious outbreak of lead-poisoning, which was investigated by David D. Stewart, occurred recently in Philadelphia, owing to the disgraceful adul- teration of a baking-powder with chromate of lead, which was used to give a yellow tint to the cakes. Lead given medicinally rarely produces poison- ing. All ages are attacked, but J. J. Putnam states that children are rela- tively less liable. The largest number of cases occur between thirty and forty. According to Oliver, from whose recent Goulstonian lectures I here quote, females are more susceptible than males. He states that they are much more quickly brought under its influence, and in a recent epidemic in which a thousand cases were involved the proportion of females to males was four to one. The lead gains entrance to the system through the lungs, the digestive organs, or the skin. Poisoning may follow the use of cosmetics contain- ing lead. Through the lungs it is freely absorbed. The chief channel, 1064 THE INTOXICATIONS, SUN-STROKE, OBESITY. according to Oliver, is the digestive system. It is rapidly eliminated by the kidneys and skin, and is present in the urine of lead-workers. The susceptibility is remarkably varied. The symptoms may be manifest with a month of exposure. On the other hand, Tanquerel (des Planches) met with a case in a man who had been a lead-worker for fifty-two years. Morbid Anatomy.—Small quantities of lead occur in the body in health. J. J. Putnam’s reports show that of 150 persons not presenting symptoms of lead-poisoning traces of lead occurred in the urine of 25 per cent. In chronic poisoning lead is found in the various organs. The affected muscles are yellow, fatty, and fibroid. The nerves present the features of a peripheral degenerative neuritis. The cord and the nerve-roots are, as a rule, uninvolved. In the primary atrophic form the ganglion cells of the anterior horns are probably involved. In the acute fatal cases there may be the most intense entero-colitis. Clinical Forms.—Acute Poisoning.—We do not refer here to the accidental or suicidal cases, which present vomiting, pain in the abdomen, and collapse symptoms. In workers in lead there are several manifesta- tions which follow a short time after exposure and set in acutely. There may be, in the first place, a rapidly developing anaemia. Acute neuritis has been described, and convulsions, epilepsy, and a delirium, which may be, as Stephen Mackenzie has noted, not unlike that produced by alcohol. There are also cases in which the gastro-intestinal symptoms are most intense and rapidly prove fatal. There was admitted under my care in the Philadelphia Hospital a painter, aged fifty, suffering with anaemia and severe abdominal pain, which had lasted about a week. He had vomiting, constipation at first, afterward severe diarrhoea and melaena, with distention and tenderness of the abdomen. There were albumin and tube-casts in the urine. The temperature was usually subnormal. Death occurred at the end of the second week. There was found the most intense entero-colitis with haemorrhages and exudation. These acute forms develop more fre- quently in persons recently exposed, and, according to Mackenzie, are more frequent in winter than in summer. Chronic poisoning presents the following symptoms : (a) Ancemia, the so-called saturnine cachexia, which may be profound. As a rule, however, the corpuscles do not sink below 50 per cent. (b) Blue line on gums, which is a valuable indication, but not invari- ably present. Two lines must be distinguished: one, at the margin be- tween the gums and teeth, is on, not in the gums, and is readily removed by rinsing the mouth and cleansing the teeth. The other is the well-known characteristic blue-black line at the margin of the gum. The color is not uniform, but being in the papillae of the gums the line is, as seen with a magnifying-glass, interrupted. The lead is absorbed and converted in the tissues into a black sulphide by the action of sulphuretted hydrogen from the tartar of the teeth. The line may form rapidly after exposure and LEAD-POISONING. 1065 disappear within a few weeks, or may persist for many months. Philip- son has noted the occurrence of a black line in miners, due to the deposition of carbon. The most important symptoms of chronic lead-poisoning are colic, lead-palsy, and the encephalopathy. Of these, the colic is the most fre- quent. Of Tanquerel’s cases, there were 1,217 of colic, 101 of paralysis, and 72 of encephalopathy. (c) Colic is the most common symptom of chronic lead-poisoning. It is often preceded by gastric or intestinal symptoms, particularly constipa- tion. The pain is over the whole abdomen. The colic is usually parox- ysmal, like true colic, and is relieved by pressure. There is often, in addi- tion, between the paroxysms a dull, heavy pain. There may be vomiting. During the attack, as Riegel noted, the pulse is increased in tension and the heart’s action is retarded. The pupils are usually unequal (Oliver). (id) Leacl-palsy.—This is rarely a primary manifestation. The onset may be acute, subacute, or chronic. It usually develops without fever. In its distribution it may be partial, limited to a muscle or to certain mus- cle groups, or generalized, involving in a short time the muscles of the extremities and the trunk. Madame Dejerine-Klumpke recognizes the following localized forms: (1) Anti-brachial type, paralysis of the extensors of the fingers and of the wrist. In this the musculo-spiral nerve is involved, causing the char- acteristic wrist-drop. The supinator longus usually escapes. In the long- continued flexion of the carpus there may be slight displacement back- ward of the bones, with distention of the synovial sheaths, so that there is a prominent swelling over the wrist. This, which is sometimes known as Gruebler’s tumor, though not of any moment, is often very annoying to the patient. (2) Brachial type, which involves the deltoid, the biceps, the brachi- alis anticus, and the supinator longus, rarely the pectorals. The atrophy is of the scapulo-humeral form. It is bilateral, and sometimes follows the first form, but it may be primary. (3) The Aran-Duchenne type, in which the small muscles of the hand and of the thenar and hypothenar eminences are involved. It produces a paralysis closely resembling that of the early stage of polio-myelitis ante- rior chronica. The atrophy is marked, and may be the first manifestation of the lead-palsy. Mobius has shown that this form is particularly de- veloped in tailors. (4) The peroneal type. According to Tanquerel, the lower limbs are involved in the proportion of thirteen to one hundred of the upper limbs. The lateral peroneal muscles, the extensor communis of the toes, and the extensor proprius of the big toe are involved, producing the steppage gait. (5) Laryngeal form. Adductor paralysis has been noted by Morell Mackenzie and others in lead-palsy. 1066 TIIE INTOXICATIONS, SUN-STROKE, OBESITY. Generalized Palsies.—There may be a slow, chronic paralysis, gradu- ally involving the extremities, beginning with the classical picture of wrist-drop. More frequently there is a rapid generalization, producing complete paralysis in all the muscles of the parts in a few days. It may pursue a course like an ascending paralysis, associated with rapid wasting of all four limbs. Such cases, however, are very rare. Death has occurred by involvement of the diaphragm. Oliver reports a case of Philipson’s in which complete paralysis supervened. Dejerine-Klumpke also recognizes a febrile form of general paralysis in lead-poisoning, which may closely resemble the subacute spinal paralysis of Duchenne. There is also a primary saturnine muscular atrophy in which the weakness and wasting come on together and develop proportionately. It is this form, according to Gowers, which most frequently assumes the Aran-Duchenne type. The electrical reactions are those of lesions of the lower motor seg- ment, and have been described under lesions of the nerves. The degener- ative reaction in its different grades may be present, depending upon the severity of the disease. Usually with the onset of the paralysis there are pains in the legs and joints, the so-called saturnine arthralgias. Sensation may, however, be unaffected. (ie) The cerebral symptoms are numerous. Optic neuritis or neuro- retinitis may develop. Hysterical symptoms occasionally occur in girls. Convulsions are not uncommon, and in fits developing in the adult the possibility of lead-poisoning should always be considered. True epilepsy may follow the convulsions. An acute delirium may occur with halluci- nations. The patients may have trance-like attacks, which follow or alternate with convulsions. A few cases of lead encephalopathy finally drift into lunatic asylums. Tremor is one of the commonest manifesta- tions of lead-poisoning. (/) Arteriosclerosis.—Lead-workers are notoriously subject to arte- rio-sclerosis with contracted kidneys and hypertrophy of the heart. The cases usually show distinct gouty deposits, particularly in the big-toe joint; but in this country acute gout in lead-workers is rare. According to Sir William Roberts, the lead favors the precipitation of the crystalline urates of the tissues. Ralfe has shown that lead diminishes the alkalinity of the blood, and so lessens the solubility of the uric acid. Prognosis.—In the minor manifestations of lead-poisoning this is good. According to Gowers, the outlook is bad in the primary atrophic form of paralysis. Convulsions are, as a rule, serious, and the mental symptoms which succeed may be permanent. Occasionally the wrist-drop persists. Treatment.—Prophylactic measures should be taken at all lead- works, but unless employes are careful poisoning is apt to occur even under the most favorable conditions. Cleanliness of the hands and of the ARSENICAL POISONING. 1067 finger-nails, frequent bathing, and the use of respirators when necessary, should be insisted upon. When the lead is in the system, the iodide of potassium should be given in from five- to ten-grain doses three times a day. For the colic, local applications and, if severe, morphia may be used. An occasional morning purge of sulphate of magnesia may be given. For the anaemia iron should be used. In the very acute cases it is well not to give the iodide, as, according to some writers, the liberation of the lead which has been deposited in the tissues may increase the severity of the symptoms. For the local palsies massage and the constant current should be used. IV. ARSENICAL POISONING. Acute poisoning by arsenic is common, particularly by Paris green and such mixtures as “ Rough on Rats,” which are used to destroy vermin and insects. The chief symptoms are intense pain in the stomach, vomit- ing, and, later, colic, with diarrhoea and tenesmus ; occasionally the symp- toms are those of collapse. If recovery takes place, paralysis may follow. The treatment should be similar to that of other irritant poisons—rapid removal with the stomach pump, the promotion of vomiting, and the use of milk and eggs. If the poison has been taken in solution, dialyzed iron may be used in large doses of from six to eight drachms. Chronic Arsenical Poisoning.—Arsenic is used extensively in the arts, particularly in the manufacture of colored papers, artificial flowers, and in many of the fabrics employed as clothing. The glazed green and red papers used in kindergartens also contain arsenic. It is present, too, in many wall-papers and carpets. Much attention has been paid to this question of late years, as instances of poisoning have been thought to de- pend upon wall-papers and other household fabrics. The arsenic com- pounds may be either in the form of solid particles detached from the paper or as a gaseous volatile body. The investigations of Gosio, con- firmed by Sanger, have shown that a volatile compound is formed by the action on arsenical organic matter in wall-papers of several moulds, notably penicillum brevieaule, mucor mucedo, etc. In moisture, and at a tem- perature of from 60° to 95° F., a volatile compound is set free, probably “an organic derivative of arsenic pentoxide ” (Sanger). The chronic poisoning from fabrics and wall-papers may be due, according to this author, to the ingestion of minute continued doses of this derivative, “ which from its state of oxidation is likely to be accumulated in the sys- tem, from which it is slowly eliminated.” Arsenic is eliminated in all the secretions, and has been found in the milk. J. J. Putnam, it should be remembered, has shown that it is not uncommon to find traces of arsenic in the urine of many persons in apparent health (30 per cent). The effects of moderate quantities of arsenic are not infrequently seen in medical practice. In chorea and in pernicious anaemia, steadily increas- 1068 THE INTOXICATIONS, SUN-STROKE, OBESITY. mg doses are often given until the patient takes from fifteen to twenty drops of Fowler’s solution three times a day. Flushing and hypersemia of the skin, puffiness of the eyelids or above the eyebrows, nausea, vomit- ing, and diarrhoea are the most common symptoms. Kedness and some- times bleeding of the gums and salivation occur. In the protracted ad- ministration of arsenic patients may complain of numbness and tingling in the fingers. Pigmentation of the skin I have seen on several occasions. In chorea neuritis has occurred, and a patient of mine with Hodgkin’s disease developed multiple neuritis after taking § iv 3 j of Fowler’s solu- tion in seventy-five days, during which time there were fourteen days on which the drug was omitted. In the slow poisoning by the absorption of arsenic in minute doses, as from wall-paper and fabrics, the symptoms are varied. J. J. Putnam groups them into the cases in which the symptoms mainly concern the general nutrition without signs of local irritation ; those in which the symptoms are due to irritation of the conjunctive, mouth, or pharynx ; those with symptoms pointing to the digestive tract; cases with marked nervous phenomena ; and those in which the nutrition of some special part of the body is involved. The most common symptoms are those of anemia and debility, perhaps with slight irritation of the mucous membrane, and numbness and tingling, and gastralgia. How far these symptoms are to be attributed to the small quantities of arsenic absorbed from wall-papers and fabrics is by some considered doubtful. That children and adults may take with impunity large doses for months without unpleasant effects, and the fact of the gradual establishment of a toleration which enables Styrian peasants to take as much as eight grains of arsenious acid in a day, speak strongly against it. On the other hand, as Sanger states, we do not know accurately the effects of many of the compounds in minute and long-continued doses, notably the arsenate. Arsenical paralysis has the same characteristics as lead-palsy, but the legs are more affected than the arms, particularly the extensors and pero- neal group, so that the patient has the characteristic steppage gait of peripheral neuritis. The electrical reaction in the muscles may be disturbed before any loss of power, and when the patient is asked to extend the wrist fully and to spread the fingers slight weakness may be detected early. PTOMAINE POISONING. 1069 V. PTOMAINE POISONING. In the bacterial decomposition of animal matters chemical compounds are formed, the putrefactive alkaloids, known as ptomaines and toxines, some of which are highly poisonous. They differ extraordinarily in their chemical characters and physiological effects. Some only are poisonous, and these Brieger has designated as toxines. The specific action of the micro-organisms in disease is now attributed in large part to the forma- tion of these bodies, and the whole question of immunity and protection is now being worked out in this direction, a special stimulus having been given of late in the discovery by Hankin of the so-called defensive alka- loids (see under Pneumonia). Our interest here is in the effects of these poisons when taken with foods.* It is quite possible that the leucomaines, the basic substances formed in the living body, may under certain circumstances be capable of causing disease. Products also of the bacterial decomposition in the intestines may be absorbed and act as poisons. Our knowledge on these points is as yet scanty and uncertain. A suggestive chapter (XIII) upon the subject is to be found in the work of Vaughan and Novy. Among the more common forms are the following : (1) Meat Poisoning.—Cases have usually followed the eating of sau- sages or pork-pie or head-cheese, and also occasionally beef, veal, and mut- ton. Sausage poisoning, which is known by the name of botulism or allantiasis, has long been recognized, and there have been numerous out- breaks, particularly in parts of Germany. Similar attacks have been pro- duced by ham and by head-cheese. The precise nature of the poison in these cases has not yet been determined. Other outbreaks have followed the eating of beef and veal. In the majority of these cases the meat has undergone decomposition, though the change may not have been evident to the taste. The symptoms of meat poisoning are those of acute gastro- intestinal irritation. Ballard’s description of the Wellbeck cases, quoted by Vaughan, holds good for a majority of them: “ A period of incubation preceded the illness. In 51 cases where this could be accurately determined, it wras twelve hours or less in 5 cases; be- tween twelve and thirty-six hours in 34 cases; between thirty-six and forty-eight hours in 8 cases; and later than this in only 4 cases. In many cases the first definite symptoms occurred suddenly, and evidently unex- pectedly, but in some cases there were observed during the incubation more or less feeling of languor and ill-health, loss of appetite, nausea, or fugitive, griping pains in the belly. In about a third of the cases the first * For a full discussion of the whole subject the student is referred to the Manual upon Ptomaines and Leucomaines, by Vaughan and Novy, second edition, Philadel- phia, 1891. 1070 THE INTOXICATIONS, SUN-STROKE, OBESITY. definite symptom was a sense of chilliness, usually with rigors, or trem- bling, in one case accompanied by dyspnoea; in a few cases it was giddi- ness with faintness, sometimes accompanied by a cold sweat and tottering •, in others the first symptom was headache or pain somewhere in the trunk of the body—e. g., in the chest, back, between the shoulders, or in the ab- domen, to which part the pain, wherever it might have commenced, subse- quently extended. In one case the first symptom noticed was a difficulty in swallowing. In two cases it was intense thirst. But however the attack may have commenced, it was usually not long before pain in the abdomen, diarrhoea, and vomiting came on, diarrhoea being of more certain occur- rence than vomiting. The pain in several cases commenced in the chest or between the shoulders, and extended first to the upper and then to the lower part of the abdomen. It was usually very severe indeed, quickly producing prostration or faintness, with cold sweats. It was variously de- scribed as crampy, burning, tearing, etc. The diarrhoeal discharges were in some cases quite unrestrainable, and (where a description of them could be obtained) were said to have been exceedingly offensive and usually of a dark color. Muscular weakness was an early and very remarkable symp- tom in nearly all the cases, and in many it was so great that the patient could only stand by holding on to something. Headache, sometimes severe, was a common and early symptom; and in most cases there was thirst, often intense and most distressing. The tongue, when observed, was described usually as thickly coated with a brown, velvety fur, but red at the tip and edges. In the early stage the skin was often cold to the touch, but afterward fever set in, the temperature rising in some cases to 101°, 103°, and 104° F. In a few severe cases, where the skin was actually cold, the patient complained of heat, insisted on throwing off the bed- clothes, and was very restless. The pulse in the height of the illness be- came quick, counting in some cases 100 to 128. The above were the symptoms most frequently noted. Other symptoms occurred, however, some in a few cases, and some only in solitary cases. These I now pro- ceed to enumerate. Excessive sweating, cramps in the legs, or in both legs and arms, convulsive flexion of the hands or fingers, muscular twitch- ings of the face, shoulders, or hands, aching pain in the shoulders, joints, or extremities, a sense of stiffness of the joints, prickling or tingling or numbness of the hands lasting far into convalescence in some cases, a sense of general compression of the skin, drowsiness, hallucinations, im- perfection of vision, and intolerance of light. In three cases (one that of a medical man) there was observed yellowness of the skin, either general or confined to the face and eyes. In one case, at a late stage of the ill- ness, there was some pulmonary congestion and an attack of what was re- garded as gout. In the fatal cases death was preceded by collapse like that of cholera, coldness of the surface, pinched features, and blueness of the fingers and toes and around the sunken eyes. The debility of conva- lescence was in nearly all cases protracted to several weeks. PTOMAINE POISONING. 1071 “ The mildest cases were characterized usually by little remarkable beyond the following symptoms, viz., abdominal pains, vomiting, diar- rhoea, thirst, headache, and muscular weakness, any one or two of which might be absent.” Many instances are on record of poisoning by canned goods, particu- larly meat. Some of these, according to John G. Johnson, have been cases of corrosive poisoning from muriate of zinc and muriate of tin used as an amalgam, but poisonous effects identical with those just described have followed the use of canned meats. Certain game birds, particularly the grouse, are stated to be poisonous, in special districts and at certain seasons of the year. (2) Poisoning by Milk Products.—Poisoning by cheese has long been known. In Michigan, in 1883 and 1884, there were nearly 300 cases of cheese poisoning, and from pieces of the cheese Vaughan separated a sub- stance which he called tyrotoxicon. Since that date other outbreaks have been reported. Apparently to this poison also are due the outbreaks fol- lowing the use of milk, several of which are reported in the manual by Vaughan and Novy. Still more numerous of late years have been the cases due to poisonous ice-cream, in which also the tyrotoxicon has been found. The symptoms are those of acute gastro-intestinal irritation, and are similar to those already detailed by Ballard. (3) Poisoning by Shell-fish and Fish.—Perhaps the most serious form of ichthysmus, as the disease is called, is that produced by the mussel, many epidemics of which have been studied of late, more particularly an outbreak at Wilhelmshaven. Brieger has separated a poison which he has called mytilotoxin. It has been shown that this exists chiefly in the liver of the mussel. It does not yet appear to be settled whether there is a spe- cial poisonous variety or whether the mussel only becomes toxic under certain conditions. The latter seems to be the most probable view, as Schmidtmann found that the non-poisonous mussels soon became toxic when placed in the Wilhelmshaven bay, while those from the bay soon lost their toxic properties when placed in the open sea. The symptoms of mussel poisoning follow the eating of either raw or cooked mussels. The symptoms are those of an acute poisoning with pro- found action on the nervous system, and without gastro-intestinal symp- toms. There are numbness and coldness, no fever, dilated pupils, rapid pulse, and death occurs sometimes within two hours with collapse symp- toms. Poisoning occasionally follows the eating of oysters which are stale or decomposed. The symptoms are usually gastro-intestinal. Certain fish also cause poisoning, more particularly the salted sturgeon used in parts of Russia, which has sometimes proved fatal to large numbers of persons. In the middle parts of Europe the barb is stated to be sometimes poison- ous, producing the so-called “ barhen cholera.” In China and Japan vari- 1072 TIIE INTOXICATIONS, SUN-STROKE, OBESITY. ous species of the tetrodon are also toxic, sometimes proving fatal within an hour, with symptoms of intense disturbance of the nervous system. Several other poisonous forms are known, which produce symptoms de- scribed as ichthysmus paralyticus. VI. GRAIN POISONING. (1) Ergotism.—The prolonged use of meal made from grains contam- inated with the ergot fungus (claviceps purpurea) causes a series of symp- toms known as ergotism, epidemics of which have prevailed in different parts of Europe. Two forms of this chronic ergotism are described—the gangrenous and the convulsive or spasmodic. In the former, mortification affects the extremities—usually the toes and fingers, less commonly the ears and nose. Preceding the onset of the gangrene there are usually anaes- thesia, tingling, pains, spasmodic movements of the muscles, and gradual blood stasis in certain vascular territories. The nervous manifestations are very remarkable. After a prodromal stage of ten to fourteen days, in which the patient complains of weakness, headache, and tingling sensations in different parts of the body, perhaps accompanied with slight fever, spasmodic symptoms develop, producing cramps in the muscles and contractures. The arms are flexed and the legs and toes extended. These spasms may last from a few hours to many days and relapses are frequent. In severer cases epilepsy develops and the patient may die in convulsions. Mental symptoms are common, mani- fested sometimes in a preliminary delirium, but more commonly, in the chronic poisoning, as melancholia or dementia. Posterior spinal sclerosis occurs in chronic ergotism. In the interesting group of 29 cases studied by Tuczek and Siemens, nine died at various periods after the infection, and four post-mortems showed degeneration of the posterior columns. A con- dition similar to tabes dorsalis is gradually produced by this slow degen- eration in the spinal cord. (2) Lathyrism (Lupinosis).—An affection produced by the use of meal from varieties of vetches, chiefly the Latliyrus sativus and L. cicera. The grain is popularly known as the chick-pea. The grains are usually powdered and mixed with the meal from other cereals in the preparation of bread. As early as the seventeenth century it was noticed that the use of flour with which the seeds of the Latliyrus were mixed caused stiffness of the legs. The subject did not, however, attract much attention until the studies of James Irving, in India, who between 1859 and 1868 pub- lished several important communications, describing a form of spastic paraplegia affecting large numbers of the inhabitants in certain regions of India and due to the use of meal made from the Latliyrus seeds. It also produces a spastic paraplegia in animals. The Italian observers describe a similar form of paraplegia, and it has been observed in Algiers by the SUN-STROKE. 1073 French physicians. The condition is that of a spastic paralysis, involving chiefly the legs, which may proceed to complete paraplegia. The arms are rarely, if ever, affected. It is evidently a slow sclerosis induced under the influence of this toxic agent. The precise anatomical condition, so far as I can ascertain, has not yet been determined. (3) Pellagra.—This is a nutritional disturbance due to the use of altered maize. The disease occurs extensively in parts of Italy, in the south of France, and in Spain. It has not been observed in this country. It pre- vails extensively among the poorer classes, particularly in the country dis- tricts, and appears to be associated in some way with the use of maize which (according to most authorities) is fermented or diseased. In the early stage the symptoms are indefinite, characterized by debility, pains in the spine, insomnia, digestive disturbances, more rarely diarrhoea. The first clear manifestation of the disease is the pellagral erythema, which al- most invariably appears in the spring. This is followed by desiccation and exfoliation of the epidermis, which becomes very rough and dry, and occasionally crusts form, beneath which there is suppuration. With these cutaneous manifestations there are digestive troubles—salivation, dyspepsia, and diarrhoea—which may be of a dysenteric nature. After lasting for a few months improvement occurs in the milder cases and convalescence is gradually established. In the more severe and chronic forms there are pronounced nervous symptoms—headache, backache, spasms, and finally paralysis and mental disturbance. The paralytic condition affects the legs and leads gradually to paraplegia. The mental manifestations, which are rarely met with until the third or fourth attack, are melancholia or suicidal mania. Finally, there may be a condition of the most pronounced cachexia. The anatomical changes are indefinite. Chronic degenerative changes have been found, particularly fatty degeneration and a peculiar pigmenta- tion in the viscera. The measures to be employed are change in diet, re- moval from the infected district, and, as a prophylaxis, proper preserva- tion of the maize.* VII. SUN-STROKE. (Heat Exhaustion; Insolation; Thermic Fever; Heat-stroke; Coup de Soleil). Definition.—A condition produced by exposure to excessive heat. It is one of the oldest of recognized diseases; two instances are men- tioned in the Bible. It was long confounded with apoplexy. The Anglo- Indian surgeons gave admirable descriptions of it. In this country the most important contributions have come from the New York Hospital and the Pennsylvania Hospital; from the former, the studies of Swift and * The most elaborate discussion of the subject is by Jules Arnould in the Diction- naire Encyclopedique des Sciences Medicates, tome xxii, 1886. 1074 THE INTOXICATIONS, SUN-STROKE, OBESITY. Darrach, from the latter, the papers of Gerhard, George B. Wood, the elder Pepper, and Levick. In New Orleans, Bennett Dowler studied the disease and recognized the difference between heat exhaustion and sun- stroke. Very little has been added to our knowledge of the disease since the publication of a monograph by II. C. Wood. Two forms are recog- nized, heat exhaustion and heat-stroke. Heat Exhaustion.—Prolonged exposure to high temperatures, particu- larly when combined with physical exertion, is liable to be followed by extreme prostration, collapse, restlessness, and in severe cases by delirium. The surface is usually cool, the pulse small and rapid, and the temperature may be subnormal—as low as 95° or 96°. The individual need not neces- sarily be exposed to the direct rays of the sun, but the condition may come on when working in close, confined rooms during midsummer. It may also follow exposure to great artificial heat; thus the stokers in the Atlantic steamships sometimes succumb to the effect of the great heat in the engine rooms. Sunstroke or Thermic Fever.—The cases are chiefly found in persons who, while working very hard, are exposed to the sun. Soldiers on the march with their heavy accoutrements are particularly liable to attack. In the larger cities of this country the cases are almost exclusively con- fined to workmen who are much exposed and, at the same time, have been drinking beer and whisky. Morbid Anatomy and Pathology.—Rigor mortis occurs early. Putrefactive changes develop with great rapidity. The venous engorge- ment is extreme, particularly in the cerebrum. The left ventricle is con- tracted (Wood), and the right chamber dilated. The blood is usually fluid; the lungs are intensely congested. Parenchymatous changes occur in the liver and kidneys. According to Wood, “heat exhaustion with lowered temperature represents a sudden vaso-motor palsy, i. e., a condition in which the exist- ing effect of the heat paralyzes the centre in the medulla.” On the other hand, thermic fever is held to be due to paralysis under the influence of the extreme external heat of the centre in the medulla which regulates the disposition of the bodily heat. Owing to this disturbance, more heat is produced and less given off than normally. Symptoms.—The patient may be struck down and die within an hour with symptoms of heart failure, dyspnoea, and coma. This form, sometimes known as the asphyxial, occurs chiefly in soldiers and is graphi- cally described by Parkes. Death indeed may be almost instantaneous, the victims falling as if struck upon the head. The usual form in this lati- tude comes on during exposure, with pain in the head, dizziness, a feel- ing of oppression, and sometimes nausea and vomiting. Visual disturb- ances are common, and a patient may have colored vision. Diarrhoea or frequent micturition may supervene. Insensibility follows, which may be transient or which deepens into a profound coma. The patients are SUN-STROKE. 1075 Chart XIX.—Case of sun-stroke treated with the iee-bath; recovery. (Rectal temperatures.) 1076 THE INTOXICATIONS, SUN-STROKE, ORESITX. usually admitted to hospital in an unconscious state, with the face flushed, the skin pungent, the pulse rapid and full, and the temperature ranging from 107° to 110°, or even higher. F. A. Packard states that of the 31 cases admitted to the Pennsylvania Hospital in the summer of 1887, in a ma- jority of them the temperature was between 110° and 111°. In one case the temperature was 112°. The breathing is labored and deep, sometimes stertorous. Usually there is complete relaxation of the muscles, but twitchings, jactitation, or very rarely convulsions may occur. The pupils may at first be dilated, but by the time the cases are admitted to hospital they are (in a majority) extremely contracted. Pete chi* may be present upon the skin. In the fatal cases the coma deepens, the cardiac pulsa- tions become more rapid and feeble, the breathing becomes hurried and shallow and of the Cheyne-Stokes type. The fatal termination may occur within twenty-four or thirty-six hours. Favorable indications are the recovery of consciousness and a fall in the fever. The recovery in these cases may be complete. In other instances there are remarkable after-effects, the most constant of which is a permanent inability to bear high temperatures. Such patients become very uneasy when the ther- mometer reaches 80° F. in the shade. An extraordinary instance came under my notice in which the patient was subsequently so sensitive to temperatures in the neighborhood of 75° F. that at such times he lived comfortably only in the cellar, and finally sought refuge in Alaska. Loss of the power of mental concentration and failure of memory are more constant and very troublesome sequel*. Such patients are always worse in the hot weather. Occasionally convulsions and marked mental disturb- ance may develop. II. C. Wood states that in a case of this kind chronic meningitis was found. Guiteras has called attention to a form of fever occurring in the South, known in Florida as “ Florida fever,” in the Carolinas as “ country fever,” and in tropical countries as fievre injlammatoire. The cases last for a vari- able time, and are mistaken for malaria or typhoid; but he believes them to be entirely distinct and due to a prolonged action of the high tempera- tures. He has called the condition a “ continued thermic fever.” The diagnosis of heat exhaustion from thermic fever is readily made, as the difference between the two conditions is striking. “ In solar ex- haustion the skin is moist, pale, and cool; the breathing is easy though hurried; the pulse is small and soft; the vital forces fall into a temporary collapse; the senses remain entire ” (Dowler); whereas in sunstroke or heat apoplexy there is usually unconsciousness and pyrexia. The mode of onset, together with the circumstances under which it occurs and the high temperature, permits thermic fever to be readily dif- ferentiated from apoplexy, and coma from other conditions. Treatment.—In heat exhaustion stimulants should be given freely, and if the temperature is below normal the hot bath should be used. Ammonia may be given if necessary. In thermic fever the indications OBESITY. 1077 are to reduce the temperature as rapidly as possible. This may be done by packing the patient in a bath with ice. Rubbing the body with ice was practised at the New York Hospital by Darrach in 1857, and is an excel- lent procedure to lower the temperature rapidly. Ice-water enemata may also be employed. At the Pennsylvania Hospital in the summer of 1887 the ice-pack was used with great advantage. Of 31 cases only 12 died, a result probably as satisfactory as can be obtained, considering that many of the patients are almost moribund when brought to hospital. It should be compared with Swift’s statistics, in which of 150 cases 78 died. In the cases in which the symptoms are those of intense asphyxia, and in which death may take place in a few minutes, free bleeding should be practised, a procedure which saved Weir Mitchell when a young man. For the con- vulsions chloroform should be given at once. Of other remedies, the anti- pyretics have been employed, and may be given when there is any special objection to hydrotherapy, for which, however, they cannot be substituted. VIII. OBESITY. Corpulence, an excessive development of the bodily fat—an “ oily dropsy,” in the words of Lord Byron—is a condition for which the physician is frequently consulted, and for which much may be done by a judicious arrangement of the diet. The tendency to polysarcia or obesity is often hereditary, and is particularly apt to be manifest after the middle period of life. It may, however, be seen early, and in this country it is not very uncommon in young girls and young boys. A very important factor is overeating, a vice which is more preva- lent and only a little behind overdrinking in its disastrous effects. A majority of persons over forty years of age habitually eat too much. In some of the most aggravated cases of obesity, however, this plays no part, and the unfortunate victim may be a notoriously small eater. A second element is lack of proper exercise; a third less important factor is the tak- ing largely of alcoholic beverages, particularly beer. In obesity it is now generally conceded that the carbohydrates, which were so long blamed, are not at fault, since they are themselves converted into water and carbon dioxide. On account, however, of the facility with which they are utilized for the purposes of oxidation the albuminous ele- ments of the food are less readily oxidized, not so fully decomposed, and the fat is in reality separated from them. So, too, the fats themselves are not so prone to cause obesity as the carbohydrates, being less readily ox- idized and interfering less with the complete metabolism of the albumi- nous elements. Many plans are now advised for the reduction of fat, the most impor- tant of which are those of Banting, Ebstein, and Oertel. In the Banting method the amount of food is reduced, the liquids are restricted, and the fats and carbohydrates excluded. 1078 THE INTOXICATIONS, SUN-STROKE, OBESITY. Ebstein recommends the use of fat and the rapid exclusion of the carbo-hydrates. The following is an example of his dietary: Breakfast (6 a. m. in summer, 7.30 a. m. in winter).—White bread, well toasted (rather less than two ounces) and well covered with butter. Tea, without milk or sugar, eight or nine ounces. Dinner, 2 p. m.—Souf) made with beef-marrow. Fat meat, with fat sauce, four to five ounces. A moderate quantity of asparagus, spinach, cabbage, peas, and beans. Two or three glasses of light white wine. After the meal, a large cup of tea without milk or sugar. Supper, at 7.30 p. m.—An egg, a little roast meat, with fat. About an ounce of bread, well covered with butter. A large cup of tea, without milk or sugar. Oertel’s method has already been considered in connection with the treatment of fatty heart, and is combined with systematic bodily exercise. It is particularly adapted for stout persons with weak heart. The so-called Schweninger cure is in reality Oertel’s, with the sole modification of the forbidding of any fluid at meals. Liquids must be taken more than two hours after the food. Yeo, after a full consideration of the various methods, gives the follow- ing useful summary : “ The albuminates in the form of animal food should be strictly lim- ited. Farinaceous and all starchy foods should be reduced to a minimum. Sugar should be entirely prohibited. A moderate amount of fats, for the reasons given by Ebstein, should be allowed. “ Only a small quantity of fluid should be permitted at meals, but enough should be allowed to aid in the solution and digestion of the food. Hot water or warm aromatic beverages may be taken freely between meals or at the end of the digestive process, especially in gouty cases, on account of their eliminative action. “No beer, porter, or sweet wines of any kind to be taken; no spirit, except in very small quantity. It should be generally recognized that the use of alcohol is one of the most common provocatives of obesity. A little Hock, still Moselle, or light claret, with some alkaline table water is all that should be allowed. The beneficial effects of such diet will be aided by abundant exercise on foot and by the free use of saline purgatives, so that we may insure a complete daily unloading of the intestinal canal. “ It is only necessary to mention a few other details. Of animal foods, all kinds of lean meat may be taken, poultry, game, fish (eels, salmon, and mackerel are best avoided), eggs. “ Meat should not be taken more than once a day, and not more than six ounces of cooked meat at a time. Two lightly boiled or poached eggs may be taken at one other meal, or a little grilled fish. “ Bread should be toasted in thin slices and completely, not browned on the surface merely. “ Hard captain’s biscuits may also be taken. OBESITY. 1079 “ Soups should be avoided, except a few tablespoonfuls of clear soup. “ Milk should be avoided, unless skimmed and taken as the chief arti- cle of diet. All milk and farinaceous puddings and pastry of all kinds are forbidden. Fresh vegetables and fruit are permitted. “ It is important to bear in mind that the actual quantity of food per- mitted must have a due relation to the physical development of the indi- vidual, and that what would be adequate in one case might be altogether inadequate in the case of another person of larger physique.” * The thyroid extract has been used in obesity, in a few cases with suc- cess. It may be tried beginning with small doses, as in myxoedema. * A System of Therapeutics, vol. i, edited by H. A. Hare, Philadelphia, 1891. SECTION XI. DISEASES DUE TO ANIMAL PARASITES. I. PSOROSPERMIASIS. TLntder this term are embraced several affections produced by the spo- rozoa. These parasites, belonging to the protozoa, are also known as psorosperms and gregarinidfe. They are extraordinarily abundant in the invertebrates, and are not uncommon in the higher mammals. The entire group of blood parasites, hasmatozoa, which live within the corpuscles, are closely related to them. Psorosperms are, as a rule, parasites of the cells — Cytozoa. The commonest and most suitable variety for study is the Coccidium oviforme of the rabbit, which produces a disease of the liver in which the organ is studded throughout with whitish nodules, ranging in size from a pin’s head to a split pea. On section each nodule is seen to be a dilated portion of a bile-duct; the walls are lined with epithelium in the interior of which are multitudes of ovoid bodies—the coccidia. Another very common form occurs in the muscles of the pig, the so-called Rainey’s tube, which is an ovoid body within the sarcolemma containing a number of small, sickle-shaped, unicellular organisms, the Sarcocystis Miescheri. Another species, the S. hominis, has been described in man. These bodies probably play a more important role in human pathology than has hitherto been thought. The cases reported may be grouped un- der the following divisions: internal and .external. (1) Internal Psorospermiasis.—In a majority of the cases of this group the psorosperms have been found in the liver, producing a disease similar to that which occurs in rabbits. In Guebler’s case there were tumors which could be felt in the liver during life, and they wrere determined by Leuckart to be due to coccidia. In W. B. Iladdon’s case the patient was admitted to St. Thomas’s Hospital with slight fever, drowsiness, and grad- ual unconsciousness; death occurred on the fourteenth day of observa- tion. Whitish neoplasms were found ujdoii the peritonaeum, omentum, and on the layers of the pericardium ; and a few were found in the liver, spleen, and kidneys. A somewhat similar case, though more remarkable, as it ran a very acute course, is reported by Silcott. A woman, aged fifty-three, PSOROSPERMIASIS. 1081 admitted to St. Mary’s Hospital, was thought to be suffering from typhoid fever. She had had a chill six weeks before admission. There were fever of an intermittent type, slight diarrhoea, nausea, tenderness over the liver and spleen, and a dry tongue; death occurred from heart-failure. The liver was enlarged, weighed eighty-three ounces, and in its substance there were caseous foci, around each of which was a ring of congestion. The spleen weighed sixteen ounces and contained similar bodies. The ileum presented six papule-like elevations. The masses resembled tubercles, but on examination coccidia were found. The parasites are also found in the kidneys and ureters. Cases of this kind have been recorded by Bland Sutton and Paul Eve. In the case reported by Eve the symptoms were haematuria and frequent micturition, and death took place on the seventeenth day. The nodules throughout the pelvis and ureters have been regarded as mucous cysts. In a case reported by Joseph Griffiths the tumors in the ureter caused hydronephrosis. (2) Cutaneous Psorospermiasis.—The parasitic nature of the keratosis follicularis of White, and of Paget’s disease of the nipple, which seemed to have been established, has been called in question, and the bodies de- scribed as psorosperms are believed to be the result of epithelial degener- ation. So, too, in molluscum contagiosum and in epithelioma, the nature of the structures which lie in and between the epithelial cells, and which have some resemblance to psorosperms, is still unsettled; some claiming that they are truly parasitic, others affirming that they are nothing but altered protoplasm of the epithelial cells. There are several undoubted instances, however, of parasitic sporozoa producing extensive disease of the skin. In Wernicke’s case (of Buenos Ayres) the lesions were scattered over the face, trunk, and left thigh. The sporozoa wTere found in numbers in the pus of the skin lesions, and also in the inguinal glands, which were excised. Rixford and Gilchrist describe two cases (Johns Hopkins Hospital Re- ports, vol. i). In the first case, which was regarded as tuberculosis of the skin, the lesion remained local for nearly eight years. The lymphatic glands then became involved. The affection gradually attacked the nose, cheeks, and other parts of the head, the left hand, the leg, and the left testicle. For seven or eight years the patient had no constitutional symp- toms, but after the glands became involved an intermittent fever devel- oped. In the later stages he had a cough with purulent expectoration. The autopsy revealed what appeared to be tuberculosis of the lungs, adrenals, and testis. There were numerous tuberculous-looking nodules in the spleen, on the surface of the liver, and the pleurae. In all of the lesions enormous numbers of sporozoa were found, especially in the case- ous masses. Successful inoculations were made into rabbits and dogs. The second case was similar, but much more acute. There were thirty skin lesions distributed over the body. The patient died within three months of the initial lesion. In an excised lymph gland enormous num- 1082 DISEASES DUE TO ANIMAL PARASITES. bers of sporozoa were found. The cycle of development was readily fol- lowed. These bodies differ in all points from the organisms described as protozoa in cancer and in molluscum contagiosum. II. PARASITIC INFUSORIA. Several flagellates have been found parasitic in man. Among the most common are the Trichomonas vaginalis, which measures 15 to 25 micromillimetres in length, and has four flagella, which are as long as or longer than the body. It is by no means an uncommon parasite in the acid vaginal mucus. The Trichomonas or Cercomonas honiinis lives in the intestines, and is met with in the stools under all sorts of conditions. It is probably not parasitic. I have met with it also in the vomit in a case of chronic gas- tric catarrh. Trichomonads have been met with also in the urine in sev- eral cases, and may be truly pathogenic. In Dock’s case the parasites were associated with a hasmorrhagic cystitis without bacteria. The Lamhlia intestinalis is another intestinal monad, larger than the common Trichomonas. Flagellates have also been found in the expec- toration in cases of gangrene of the lung and of bronchiectasis, and in pleurisy. Among the parasitic Ciliata may be mentioned the Balantidium coli, which has been found occasionally in the large intestine in forms of dys- entery. The parasite is oval in form, 70 to 100 micromillimetres long and 50 to 70 micromillimetres broad. It is doubtful whether it is patho- genic. III. DISTOMIASIS. Several forms of trematodes or flukes are parasitic in man, and when in numbers may cause serious disease. (1) Liver Flukes.—The following species of flukes have been found: The Fasciola hepatica, a very common parasite in ruminants, which has a length of from twenty-eight to thirty-two millimetres. The Distomum lanceolatum, a much smaller form, from eight to ten millimetres in length, which is also very common in sheep and cattle. The Distoma Buski, the largest form, measuring from four to eight centimetres in length. One or two other less important forms have occasionally been met with. The studies of the Japanese physicians have brought to light the interesting fact that there is a distoma widely endemic in certain provinces in that country. The two forms described as Distoma endemi- cum and Distoma perniciosum are identical, and are known now as Dis- toma sinense. According to Baelz, fully twenty per cent of the inhabit- ants of certain provinces are affected. The Distoma felineum, which has been found recently by Ward in Nebraska, in cats, also occurs in man. DISEASES CAUSED BY NEMATODES. 1083 The flukes occupy the bile-passages and the upper portion of the small intestine. When in large numbers they may cause serious and fatal disease of the liver, usually with ascites and jaundice. The liver may be enormously enlarged ; in Kichner’s case it weighed eleven pounds. The flukes may cause a chronic cholangitis, leading to great thickening or even calcification of the walls of the bile-duct. The endemic fluke disease of Japan is characterized by enlargement of the liver, emaciation, diarrhoea, and frequently ascites. (2) The Blood Fluke; Schistosoma hcematobium (Bilharzia hcemato- bia).—This trematode is found in Egypt, southern Africa, and Arabia, and is the cause in these countries of the endemic haematuria. The female is about two centimetres in length, cylindrical, filiform, and about •07 millimetre in diameter. The parasite lives in the venous system, par- ticularly in the portal vein, and in the veins of the spleen, bladder, kid- neys, and mesentery. According to Bilharz, at least fifty per cent of the lower classes in Egypt are infected with it. It is not yet known how the parasite gains entrance to the body. In all probability it is by drinking impure water containing the embryos. The symptoms are due to changes in the mucous membrane of the urinary organs caused by the presence of the ova in the blood-vessels of these parts. Hematuria is the first and most constant symptom, leading gradually to anaemia. There is generally pain during micturition. The blood is not constant in the urine. The ova of the Bilharzia are readily seen under a microscope with a low power. They are ovoid in shape, translucent, with a small spike at one end. The embryo can be readily seen. The disease is rarely fatal; a great majority of the cases recover. Children are more commonly attacked than grown persons, and the dis- ease often disappears by the time of puberty. (3) Bronchial Fluke; Distomum Westermanni; Parasitic Hcemop- tysis.—In parts of China, Japan, and Formosa there is an epidemic dis- ease, described by Kinger and Manson, characterized by attacks of cough and haemoptysis associated with the presence of a small fluke in the bron- chial tubes. IV. DISEASES CAUSED BY NEMATODES. I. Ascariasis. {a) Ascaris lumbricoides, the most common human parasite, is found chiefly in children. The female is from seven to twelve inches in length, the male from four to eight inches. The worm is cylindrical, pointed at both ends, and has a yellowish-brown, sometimes a slightly reddish color. Four longitudinal bands can be seen, and it is striated transversely. The ova, which are sometimes found in large numbers in the faeces, are small, 1084 DISEASES DUE TO ANIMAL PARASITES. brownish-red in color, elliptical, and have a very thick covering. They measure -075 millimetre in length and -058 millimetre in width. The life history has been demonstrated to be “ direct ”—i. e., without intermediate host. The parasite occupies the upper portion of the small intestine. Usually not more than one or two are present, but occasionally they occur in enormous numbers. The migrations are peculiar. They may pass into the stomach, from which they may be ejected by vomiting, or they may crawl up the oesophagus and enter the pharynx, from which they may be withdrawn. A child under my care in the small-pox department of the General Hospital, during convalescence, withdrew in this way more than thirty round worms within a few weeks. In other instances the worm passes into the larynx, and has been known to cause fatal asphyxia, or, passing into the trachea, to cause gangrene of the lung. They may pass into the Eustachian tube and appear at the external meatus. The most serious migration is into the bile-duct. There is a specimen in the Wistar- Ilorner Museum of the University of Pennsylvania in which not only the common duct, but also the main branches throughout the liver, are enor- mously distended and packed with numerous round worms. The bowel may be perforated by them and peritonitis result. The symptoms are not definite. When a few are present they may be passed without causing disturbance. In children there are irritative symptoms usually attributed to worms, such as restlessness, irritability, picking at the nose, grinding of the teeth, twitcliings, or convulsions. These symptoms may be marked in very nervous children. Treatment.—Santonin can be given, mixed with sugar, in doses of from one to three grains for a child and three to five grains for an adult, followed by a calomel or a saline purge. The dose may be given for three or four days. An unpleasant consequence which sometimes follows the administration of this drug is xanthopsia or yellow vision. (b) Oxyuris vermicularis {Thread-worm; Pin-worm').—This com- mon parasite occupies the rectum and colon. The male measures about four millimetres in length, the female about ten millimetres. They pro- duce great irritation and itching, particularly at night, symptoms which become intensely aggravated by the nocturnal migration of the parasites. The patients become extremely restless and irritable, the sleep is often disturbed, and there may be loss of appetite and anaemia. Though most common in children, the parasite occurs at all ages. The worm is readily detected in the faeces. Infection probably takes place through the water or possibly through salads, such as lettuces and cresses. A person the subject of the worms passes ova in large numbers in the faeces, and the possibility of reinfection must be scrupulously guarded against. The treatment is simple, though occasionally there are instances in which all forms of medication are resisted. A case is mentioned of a gen- tleman, aged forty, who had suffered from childhood and had failed to DISEASES CAUSED BY NEMATODES. 1085 obtain any benefit from prolonged treatment by many helminthologists. Santonin may be used in small doses, and mild purgatives, particularly rhubarb. Large injections containing carbolic acid, vinegar, quassia, aloes, or turpentine may be employed. In children the use of cold injec- tions of strong salt and water is usually efficacious. They should be re- peated for at least ten days. In giving the injection care should be taken to have the hips well elevated, so that the fluid can be retained as long as possible. For the intense itching and irritation at night vaseline may be freely used, or belladonna ointment. II. Trichiniasis. The Trichina spiralis in its adult condition lives in the small intes- tine. The disease is produced by the embryos, which pass from the intestines and reach the voluntary muscles, where they finally become encapsulated larvae—muscle trichinae. It is in the migration of the em- bryos that the group of symptoms known as trichiniasis is produced. Description of the Parasites.—(a) Adult or intestinal form. The female measures from three to four millimetres; the male, T5 millimetre, and has two little projections from the hinder end. (b) The larva or muscle trichina is from 0-6 to one millimetre in length and lies coiled in an ovoid capsule, which is at first translucent, but subsequently opaque and infiltrated with lime salts. The worm pre- sents a pointed head and a somewhat rounded tail. When flesh containing the trichinae is eaten by man or by any ani- mal in which the development can take place, the capsules are digested and the trichinae set free. They q>ass into the small intestine, and about the third day attain their full growth and become sexually mature. Vir- chow’s experiments have shown that on the sixth or seventh day the em- bryos are fully developed. The young produced by each female trichina have been estimated at several hundred. Leuckart thinks that various broods are developed in succession, and that as many as a thousand em- bryos may be produced by a single worm. The time from the ingestion of the flesh containing the muscle trichin* to the development of the brood of embryos in the intestines is from seven to nine days. As soon as born the embryo trichinae leave the intestines; wandering through the peritonaeum and the connective tissues, probably through the mesentery and retroperitoneal tissues—some hold by means of the blood current— they finally reach the muscles, which constitute “ the seat of election.” After a preliminary migration in the intermuscular connective tissue they penetrate the primitive muscle-fibres, and in about two weeks develop into the full-grown muscle form. In this process an interstitial myositis is ex- cited and gradually an ovoid capsule develops about the parasite. Two, occasionally three or four, worms may be seen within a single capsule. This process of encapsulation has been estimated to take about six weeks. 1086 DISEASES DUE TO ANIMAL PARASITES. Within the muscles the parasites do not undergo further development. Gradually the capsule becomes thicker, and ultimately lime salts are de- posited within it. This change may take place in man within four or five months. In the hog it may be deferred for many years. The cal- cification renders the cyst visible, and since first seen by Tiedemann, in 1822, and Hilton, in 1832, these small, opaque, oat-shaped bodies have been familiar objects to demonstrators of normal and morbid anatomy. The trichinse may live within the muscles for an indefinite period. They have been found alive and capable of developing as late as twenty or even twenty-five years after their entrance into the system. In many instances, however, the worms are completely calcified. The trichina has been found or “raised” in twenty-six different species of animals (Stiles). Medical literature abounds in reference to its presence in fish, earth- worms, etc., but these parasites belong to other genera. In faecal exam- inations for the parasite it is well to remember that the “ cell body ” of the anterior portion of the intestine is a diagnostic criterion of the T. spiralis. It was first found in the hog by the late Joseph Leidy. Ex- perimentally, guinea-pigs and rabbits are readily infected by feeding them with muscle containing the larval form. Dogs are infected with difficulty; cats more readily. Experimentally, animals sometimes die of the disease if large numbers of the parasites have been eaten. In the hog the trichinae, like the cysticerci, cause few if any symptoms. An animal the muscles of which are swarming with living trichinae may be well nourished and healthy-looking. An important point also is the fact that in the hog the capsule does not readily become calcified, so that the parasites are not visible as in the human muscles. For a long time the trichina was looked upon as a pathological curiosity, but in 1860 Zenker discovered in a girl in the Dresden Hospital who had symptoms of typhoid fever both the intestinal and the muscle forms of the trichinse, since which time the dis- ease has been thoroughly studied. Man is infected by eating the flesh of trichinous hogs. The incidence of the disease in swine varies much in different countries. In Germany, where a thorough and systematic microscopic examination of all swine flesh is made, the proportion of trichinous hogs is about 1 in 1,852. At the Berlin abattoir, where the microscopic examination is conducted by a staff of over eighty men and women, two portions are taken from the ab- dominal muscles, from the diaphragm, and from the intercostal muscles, and one piece from the muscles of the larynx and tongue. A special com- pressor is used to flatten the fragments of the muscle, and the examination is made with a magnifying power of from seventy to one hundred diam- eters. During the three years ending in 1885 there were 603 trichinous hogs detected, a ratio of 1 to 1,292. Statistics are not available in Eng- land. In the United States systematic inspection is unknown, and the statistics are by no means extensive enough. “ Taking all the examina- tions of American pork thus far made, both at home and abroad, and we DISEASES CAUSED BY NEMATODES. 1087 have a total of 298,782, in which trichinae were found 6,280 times, being 2-1 per cent, or 1 to 48 ” (Salmon, 1884). In 1883, in conjunction with A. W. Clement, I examined 1,000 hogs at the Montreal abattoir, and found only 4 infected. There is no reason to believe that the hog of this country is less liable to trichina than the German animal. Modes of Infection.—The danger of infection depends entirely upon the mode of preparation of the flesh. Thorough cooking, so that all parts of the meat reach the boiling point, destroys the parasites; but in large joints the central portions are often not raised to this temperature. The frequency of the disease in different countries depends largely upon the habits of the people in the preparation of pork. In North Germany, where raw ham and ivurst are freely eaten, the greatest number of cases have occurred. In South Germany, France, and England cases are rare. In this country the greatest number of persons attacked have been Ger- mans. Salting and smoking the flesh are not always sufficient, and the Havre experiments showed that animals are readily infected when fed with portions of the pickled or the smoked meat as prepared in this coun- try. Carl Fraenkel, however, states that the experiments on this point have been negative, and that it is very doubtful if any cases of trichiniasis in Germany have been caused by American pork. Germany has yet to show a single case of trichiniasis due to pork of unquestioned American origin. Frequency of Infection.—The dissecting-room and post-mortem statis- tics show that from one half to two per cent of all bodies contain trichinae. Of 1,000 consecutive autopsies of which I have notes the trichinae were present in six instances. I have, in addition, seen them in two dissecting- room cases and in two bodies at the Philadelphia Hospital. The disease often occurs in epidemics, a large number of persons being infected from a single source. Among the best known of these outbreaks are the Hedersleben, in which there were 337 persons affected, and the Emersleben, in which there were 250 persons attacked. The extensive outbreaks of this sort have been, with few exceptions, in North Germany. Alfred Mann, after a careful search, at my request, of the literature in the Surgeon-General’s library, finds records of 456 cases in this country. The two largest groups of cases were at Astoria, Ore., reported by Kinney, 15 cases and one death; and at Colerain, Mass. (1892), in which 50 persons were attacked, four of whom died. Symptoms.—The ingestion of trichinous flesh is not necessarily fol- lowed by the disease. When a limited number are eaten only a few em- bryos pass to the muscles and may cause no symptoms. Well-characterized cases present a gastro-intestinal period and a period of general infection. In the course of a few days after eating the infected meat there are signs of gastro-intestinal disturbance—pain in the abdomen, loss of appe- tite, vomiting, and sometimes diarrhoea. The preliminary symptoms, how- 1088 DISEASES DUE TO ANIMAL PARASITES. ever, are by no means constant, and in some of the large epidemics cases have been observed in which they have been absent. In other cases the gastro-intestinal features have been marked from the outset, and the attack has resembled cholera nostras. Pains in different parts of the body, gen- eral debility, and weakness have been noted in some of the epidemics. The invasion symptoms develop between the seventh and the tenth day, sometimes not until the end of the second week. There is fever, except in very mild cases. Chills are not common. The thermometer may register 102° or 104°, and the fever is usually remittent or intermittent. The mi- gration of the parasites in the muscles excites a more or less intense myo- sitis, which is characterized by pain on pressure and movement, and by swelling and tension of the muscles. The limbs are placed in the posi- tions in which the muscles are in least tension. The involvement of the muscles of mastication and of the larynx may cause difficulty in chewing and swallowing. In severe cases the involvement of the diaphragm and intercostal muscles may lead to intense dyspnoea, which sometimes proves fatal. (Edema, a feature of great importance, may be early in the face. Later it develops in the extremities when the swelling and stiffness of the muscles are at their height. Profuse sweats, tingling and itching of the skin, and in some instances urticaria, have been described. The general nutrition is much disturbed and the patient becomes emaciated and often anaemic, particularly in the protracted cases. The patellar tendon reflex may be absent. The patients are usually conscious, except in cases of very intense infection, in which the delirium, dry tongue, and tremors give a picture similar to typhoid fever. In addition to the dyspnoea, present in the severer cases, there may be bronchitis, and in the fatal cases pneumo- nia or pleurisy. In some epidemics polyuria has been a common symptom. Albuminuria is frequent. The intensity and duration of the symptoms depend entirely upon the grade of infection. In the mild cases recovery is complete in from ten to fourteen days. In the severe forms convalescence is not established for six or eight weeks, and it may be months before the patient recovers the muscular strength. One case in the Hedersleben epidemic was weak eight years after the attack. Of 72 fatal cases in the Hedersleben epidemic the greatest mortality occurred in the fourth and fifth and sixth weeks ; namely, 52 cases. Two died in the second week with severe choleraic symptoms. The mortality has ranged in different outbreaks from one or two per cent to thirty per cent. In the Hedersleben epidemic 101 persons died. Among the 456 cases reported in this country there were 122 deaths. The anatomical changes are chiefly in the voluntary muscles. In the early stages they look normal, but in the fourth or fifth week grayish- white areas appear in which the muscle-fibres are extensively degenerated and in the neighborhood of the trichinae there is an acute interstitial myositis. Cohnheim has described a fatty degeneration of the liver and DISEASES CAUSED BY NEMATODES. 1089 enlargement of the mesenteric glands. At the time of death in the fourth or fifth week or later the adult trichinae are still found in the in- testines. The prognosis depends much upon the quantity of infected meat which has been eaten and the number of trichinae which mature in the intestines. In children the outlook is more favorable. Early diarrhoea and moder- ately intense gastro-intestinal symptoms are, as a rule, more favorable than constipation. Diagnosis.—The disease should always be suspected when a large birthday party or Fest among Germans is followed by cases of apparent typhoid fever. The parasites may be found in the remnants of the ham or sausages used on the occasion. The worms may be discovered in the stools. The stools should be spread on a glass plate or black background and examined with a low-power lens, when the trichinae are seen as small, glistening, silvery threads. In doubtful cases the diagnosis may be made by the removal of a small fragment of muscle. A special harpoon has been devised for this purpose by means of which a small portion of the biceps or of the pectoral muscle may be readily removed. Under cocaine anaesthesia an incision may be made and a small fragment removed. The disease may be mistaken for acute rheumatism, particularly as the pains are so severe on movement, but there is no special swelling of the joints. The tenderness is in the muscles both on pressure and on movement. The intensity of the gastro-intestinal symptoms in some cases has led to the diagnosis of cholera. Many of the former epidemics were doubtless de- scribed as typhoid fever, which the severer cases, owing to the prolonged fever, the sweats, the delirium, dry tongue, and gastro-intestinal symp- toms, somewhat resemble. The pains in the muscles, swelling, oedema, and shortness of breath are the most important diagnostic points. Under acute myositis reference has already been made to the cases which closely resemble trichiniasis. The epidemic in 1879 on board the training ship Cornwall presented symptoms similar to those of trichiniasis. One patient died. Two months after burial the body was examined, and living and dead nematode worms were found which, as Bastian showed, were not the trichina, but a rhabditis. They were probably not parasitic, but entered the body of the cadet after burial. Prophylaxis.—It is not definitely known how swine become dis- eased. It has been thought that they are infected from rats about slaugh- ter-houses, but it is just as reasonable to believe that the rats are infected by eating portions of the trichinous flesh of swine. The swine should, as far as possible, be grain-fed, and not, as is so common, allowed to eat offal. The most satisfactory prophylaxis is the complete cooking of pork and sausages, and to this custom in England, France, South Germany, and particularly in this country, immunity is largely due. Treatment.—If it has been discovered within twenty-four or thirty- six hours that a large number of persons have eaten infected meat, the 1090 DISEASES DUE TO ANIMAL PARASITES. indications are to thoroughly evacuate the gastro-intestinal canal. Purga- tives of rhubarb and senna may be given, or an occasional dose of calomel. Glycerin has been recommended in large doses in order that by passing into the intestines it may by its hygroscopic properties destroy the worm. Male-fern, kamala, santonin, and thymol have all been recommended in this stage. Turpentine may be tried in full doses. There is no doubt that diarrhoea in the first week or ten days of the infection is distinctly favorable. The indications in the stage of invasion are to relieve the pains, to secure sleep, and to support the patient’s strength. There are no medicines which have any influence upon the embryos in their migra- tion through the muscles. III. Anchylostomiasis. The Uncinaria (Dochmius, Strongylus) duodenalis, also known as the Sclerostomum or Anchylostomum duodenale, is the only strongyle harmful to man. It belongs to the same family as the Sclerostomum equi- num, which causes the verminous aneurism in the horse. The parasites live in the upper portion of the small intestine, chiefly in the jejunum. They are easily seen, the male having a length of from six to ten milli- metres, and the female from ten to eighteen millimetres. The mouth is provided with a series of tooth-like hooks, by means of which the parasite attaches itself to the mucous membrane. The male has a prominent ex- pansion or bursa at the tail end. The existence of the parasite has long been known, but it was not thought to be pathogenic until Griesinger demonstrated its association with the Egyptian chlorosis. It has also been shown to be the cause of the anaemia to which miners and brick-makers are subject. Throughout Europe the disease has been widely spread by the employment of Italian and Polish laborers. In certain Italian prov- inces it is extremely prevalent and serious. It occurs in the Indies, in Brazil, and the West Indies, and has been described in Jamaica (Strachan). Dolley states that the parasite was described many years ago by physicians in the Southern States, but no recent observations upon the disease have been made in this country. Symptoms.—The parasites withdraw blood by suction, and the symptoms result from this slow depletion. In the early stage there may only be gastric or gastro-intestinal disturbance, but if the parasites are present in large numbers anaemia is gradually produced and constitutes the characteristic feature of the disease. The Egyptian chlorosis, brick- maker’s anaemia, tunnel anaemia, miner’s cachexia, and mountain anaemia are due to this cause. The clinical course is variable. In some instances the anaemia develops acutely and reaches a high grade within a short time, causing great shortness of breath and oedema. There is serious disturb- ance of nutrition, sometimes diarrhoea and colicky pains; but the most pronounced symptom is the pallor and the associated phenomena of DISEASES CAUSED BY NEMATODES. 1091 chronic anaemia, with debility and wasting. The lesions of the intestines are those of chronic catarrh, and small haemorrhages occur in the mucosa. The worms are found within two metres of the pylorus, often with their heads buried in the mucosa. Dilatation and hypertrophy of the heart have been found in many cases. Band with states that in Egypt the dis- ease is most common in peasants who work in the damp earth, many of whom are earth-eaters. The diagnosis is not difficult. The ova, which are abundant in the stools, are oval, about 52 micromillimetres long by 32 micromillimetres broad, and possess a thin, transparent shell. There is no operculum, as in the ovum of the oxyuris, and eggs found in the fasces are in various stages of segmentation. The larvae develop in moist earth and readily get into the drinking water, through which infection occurs. The systematic employment of latrines and the boiling of all water used for drinking purposes are the important prophylactic measures. Thymol, recommended by Bozzolo, is a specific, and should be given in large doses, two grammes (in wafers) at 8 a. m. and two grammes at 10 a. m. (Sandwith). The diet should be milk and soup. Two hours after the second dose of thymol a purge of castor oil or magnesia is given. If necessary, the treatment may be repeated in a week. Zoologically the Filaria sanguinis hominis is as yet sub judice. Man- son’s views are as follows : Under the general term Filaria sanguinis liominis three species of nematodes are included : 1. Filaria Bancrofti, Cobold, 1877. This is the ordinary blood filaria. The embryos are found in the peripheral circulation only during sleep or at night. The mosquito is the intermediate host. The embryos measure 270 to 340 micromillimetres long by 7 to 11 micromillimetres broad; tail pointed. The adult male measures 83 millimetres long by ‘407 milli- metres broad; the tail forms two turns of a spiral. The adult female measures 155 millimetres long by ‘715 millimetres broad; vulva 2’56 mil- limetres from anterior extremity; eggs 38 micromillimetres by 14 micro- millimetres. This is the species to which haBmato-chyluria and ele- phantiasis are attributed. 2. Filaria diurna, Manson, 1891. The larvae agree with the preceding, except that Manson indicates the absence of granules in the axis of the body. The worms occur in the peripheral circulation only during the day, or when the patient stays awake. Manson suspects that the Filai'ia loa represents the adult stage. 3. Filaria perstans, Manson, 1891. Only the embryos are known. These are much smaller than the preceding—200 micromillimetres long, posterior extremity obtuse, anterior extremity with a sort of retractile rostellum. IV. Filariasis. DISEASES DUE TO ANIMAL PARASITES. This is the species to which Manson is inclined to attribute the sleep- ing-sickness of the negroes. He is also inclined to regard the Filaria perstans as the cause of craw-craw, a papillo-pustular skin eruption of the west coast of Africa, which is probably the same as Nielly’s dermatose parasitaire, the parasite of which was called by Blanchard Rkabditis Nielly. The most important of these is the Filaria Bancrofti, which produces the haematochyluria and the lymph-scrotum. The female produces an extraordinary number of embryos, w’hich enter the blood current through the lymphatics. Each embryo is within its shell, which is elongated, scarcely perceptible, and in no way impedes the movements. They are about the ninetieth part of an inch in length and the diameter of a red blood-corpuscle in thickness, so that they readily pass through the capillaries. They move with the greatest ac- tivity, and form very striking and readily recognized objects in a blood- drop under the microscope. A remarkable feature is the periodicity in the occurrence of the embryos in the blood. In the daytime they are almost or entirely absent, whereas at night, in typical cases, they are present in large numbers. If, however, as Stephen Mackenzie has shown, the patient, reversing his habits, sleeps during the day, the periodicity is reversed. The further development of the embryos appears to be associ- ated with the mosquito, which at night sucks the blood and in this way frees them from the body. Some slight development takes place within the body of the mosquito, and it is probable that the embryos are set free in the water after the death of the host. The further development is not known, but it is probably in drinking wrater. The filarise may be present in the body without causing any symptoms. In animals blood filarise are very common and rarely cause inconvenience. It is only when the adult worms or the ova block the lymph channels that certain definite symp- toms occur. Manson suggests that it is the ova (prematurely discharged), which are considerably shorter and thicker than the full-grown embryos, which block the lymph channels and produce the conditions of liasmato- chyluria, elephantiasis, and lymph-scrotum. The parasite is widely distributed, particularly in tropical and sub- tropical countries. Guiteras has shown that the disease prevails exten- sively in the Southern States, and since his paper appeared contributions have been made by Matas, of New Orleans, Mastin, of Mobile, and De Saussure, of Charleston. The effects produced may be described under the above-mentioned conditions. (a) Ilmnatochyluria.—Without any external manifestations, and in many cases without special disturbance of health, the subject from time to time passes urine of an opaque white, milky appearance, or bloody, or a chylous fluid which on settling shows a slightly reddish clot. The urine may be normal in quantity or increased. The condition is usually inter- DISEASES CAUSED BY NEMATODES. 1093 mittent, and the patient may pass normal urine for weeks or months at a time. Microscopically, the chylous urine contains minute molecular fat granules, usually red blood-corpuscles in various amounts. The embryos were first discovered by Demarquay, at Paris (1863), and in the urine by Wucherer, at Bahia, in 1866. It is remarkable for how long the condition may persist without serious impairment of the health. A patient, sent to me by Dawson, of Charleston, has had haematochyluria intermittently for eighteen years. The only inconvenience has been in the passage of the blood-clots which collect in the bladder. At times he has also uneasy sensations in the lumbar region. The embryos are present in his blood at night in large numbers. Chyluria is not always due to the filaria. The non-parasitic form of the disease has already been considered. Opportunities for studying the anatomical condition of these cases rarely occur. In the case described by Stephen Mackenzie the renal and peritoneal lymph plexuses were enormously enlarged, extending from the diaphragm to the pelvis. The thoracic duct above the diaphragm was impervious. (b) Lymph-scrotum and certain forms of elephantiasis are also caused by the filaria. In the former the tissues of the scrotum are enormously thickened and the distended lymph-vessels may be plainly seen. A clear, sometimes a turbid, fluid follows puncture of the skin. The parasites are not always to be found. I have examined two typical cases without find- ing filaria in the exuded fluids or in the blood at night. So also the majority of cases of elephantiasis which occur in this country are non- parasitic. In China it is stated that the parasites occur in all these cases.* Y. Dracontiasis (Guinea-worm Disease). The Filaria or Dracunculus medinensis is a widely spread parasite in parts of Africa and the East Indies. In the United States cases occasion- ally occur. Jarvis reports a case in a post chaplain who had lived at For- tress Monroe, Ya., for thirty years. Van Harlingen’s patient, a man aged forty-seven, had never lived out of Philadelphia, so that the worm must be included among the parasites of this country. A majority of the cases reported in American journals have been imported. Only the female is known. It develops in the subcutaneous and inter- muscular connective tissues and produces vesicles and abscesses. In the large majority of the cases the'parasite is found in the leg. Of 181 cases, in 124 the worm was found in the feet, 33 times in the leg, and 11 times in the thigh. The worm is usually solitary, though there are cases on record in which six or more have been present. It is cylindrical in form, about two millimetres in diameter, and from fifty to eighty centimetres in length. * For full consideration of the subject of congenital occlusion and dilatation of lymph channels, see work on this subject by Samuel C. Busey, New York, 1878. 1094 DISEASES DUE TO ANIMAL PARASITES. The worm gains entrance to the system through the stomach, not through the skin, as was formerly supposed. It is probable that both male and female are ingested; but the former dies and is discharged, while the latter after impregnation penetrates the intestine and attains its full development in the subcutaneous tissues, where it may remain quies- cent for a long time and can be felt beneath the skin like a bundle of string. Suppuration is after a time excited, and when the abscesses are opened or burst the worm appears and is sometimes discharged entire. The worm contains an enormous number of living embryos, which escape into the water and develop in the cyclops—a small crustacean—and it seems likely that man is infected by drinking the water containing these developed larvae. The treatment consists in promoting the suppuration, and when the worm is seen the common procedure is to roll it round a portion of smooth wood and in this way prevent the retraction, and each day wind a little more until the entire worm is withdrawn. It is stated that special care must be taken to prevent tearing of the worm, as disastrous consequences sometimes follow, probably from the irritation caused by the migration of the embryos. It is stated that the leaves of the plant called amarpattee are almost a specific in the disease. Asafcetida in full doses is said to kill the worm. VI. Other Nematodes, (a) Among less important filarian worms parasitic in man the follow- ing may be mentioned : Filaria Loa, which is a cylindrical worm of about three centimetres in length and whose habitat is beneath the con- junctiva. It has been found on the West African coast, in Brazil, and in the West Indies. Filaria lentis, which has been found in a cataract. Three specimens have been found together. Filaria labialis, which has been found in a pustule in the upper lip. Filaria hominis oris, which was described by Leidy, from the mouth of a child. Filaria bronchialis, which has been found occasionally in the trachea and bronchi. This parasite has been seen in a few cases in the bronchioles and in the lungs. There is no evidence that it ever produces an extensive verminous bron- chitis similar to that which I have described in dogs. Filaria imitis— the common Filaria sanguinis of the dog—of which Bowlby has de- scribed two cases in man. In one case with hasmaturia female worms were found in the portal vein, and the ova were present in the thickened bladder wall and in the ureters. (b) Trichocephalus dispar ( Whip-worm).—This parasite is not infre- quently found in the caecum and large intestine of man. It measures from four to' five centimetres in length, the male being somewhat shorter than the female. The worm is readily recognized by the remarkable difference between the anterior and posterior portions. The former, which is at least three fifths of the body, is extremely thin and hair-like DISEASES CAUSED BY NEMATODES. 1095 in contrast to the thick hinder portion of the body, which in the female is conical and pointed, and in the male more obtuse and usually rolled like a spring. The ova are oval, lemon-shaped, *05 millimetre in length, and each is provided with a button-like projection. The number of the worms found is variable, as many as a thousand having been counted. It is a widely spread parasite. In parts of Europe it occurs in from ten to thirty per cent of all bodies examined, but in this country it is not so common. The trichocephalus rarely causes symptoms. It has been thought by certain physicians in the East to be the cause of beri-beri. Several cases have been reported recently in which profound anaemia has occurred in connection with this parasite, usually with diar- rhoea. Enormous numbers may occur, as in Rudolphi’s case, without pro- ducing any symptoms. The diagnosis is readily made by the examination of the faeces, which contain, sometimes in great abundance, the characteristic lemon-shaped, hard, dark-brown eggs. (c) Dioctophyme gigas (Eustrongylus gigas).—This enormous nema- tode, the male of which measures about a foot in length and the female about three feet, occurs in very many animals and has occasionally been met with in man. It is usually found in the renal region and may en- tirely destroy the kidney. (d) Strongyloides intestinalis.—Under this name are now included the small nematode worms found in the faeces and formerly described as Anguillula stercoralis, AnguiUula intestinalis, and Rliabdonema intesti- nale. This parasite occurs abundantly in the stools of the endemic diar- rhoea of hot countries, and has been specially described by the French in the diarrhoea of Cochin-China. It occurs also in Brazil, and has been found in Italy in connection with the anchylostoma in cases of miner’s anaemia. It is stated that the worms occupy all parts of the intestines, and have even been found in the biliary and pancreatic ducts. It is only when they are in very large numbers that they produce severe diarrhoea and anaemia. Acanthocephala (Thorn-headed Worms). The Giganlorhynchus or Echinorhynchus gigas is a common parasite in the intestine of the hog and attains a large size. The larvae develop in cockchafer grubs. The American intermediate host is the June bug (Stiles). Lambl found a small Echinorhynchus in the intestine of a boy. Welch’s specimen, which was found encysted in the intestine of a soldier at Netley, is stated by Cobbold probably not to have been an Echinorhyn- chus. Recently a case of Echinorhynchus moniliformis has been described in Italy by Grassi and Calandruccio. 1096 DISEASES DUE TO ANIMAL PARASITES. V. DISEASES CAUSED BY CESTODES (Tape-ivorms; Hydatid Disease). Man harbors the adult parasites in the small intestine, the larval forms in the muscles and solid organs. I. Intestinal Cestodes; Tape-worms. (a) Tcenia solium, or pork tape-worm. This is not a common form in this country. It is much more frequent in parts of Europe and Asia. AVhen mature it is from six to twelve feet in length. The head is small, round, not so large as the head of a pin, and provided with four sucking disks and a double row of hooklets; hence it is called, in contradistinction to the other form in man, the armed tape-worm. To the head succeeds a narrow, thread-like neck, then the segments, or proglottides, as they are called. The segments possess both male and female generative organs, and about the four hundred and fiftieth become mature and contain ripe ova. The worm attains its full growth in from three to three and a half months, after which time the segments are continuously shed and appear in the stools. The segments are about one centimetre in length and from seven to eight millimetres in breadth. Pressed between glass plates the uterus is seen as a median stem with about eight to fourteen lateral branches. There are many thousands of ova in each ripe segment, and each ovum consists of a firm shell, inside of which is a little embryo, pro- vided with six hooklets. The segments are continuously passed, and if the ova are to attain further development they must be taken into the stomach, either of a pig, or of man himself. The egg-shells are digested, the six-hooked embryos become free, and passing from the stomach reach various parts of the body (the liver, muscles, brain, or eye), where they develop into the larvae or cysticerci. A hog under these circumstances is said to be measled, and the cysticerci are spoken of as measles or bladder worms. The tcenia solium received its name because it was thought to exist as a solitary parasite in the bowel, but two or three or even more worms may occur. (b) Tconia saginata or mediocanellata—the unarmed or beef tape-worm. This is a longer and larger parasite than the Tcenia solium. It is certainly the common tape-worm of this country. Of scores of specimens which I have examined almost all were of this variety. According to Berenger- Ferand it has spread rapidly in western Europe, owing probably to the importation of beef and live-stock from the Mediterranean basin. It may attain a length of fifteen or twenty feet, or more. The head is large in comparison to the Tcenia solium, and measures over two millimetres in breadth. It is square-shaped and provided with four large sucking disks, DISEASES CAUSED BY CESTODES. 1097 but there are no hooklets. The ripe segments are from seventeen to eighteen millimetres in length, and from eight to ten millimetres in breadth. The uterus consists of a median stem with from fifteen to thirty-five lateral branches, which are given off more dichotomously than in the Tania solium. The ova are somewhat larger, and the shell is thicker, but the two forms can scarcely be distinguished by their ova. The ripe segments are passed as in the tania soliian, and are ingested by cattle, in the flesh or organs of which the eggs develop into the bladder worms or cysticerci. No instance of the cysticercus of the tcenia saginata has, so far as I know, been reported in man. Of other forms of tape-worm may be mentioned : (c) Dipylidium caninum {Tania elliptica, Tania cucumerina). A small parasite very common in the dog and occasionally found in man; the larvae develop in the lice and fleas of the dog. (d) Hymenolepsis diminuta {Tania jlavo-punctata). A small cestode was found in the intestine of a child in Boston, and has since been met with in one or two cases. It is common in rats. The larvae develop in Lepicloptera and in beetles. (e) Hymenolepsis nana {Tania nana) and the BavaineaMadagasca- riensis (Tania Madagascariensis) have been found only once or twice. (/) Bothriocephalus latus. A cestode worm found only in certain districts bordering on the Baltic Sea and in parts of Switzerland. So far as I know, it has not been found in this country except in a few imported cases. The parasite is large and long, measuring from twenty-five to thirty feet or more. Its head is different from that of the taenia, as it possesses two lateral grooves or pits and has no hooklets. The larvae develop in the peritonaeum and muscles of the pike and other fish, and it has been shown experimentally that they grow into the adult worm when eaten by man. Symptoms.—These parasites are found at all ages. They are not uncommon in children and are occasionally found in sucklings. W. T. Plant refers to a number of cases in children under two years, and there is a case in the literature in which it is stated that the tape-worm was found in an infant five days old. The parasites may cause no disturbance and are rarely dangerous. A knowledge of the existence of the worm is generally a source of worry and anxiety; the patient may have considerable distress and complain of ab- dominal pains, nausea, and sometimes diarrhoea. Occasionally the appe- tite is ravenous. In women and in nervous patients the constitutional dis- turbance may be considerable, and we not infrequently see great mental depression and even hypochondria. Various nervous phenomena, such as chorea, convulsions, or epilepsy, are believed to be caused by the parasites. Such effects, however, are vejy rare. The Bothriocephalus may cause a severe and even fatal form of angemia, which has been described fully in a recent monograph by Schauman, of Helsingfors. 1098 DISEASES DUE TO ANIMAL PARASITES. The diagnosis is never doubtful. The presence of the segments is dis- tinctive. The ova, too, may be recognized in the stools. It makes but little difference as to the form of tape-worm, but the ripe segments of the Tcenia saginata are larger and broader, and show differences in the gener- ative system as already mentioned. The prophylaxis is most important. Careful attention should be given to two points. First, all tape-worm segments should be burned. They should never be thrown into the water-closet or outside. And second, the meat should be cooked throughout, in which way alone larvee are destroyed. Possibly it is owing to the fact that in this country pork is, as a rule, better cooked than beef that the Tcsnia saginata is the most common form. Cer- tainly in the market and at the abattoirs one more commonly sees measly pork than measly veal. In the examination of a thousand hogs in Mont- real there were seventy-six instances of cysticerci. * The measle is more readily overlooked in beef than in pork, as in the former it has not such an opaque white color. Treatment.—For two days prior to the administration of the reme- dies the patient should take a very light diet and have the bowels moved occasionally by a saline cathartic. The practitioner has the choice of a large number of drugs. As a rule, the male fern acts promptly and well. The ethereal extract, in two-drachm doses, may be given fasting, and fol- lowed in the course of a couple of hours by a brisk purgative. This usu- ally succeeds in bringing away a large portion, but not always the entire worm. A combination of the remedies is sometimes very effective. An in- fusion is made of pomegranate root, half an ounce; pumpkin seeds, one ounce ; powdered ergot, a drachm; and boiling water, ten ounces. To an emulsion of the male fern (a drachm of ethereal extract), made with acacia powder, two minims of croton oil are added. The patient should have had a low diet the previous day and have taken a dose of salts in the evening. The emulsion and infusion are mixed and taken fasting at nine in the morning. The pomegranate root is a very efficient remedy, and may be given as an infusion of the bark, three ounces of which may be macerated in ten ounces of water and then reduced to one half by evaporation. The entire quantity is then taken in divided doses. It occasionally produces colic, but is a very effective remedy. The active principle of the root, pelle- tierine, is now much employed. It is given in doses of one fourth to one half of a grain, and is followed in an hour by a purge. Pumpkin seeds are sometimes very efficient. Three or four ounces should be carefully bruised and then macerated for twelve or fourteen hours and the entire quantity taken and followed in an hour by a purge. Of other remedies, koosso, turpentine in ounce doses in honey, and kamala may be mentioned. Unless the head is brought away, the parasite continues to grow, and DISEASES CAUSED BY CESTODES. 1099 within a few months the segments again appear. Some instances are extraordinarily obstinate. Doubtless it depends a good deal upon the exposure of the worm. The head and neck may be thoroughly protected beneath the valvulae conniventes, in which case the remedies may not act. Owing to its armature the tcenia solium is more difficult to expel. It is probable that no degree of peristalsis could dislodge the head, and unless the worm is killed it does not let go its extraordinarily firm hold on the mucous membrane. II. Visceral Cestodes. Whereas adult taeniae cause little or no disturbance, and rarely, if ever, prove directly fatal, the affections caused by the larvae or immature forms in the solid organs are serious and important. There are two chief cestode larvae known to frequent man—(a) the Cysticercus cellulosce, the larva of the TcBnia solium, and (b) the Echinococcus, the larva of the Tcenia echi- nococcus. I. Cysticercus cellulosae.—When man accidentally takes into his stom- ach the ripe ova of Tcenia solium he is liable to become the intermediate host, a part usually played for this tape-worm by the pig. This accident may occur in an individual the subject of Tcenia solium, in which case the mature proglottides either themselves wander into the stomach or, what is more likely, are forced into the organ in attacks of prolonged vomiting. Of course the accidental ingestion from the outside of a few ova is quite possible, and the liability of infection should always be borne in mind in handling the segments of the worm. The symptoms depend entirely upon the number of ova ingested and the localities reached. In the hog the cysticerci produce very little dis- turbance. The muscles, the connective tissue, and the brain may be swarming with the measles, as they are called, and yet the nutrition is maintained and the animal does not appear to be seriously incommoded. In the invasion period, if large numbers of the parasites are taken, there is, in all probability, constitutional disturbance ; certainly there is in the calf, when fed with the ripe segments of Tcenia saginata. In man a few cysticerci lodged beneath the skin or in the muscles may cause no damage, and in time the larvae die and become calcified. They are occasionally found in dissection subjects or in post-mortems as ovoid white bodies in the muscles or subcutaneous tissue. In this country they are very rare. I have seen but one instance in my post- mortem experience. Depending on the number and the locality spe- cially affected, the symptoms may be grouped into general, cerebro-spinal, and ocular. (1) General.—As a rule the invasion of the larvas in man, unless in very large numbers, does not cause very definite symptoms. It occasion- ally happens, however, that a striking picture is produced. For instance, 1100 DISEASES DUE TO ANIMAL PARASITES. a patient was admitted to my wards very stiff and helpless, so much so that he had to be assisted up-stairs and into bed. He complained of numbness and tingling in the extremities and general weakness, so that at first he was thought to have a peripheral neuritis. At the examination, however, a number of painful subcutaneous nodules were discovered, which proved on excision to be the cysticerci. Altogether seventy-five could be felt subcutaneously, and from the soreness and stiffness they probably existed in large numbers in the muscles. There were none in his eyes, and he had no symptoms pointing to brain lesions. (2) Cerebrospinal.—Remarkable symptoms may result from the pres- ence of the cysticerci in the brain and cord. In the silent region they may be abundant without producing any symptoms. I have in my pos- session the brain of a pig containing scores of “ measles,” yet the animal in the few moments in which I saw it just prior to death did not present any symptoms to attract attention. In the ventricles of the brain the cysticerci may attain a considerable size, owing to the fact that in regions in which they are unrestrained in their growth, as in the peritonseum, the bladder-like body grows freely. When in the fourth ventricle re- markable irritative symptoms may be produced. In 1884 I saw with Fried lander in Berlin a case from Riess’s wards in which during life there had been symptoms of diabetes and anomalous nervous symjDtoms. Post mortem, the cysticercus was found beneath the valve of Vieussens, press- ing upon the floor of the fourth ventricle. (3) Ocular.—Since von Graefe demonstrated the presence of the cysti- cercus in the vitreous humor many cases have been placed on record, and it is a condition easily recognized by oculists. Except in the eye, the diagnosis can rarely be made; when the cysti- cerci are subcutaneous, one may be excised. It is possible that when numerous throughout the muscles they may be seen under the tongue, in which situation they may exist in the pig in numbers. II. Echinococcus Disease.—The hydatid worms or echinococci are the larvae of the Taenia echinococcus of the dog. This is a tiny cestode not more than four or five millimetres in length, consisting of only three or four segments, of which the terminal one alone is mature, and has a length of about two millimetres and a breadth of 0-6 millimetre. The head is small and provided with four sucking disks and a rostellum with a double row of hooklets. This is an exceedingly rare parasite in the dog. Cobbold states that 'he has never met with a natural specimen in England. Leidy had not one in his large collection. I have not met with an in- stance in this country, nor do I know of its ever having been described. The only specimens in my cabinet I procured experimentally by feeding a dog with echinococcus cysts from an ox. The worms are so small that they may be readily overlooked, since they form small white, thread-like bodies closely adherent among the villi of the small intestines. The ripe segment contains about 5,000 eggs, which attain their development in the DISEASES CAUSED BY CESTODES. 1101 solid organs of various animals, particularly the hog and ox ; more rarely the horse and the sheep. In some countries man is a common intermedi- ate host, owing to the accidental ingestion of the ova. Development.—The little six-hooked embryo, freed from the egg- shell by digestion, burrows through the intestinal Avail and reaches the peritoneal cavity or the muscles; it may enter the portal vessels and is carried to the liver. It may enter the systemic vessels, and, passing the pulmonary capillaries, as it is protoplasmic and elastic, may reach the brain or other parts. Once having reached its destination, it undergoes the following changes: The hooklets disappear and the little embryo is gradually converted into a small cyst which presents two distinct layers— an external, laminated, cuticular membrane or capsule, and an internal, granular, parenchymatous layer, the endocyst. The little cyst or vesicle contains a clear fluid. There is more or less reaction in the neighboring tissues, and the cyst in time has a fibrous investment. When this primary cyst or vesicle has attained a certain size buds develop from the parenchymatous layer, which are gradually converted into cysts, present- ing a structure identical with that of the original cyst, namely, an elastic chitinous membrane lined with a granular parenchymatous layer. These secondary or daughter cysts are first connected with the lining membrane of the primary, but are soon set free. In this way the primary cyst as it grows may contain a dozen or more daughter cysts. Inside these daughter cysts a similar process may occur, and from buds in the walls grand- daughter cysts are developed. From the granular layer of the parent and daughter cysts buds arise which develop into brood capsules. From the lining membrane the little outgrowths arise and gradually develop into bodies known as scolices, which represent in reality the head of the Tcenia echinococcus and present four sucking disks and a circle of hooklets. Each scolex is capable when transferred to the intestines of a dog of de- veloping into an adult tape-worm. The difference between the ovum of an ordinary tape-worm, such as the Tcenia solium, and the Tcenia echino- coccus is in this way very striking. In the former case the ovum devel- ops into a single larva—the Cysticercus cellulosce—whereas the egg of the Tcenia echinococcus develops into a cyst which is capable of multiplying enormously and from the lining membrane of which millions of larval tape-worms develop. Ordinarily in man the development of the echino- coccus takes place as above mentioned and by an endogenous form in which the secondary and tertiary cysts are contained within the primary; but in animals the formation may be different, as the buds from the pri- mary cyst penetrate between the layers and develop externally, forming the exogenous variety. A third form is the multilocular echinococcus, in which from the primary cysts buds develop which are cut off completely and are surrounded by thick capsules of a connective tissue, which join together and ultimately form a hard mass represented by strands of con- nective tissue enclosing alveolar spaces about the size of peas or a little 1102 DISEASES DUE TO ANIMAL PARASITES. larger. In these spaces are found the remnants of the echinococcus cyst, occasionally the scolices or booklets, but they are often sterile. The fluid of the echinococcus cysts is clear and limpid, and has a spe- cific gravity from 1-005 to 1-009. It does not contain albumin, but may contain traces of sugar. As a rule, the cysts, when not degenerated, con- tain the hydatid heads or scolices or the characteristic hooklets. Changes in the Cyst.—It is not known definitely how long the echino- coccus remains alive, but it probably lives many years—according to some authors as long as twenty years. The most common change is death and the gradual inspissation of the contents and conversion of the cyst into a mass containing putty-like or granular material which may be partially calcified. Remnants of the chitinous cyst wall or hooklets may be found. These obsolete hydatid cysts are not infrequently found in the liver. A more serious termination is rupture, which may take place into a serous sac, or perforation may take place externally, when the cysts are discharged, as into the bronchi or alimentary canal or urinary passages. More unfa- vorable are the instances in which rupture occurs into the bile-passages or into the inferior cava. Recovery may follow the rupture and discharge of the hydatids externally. Sudden death has been known to follow the rup- ture. A third and very serious mode of termination is suppuration, which may occur spontaneously or follow rupture and is found most frequently in the liver. Large abscesses may be formed which contain the hydatid membranes. Geographical Distribution of the Echinococcus.—The disease prevails most extensively in those countries in which man is brought into close contact with the dog, particularly when, as in Australia, the dogs are used extensively for herding sheep, the animal in which the larval form of the Ttenia echinococcus is most frequently found. In Iceland the cases are very numerous. In Europe the disease is not uncommon. In this coun- try it is extremely rare and a great majority of all cases are in foreigners. Up to July, 1891, I have been able to find in the literature (and in the museums) only 85 cases in the United States and Canada.* In the Ice- landic settlements of Manitoba many cases occur. A. H. Ferguson, who has operated on a number of cases at the Winnipeg General Hospital, states that between forty-five and fifty persons with echinococcus disease have been treated in Winnipeg since 1874, the date of the Icelandic immi- gration. Distribution in the Body.—Of the 1,862 cases comprised in the statis- tics of Davaine, Cobbold, Finsen, and Neisser, the parasites existed in the liver in 953, in the intestinal canal in 163, in the lung or pleura in 153, in the kidneys, bladder, and genitals in 186, in the brain and spinal canal in 127, bone 61, heart and blood-vessels 61, other organs 158.f Of the 85 * American Journal of the Medical Sciences, October, 1882. Since that date Alfred Mann has collected for me 24 cases in addition to the 61 there reported, f Dictionnaire Encyclopedique des Sciences MSdicales, tome xxxii, 1885. DISEASES CAUSED BY CESTODES. 1103 cases in this country, the liver was the seat of the disease in 59. Of 50 consecutive cases treated by Mosler at the G-reifswald clinic, 36 involved the liver, 10 the lungs, 3 the right kidney, and 1 the spleen. Symptoms.—(a) Hydatids of the Liver.—Small cysts may cause no disturbance; large and growing cysts produce signs of tumor of the liver with great increase in the size of the organ. Naturally the physical signs depend much upon the situation of the growth. Near the anterior sur- face in the epigastric region the tumor may form a distinct prominence and have a tense, firm feeling, sometimes with fluctuation. A not infre- quent situation is to the left of the suspensory ligament, forming a tumor which pushes up the heart and causes an extensive area of dulness in the lower sternal and left hypochondriac regions. In the right lobe, if the tumor is on the posterior surface, the enlargement of the organ is chiefly upward into the pleura and the vertical area of dulness in the posterior axillary line is increased. Superficial cysts may give what is known as the hydatid fremitus. If the tumor is palpated lightly with the fingers of the left hand and percussed at the same time with those of the right, there is felt a vibration or trembling movement which persists for a certain time. It is not always present, and it is doubtful whether it is peculiar to the hydatid tumors or is due, as Briamjon held, to the collision of the daugh- ter cysts. Very large cysts are accompanied by feelings of pressure or dragging in the hepatic region, sometimes actual pain. The general con- dition of the patient is at first good and the nutrition little, if at all, in- terfered with. Unless some of the accidents already referred to occur, the symptoms indeed may be trifling and due only to the pressure or weight of the tumor. Suppuration of the cyst changes the clinical picture into one of pyaemia. There are rigors, sweats, more or less jaundice, and rapid loss of weight. Perforation may occur into the stomach, colon, pleura, bronchi, or exter- nally, and in some instances recovery has taken place. Perforation into the pericardium and inferior vena cava is fatal. In the latter case the daughter cysts have been found in the heart, plugging the tricuspid ori- fice and the pulmonary artery. Perforation of the bile-passages causes intense jaundice, and may lead to suppurative cholangitis. An interesting symptom connected with the rupture of hydatid cysts is the development of urticaria, which may also follow aspiration of the cysts and is probably due to the absorption of toxic materials contained in the fluid. Diagnosis.—Cysts of moderate size may exist without producing symp- toms. Large multiple echinococci may cause great enlargement with irregularity of the outline, and such a condition persisting for any time with retention of the health and strength suggests hydatid disease. An irregular, painless enlargement, particularly in the left lobe, or the pres- ence of a large, smooth, fluctuating tumor of the epigastric region is also very suggestive, and in this situation, when accessible to palpation, it 1104 DISEASES DUE TO ANIMAL PARASITES. gives a sensation of a smooth elastic growth and possibly also the hydatid tremor. When suppuration occurs the clinical picture is really that of abscess, and only the existence of previous enlargement of the liver with good health would point to the fact that the suppuration was associated with hydatids. Syphilis may produce irregular enlargement without much disturbance in the health, sometimes also a very definite tumor in the epigastric region, but it is usually firm and not fluctuating. The clinical features may simulate cancer very closely. In a case which I reported the liver was greatly enlarged and there were many nodular tumors in the abdomen. The post-mortem showed enormous suppurating hydatid cysts in the left lobe of the liver which had perforated the stomach in two places and also the duodenum. The omentum, mesentery, and pelvis also contained numerous cysts. As a rule, the clinical course of the dis- ease would suffice to separate it clearly from cancer. Dilatation of the gall-bladder and hydronephrosis have both been mistaken for hydatid disease. In the former the movable character of the tumor, its shape, and the mucoid character of the contents suffice for the diagnosis. In some instances of hydronephrosis only the exploratory puncture could distinguish between the conditions. More frequent is the mistake of confounding a hydatid cyst of the right lobe pushing up the pleura with pleural effusion of the right side. The heart may be dislocated, the liver depressed, and dulness, feeble breathing, and diminished fremitus are present in both conditions. Frerichs lays stress upon the different character of the line of dulness; in the echinococcus cyst the upper limit presents a curved line, the maximum of which is usually in the scapular region. Suppurative pleurisy may be caused by the perforation of the cyst. If adhesions result, the perforation takes place into the lung, and fragments of the cysts or small daughter cysts may be coughed up. For diagnostic purposes the exploratory puncture should be used. As stated, the fluid is usually perfectly clear or slightly opalescent, the reac- tion is neutral, and the specific gravity varies from 1-005 to 1-009. It is non-albuminous, but contains chlorides and sometimes traces of sugar. Hooklets may be found either in the clear fluid or in the suppurating cysts. They are sometimes absent, however, as the cyst may be sterile. (£) Echinococcus of the Respiratory Systein.—The larvas may develop primarily in the pleura and attain a large size. The symptoms are at first those of compression of the lung and dislocation of the heart. The phys- ical signs are those of fluid in the pleura and the condition could scarcely be distinguished from ordinary effusion. The line of dulness may be quite irregular. As in the echinococcus of the liver, the general condition of the patient may be excellent in spite of the existence of extensive dis- ease. Pleurisy is rarely excited. The cysts may become inflamed and perforate the chest wall. In a case of D. F. Smith’s, of Walkertown, Ontario, a girl, aged twenty, had a running sore in the eighth left inter- costal space. This was freely opened, and in the pus which flowed out DISEASES CAUSED BY CESTODES. 1105 were a number of well-characterized echinococcus cysts of various size. The patient recovered. Echinococci occur more frequently in the lung than in the pleura. If small, they may exist for some time without causing serious symptoms. In their growth they compress the lung and sooner or later lead to inflam- matory processes, often to gangrene, and the formation of cavities which connect with the bronchi. Fragments of membrane or small cysts may be expectorated. Haemorrhage is not infrequent. Perforation into the pleura with empyema is common. A majority of the cases are regarded during life as either phthisis or gangrene, and it is only the detection of the char- acteristic membranes or the hooklets which leads to the diagnosis. The condition is usually fatal; only a few cases have recovered. Of the 85 American cases, in six the cysts occurred in the lung or pleura. (c) Echinococcus of the Kidneys.—In the collected statistics referred to above the genito-urinary system comes second as the seat of hydatid disease, though it is rare in comparison with the affection of the liver. Of the 85 American cases, there were only three in which the kidneys or blad- der were involved. The kidney may be converted into an enormous cyst resembling hydronephrosis. The diagnosis is only possible by puncture and examination of the fluid. The cyst may perforate into the pelvis of the kidney, and portions of the membrane or cysts may be discharged with the urine, sometimes producing renal colic. I have reported a case in which for many months the patient passed at intervals numbers of small cysts with the urine. The general health was little if at all disturbed, except by the attacks of colic during the passage of the parasites. (d) Echinococcus of the Nervous System.—In this country very few instances have occurred in the brain. One or two reports indicate clearly that the common cystic disease of the choroidal plexuses has been mis- taken for hydatids. Davies Thomas, of Australia, has tabulated 97 cases, including some of the Cysticercus celluloses. According to his statistics, the cyst is more common on the right than on the left side, and is most frequent in the cerebrum. The symptoms are very indefinite, as a rule, being those of tumor. Persistent headache, convulsions, either limited or general, and gradually developing blindness have been prominent features in many cases. Multilocular Echinococcus.—This form merits a brief separate descrip- tion, as it differs so remarkably from the usual type of the disease. About one hundred instances are on record, the great majority of which have occurred in Bavaria and in Switzerland. Only one case has been reported in the United States.* The patient was a German, who had been in the country five years. For a year previous to his death he was out of health, jaundiced, and somewhat emaciated. A fluctuating tumor was found in * Delafield and Prudden, Pathological Anatomy, third edition, page 317. 1106 DISEASES DUE TO ANIMAL PARASITES. the right lumbar and umbilical regions, apparently connected with the liver. This was opened, and death followed from haemorrhage. About a fourth of the right lobe of the liver was occupied by an irregular cavity with rough, ragged walls, which in places were from one to two inches in thickness and enclosed irregular small cavities. The lamellated cuticula characteristic of the echinococcus cyst was found lining these cavities. In some instances the tumor bears a striking likeness to colloid cancer, as on section it presents a fibrous stroma with cavities containing gelatinous material. They are often sterile—that is, without the hydatid heads or larvae. This form is almost exclusively confined to the liver, and the symptoms resemble more those of tumor or cirrhosis. The liver is, as a rule, enlarged and smooth, not irregular as in the ordinary echinococ- cus. Jaundice is a common symptom. The spleen is usually enlarged, there is progressive emaciation, and toward the close haemorrhages are common. Treatment of Echinococcus Disease.—Medicines are of no avail. Post-mortem reports show that in a considerable number of cases the parasite dies and the cyst becomes harmless. Operative measures should be resorted to when the cyst is large or troublesome. The simple aspiration of the contents has been successful in a large number of cases, and as it is not in any way dangerous, it may be tried before the more radical procedure of incision and evacuation of the cysts. Suppuration has occasionally followed the puncture. Injections into the sac should not be practised. With modern methods surgeons now open and evacuate the echinococcus cysts with great boldness, and the Australian records, which are the most numerous and important on this subject, show that recovery is the rule in a large proportion of the cases. Suppurative cysts in the liver should be treated as abscess. Naturally the outlook is less favorable. The practical treatment of hydatid disease has been greatly advanced by Australian surgeons. The recent work of James Graham, of Sydney, may be consulted for interesting details in diagnosis and treat- ment. VI. PARASITIC ARACHNIDA. (1) Pentastomes.—(a) Linguatula rliinaria (Pentastoma tmiioides) has a somewhat lancet-shaped body, the female from three to four inches in length, the male about an inch in length. The body is tapering and marked by numerous rings. The adult worm infests the frontal sinuses and nostrils of the dog, more rarely of the horse. The larval form, which is known as the Linguatula serrata (Pentastomum denticulatum), is found in the internal organs, particularly the liver, but lias also been found in the kidney. The adult worm has been found in the nostril of man, but is very rare and seldom occasions any inconvenience. The larvae are by no means uncommon, particularly in parts of Germany. PARASITIC ARACHN1DA. 1107 (b) The Porocephalus constrictus (Pentastomum constrictum), which is about the length of half an inch, with twenty-three rings on the abdo- men, was found by Aitken in the liver and lungs of a soldier of a West Indian regiment. The parasite is very rare in this country. Flint refers to a Missouri case in which from 75 to 100 of the parasites were expectorated. The liver was enlarged and the parasites probably occupied this region. In 1869 I saw a specimen which had been passed with the urine by a patient of James II. Richardson, of Toronto. (2) Demodex (Acarus) folliculorum (var. hominis).—A minute para- site, from 0-3 millimetre to 0-4 millimetre in length, which lives in the sebaceous follicles, particularly of the face. It is doubtful whether it pro- duces any symptoms. Possibly when in large numbers they may excite inflammation of the follicles, leading to acne. (3) Sarcoptes (Acarus) scabiei (Itch Insect).—This is the most im- portant of the arachnid parasites, as it produces troublesome and dis- tressing skin eruptions. The male is ’23 millimetre in length and T9 millimetre in breadth ; the female is 0-45 millimetre in length and 0-35 millimetre in width. The female can be seen readily with the naked eye and has a pearly-white color. It is not so common a parasite in the United States and Canada as in Europe. The insect lives in a small burrow, about one centimetre in length, which it makes for itself in the epidermis. At the end of this burrow the female lives. The male is seldom found. The chief seat of the parasite is in the folds where the skin is most delicate, as in the web between the fingers and toes, the backs of the hands, the axilla, and the front of the abdomen. The head and face are rarely involved. The lesions which re- sult from the presence of the itch insect are very numerous and result largely from the irritation of the scratching. The commonest is a papular and vesicular rash, or, in children, an ecthymatous eruption. The irrita- tion and pustulation which follow the scratching may completely destroy the burrows, but in typical cases there is rarely doubt as to the diagnosis. The treatment is simple. It should consist of warm baths with a thor- ough use of a soft soap, after which the skin should be anointed with sulphur ointment, which in the case of children should be diluted. An ointment of naphthol (drachm to the ounce) is very efficacious. (4) Leptus autumnalis (Harvest Bug).—This reddish-colored para- site, about one half millimetre in size, is often found in large numbers in fields and in gardens. They attach themselves to animals and man with their sharp proboscides, and the hooklets of their legs produce a great deal of irritation. They are most frequently found on the legs. They are readily destroyed by sulphur ointment or corrosive-sublimate lotions. Several varieties of ticks are occasionally found on man—the Ixodes ricinus and the Dermacentor america?ius, which are met with in horses and oxen. 1108 DISEASES DUE TO ANIMAL PARASITES. VII. PARASITIC INSECTS. (1) Pediculi (Phthiriasis ; Pediculosis).—There are three varieties of the body louse, which are found only in persons of uncleanly habits. Pediculus capitis.—The male is from 1 to 1-5 millimetre in length and the female nearly two millimetres in length. The color varies some- what with the different races of men. It is light gray with a black mar- gin in the European, and very much darker in the negro and Chinese. They are oviparous, and the female lays about sixty eggs, which mature in a week. The ova are attached to the hairs, and can be readily seen as white specks, known popularly as nits. The symptoms are irritation and itching of the scalp. When numerous they may excite an eczema or a pustular dermatitis, which causes crusts and scabs, particularly at the back of the head. In the most extreme cases the hair becomes tangled in these crusts and matted together, forming at the occiput a firm mass which is known as plica polonica, as it was not infrequent among the Jewish in- habitants of Poland. Pediculus corporis (vestimentorum).—This is considerably larger than the head louse. It lives on the clothing, and in sucking the blood causes minute haemorrhagic specks, which are very common about the neck, back, and abdomen. The irritation of the bites may cause urticaria, and the scratching is usually in linear lines. In long-standing cases, particu- larly in the old dissipated characters, the skin becomes rough and greatly pigmented, a condition which has been termed the vagabond’s disease— morbus errorum—and which may be mistaken for the bronzing of Addi- son’s disease. * . Phthirius pubis differs somewhat from the other forms, and is found in the parts of the body covered with short hairs, as the pubes; more rarely the axilla and eyebrows. The taches bleuatres are stated by French writers to be excited by the irritation of pediculi. They are certainly associated with them in a con- siderable number of cases, but, if really caused by these parasites, it is diffi- cult to understand why they should only be present with fever. Treatment.—For the Pediculus capitis, when the condition is very bad, the hair should be cut short, as it is very difficult to destroy thor- oughly all the nits. Kepeated saturations of the hair in coal-oil or in tur- pentine are usually efficacious, or with lotions of carbolic acid, one to fifty. Scrupulous cleanliness and care are sufficient to prevent recurrence. In the case of the Pediculus corporis the clothing should be placed for sev- eral hours in a disinfecting oven. To allay the itching a warm bath con- taining four or five ounces of bicarbonate of soda is useful. The skin may be rubbed with a lotion of carbolic acid, two drachms to the pint, with two ounces of glycerin. For the Phthirius pubis white precipitate or ordinary mercurial ointment should be used, and the parts should MYIASIS. 1109 be thoroughly washed two or three times a day with soft soap and water. (2) Cimex lectularius (Common Bed-bug).—This parasite is from three to four millimetres in length and has a reddish-brown color. It lives in the crevices of the bedstead and in the cracks in the floor and in the walls. It is nocturnal in its habits. The peculiar odor of the insect is caused by the secretion of a special gland. The parasite possesses a long proboscis, with which it sucks the blood. Individuals differ remarkably in the reac- tion to the bite of this insect; some are not disturbed in the slightest by them, in others the irritation causes hypersemia and often intense urti- caria. Fumigation with sulphur or scouring with corrosive-sublimate solution or kerosene destroys them. Iron bedsteads should be used. (3) Pulex irritans (The Common Flea).—The male is from 2 to 2-5 millimetres in length, the female from 3 to 4 millimetres. The flea is a transient parasite on man. The bite causes a circular red spot of hyperaemia in the centre of which is a little speck where the boring appa- ratus has entered. The amount of irritation caused by the bite is variable. Many persons suffer intensely and a diffuse erythema or an irritable urti- caria develops; others suffer no inconvenience whatever. The Pulex penetrans (sand-flea; jigger) is found in tropical coun- tries, particularly in the West Indies and South America. It is much smaller than the common flea, and not only penetrates the skin, but bur- rows and produces an inflammation with pustular or vesicular swelling. It most frequently attacks the feet. It is readily removed with a needle. Where they exist in large numbers the essential oils are used on the feet as a preventive. VIII. MYIASIS. Of these, the most important are the larvae of certain diptera, particu- larly the flesh flies—Creophila. The condition is called myiasis. The most common form is that in which an external wound becomes living, as it is called. This myiasis vulnerum is caused by the larvae of either the blue-bottle or the common flesh fly. The larvae of the Lucilia macellaria, the so-called screw-worm, has been found in the nose, in wounds, and in the vagina after delivery. The larvae can be removed readily with the forceps; if there is any difficulty, thorough cleansing and the application of an antiseptic bandage is sufficient to kill them. The ova of these flies may be deposited in the nostrils, the ears, or the con- junctiva—the myiasis narium, aurium, conjunctivae. This invasion rarely takes place unless these regions are the seat of disease. In the nose and in the ear the larvae may cause serious inflammation. The cutaneous myiasis may be caused by the larvae of the Musca vomi- toria, but more commonly by the bot-flies of the ox and sheep, which occasionally attack man. This condition is rare in temperate climates. 1110 DISEASES DUE TO ANIMAL PARASITES. Matas has described a case in which oestrus larvae were found in the glu- teal region. In parts of Central America the eggs of another bot-fly, the Dermatobia, are not infrequently deposited in the skin and produce a swelling very like the ordinary boil. Myiasis interna may result from the swallowing of the larvae of the common house fly or of species of the genus Antliomyia. There are many cases on record in which the larvae of the Musca domestica have been dis- charged by vomiting. Instances in which dipterous larvae have been passed in the faeces are less common. Finlayson, of Glasgow, has recently reported an interesting case in a physician, who, after protracted consti- pation and pain in the back and sides, passed large numbers of the larvae of the flower fly—Antliomyia canicularis. Among other forms of larvae or gentles, as they are sometimes called, which have been found in the faeces, are those of the common house fly, the blue-bottle fly, and the Techomyza fusca. The larvae of other insects are extremely rare. It is stated that the caterpillar of the tabby moth has been found in the faeces. Here may be mentioned among the effects of insects the remarkable urticaria epidemica, which is caused in some districts by the procession caterpillars, particularly the species Cnethocampa. There are districts in the Kahlberger Schweiz which have been rendered almost uninhabitable by the irritative skin eruptions caused by the presence of these insects, the action of which is not necessarily in consequence of actual contact with them. In Africa the larvae of the Cayor fly are not uncommonly found be- neath the skin, in little boils. INDEX. Abasia, 1040. Abdomen in typhoid fever, 24. Abdominal typhus, 1. Abducens nerve (see Sixth Nerve), 851. Aberrant, thyroid glands, 751; adrenals, 811. Abortion, in chorea, 987; in relapsing fever, 49; in small-pox, 60; in syphilis, 199. Abscess, atheromatous, 701; of brain, 974; in appendicitis, 433, 437; in glanders, 281; of kidney (pyonephrosis), 799 ; of liver, 480 ; of lung, 586; of mediastinum, 613; of pa- rotid gland, 357 ; of tonsils, 363 ; perinephric, 814; pulmonal-cerebral, 975 ; pysemic, 130 ; retroperitoneal, 434 ; retropharyngeal in cer- vical caries, 361, 915. Aeanthocephala, 1095. Acardia, 695. Acarus scabiei, A. folliculorum, 1107. Accentuated second sound, in chronic Bright’s disease, 794 ; in arterio-sclerosis, 704. Accessory spasm, 868. Aeephalocysts (see Hydatid Cysts), 1100. Acetomemia, 326. Acetone, 324; test for (Le Nobel’s), 324. Acetonuria, 777. Achondroplasy, 332. Achromatopsia in hysteria, 1026. Acne, from iodide of potassium, 1010 ; rosacea, 1059. Acromegalia, 1045, and gigantism, 1046. Actinomyces, or ray fungus, 282. Actinomycosis, 282; pulmonary, 283; cuta- neous, 284; cerebral, 284. Acupuncture, in dropsy, 786 ; in lumbago, 304; in sciatica, 879. Acute bulbar paralysis, 922. Acute tuberculosis, 217. Acute yellow atrophy, 459. Addison’s, disease, 746 ; pill, 202 ; keloid, 1048. Adenie, 742. Adenitis in scarlet fever, 77. Adenitis, tuberculous, 226, 745. Adenoid growths in pharynx, 364. Adherent pericardium, 624. Adhesive pylephlebitis, 462. Adirondack Mountains for tuberculosis, 273. Adrenals in Addison’s disease, 747. JSgophony, 554, 596. Age, influence of, in tuberculosis, 212. Ageusia, 863. Agraphia, 930. Ague, 155. Ague cake (see Enlarged Spleen), 171. Ainhum, 1049. “ Air-hunger ” in diabetes, 326. Air, impure, influence in tuberculosis, 213. Albini, nodules of, 696. Albinism, in leprosy (lepra alba), 279 ; of the lung, 580. Albumin, tests for, 769. Albuminuria, 767, and life assurance, 770 ; cy- clic, 768; febrile, 768; functional, 767; in acute Bright’s disease, 783 ; in chronic Bright’s disease, 793; in diabetes, 324; in diphtheria, 113; in epilepsy, 1006; in ery- sipelas, 125; in gout, 317; in pneumonia, 555; in scarlet fever, 74, 75; in typhoid fever, 28; in variola, 59; neurotic, 769; physiological, 767 ; prognosis in, 770. Albuminous expectoration in pleurisy, 604. Albuminuric retinitis, 842. Albuminuric ulceration of the bowels, 423. Albumose in cultures of tubercle bacilli, 205. Albumosuria, 770. Alcaptonuria, 777. Alcohol, effects of, on the digestive system, 1058 ; on the kidneys, 1059 ; on the nervous system, 1058 ; poisonous effects of, 1057. Alcoholic neuritis, 836. Alcoholism, 1057; acute, 1057; and tubercu- losis, 1059; chronic, 1057; treatment of, 1060. Alexia, 930. Algid form of malaria, 170. Alimentary canal, tuberculosis of, 260. Alkaloids, putrefactive, 1069. Allantiasis, 1069. Allocheiria, 907. Allorrhythmia, 685. Alopecia, in syphilis, 187. Alternating paralysis (see Crossed Paraly- sis). Altitude, effects of high, 289. 1112 INDEX. Altitude in tuberculosis, 204, 272. Amaurosis, hysterical, 843, 1026; toxic, 843; uraemic, 795 ; in hsemutemesis, 413. Amblyopia, 843 ; crossed, 847. Ambulatory typhoid fever, 13, 31. Amoeba coli (amoeba dysenterise), 147; in liver abscess, 147, 480; in sputa, 153. Amoebic dysentery, 147. Ammoniacal decomposition of urine, 775. Ammonisemia, 778, 802. Amnesia, auditory, 929; visual, 928. Amphoric breathing, 247, 610. Amphoric echo, 247. Amusia, 929. Amyloid disease, in phthisis, 238; in syphilis, 188; of kidney, 798; of liver, 490. Amyotrophic lateral sclerosis, 919, 921. Anaemia, 720; bothrioceplialus, 1097; in an- chylostomiasis, 1090; from Bilharzia, 1083; from gastric atrophy, 380; from haemorrhage, 720; miner’s, 1090; brick-maker’s, 1090; tunnel, 1090 ; from inanition, 722; from lead, 1064; idiopathic, 726; in gastric cancer, 407; in gastric ulcer, 398 ; mountain, 289,1090; in malarial fever, 170; in rheumatism, 294; in syphilis, 187; in typhoid fever, 18; pri- mary or essential, 723; chlorosis, 723; pro- gressive pernicious, 726; secondary or symp- tomatic, 720; spinal cord lesions in, 886; toxic, 722. Anaemic murmurs (see H.emic Murmurs). Anaesthesia, dolorosa, 914; in chorea, 991; in hemiplegia, 946; in hysteria, 1025; in lepro- sy, 280; in locomotor ataxia, 906; in Mor- van’s disease, 913; in railway spine, 1037; in unilateral lesions of the cord, 880. Analgesia in hysteria, 1025; in Morvan’s dis- ease, 913: in syringo-myelia, 913. Anarthria, 927. Anasarca (see Dropsy). Anastomotic pulse, 704. Ar>chylostoina, 421. Anchylostomiasis, 1090; symptoms ot, 1090. Ancliylostomum duodenale, 1090. Aneurism, 706 ; arterio-venous, 706, 718; cir- soid, 706; congenital, 718; cylindrical, 706; dissecting, 706 ; embolic, 707; etiology of, 706 ; false, 706; fusiform, 706; mycotic, 707 ; of the abdominal aorta, 716; of the branches of the abdominal aorta, 717; of the cerebral arteries, 955 ; of the coeliac axis, 717; of heart, 681; of the hepatic artery, 718; of the renal artery, 718; of the splenic artery, 717 ; of the superior mesenteric artery, 718; of pulmo- nary artery, 237; true, 706. Aneurism, of thoracic aorta, 707; cough in, 711; diagnosis of, 709; dyspnoea in, 711; haemor- rhage in, 711; pain in, 711; physical signs ot, 709; symptoms of, 708 ; treatment of, 714; Tufnell’s treatment of, 714 ; unilateral sweat- ing in, 712. Aneurism, verminous, in the horse, 707, 1090. Angina, Ludovici, 361; simplex, 359; suffoca- tiva, 103. Angina pectoris, 690; pseudo- or hysterical, 693 ; vaso-motoria, 691. Angio-eholitis, 466. Angio-neurotic oedema, 1043; heredity in, 1044; recurring colic in, 1044. Angio-sclerosis, 703. Angor animi, 692. Anguillula stercoralis, A. intestinalis, 1095. Animal lymph, 68. Anisocoria, 850. Ankle clonus, in hysterical paraplegia, 901. 1024; in spastic paraplegia, 899; spurious, J023. Anorexia nervosa, 1027. Anosmia, 841. Ano-vesical centre, 917. Anterior cerebral artery, embolism of, 953. Anterior crural nerve, paralysis of, 876. Anthomyia canicularis, 1110. Anthracosis, of lungs, 587; of liver, 474. Anthrax, 174; bacillus, 174; in animals, 174; external, 175; internal, 176. Antiperistalsis, 388. Antipneumotoxin, 548. Antiseptic medication in typhoid fever, 40. Antitoxine of diphtheria, 106, 121; of pneu- monia, 548 ; of tetanus, 183. Anuria, 763; complete, 758; from stone, 763; hysterical, 764. Anus, imperforate, 445. Aorta, aneurism of, 707; dynamic pulsation of, 713; throbbing, 717,1034; hypoplasia of, in chlorosis, 723 ; tuberculosis of, 267. Aortic incompetency, 637 ; sudden death in, 642; symptoms of, 639. Aortic orifice, congenital lesions of, 697; size of, 638. Aortic stenosis, 643. Aortic valves, bicuspid, condition of, 696; rela- tive insufficiency of, 638. Apex of lung, catarrh of, 251; puckering of, 271; in tuberculosis, 234. Apex pneumonia, 556, 559. Aphasia, 927; anatomical localization of, 930; ataxic, 929; hemiplegia with, 930; in in- fantile hemiplegia, 960; mixed forms of, 930; motor, 929; of conduction, 930; in phthisis, 249; prognosis of, 931; sensory, 928; in typhoid fever, 27; tests for, 931; transient, in migraine, 1012; Wernicke’s, 930. Aphemia (see Aphasia). Aphonia, hysterical, 1026; in acute laryngitis, 518; in abductor paralysis, 865 ; in pericar- dial effusion, 620. INDEX. 1113 Aphthae (see Stomatitis, Aphthous), 351. Aphthous fever, 290. Apoplectic habitus, 940 ; stroke, 943. Apoplexy, cerebral, 940 ; ingravescent, 943 ; pulmonary, 542. Apparitions in migraine, 1011. Appendicitis, 429; obliterans, 431; infective, 432; perforative, 431; relapsing, 439 ; ulcera- tive, 431. Appendicular colic, 431, 435. Appendix vermiformis, situation of, 430; per- foration of, in typhoid fever, 9; faecal con- cretions in, 430; foreign bodies in, 430; ne- crosis and sloughing of, 432. Apraxia, 928. Aprosexia, 364, 367. Arachnida, parasitic, 1106. Arachnitis (see Meningitis), 933. Aran-Duchenne type of muscular atrophy, 919; in lead-poisoning, 1066. Arch of aorta, aneurism of, 708. Arcus senilis, 679. Argyll-Robertson pupil, 850; in ataxia, 905. Arithmomania, 997. Arm, peripheral paralysis of (see Paralysis of Brachial Plexus). Arrythmia, 685. Arsenical neuritis, 837. Arsenical pigmentation, 1068 ; in chorea, 992. Arsenical poisoning, 1067; paralysis in, 1068. Arteries, diseases of, 699: calcification of, 699; degeneration of, 699; fatty, 699 ; hyaline, 700; tuberculosis of, 267. Arterio-capillary fibrosis, 700. Arterio-sclerosis, 700; diffuse, 702; in lead- poisoning, 1066; in migraine, 1012; nodular form, 701; in phthisis, 253 ; senile form, 702; symptoms of, 704; treatment of, 705. Arteritis in typhoid fever, 10, 20. Arteritis, syphilitic, 197. Arthralgia from lead, 1066. Arthritides, post-febrile, 131; in gout, 315. Arthritis, 297; acute, in infants, 298; gonor- rhoeal, 801; in acute myelitis, 890; in cerebro- spinal meningitis, 100; in chorea, 985; in dengue, 95; in dysentery, 152; in haemo- philia, 349; in small-pox, 59; in tabes dor- salis, 907; multiple secondary, 297; in pur- pura, 344; rheumatoid, 305; in scarlet fever, 76; septic, 297. Arthritis deformans, 305; chronic form, 307; general progressive form, 306; Heberden's nodosities in, 306 ; partial or mono-articular form, 308. Arthropathies in tabes, 907. Ascariasis, 1083. Ascaris lumbricoides, 1083. Ascites, 507,511; chylous, 509; from cancerous peritonitis, 507; from cirrhosis of the liver, 477; from syphilis of the liver, 196; in cancer of the liver, 488 : in tuberculous peritonitis, 259 ; physical signs of, 508; treatment of, 511. Ascitic fluid, chylous, 509 ; serous, 509; haemorrhagic, 509. Ascomycetc in typhus fever, 44. Aspect, facial, in typhoid fever, 13 ; in pneu- monia, 551; in hereditary lues, 190; in pa- ralysis agitans, 983. Aspergillus in lung, 242. Asphyxia, local, 1041; death by, in phthisis, 255. Aspiration, Bow ditch's conclusions on, 604; in empyema, 605; in pericardial effusion, 624; in pleuritic effusion, 603; tuberculosis after, 213. Aspiration pneumonia, 571. Astasia-abasia, 1040. Asthma, bronchial, 531; etiology of, 531; nasal affections in, 532 ; sputum in, 533; symptoms of, 533; treatment of, 534; cardiac, 531; hay, 515; Leyden's crystals in, 534; renal, 780; thymic, 520, 614. Atavism, in haemophilia, 348 ; in gout, 309. Ataxia, cerebellar, 926; cerebellar-heredo, 912; hereditary, 911; in peripheral neuritis, 837: in progressive paresis, 969; locomotor, 902; after small-pox, 59. Ataxic gait, 906. Ataxic paraplegia, 900. Ataxie-variolique, 59. Atelectasis, pulmonary, 571. Atheroma (see Artekio-sclerosis and Phlebo- SOLEROSIS). Athetosis, 960; bilateral or double, 962. Athlete’s heart, 637. Athyrea, 751, 754. Atmospheric pressure, effects of, 888. Atrophic cirrhosis, 475. Atrophy, acute yellow, of liver, 459; of brain, diffuse, in general paresis, 967; of brain, unilateral, 959; of muscles, various forms of, 1052; progressive muscular, of spinal origin, 919 ; unilateral, of face, 1044. Attitude, in pseudo-hypertrophic muscular pa- ralysis, 1051; in paralysis agitans, 983. Auditory centre, affections of, 859 ; nerve, dis- eases of, 859; vertigo, 861. Aura, forms of, in epilepsy, 1004. Auto-infection in tuberculosis, 218. Automatism, in petit mal, 1006; in cerebral syphilis, 192. Autumnal fever, 3. Avian tuberculosis, 203. Baccelli’s sign, 596, 598. Bacillus, anthracis, 174; of cholera, 133. Bacillus coli communis—distinction from ty- Apraxia, 928. 1114 INDEX. phoid bacillus, 3; in bile-passages, 469; in faeces of sucklings, 417, 418; in fat necrosis with colitis, 494; in peritonitis, 499; in sup- purative ependymitis, 935. Bacillus diphtheriae, 105, 362 ; value of, in diagnosis, 117. Bacillus gas (B. aerogenes capsulatus) in peri- tonitis, 499; in pneumo-pericardium, 626. Bacillus, gastricus, 377; of glanders, 280; of smegma, 184; in whooping-cough, 88; ma- larias, 157; of leprosy, 279; of syphilis, 184; of tetanus, 181; pyocyaneus, 128; strepto-, in typhus fever, 44. Bacillus, Klebs-Loeffler, 105; toxine of, 106. Bacillus pneumoniae, 573. Bacillus tuberculosis, 204; diagnostic value of, 250; distribution of, 205; in sputum, 240; methods of detection, 241; outside the body, 205; products of growth of, 205. Bacillus smegma, 184. Bacillus typhi abdominalis, 3, 631. Bacillus proteus fluorescens, 286. Bacteria, proteus group in diarrhoea, 418; rela- tion to diarrhoea, 417. Bacterium, coli commune (see Bacillus Coli Communis) ; lactis aerogenes, 418. Balanitis in diabetes, 325. Balantidium coli, 1082. “ Balloon-man,” the, 454. Ball-thrombus in left auricle, 651. Banting's method in obesity, 1077. “ Barben cholera,” 1071. Barking cough of puberty, 1026. Barlow's disease, 341. Barrel-shaped chest in emphysema, 580, 582; in enlarged tonsils, 366. Basedow's disease, 751. Basilar artery, embolism and thrombosis of, 952. Baths, cold, in typhoid fever, 38; in hyperpy- rexia of rheumatism, 299; in scarlet fever, 80. Beaded ribs in rickets, 334. Bed-bug, 1109. Bed-sores, acute, 890 ; in paraplegia, 891. Bednar's aphtluc, 353. Beer-drinkers, heart disease in, 674. Bell's (Luther) mania, 980. Bell's palsy, 855. Beri-beri, 838; in Great Britain, 838; in Ja- pan, 838 ; in the United States, 838. Besoin de respirer, 289. Biernacik's symptom, 969. “ Big-jaw ” in cattle, 282. Bile coloring matter, tests for, 458. Bile-ducts, ascarides in, 471; cancer of, 471, 487 ; stenosis of, 471. Bile-passages, diseases of, 463. Bilharzia haematobia, 1083. Bilious remittent fever, 167. Biliary cirrhosis of liver, 475. Biliary colic, 466. Biliary fistulae, 470. Birth palsies, 961. Black death, 144. Black spit of miners, 589. Black vomit, 140. Bladder, paralysis of, in locomotor ataxia, 907 ; care of, in myelitis, 895 ; hypertrophy of, in diabetes insipidus, 331; tuberculosis of, 265. Bleeders,” 348. Bleeding, in arterio-sclerosis, 706; in cerebral hsemorrhage, 953; in emphysema, 583; in heart-disease, 659 ; in pneumonia, 564; in sunstroke, 1077 ; in yellow fever, 143. Blepharospasm, 858. Blindness (see Amaurosis). Blood and ductless glands, diseases of, 720. Blood-casts (see Casts). Blood, characters of, in anaemia, 720 ; in cancer of the stomach, 407 ; in chlorosis, 723; in cholera. 135 ; in diabetes, 322; in gout, 312; in haemophilia, 349; in leukaemia, 737; in pernicious anaemia, 729 ; in pseudo-leukae- mia, Hodgkin’s disease, 744; in purpura, 346 ; in secondary anaemia, 720. Blood serum therapy in diphtheria, 121; in pneumonia, 548 ; in tetanus, 183 ; in typhoid fever, 41. Blood-vessels of liver, affections of, 461. “ Blue disease,” 697. Blue line on gums in lead poisoning, 1064. Boils, in diabetes, 325 ; after small-pox, 59. Bones, lesions of, in acromegalia, 1045 ; in con- genital syphilis, 190; in leukaemia, 740; in rickets, 333; in typhoid fever, 29. Borborygmi, 388, 416. Bothriocephalus latus, 1097; anaemia, 1097. Botulism, 1069. Botyroid liver in syphilis, 196. Bovine tuberculosis, 203. Bowel, affections of (see Intestines) ; acute obstruction of, 446 ; infarction of, 455. Brachial plexus, affections of, 873. Brachycardia (Bradycardia), 688; in typhoid fever, 18. Brain, diseases of, 924; abscess of, 974; abscess of, in congenital heart disease, 698 ; anaemia of, 938 ; atrophy and sclerosis of, 959 ; con- gestion of, 937 ; cortical centres of, 821; cysts in, 971; echinococcus of, 1105; in syphilis, 191; glioma of 970; hyperaemia of, 937 ; in- flammation of, 974; oedema of, 939: poren- cephalus of, 959. Brain, sclerosis of, 963 ; diffuse, 964; insular, 965 ; miliary, 964 ; tuberous, 965. Brain-murmur in rickets, 335. Brain, softening of, red, yellow, and white, 949, 950. INDEX. 1115 Brain, tubercle of, 263, 970. Brain, tumors of, 970; medical treatment of, 974; surgical treatment of, 974; symptoms, general and localizing, 971. Brand's method in typhoid fever, 38. Breakbone fever (see Dengue), 94. Breast-pang, 690. Breath, odor of, in diabetic coma, 326; foul, in scurvy, 339 ; foetid, in enlarged tonsils, 367. Breathing (see Kespiration) ; mouth, 364. Brick-maker’s anaemia, 1090. Bright’s disease, acute, 782; diagnosis of, 784; etiology of, 782; prognosis in, 785; symp- toms of, 783 ; treatment of, 785. Bright’s disease, chronic, 787 ; interstitial form of, 790; causes of, 790; cardio-vascular changes in, 794 ; hereditary influences in, 790 ; symptoms of, 793 ; treatment of, 796 ; parenchymatous form of, 788. Brisbane Hospital, statistics of Brand’s method at, 39. “ Broken-winded,” 671. Bromism, 1010. Bronchi, casts of, 536; diseases of, 524. Bronchial asthma, 531. Bronchial catarrh (Bronchitis), 524. Bronchial glands, tuberculosis of, 209, 212, 218, 227; enlargement in whooping-cough, 90, 611; suppuration in, 611; perforation of, into oesophagus, 612. Bronchiectasis, 529 ; abscess of brain in, 531; congenital, 529; cylindrical, 529; etiology of, 529; rheumatoid affections in, 531; sac- cular, 529; sputum in, 530 ; universalis, 529. Bronchiolitis exudativa, 531. Bronchitis, 524; acute, 524; etiology of, 524; symptoms of, 524; treatment of, 525; capil- lary, 570. Bronchitis, chronic, 526 ; etiology of, 526 ; symptoms of, 527 ; treatment of, 528. Bronchitis, fibrinous, 535. Bronchitis, in measles, 83; in small-pox, 59; in typhoid fever, 25; putrid, 528. Bronchocele (see Goitre), 750. Bronchophony, 554. Broncho-pneumonia, acute, 570; chronic, 567 ; acute tuberculous, 231. Bronchorrhagia, 540. Bronchorrhcea, 527 ; serous, 528. Bronze-skin, in phthiriasis, 1108 ; in Addison’s disease, 748 ; in Basedow’s disease, 753. Brown atrophy of heart, 678. Brown induration of lung, 538. Brown-Sequard's paralysis, 880. Bruit, d’airain, 610; de euir neuf, 618; de diable, 726; de pot fele (see Cracked-pot Sound), 247; de souffle, 629; oesophageal, 371. Bubo, parotid (see also Parotitis), 357. Bubonic plague, 144; bacillus of, 144. Buccal psoriasis, 356- Buhl's disease, 347. Bulbar paralysis, 922; acute, 922; chronic, 923; in progressive muscular atrophy, 922. Bulimia, 325. Cachexia, in cancer of the stomach, 404, 409; malaria], 161,170; periosteal, 341; saturnine, 1064; strumipriva, 755; syphilitic, 187. Caisson disease, 888. Calcareous concretions, in phthisis, 236; in the tonsils, 367. Calcareous degeneration, of arteries, 699; of heart, 678; of muscle fibres, 1050. Calcification, annular, of arteries, 699. Calcification in tubercle, 215. Calculi, biliary, 465; “coral,” 806; pancreatic, 497; renal, 806; tonsillar, 367; urinary, forms of, 806. Calculous pyelitis, 799. Calm, stage of, in yellow fever, 141. Cancer, of bile-passages, 471, 487; of bowel, 445; of brain, 971; of gall-bladder, 487; of kidney, 811; of liver, 485; of lung, 590: of oesophagus, 372; of pancreas, 496; of peri- tonaeum, miliary, 506; of pleura and lung, 590; of stomach, 402; acute, 404. Cancrum oris, 354; in measles, 83. California, southern, climate of, for tubercu- losis, 273. Canities, the result of neuralgia, 1014. Canned goods, poisoning by, 1071. Capillary pulse, in aortic insufficiency, 641; in neurasthenia, 1034; in phthisis, 248. Capsule, internal, lesions of, 925. Caput Medusae, 476, 508. Caput quadratum, in rickets, 335. Carboluria, 777. Carbuncle in diabetes, 325. Cardiac, compensation, rupture of, 669; disease (see Disease of Heart). Cardiac murmurs, haimic, in chlorosis, 725; in chorea, 990; in idiopathic anaemia, 730. Cardiac murmurs, organic, in aortic insuffi- ciency, 640; in aortic stenosis, 644; in con- genital heart affections, 698; in mitral in- competency, 648; in mitral stenosis, 651; in tricuspid valve disease, 654. Cardiac nerves, neuralgia of, 690. Cardiac overstrain, 671. Cardiac septa, anomalies of, 695. Cardialgia (see Gastralgia). Cardinal’s case (hydrocephalus), 978. Cardiocentesis, 683. Cardio-respiratory murmur, 247. Cardio-sclerosis, 678. Cardio-vascular changes in renal disease, 794. Caries of cervical vertebrae, 914. 1116 INDEX. Caries of spine, 914. Carinated abdomen, 223. Carotid artery, ligature and compression of, in cerebral haemorrhage, 953. Carphologia, 27. Carpo-pedal spasm, 1020. Carreau, 260. Caseation, 215. Casts, blood, of bronchial tubes in haemopty- sis, 542; in fibrinous bronchitis, 536; of pel- vis of kidney and ureter, 811. Casts of urinary tubules, 785; epithelial, 783, 785; fatty, 789; granular, 789, 794. Casts, tube, in acute Bright’s disease, 783; in chronic Bright’s disease, 790, 794. Catalepsy in hysteria, 1029. Cataract, diabetic, 327; after typhoid fever, 28. Catarrh, acute gastric, 374; autumnal, 515; bronchial, 524; chronic gastric, 377; dry, 528; nasal, 513; simple chronic (nasal), 513; suffocative, 574. Catarrhal inflammation, influence in tubercu- losis, 212. Catarrhe sec, 528. Catarrhus rostivus, 515. Cats, diphtheria in, 104. Cauda equina, lesions of, 916. Cavernous breathing, 247. Cavities, pulmonary, physical signs of, 247; quiescent, 237. Cayor fly, 1110. Cellulitis of the neck, 361. Centrum ovale, lesions of, 925. Cephalalgia (see Headache). Cephalic tetanus, 182. Cephalodynia, 304. Cercomonas intestinalis, 147,1082; C. hominis, 1082. Cerebellar, ataxia, 912,926 ; heredo-ataxia, 912; vertigo, 926. Cerebellum, tumors of, 926; affections of, 926. Cerebral arteries, aneurism of, 955; arterio- sclerosis of, 956; endarteritis of, 956; syphi- litic endarteritis of, 191, 956. Cerebral haemorrhage, 940; aneurisms, miliary, in, 941; convulsions in, 948; diagnosis of, 948; etiology of, 940; forms of, 941; morbid anatomy of, 941; prognosis in, 949; symp- toms of, 942; treatment of, 953. Cerebral localization, 821. “ Cerebral pneumonia,” 556. “ Cerebral rheumatism,” 296. Cerebral sinuses, thrombosis of, 956. Cerebral softening, 949. Cerebritis (see Encephalitis), 974. Cerebro-spinal meningitis, epidemic, 96; anom- alous forms of, 100; complications of, 100; malignant form, 98 ; ordinary form, 98. Cerebro-spinal motor segment, lesions of, 831. Cervical pachymeningitis, 882. Cervical vertebrae, caries of, 914. Cervicp-brachial neuralgia, 1014. Cervico occipita) neuralgia, 1014. Cestodes, disease due to, 1096; visceral, 1099. Chalicosis, 587. Chancre, 185. Charbon, 174. Charcot-Leyden's crystals, 416, 534, 735; joints, 907. Chattering teeth, 854. Cheek, gangrene of, 354. Cheese, poisoning by, 1071. Cheesy pneumonia, 217. Chest expansion, diminution of, in Graves’s disease, 753. Cheyne-Stokes breathing, Cheyne’s original description of, 679 ; in apoplexy, 943; in fatty heart, 679; in sunstroke, 1076 ; in tuber- culous meningitis, 219; in uraemia, 780. Chiasma and tract, affections of, 845. Chicken-breast, 335, 366. Chicken-pox, 69. Child-crowing, 520. Children, constipation in, 452; diabetes in, 325; tuberculous broncho-pneumonia in, 232; pneumonia in, 559; tuberculosis of mesen- teric glands in, 228; mortality from small- pox in, 60; rheumatism in, 292; typhoid fever in, 32. Chills (see Rigors), in typhoid fever, 15. Chloasma phthisicorum, 250. Chloro-anaemia in phthisis, 248. Chloroma, 741. Chlorosis, 723; and anamiia, sinus thrombosis in, 957; diagilosis of, 726 ; dilatation of stom- ach in, 725; Egyptian, 1090; etiology of, 723; fever in, 726; heart symptoms in, 725; men strual disturbance in, 726; morbid anatomy of, 723; symptoms of, 723; thrombosis in, 726, 956. Choked disk, 844. Cholaemia, 458. Cholangitis, catarrhal, 468; suppurative, 469, 481. Cholecystectomy, 473. Cholecystitis acuta, 466. Cholecystitis, suppurative, 468; phlegmonous, 468. Cholecystotomy, indications for, 473. Cholelithiasis, 465. Cholera, asiatica, 132; bacillus of, 133; epi- demics of, 132; infantum, 419; nostras, 137; sicca, 136; typhoid, 136. Cholerine, 136. Cholestersemia, 458. Cholesterin in biliary calculi, 465. Choluria, 778. Chondrodystrophia foetalis, 333. INDEX. 1117 Chorea, acute, 985; etiology of, 985; heart symptoms of, 987, 990; infectious origin of, 988; in pregnancy, 986 ; paralysis in, 990; rheumatism and, 985; school-made, 987 ; seasonal relations of, 985. Chorea, canine, 986, 999; chronic, 998, 985. Chorea, habit or spasm, 996. Chorea, Huntingdon's or hereditary, 998. Chorea, insaniens, 989, 991 ; limp or paralytic form of, 990; major, 996; pandemic, 996; post-hemiplegic, 960; prehemiplegic, 943; rhythmic or hysterical, 999 ; senile, 998; spastica, 962, 993; Sydenham's, 985. Choreas, painful, 991. Choroid plexuses, sclerosis of, 978. Choroid, tubercles in, 224. Choroiditis in syphilis, 187. Chovestek's symptom in tetany, 1020. Chylangiomata, 456. Chyle vessels, disorders of, 456. Chylo-pericardium, 626. Chyluria, non-parasitic, 772; parasitic, 1093. Cicatrices fistuleuses, 271. Cicatricial stenosis of bowel, 445. Ciliary muscle, paralysis of, 850. Ciliata, parasitic, 1082. Cimex lectularius, 1109. Circulatory system, diseases of, 616. Circumcision, inoculation of tuberculosis by, 208; in haemophilia, 349. Circumflex nerve, affections of, 874. Cirrhosis, of kidney, 790; of liver, 474; of lung, 566; of pancreas, 495; ventriculi, 378. Cladothrix, 282. Cl'apotement, 392. Clarke's vesicular column, 825, 904. Claudication, intermittent, 691. Claviceps purpurea, poisoning by, 1072. Clavus hystericus, 1025. Claw-hand (main en grifle), 921. Climate, influence of, in asthma, 535; in chronic Bright’s disease, 796; in tubercu- losis, 272. Cloisters, tuberculosis in, 209. Clonus (see Ankle Clonus) ; jaw, 921. Clownism in hysteria, 1023. Cnethocampa, 1110. Cobalt miners, cancer of lung in, 590. Coccidium oviforme, 1080. Coccydynia, 1015. Cochin-China diarrhoea, 1095. Cceliac affection in children, 420. Coffee-ground vomit, 405. Cog-wheel respiration, 246. Coin-sound, 610. Cold pack, method of giving, 80. Colic, biliary, 466; in appendicitis, 431, 435; in angio-neurotic oedema, 1043; in purpura, 345; lead, 1065; mucous, 422; renal, 808. Colica Pictonum, 1063. Colitis, mucous, 422; simple ulcerative, 423; croupous, 558. Collapse stage, in cholera, 135; in peritonitis, 500. Collateral oedema of lung, 560. Collective Investigation Reports of the British Medical Association, 210, 292, 986. Colles's law, 185. Colloid cancer, of lung, 590; of peritonamm, 507; of stomach, 403. Colon, cancer of, 445; dilatation of, 454. Coma, diabetic, 326 ; epileptic, 1005; from heat- stroke, 1074; from muscular exertion, 781; in abscess of brain, 936; in acute yellow atrophy, 460; in alcoholic poisoning, 1057 ; in apoplexy, 943, 948; in cerebral syphilis, 192; in general paresis, 968; in multiple sclerosis, 966; in pernicious malaria, 169; in thrombosis of cerebral sinuses, 957 ; in typhoid fever, 27; uraemic, 779. Coma vigil, 27. Comatose form of malaria, 169. Coma-vigil, in typhoid fever, 27; in typhus fever, 45. Comma bacillus, 133. Common bile-duct, obstruction of, 468. Compensation in valve lesions, 636 ; periods in, 669 ; rupture of, 669. Composite portraiture in tuberculosis, 211. Compression and contraction of the bowel, 445. Compression paraplegia, 914. Concretions (see Calcareous). Concussion of spinal cord, 1037. Confusional insanity, 28. Congenital heart affections, 695. Congenital stricture of the bowel, 445. Congenital syphilis, 188. Conjugate deviation, in brain tumor, 973; in hemiplegia, 944; in meningitis, 224. Conjunctiva, diphtheria of, 114. Consecutive nephritis, 799. Constipation, 451; in adults, 451; ki infants, 452; spasmodic, 451; treatment of, 452. Constitutional diseases, 292. Consumption (see Tuberculosis), 228. Contracted kidneys, 790. Contracture, hysterical, 1023; in hemiplegia, 947 ; of nurses, 1019. Contusion pneumonia, 546. Conus arteriosus, stenosis of, 697. Conus medullaris, lesions of, 916. Convalescence, fever of, 15; from typhoid fever, management of, 42. Convulsions, epileptic, 1005 ; hysterical, 1005, 1022 ; in acute yellow atrophy, 460 ; in alco- holism, 1057; in aspiration of pleural effu- sion, 605 ; in cerebral haemorrhage, 943 ; in cerebral syphilis, 192, 1008; in cerebral tu- 1118 INDEX. mors, 971 ; in chronic Bright’s disease, 789. Convulsions, infantile, 999 ; diagnosis of, 1001; etiology of, 999; relation to rickets, 336; symptoms of, 1000 ; treatment of, 1001. Convulsions, in general paralysis, 968 ; in he- patic colic, 467 ; in infantile hemiplegia, 959 ; in lead-poisoning, 1066 ; in meningitis, 936 ; in sun-stroke, 1076; in uraemia, 779; Jack- sonian, 1007. Convulsive tic, 996, 997. Co-ordination, disturbance of, in tabes, 906. Copaiba eruption, 84. Copper test for sugar, 324. Copraemia, 451, 723. Coprolalia, 997. Cor adiposum, 678. Cor biloculare, 695. Cor bovinum, 639. Cor villosum, 617. Cornea, ulceration of, in small-pox, 60. Coronary arteries, in angina pectoris, 691; ob- literation of, 676. Corpora quadrigemina, tumors in, 973. Corpulence, 1077. Corrigan's disease, 637. Corrigan's pulse, 641. Coryza, acute, 512; foetida, 514; from the io- dides, 202. Costiveness, 451. Cough, barking, of puberty, 1026 ; hysterical, 1026 ; in acute bronchitis, 525; in chronic bronchitis, 527 ; in pertussis, 89 ; in phthisis, 240; during aspiration of pleural effusion, 604; in pneumonia, 553; paroxysmal, in bronchiectasis, 530; paroxysmal, in fibroid phthisis, 252; stomach, 380. Country fever, 1076. Coup de soleil, 1073. Cow-pox, 64, 72. Cracked-pot sound, 247. Cramp, writer’s, 1017. Cramps, in cholera, 135; in gout, 316; in chronic Bright’s disease, 795. Cranio-sclerosis, 335. Cranio-tabes, relation to congenital syphilis, 335 ; in rickets, 335. Craw-craw, 1092. Creophila, 1109. Crepitus, gall-stone, 468. Crescents in blood in malaria, 160. Cretinism, sporadic, 754. Cretinoid change, 754. Crises, gastro-intestinal, in angio-neurotic oedema, 1044; in locomotor ataxia, 400, 907; in purpura, 345. Crisis, in pneumonia, 551; in relapsing fever; 49 ; in typhus fever, 46. Crossed or alternating paralysis, 925, 946. Crossed sensory paralysis, 925. Croup, membranous, 109 ; spasmodic, 521. Croupous enteritis, 421. Croupous pneumonia, 545. Crura cerebri, lesions of, 925, 946. Crutch paralysis, 874. Cruveilhier's palsy, 919. Cry, epileptic, 1005 ; hydrocephalic, 222; hys- terical, 1026 ; in congenital syphilis, 189. Cryptogenetic septicaemia, 128. Crystals, Leyden's, 534, 537. Curschmann's spirals, 534, 537. Cyanosis, in acute tuberculosis, 219 ; in oongen- ital heart-disease, 697 ; in emphysema, 581. Cycloplegia, 850. Cynanche maligna, 103. Cynobex hebetica, 1026. Cystic disease, of kidney, 813 ; of liver, 814. Cystic duct, obstruction of, 467. Cysticercus cellulosae, 1099; ocular, 1100; sub- cutaneous, 1099; symptoms of invasion of, 1099 ; general, 1099 ; cerebro-spinal, 1100. Cystine calculi, 774, 807. Cystinuria, 774. Cystitis, in locomotor ataxia, 907 ; in transverse myelitis, 892; tuberculous, 265. Cytozoa, 1080. Cysts, chylous, of mesentery, 456 ; in kidneys, 813 ; of brain, apoplectic, 942; porencephalic, 959; of brain, thrombotic, 951; pancreatic, 495. Dancing mania, 996. Dandy lever (dengue), 94. Davainea Madagascariensis, 1097. Day-blindness, 843; in scurvy, 340. Deaf-mutism after cerebro-spinal fever, 101. Deafness, in cerebral tumor, 973; in cerebro- spinal meningitis, 101; in hysteria, 1026 ; in Meniere's disease, 861; in scarlet fever, 77; in tabes dorsalis, 907; nervous, 860. Death, modes of, in tuberculosis, 255 ; sudden, in typhoid fever, 35; in pleural effusion, 597. Debility, nervous (see Neurasthenia), 1082. Debove's forced feeding, 274,1032. Decubitus, acute, 944; (bed-sores) in trans- verse myelitis, 890. Defensive alkaloids, 1069. Degeneration, reaction of, 829, 838, 857. Degeneration, systemic, of spinal cord, 881. Deglutition, difficult (see Dysphagia). Deglutition pneumonia, 571. Delayed resolution in pneumonia, 561. Delayed sensation in tabes, 906. Delirium, acute, 980; acute, in lead-poisoning, 1066 ; cordis, 35, 684, 686 ; expansive, 968; in acute rheumatism, 296 ; in pneumonia, 555; in typhoid fever, 26; in typhus fever, 45; tremens, 1059. Deltoid, paralysis of, 874. INDEX. 1119 Delusional insanity after fevers, 28, 59, 556. Delusions of grandeur, 968. Dementia paralytica, 966; alcohol as a factor in, 1058; syphilis and, 188, 192, 967. Demodex folliculorum, 1107. Dendrons, 816. Dengue, 94. Dentition, in congenital syphilis, 190; in mer- curial stomatitis, 356; in rickets, 335. Dermacentor americanus, 1107. Dermatitis, exfoliative form, 77. Derinatobia, 1110. Dermatose parasitaire, 1092. Desiccation in small-pox, 56. Desquamation, in measles, 82; in rubella, 85; in scarlet fever, 74; in small-pox, 56; in typhoid fever, 16. Deviation, secondary, 851. Devonshire colic, 1063. Dextrocardia, 695. Diabetes insipidus, 330; heredity in, 330; in abdominal tumor, 331; in tuberculous peri- tonitis, 331. Diabetes mellitus, 320; acute form, 323; chronic form, 323; coma in, 326; diet in, 328; die- tetic form, 323 ; gangrene in, 325; hereditary influences in, 320; in obesity, 320; in chil- dren, 325; lipogenic form, 323; neurotic form, 323; pancreas in, 321, 322; pancreatic form, 323; paraplegia in, 327'; theories of, 321; treatment of, 327 ; urine in, 323. Diabetes, phosphatic, 776. Diabetic, centre in medulla, 320; cirrhosis, 322; coma, 326; phthisis, 322; tabes, 326. Diacetic acid, 777. Diagnosis, topical, cerebral, 924; spinal, 879. Diaphragm, paralysis of, 872; degeneration of muscle of, 872. Diarrhoea, 414; acute dyspeptic, 418; alba, 420; bacteria in, 417; chronic, treatment of, 426; chylosa, 420; endemic, of hot countries, 1095; from anchylostomiasis, 1090; hill, 421; in children, treatment of, 426; in cholera, 135; in dysentery, 146, 150, 151; in hysteria, 1027; in phthisis, 249; in typhoid fever, 21; in uraemia, 780; nervous, 415; of Cochin- China, 1095 ; tubular, 422; lienteric, 416. Diathesis, gouty, 310, 315; haemorrhagic, 343 ; lithsemic, 773 ; tuberculous or scrofulous, 211. Diazo-re action in typhoid fever, 28. Dicrotism of pulse in typhoid fever, 11,18. Diet, in chronic dyspepsia, 381; in constipation, 453; in convalescence from typhoid fever, 42; in diabetes, 328; in gout, 317; in infan- tile diarrhoea, 427; in leprosy, 278; in obe- sity, 1078; in scurvy, 340; in tuberculosis, 273; in typhoid fever, 37. Dietl's crises, 760. Digestive system, diseases of, 351. Dilatation of bronchi, 529; of colon, 454; of heart, 670; of stomach, 390. Dioctophyme gigas, 1095. Diphtheria, 103; atypical forms of, 111; of au- ditory meatus, 115; of conjunctiva, 114; and croup, 109; bacillus of, 105; contagiousness of, 103; diagnosis of, 117; immunity from, 106; in animals, 104; laryngeal, 113; latent, 112; morbid anatomy of, 108; nephritis in, 115; neuritis in, 117; nasal, 113; pharyngeal, 111; of skin, 115; symptoms of, 111; sys- temie infection, 112; treatment of, 120; anti- toxine treatment of, 121; of wounds, 115. Diphtheritic, colitis, 421; membrane, histology of, 110; processes in pneumonia, 550; pro- cesses in typhoid fever, 30. Diphtheritis, 106. Diphtheroid inflammations, 106. Diplegia, facial, 856; in children, 958, 961. Diplococcus pneumoniae (micrococcus lanceo- latus, pneumococcus), 546 ; in empyema, 598; in endocarditis, 631; in peritonitis, 499. Diplopia (see Double Vision), 852. Dipsomania (see Chronic Alcoholism), 1057. Dipylidium caninum, 1097. Discrete form of small-pox, 55. Disinfection in diphtheria, 119; in typhoid fever, 36. Dissecting aneurism, 706. Distomiasis, 1082. Distomum lanceolatum, 1082; D. Buski, 1082; D. endemicum, 1082 ; D. perniciosum, 1082; D. Sinense, 1082; D. felineum, 1082; D. Westermanni, 541, 1083. Dittrich's plugs, 528. Diuresis, 330. Diver’s paralysis, 888. Diverticula of oesophagus, 373. Dochmius duodenalis, 1090. Dolor pectoris, 692. Dorsodynia, 304. Dothienenterite, 1. Double heart, 695. Double vision, 852; in ataxia, 905. Dracontiasis, 1093. Dracunculus medinensis, 1093. Drainage, and diphtheria, 103; and scarlet fever, 72; and tonsillitis, 361; and typhoid fever, 4. Dreamy state in epilepsy, 1004. Drepanidium ranarum, 158. Dropsy, cardiac, treatment of, 661; in anae- mia (oedema), 729; in acute Bright’s disease, 783; in aortic insufficiency, 642; in aortic stenosis, 644; in cancer of stomach, 407 ; in chronic Bright’s disease, 795; in mitral in- sufficiency, 647; in mitral stenosis, 653; in phthisis, 250; in scarlet fever, 76. Drug-rashes, 78, 343. 1120 INDEX. Drunkenness, diagnosis from apoplexy, 949, 1057. Dry-mouth, 357. Duchenne's paralysis, 922. Dulness, movable, in pleural effusion, 596; in pneumothorax, 610. Dumb ague, 172. Duodenal ulcer, 394; diagnosis of, from gastric, 400. Duodenum, defect of, 445; ulcer of, 394. Dura mater, diseases of, 881, 932; haematoma of, 932. Durande's mixture, 472. Duroziez's murmur, 641. Dust, diseases due to, 568,587; tubercle bacilli in, 206. Dysacusis, 860. Dysentery, 145; abscess of liver in, 148, 152; acute catarrhal, 146; amoeba coli in, 147; chronic, 151; diphtheritic, 149; treatment of, 153; tropical or amoebic, 147. Dyspepsia, acute, 374; chronic, 377; nervous, 386 ; treatment of chronic, 381. Dysphagia, hysterical, 370, 1027; in cancer of the oesophagus, 372 ; in hydrophobia, 171; in oesophagismus, 370; in oesophagitis, 369 ; in pericardial effusion, 620; in thoracic an- eurism, 712; in tuberculous laryngitis, 522. Dyspnoea, cardiac, treatment of, 661; from aneurism, 711; hysterical, 1026, 1036; in acute tuberculosis, 220 ; in aortic insuffi- ciency, 642; in bilateral paralysis of ab- ductors, 864; in cardiac dilatation, 673; in chlorosis, 725; in diabetic coma, 326; in mitral insufficiency, 647; in mitral stenosis, 652; in pneumonia, 551; in phthisis, 242; in oedema of the glottis, 519; in spasmodic laryngitis, 520 ; uraemic, 780. Dystrophies, muscular, 1051; etiology of, 1051; symptoms of, 1051; clinical forms of, 1052; morbid anatomy of, 1053; diagnosis of, 1053. Ear, complications of scarlet fever, 77; affec- tions of, in syphilis, 187, 190; symptoms simulating meningitis, 977. Ears, care of, in scarlet fever, 80. Ebsteinh method in obesity, 1078. Eburnation of cartilages, 306. Echinococcus cyst, fluid of, 1102,1104. Echinococcus disease, 1100; distribution of, 1102; symptoms of, 1103; of liver, 1103; of respiratory system, 1104; of kidneys, 1105; of nervous system, 1105. Echinococcus, endogenous, 1101; exogenous, 1101; multilocular, 1001,1105. Echinorhynchus gigas; E. moniliformis, 1095. Echokinesis, 997. Echolalia, 997. Eclampsia, 999. Ectopia cordis, 695. Eczema, of the tongue, 356; in diabetes, 325; in gout, 315. Ehrlich's reaction in typhoid fever, 28. Elastic tissue in sputum, 241. Electrical reactions, in exophthalmic goitre, '753; in facial palsy, 857; in Landry's paraly- sis, 897; in multiple neuritis, 838 ; in period- ical paralysis, 1040; in poliomyelitis anterior, 894; in Thomsen's disease, 1055. Electrolysis in aneurism, 715. Elephantiasis, 1093. Eliminative treatment in typhoid fever, 40. Emaciation, in anorexia nervosa, 1027; in gas- tric cancer, 404; in oesophageal cancer, 372; in phthisis, 245. Embolic abscesses, 130. Embolism, and aneurism, 707 ; in chorea, 987; in typhoid fever, 21; of cerebral arteries, 949; of cerebral arteries, diagnosis of, 951. Embryocardia, 554, 686. Emphysema, 578; atrophic, 583; compensa- tory, 578; hypertrophic, 579: hypertrophic, cyanosis in, 581; hypertrophic, hereditary character of, 579; interstitial, 578; vesicular, 578. Emphysema, subcutaneous, after tracheotomy, 615; in gastric ulcer, 395; in phthisis, 250; of the mediastinum, 615. Emprosthotonos in tetanus, 182. Empyema, 597 ; bacteriology of, 598; necessi- tatis, 284, 599, 713; perforation of lung in, 599 ; terminations of, 599; treatment of, 604. Encephalitis, meningo-, chronic diffuse, 966 ; meningo-, foetal, 961; polio-, of Strumpell, 959; suppurative, 974; syphilitic, 191. Encephalopathy, lead, 1066. Enchondroma of lung, 590. Endocarditis, acute, 627; chronic, 634; chronic vegetative, 632; diphtheritic, 630; etiology of, 630; in chorea, 630, 986; infectious, 630; in the foetus, 636, 696; in gonorrhoea, 630; in pneumonia, 630; in puerperal fever, 630; in rheumatism, 295, 630; in septicaemia, 630; in typhoid fever, 10; in tuberculosis, 238, 630; malignant, 629; meningitis in, 630; micro- organisms in, 631; mural, 631; recurring, 629 ; sclerotic, 636; simple or verrucose, 627; syphilitic, 197; ulcerative, 630. Endophlebitis, 704. Enteric fever (see Typhoid Fever), 1. Enteritis, catarrhal, 414; croupous, 421; diph- theritic, 421; in children, 417 ; phlegmonous, 422; membranous or tubular, 422; ulcerative, 423. Entero-colitis, acute, 420, 501. Enteroclysis in cholera, 138. Enteroliths, 430, 446 ; as a cause of appendici- tis, 430; in sacculi of colon, 452. INDEX. 1121 Enteroptosis, 759,760, 1034. Entozoa (see Animal Parasites), 1080. Environment, in tuberculosis, 272; experiment, of Trudeau, 272. Eosinophiles in leukaemia, 738. Ependymitis, purulent, 935, 979; granular, in general paresis, 967. Ephemeral fever, 285. Epidemic haemoglobinuria, 347, 766. Epidemic roseola, 85. Epidemic stomatitis, 290. Epididymitis (see Orchitis), 198, 266. Epilepsia, larvata, 1007 ; nutans, 870. Epilepsy, 1002 ; and alcoholism, 1003; and syphilis, 1003, 1008; diagnosis of, 1007; eti- ology of, 1002 ; heredity in, 1003 ; in chronic ergotism, 1072; in general paresis, 968; in lead-poisoning, 1066; in Raynaud's disease, 1043; Jacksonian, 832, 1007 ; masked, 1007 ; symptoms of, 1004; post-epileptic symptoms of, 1006; procursive, 1005; reflex, 1004; ro- tatory, 1005; spinal, 899 ; surgical treatment of, 1010 ; treatment of, 1009. Epileptic fits, stages of, 1005. Epistaxis, 516; in haemophilia, 349 ; in scurvy, 339 ; in typhoid fever, 25; “ renal,” 764; vi- carious, 517. Epithelioid cells in tubercle, 215. Ergotism, 1072; convulsive, 1072 ; gangrenous, 1072. Erichsen's disease (railway spine), 1035. Erosion ot teeth, 356. Erroneous projection from strabismus, 852. Eructations, 379. Eruptions (see Rashes). Erysipelas, 123 ; abscess in, 125 ; after vaccina- tion, 65 ; complications of, 125 ; diagnosis of, 125; facial, 124; in typhoid fever, 30 ; mi- grans, 125; puerperal, 123. Erythema, exudativum, 344; in pellagra, 1073; in typhoid fever, 16; in tonsillitis, 363. Erythromelalgia, 1016. Eschar, sloughing, in hemiplegia, 944. Eustrongylus gigas, 1095. Exaltation of ideas in general paresis, 968. Exanthematic typhus, 43. Exfoliative dermatitis, 77. Exophthalmic goitre, 751; acute form, 752; diminution of electrical resistance in, 753; pigmentation in, 753; tremor in, 753; urti- caria in, 753. Experts, medical, function of, in railway cases, 1038. Eye, motor nerves of, paralysis of, 851. Eye-strain in migraine, 1011. Eyes, conjugate deviation of, in brain tumor, 973 ; in hemiplegia, 944 ; in meningitis, 224. Facial, asymmetry, 868, 1044; diplegia, 856 ; hemiatrophy, 1044 ; nerve, paralysis of, 855 ; paralysis from cold, 856; paralysis from lesion of trunk of nerve, 856 ; paralysis from lesion of cortex, 855 ; paralysis, symp- toms of, 856. Facial spasm, 858. Facies, Hippocratic, 500; leontina, in lepro- sy, 279; in mouth-breathers, 365 ; Parkin- sonian, 983; syphilitic, 190; in typhoid fever, 13. Faecal, accumulation, 446, 451 ; concretions, 430, 452 ; vomiting, 449. Faeces, bacteria in, 417 ; in jaundice, 458. Falkenstein Sanitarium, 273. Fallopian tubes, tuberculosis of, 266. Famine fever (see .Relapsing Fever), 47. Farcy, acute, 281; chronic, 281. Farcy-buds, 281. Havre's tubercles, 486. Fasciola hepatica, 1082. Fat embolism in diabetes, 326. Fat necrosis, 494; of pancreas, in diabetes, 323. Fatty degeneration, in anaemia, 728; of ar- teries, 699 ; of heart, 677 ; of kidneys, 788; of liver, 489 ; of the new-born (Buhl's dis- ease), 347. Fatty stools, 497. Febricula, 285. Febris, carnis, 43 ; recurrens, 47. Fehling's test for sugar, 324. Fermentation, test for sugar, 324. Fetid stomatitis, 352. Fever, in cholera, 136 ; gastric, 374 ; hysterical, 1029 ; pernicious malarial, 161,169 ; in pneu- monia, 551; in acute pneumonic phthisis, 230, 231 ; in acute miliary tuberculosis, 219 ; in primary multiple neuritis, 835 ; in menin- gitic tuberculosis, 222 ; in pulmonary tuber- culosis, 242; in pyaemia, 130; in pylephle- bitis, suppurative, 484; in intermittent fever, 166; in relapsing fever, 49; in remittent fever, 168; in scarlet fever, 74; in septicae- mia, 127; in small-pox, 54; in sun-stroke, 1076; in appendicitis, 436 ; in secondary syphilis, 186; in typhoid fever, 13 ; in yellow fever, 141; lung, 545 ; Malta, 287 ; Mediter- ranean, 287 ; mountain, 288 ; Neapolitan, 287 ; putrid malignant, 1; relapsing, 47; ship, 43; slow nervous, 1; splenic, 174; spotted, 43 ; typhoid, 1; typho-malarial, 34, 169 ; typhus, 43 ; yellow, 139. Fever, idiopathic intermittent, 129. Fever, intermittent, in abscess of liver, 482; in ague. 166 ; in chronic obstruction of bile- passages, 469 ; by gall-stones, 469 ; in gastric cancer, 407; in Hodgkin's disease, 745; in pyaemia, 130; in pyelitis, 801; in secondary syphilis, 186 ; in tuberculosis, 239, 243. 1122 INDEX. Fibrillation, 921. Fibrinous, bronchitis, 535 ; pneumonia, 545. Fibro-caseous change in tubercles, 216. Fibroid disease of heart, 676. Fibrosis, arterio-capillary, 700. Fievre, inflammatoire, 1076 ; typhoide a forme renale, 29. Fifth nerve, paralysis of, 853; gustatory branch, 854; symptoms of, 853; trophic changes in paralysis of, 854. Filaria hominis sanguinis, F. Bancrofti, F. diurna, F. perstans, 1091; F. medinensis, 1093. Filaria Loa, F. lentis, F. labialis, F. hominis oris, F. bronchialis, F. imitis, 1094. Filariasis. 1091. First sound of heart, obliteration of, in typhoid fever, 19. Fish, poisoning by, 1071. Fisher's brain murmur, 335. Fistula in ano in tuberculosis, 253, 262. Fistula, cesophago-pleuro-cutaneous, 373. Flagellated organisms in blood in malaria, 160. Flatulence, in hysteria, 1027 ; in nervous dys- pepsia, 390; treatment of, 384. Flea, bite of, 1109. Flint's murmur in heart-disease, 640, 651. Floating kidney, 758. Florida fever, 1076. Fluke, bronchial, 1083; blood, 1083; liver, 1082. Flukes, diseases caused by, 1082. Foetal heart-rhythm, 686. Foetus, endocarditis in, 696 ; syphilis in, 188; tuberculosis in, 206; white pneumonia of, 194. Folie Brightique, 779. Follicular colitis, 420. Follicular tonsillitis, 361. Food (see Diet). Foot and mouth disease, 290. Foot-drop, 835, 836. Foreign bodies in intestines, 446. Fourth nerve, 850 ; paralysis of, 851. Fractures in rickets, 336. Fremitus, vocal, 245, 554; hydatid, 1103. Fresh-air treatment in tuberculosis, 272. Friction, pericardial, 618; peritoneal, 506; pleural, 247, 596 ; pleuro-pericardial, 247. Friedreich's ataxia, 911. Friedreich's sign in adherent pericardium, 625. Frontal convolutions, lesions of, 972. Frontal sinuses, pentastomes in, 1106. Fungi in pulmonary cavities, 242. Funnel breast, 245, 366. Gait, ataxic, 906; in paralysis agitans, 983 ; in pseudo-hypertrophic muscular paralysis, 1052; in spastic paraplegia, 899; pseudo- tabetic, 908 ; steppage, in peripheral neuritis, 837 ; in diabetic tabes, 326. Gall-bladder, atrophy of, 468; calcification of, 468; dilatation of, 467 ; empyema of, 468; forming abdominal tumor, 467 ; phlegmonous inflammation of, 468. Gallop-rhythm, 686. Galloping consumption, 232. Gall-stone crepitus, 468. Gall-stones, 465. Galvano-puncture in aneurism, 715. Game-birds, poisoning by, 1071. Ganglia, basal, tumors of, 972. Gangrene, in diabetes, 325 ; in ergotism, 1072; in pneumonia, 561; in typhoid fever, 20 ; in typhus, 46 ; local or symmetrical, 1042; mul- tiple, 1042 ; of lung, 584 ; of mouth, 354. Gangrenous stomatitis, 354. Garrod's thread test for uric acid, 312. Gas-bacillus (see Bacillus .erogenes capsu- latus). Gastralgia, 385. Gastrectasis, 390. Gastric catarrh, acute, 374. Gastric, crises, 375, 400, 907; fever, 374. Gastric juice, hyperacidity of, 387, 400; sub- acidity of, 387. Gastric ulcer, 394; clinical forms of, 398. Gastritis, acute, 374; acute suppurative, 376 ; chronic, 377 ; diphtheritic, 377 ; membra- nous, 377 ; mycotic, 377; parasitic, 377; phlegmonous, 376 ; polyposa, 378 ; sclerotic, 378 ; simple, 374 ; simple chronic, 378 ; toxic, 376. Gastrodynia, 385. Gastro-enterostomy, statistics of, 393. Gastrorrhagia, 411. Gastrotomy, 373. Gastroxynsis, 387. General paralysis of the insane (general pa- resis), 966 ; diagnosis of from syphilis. 192, 969 ; influence of syphilis in, 188, 192, 967. Genito-urinary system, tuberculosis of, 264. Gentles, 1110. Geographical tongue, 356. Geophagism, 389. Gerlier's disease, 862. German measles, 85. Giant cells, 215. Giant growth, 1047. Giants, relation to acromegaly, 1046. Gigantism and acromegaly, 1046. Gigantoblasts, 729. Gigantorhynchus gigas, 1095. Gilbert's sirup, 201. Gilles de la Tourette's disease, 997. Gin-drinker’s liver (see Cirrhosis of Liver), 474. Girdle-feeling in transverse myelitis, 891. INDEX. 1123 Glanders, 280; acute, 281; chronic, 281; diag- nosis from small-pox, 62. Glioma of brain, 970. Gliosis, 913. Glissonian cirrhosis, 475. Globulin in urine, 770. Globus hystericus, 1022. Glomerulo-nephritis, 783. Glosso-labio-laryngeal paralysis, 922. Glosso-pharyngeal nerve, 863. Glossy skin in arthritis deformans, 307. Glottis, oedema of, 519 ; in Bright’s disease, 519, 784; in small-pox, 59; in typhoid fever, 10. Gluteal nerve, 876. Glycogen, formation of, 321. Glycogenic function of liver, 321. Glycosuria, 321, 778; gouty, 317. Gmelin's test, 458. Goitre, 750; exophthalmic, 751; sudden death in, 750; symptoms of, 750. Gonorrhoeal arthritis, 301 ; anatomical changes in, 301; endocarditis in, 302. Gout, 309 ; acute, 313 ; chronic, 314; Ebstein's theory of, 312; etiology of, 309; hereditary influence in, 309 ; influence of alcohol in, 309; influence of food in, 309; influence of lead in, 310 ; irregular, 315 ; morbid anatomy of, 312; nervous theory of, 312 ; retrocedent or suppressed, 314 ; symptoms of, 313 ; treat- ment of, 317. Gouty kidney, 790. von Graefe's sign, 752. Grain, poisoning by, 1072. Grandeur, delusions of, 968. Grand mal, 1004. Granular kidney, 790. Gravel, renal, 806. Graves's disease, 751. Green cancer, 741. Green-sickness (see Chlorosis), 723. Green-stick fracture in rickets, 336. Gregarinidae, parasitic, 1080. Grinder’s rot, 587. Grippe, la, 92. Gruebler's tumor, 1065. Guaiacum test for blood, 765. Guinea-worm disease, 1093. Gummata, 185; in acquired syphilis, 188; in congenital syphilis, 191; of brain and spinal cord, 191; of heart, 197 ; of kidneys, 198; of liver, 195; of lungs, 194; of rectum, 197; of testis, 198; structure of, 185. Gummatous periarteritis, 198. Gums, black line on, in miners, 1065; blue line on, in lead-poisoning, 1064; in scurvy, 339; in stomatitis, 352; red line on, in pul- monary tuberculosis, 248. Gustatory paralysis, 854. Habit spasm, 996; in mouth-breathers, 367. Habitus, apoplectic, 940; phthisicus, 211. Haematemesis, 411; causes of, 411; in cirrho- sis of liver, 477; diagnosis from haemoptysis, 413; in enlarged spleen, 171, 411; in scurvy, 339. Haemato-chyluria, non-parasitic, 772; para- sitic, 1092. Haematogenous jaundice, 457. Haematoma of dura, of brain, 932; of cord, 883; of mesentery, 454. Haematomyelia, 887. Haematorrhachis, 885. Haematozoa of malaria, 155, 158. Haematuria, 764; endemic, of Egypt, 1083; in acute nephritis, 783; in chronic phthisis, 250; in psorospermiasis, 1081; in renal cal- culus, 809; in renal cancer, 811; in tubercu- losis of kidney, 265; malarial, 170. Haemoglobin, reduction of, in chlorosis, 724. Haemoglobinaemia, 767. Haemoglobinuria, 765; epidemic, in infants, 190, 347, 766; in Raynaud's disease, 1042; paroxysmal, 766 ; toxic, 766. Haemolysis, 457; in pernicious anaemia, 727; in toxic haemoglobinuria, 767. Haemo-pericardium, 626. Haemophilia, 343, 348. Haemoptysis, causes of, 540; hysterical, 1026; at onset of phthisis, 239; in acute broncho- pneumonic phthisis, 233; in acute tubercu- losis, 220; in aneurism, 541,711; in aortic in- sufficiency, 642; in arthritic subjects, 541; in bronchiectasis, 531; in cirrhosis of lung, 569; in emphysema, 583 ; in miliary tuberculosis, 220; in mitral insufficiency, 647; in mitral stenosis, 653; in pneumonia, 553; in pul- monary gangrene, 585; in scurvy, 339 ; symptoms of, 541; treatment of, 543; in ty- phoid fever, 26; relation to tuberculosis, 541; parasitic,-1083; periodic, 541; vicarious, 541. Haemorrhage, broncho-pulmonary, 540 ; cere- bral, 940; from mesentery, 454; from the stomach, 411; in acute yellow atrophy, 460; in anaemia, 731; in cirrhosis of the liver, 477; in contracted kidney, 794; in gastric cancer, 405; in gastric ulcer, 397 ; in haemophilia, 349; in hysteria, 1026, 1028; in intussusception, 449; in leukaemia, 736; in malaria, 170,171; in nephrolithiasis, 809; in the new-born, 347; in purpura haemorrhagica, 346; in scarlet fever, 75; in scurvy, 339; in small-pox, 56; in splenic enlargement, 171, 411; into pan- creas, 492; into spinal cord, 887; into spinal membranes, 885; in tuberculous pyelitis, 265; in tuberculosis of bowels, 262; into ventri- cles of brain, 942 ; in typhoid fever, 9, 23; in yellow fever, 141; pulmonary, 242, 540. Haemorrhagic diathesis, 343, 348. 1124 INDEX. Haemorrhagic diseases of the new-born, 347. Ilaemothorax, 600. Hair tumors in stomach, 410. Hair, the, in typhoid fever, 17. Hallucinations in hysteria, 1029. Handwriting in general paresis, 968. Harrison's groove in rickets, 335; in enlarged tonsils, 366. Harvest-bug, 1107. Hay-asthma (hay-fever), 515. Haygarth's nodosities, 306. Headache, from cerebral tumor, 971; in cere- bral syphilis, 192; in mouth-breathers, 367; in typhoid fever, 11,12, 26; in uraemia, 780; sick, 1011. Head-cheese, poisoning by, 1069. Heart, diseases of, 627; diseases of, Oertel's treatment of, 681; amyloid degeneration of, 678; aneurism of, 681; athlete’s, 637 ; brown atrophy of, 678; calcareous degeneration of, 678 ; congenital affections of, 695 ; dilatation of, 670; displacement in pleuritic effusion, 594; displacement in pneumothorax, 609; fatty disease of, 677; fragmentation of fibres of, 677; hydatids of, 683; hypertrophy of, 663; hypertrophy of, in Bright’s disease, 794; in exophthalmic goitre, 752; irritable, 674, 684; new growths in, 682; neuroses of, 684; palpitation of, 684; parenchymatous degeneration of, 677; rupture of, 682; scle- rosis of, 676 ; valvular diseases of, 637. Heart-failure in diphtheria, 116. Heart-muscle in fevers, 677. Heart-valves, congenital anomalies and lesions of, 696; rupture of, 638. Heart- weakness, treatment of, in typhoid fever, 38. Heat, exhaustion, 1073; stroke, 1073. Heberden's nodes, 306. Hebrews, prevalence of diabetes among, 320. Hectic fever, 243, 244. * Heel, painful, 1015. Heller's test, 769. Helminthiasis (see Animal Parasites), 1080. Hemeralopia, 848; in scurvy, 340. Hemialbumose, 770. Hemiansesthesia, in cerebral haemorrhage, 946; in hysteria, 1025; in lesions of internal cap- sule, 925; in unilateral cord lesions, 880. Hemianopia, heteronymous, 845; homonymous, 845; in migraine, 1011; lateral, 845; nasal, 845; significance of, 848; temporal, 845. Hemicrania, 1011. Hemiopic pupillary inaction, 847. Hemiplegia, 944; crossed, 925, 946. Hemiplegia, infantile, 958; aphasia in, 960; epilepsy in, 960; in hysteria, 1023; mental defects in, 960; post-hemiplegic movements in, 960; spast'ca cerebralis, 960. Hemiplegie flasque, 947. Henoch's purpura, 345. Hepatic, abscess, 480; artery, enlargement of, 463; colic, 466; intermittent fever, 469; vein, affections of, 463. Hepatitis, diffuse syphilitic, 195; interstitial (see Cirrhosis), 474; suppurative, 480. Hepatization, of lung, 548; white, of foetus, 194. Hepatogenous jaundice, 457. Hereditary form of oedema, 1044. Heredity, in Bright’s disease, 790; in diabetes insipidus, 330; in Friedreich's ataxia, 911; in gout, 309; in haemophilia, 348; in para- myoclonus multiplex, 1056; in spastic para- plegia, 900; in syphilis, 184; in tuberculosis, 206; in tuberculosis, chart of, 207. Herpes, in trifacial neuralgia, 1014; in cerebro- spinal meningitis, 99; in febricula, 286; in malaria, 166; in pneumonia, 555; zoster, 1015. Hiccough, 872; hysterical, 1026. Hiccough, Causes of, 872; treatment of, 873. High-tension pulse, characters of, 704, 794. Hill diarrhoea, 421. Hippocratic, facies, 500; fingers, 250; succus- sion, 610. Ilippus, 1012. Hodgkin's disease, 742; intermittent fever in, 745; morbid anatomy of, 742; symptoms of, 743. Horn-pox, 58. Hot Springs, of Arkansas, 301; of Banff, 301; of Virginia, 301. Huntingdon's chorea, 998. Husband and wife, diabetes in, 320; tubercu- losis in, 210. Hutchinson's teeth, 190. Hyaline casts in urine, 783, 789, 794. Hybrid measles, 85. Hydatid disease (see Echinococcus), 1096, 1100; prevalence of, in America, 1102. Hydatid thrill or fremitus, 1103. Hydrarthrosis, chronic, 302; intermittent, 1028. “ Hydrencephaloid condition,” 419, 939. Hydriatic treatment (see Hydrotherapy). Hydrocephalus, acquired, 978 ; acute, 221, 978; chronic, 977 ; chronic, after cerebro-spinal meningitis, 101; congenital, 977; spurious, 419. Hydromyelus, 882, 912. Hydronephrosis, 803; congenital, 803; inter- mittent, 761, 804. Hydropericardium, 626. Hydroperitonseum, 507. Hydrophobia, 177. Hydro-pneumothorax, 608. Hydrops vesica; felleae, 467. Hydrotherapy, in typhoid fever, 38. Hydrotliorax, 608. INDEX. 1125 Hymenolepsis diminuta; H. nana, 1097. Hyperacusis, 860. Hypersesthesia, in ataxia, 906 ; in hysteria, 1025; in rickets, 334; in unilateral cord lesions, 880. Hyperosmia, 841. Hyperpyrexia, hysterical, 1030; in rheumatic fever; 295 ; in scarlet fever, 75; in sun-stroke, 1076 ; in tetanus, 182. Hyperthyrea, 751. Hyperthyroidism, 751. Hypertrophic cirrhosis of liver, 475. Hypnotism in hysteria, 1032. Hypochondriasis and neurasthenia, 1032. Hypodermic syringe in diagnosis of pleural effusion, 602. Hypoglossal nerve, diseases of, 870; paralysis of, 870; spasm of, 871. Hypophysis, enlargement of, 1046. Hypoplasia of aorta, 723. Hypostatic congestion, of lungs, 539; in ty- phoid fever, 26. Hysteria, 1021; and disseminated sclerosis, 966; contractures and spasms in, 1023; convulsive forms of, 1022; cries in, 1026; diagnosis of, 1030; disorders of sensation in, 1025; etiology of, 1021; forms of fever in, 1029; haamopty- sis in, 1026; insanity in, 1029; joint affec- tions in, 1028; mental symptoms of, 1028; metabolism in, 1029 ; metallotherapy in, 1025; non-convulsive forms of, 1023; paralysis in, 1023; special senses In, 1026; stigmata in, 344, 1028; traumatic, 1035; treatment of, 1030; visceral manifestations of, 1026. Hysterical angina pectoris, 693. llystero-epilepsy, 1007,1022. Hysterogenic points, 1025. Ice-cream, poisoning by, 1071. Ice, typhoid bacillus in, 4. Ichthyosis lingualse, 356. Ichthysmus, 1071; paralyticus, 1072. Icterus (see Jaundice), 457; acute febrile, 286; gravis, 459; neonatorum, 459. Idiocy in infantile hemiplegia, 960. Idiopathic anaemia of Addison, 726. Idiopathic intermittent fever, 129. Ileo-csecal region, in typhoid fever, 24; in ap- pendicitis, 436; in primary tuberculosis of bowel, 262. Ileus (see Strangulation of Bowel), 443. Imbecility in infantile hemiplegia, 960. Imitation in chorea, 987. Impetigo, contagious, and vaccination, 65. Impetigo, contagious, and ulcerative stomatitis, 352. Impotence, in diabetes, 327; in locomotor ataxia, 907. Incarceration of bowel, 443. Incoordination, of arms, 906; of legs, 906. Indians, American, chorea in, 985; consump- tion in, 204; small-pox among, 51. Indicanuria, 776. Infantile, convulsions, 999; paralysis, 892; scurvy, 341. Infantilism, 190. Infarcts, haemorrhagic, in typhoid fever, 21; pysemic, 130. Infection, definition, 126. Infectious diseases, 1; multiple neuritis in, 837. Inflation of bowel for intussusception, 450. Influenza, 92; diagnosis of, 93; etiology of, 92; symptoms of, 92; treatment of, 94; complica- tions of, 92. Infusoria, parasitic, 1082. Inhalation pneumonia (see Aspiration Pneu- monia), 571. Injection, intravenous, of milk, 138; intra- venous, of salines in diabetes, 330; subcu- taneous, of salines in cholera, 138. Inoculation, against small-pox, 50, 58 ; pro- tective, in cholera, 138 ; preventive, in hydro- phobia, 179; preventive, in pneumonia, 547 ; preventive, in yellow fever, 143 ; tuberculosis transmitted by, 208. Insanity, post-febrile, 28 ; in small-pox, 59. Insanity, relation of drink to, 1058 ; relations of chronic phthisis to, 250 ; relation of heart- disease to, 642. Insects, parasitic, 1108. Insolation, 1073. Insular sclerosis, 965. Intention tremor (see Volitional Tremor). Intermittent claudication, 691. Intermittent fever, 163 ; forms of (see Fever). Intermittent hepatic fever, 469. Intermittent hydrarthrosis, 1028. Internal capsule, lesions of, 925. Internal carotid artery, blocking of, 952. Intestinal casts, 422. Intestinal coils, tumor formed by, 259. Intestinal obstruction, 443. Intestines, diseases of, 414; actinomycosis of, 283 ; dilatation of, 454. Intestines, haemorrhage from, in typhoid fever, 9, 23 ; in dysentery, 146,150 ; in tuberculosis of bowel, 262; in intussusception of, 449 ; in ulceration of, 424. Intestines, infarction of, 455; intussusception of, 444, 449; invagination of, 444; miscel- laneous affections of, 454; new growths in, 445. Intestines, obstruction of, 443, 501; acute, 446 ; by enteroliths, 446; by foreign bodies, 446 ; by gall-stones, 446. Intestines, perforation of, in typhoid fever, 8. Intestines, primary tuberculosis of, 261: stran- gulation of, 443, 449 ; strictures and tumors 1126 INDEX. of, 445; twists and knots in, 445; ulcers of, 423. Intoxication, definition of, 127. Intoxications, 1057. Intussusception, 444,449. Invagination, 444; post-mortem, 444. Inverse type of temperature, in tuberculous meningitis, 219 ; in typhoid fever, 15. Iodide eruptions, 202. Iridoplegia, 850 ; accommodative, 850 ; reflex, 850. Iritis, syphilitic, 187, 190. Itch, 1107. Itching, of feet in gout, 316; of eyeballs in gout, 316; of skin in Bright’s disease, 795 ; of skin in jaundice, 457. Itch insects, 1107. Ixodes ricinus, 1107. Jacksonian epilepsy, 832,1007. Japan, Beri-beri in, 838; endemic fluke dis- ease in, 1082. Jaundice, black, 457 ; catarrhal, 463; choluria in, 458 ; from cirrhosis of liver, 477,478; epi- demic form of, 464 ; febrile, 286 ; from acute yellow atrophy, 459; from cancer of liver, 488 ; from gall-stones, 467, 469 ; hematoge- nous, 457; hepatogenous, 457 ; in pneumonia, 558 ; purpura in, 343, 458 ; in Weil's disease, 286 ; malignant, 459 ; of the new-born, 459 ; non-obstructive, 458 ; obstructive, 457 ; xan- thelasma in, 457; in yellow fever, 141. Jaw clonus, 921. Jigger. 1109. Johns Hopkins Hospital, statistics of tubercu- losis at, 204, 207. Joints (see Arthritis). Jumpers, 997. “ June cold,” 515. Keloid of Addison, 1048. Keratitis, in small-pox, 60; interstitial, of in- herited syphilis, 190. Keratosis follicularis, 1081. Keratosis mucosae oris, 356. Kidney, diseases of, 758 ; amyloid or larda- ceous disease of, 798; anomalies in form and position of, 758 ; cancer of, 811; cardiac, 763; circulatory disturbance in, 762; cir- rhosis of, 790; congenital cystic, 813; con- gestion of, 762 ; contracted, 7 90; cyanotic induration of, 763; cystic disease of, 813; echinococcus of, 1105; fused, 758; gouty, 790; granular, 790 ; horseshoe, 758; large white, 787, 788 ; movable, 758. Kidney, removal of, for cancer, 812; for mov- able kidney, 761. Kidney, rhabdo-myoma of, 811; sarcoma of, 811; scrofulous, 265, 800; small white kid- ney, 788 ; surgical kidney, 800 ; syphilis of, 198; tuberculosis of, 264; tumors of, 811 ; unsymmetrical, 758. Klebs-Loeffler bacillus, 105. Knee-jerk, loss of, in ataxia, 905 ; in diphtheria, 116. Koch treatment of tuberculosis, 264. Kopftetanus of Rose, 182. Labyrinthine disease, 860, 861. “ Lacing ” liver, 491. Lacunar tonsillitis, 361. “ Ladder pattern,” 448. La grippe, 92. Lamblia intestinalis, 1082. Landry's paralysis, 896. Lardaceous degeneration (see Amyloid). Larvae of flies, diseases caused by (myiasis), 1109. Laryngeal crises, 907. Laryngismus stridulus, 520. Laryngitis, acute catarrhal, 518 ; chronic, 519 ; oedematous, 519; spasmodic, 520 ; syphilitic, 523; tuberculous, 521. Larynx, diseases of, 518, 864 ; adductor paral- ysis of, 865 ; anaesthesia of, 866 ; hyperaesthe- sia of, 866; paralysis of abductors of, 864; spasm of the muscles of, 866 ; unilateral ab- ductor, paralysis of, 865. Latah, 997. Lateral sclerosis, primary, 898; amyotrophic, 919. Lateritious deposit, 773. Lathyrism, 1072. Lavage, 383 ; in dilatation of stomach, 393; in gastric ulcer, 401. Lead, colic, 1065; in the urine, 1064. Lead-palsy, 1065; localized forms of, 1065. Lead-pipe contraction, 900. Lead-poisoning, 1063; acute, 1064; arterio- sclerosis in, 1066; cerebral symptoms in, 1066; chronic, 1064; convulsions from, 1066; gouty deposits in, 1066: treatment of, 1066. Lead-workers, prevalence of gout in, 310. Leichen-tubercle, 208. Leontiasis ossea, 1047. Lepra alba, 279. Lepra mutilans, 279. Leprosy, 277; anaesthetic, 279; bacillus leprae in, 279; contagiousness of, 278; diagnosis of, 280; etiology of, 277 ; macular form of, 279; morbid anatomy of, 279; treatment of, 280; tubercular, 279. Leptomeningitis, acute, 883, 933 ; chronic, 884, 937 ; in Bright’s disease, 934; infantum, 934, 935; in pneumonia, 934. Leptothrix in mouth, 284. Leptus autumnalis, 1107. Leucin, 461. INDEX. 1127 Leucocytes, varieties of, 737; relation to uric acid, 312. Leucocytosis, in anemia, 722, 730; chlorosis, 725 ; cerebro-spinal meningitis, 99; diph- theria, 113; empyema, 598; erysipelas, 125; Hodgkin's disease, 744; leukemia, 738; ma- laria, 171; measles, 84; pyemia, 131; pneu- monia, 554, 560; pleurisy, 596; rheumatic fever, 294; scarlet fever, 78; stomach cancer, 407; tuberculosis (acute), 220; tuberculosis (chronic pulmonary), 248; typhoid fever, 18, 34. Leucoderma, 753,1048. Leucomaines, 1069. Leucomata, 187. Leukemia, 733; lymphatic, 740 ; blood in, 737; congenital, 734; definition of, 733 ; diagnosis of, 740; etiology of, 734; heredity in, 734; in animals, 734; in pregnancy, 734; morbid anatomy of, 734; myelogenous, 735; prog- nosis of, 741; spleno-medullary, 736; symp- toms of, 736 ; treatment of, 741. Leukoplakia buccalis, 356. Leyden's crystals, 534, 537. Lichtheim's schema, 927. Lienteric diarrhoea, 416. Life assurance, .and albuminuria, 770; and syphilis, 202. Lightning pains in ataxia, 905. Lineae atrophicae, 17. Lingual corns, 356. Lipaciduria, 777. Lipaemia, 322, 326. Lipothymia, 500. Lipuria, 777. Lips, tuberculosis of, 260; chancre of, 184. Lissauer's zone, 904. Lithaemia, 772, 773. Lithaemic state, 315. Lithiasis, 773. Lithic-acid diathesis, 772. Lithuria, 772. Liver, abscess of, 480; actinomycosis of, 283; acute yellow atrophy of, 459; amyloid, 490; anaemia of, 461; angioma of, 487; cardiac, 462; anomalies in form and position of, 491. Liver, cirrhosis of, 474; ascites in, 477; atro- phic, 475; fatty, 475 ; Glissonian, 475; haem- orrhage from stomach in, 477 ; hypertrophic, 475, 478; in tuberculosis, 263; in children, 474; jaundice in, 477; toxic symptoms in, 477; with cancer, 486. Liver, cysts of, 487; fatty, 489; gummata of, 195; hepato-phlebotomy in congestion of, 462; hydatids of, 1103; hyperaemia of, 461; infarc- tion of, 463; melano-sarcoma of, 487; new growths in, 485; nutmeg, 462; passive con- gestion of, 461; periodical enlargement of, 461; primary cancer of, 486; psorospermiasis of, 1080; pulsation of, 462; sarcoma of, 487; secondary cancer of, 486; syphilis of, 195; tuberculosis of, 263; in typhoid fever, 9, 25. Liver, diseases of, 457. Liver dulness, obliteration of, in perforative peritonitis, 24, 500. Liver, movable, 491. Liver, new growths in, 485. Living skeletons, 921. Lobar pneumonia, 545. Lobstein's cancer, 812. Localization, cerebral, 821; spinal, 819. Localized peritonitis, 433, 502. Lock-jaw, 180. Lock-spasm, 1018. Locomotor ataxia, 902; diagnosis of, 908; eti- ology of, 902; gastric crises in, 907; hemi- plegia in, 908; morbid anatomy of, 903 ; paresis in, 908; prognosis of, 909; rectal crises in, 907; relation of syphilis to, 903; reputed cures of, 909; symptoms of, 905; treatment of, 909. Long thoracic nerve, afl'ections of, 874. Loose shoulders, 1052. Loreto's operation, 715. Louis' law, 212. Lucilia macellaria, 1109. Ludwig's angina, 361. Lues venerea (syphilis), 184. Lumbago, 303. Lumbar plexus, lesions of, 876. Lumbar puncture of Quincke, 937, 979. Lung, abscess of, 586 ; causes of, 586 ; embolic, 586 ; etiology of, 586; symptoms of, 586. Lung, actinomycosis of, 283 ; albinism of, 580 ; brown induration of, 538 ; cancer of, acute, 591; carniiication of, 572; cirrhosis of, 566. Lung, diseases of, 537; stones, 236. Lung fever, 545. Lungs, congestion of, 537; active, 537 ; acute haemorrhagic, 538; hypostatic, 539; mechan- ical, 538; passive, 538. Lungs, echinococcus of, 1105. Lungs, gangrene of, 584; abscess of brain in, 585, 975; causes of, 584 ;etiology of, 584; mor- bid anatomy of, 584; symptoms and course of, 585; treatment of, 585. Lungs, new growths in, 590; in cobalt-miners, 590; physical signs of, 591; diagnosis of, 591. Lungs, hemorrhagic infarction of, 542; oedema of, 539; splenization of, 539, 572; syphilis of, 193; tuberculosis of, 228. Lupinosis, 1072. Lymphadenitis, general tuberculous, 226; local tuberculous, 226; simple, 611; suppurative, 611. Lymphadenoma, general, 742. Lymph-scrotum, 1093. Lymph, vaccine, 67. 1128 INDEX. Lymph vessels, dilatation of, 1093. Lyssa, 177. Lyssophobia, 180. Macular syphilides, 187. Main en griffe 882, 921. Maize, poisoning by (pellagra), 1073. Malarial fever, 155; accidental and late lesions of, 162; testivo-autumnal, 167; algid form of, 170; comatose form of, 169; continued and remittent form of, 167; description of the paroxysm in, 163; diagnosis of, 171; etiology of, 155; geographical distribution of, 155; haemorrhagic form of, 170; intermittent, 163; malarial cachexia, 161, 170; meteorological conditions influencing, 157; morbid anatomy of, 161; pernicious, 161, 169; pneumonia in, 163; quartan, 167 ; quotidian, 167 ; season in, 156; specific germ of, 157; telluric conditions influencing, 156; tertian, 167; treatment of, 172. Malignant jaundice, 459. Malignant oedema, 175; pustule, 175. Malignant purpuric fever, 96. Mallein, 282. Malta fever, 287. Mammary glands, hypertrophy in tuberculosis, 250 ; in hysteria, 1024; tuberculosis of, 267. Mammitis, chronic interstitial, in tuberculosis, 250, 267. Mania a potu, 1059. Mania, Bell's, 980. Marantic thrombi, 956. Marine Hospital Service, statistics of malaria in, 155. Marriage, question of, in haemophilia, 350; in syphilis, 202; in tabes dorsalis, 910; in tu- berculosis, 268. Marrow of bones, in small-pox, 53 ; in leukae- mia, 735; in pernicious anaemia, 728. Masque des femmes enceinte, 749. Mastication, spasm of the muscles of, 854. McBurney's tender point, 436. Measles, 81; complications and sequelae of, 83 ; contagiousness of, 81; desquamation in, 82; diagnosis of, 84; eruption in, 82; etiology of, 81; German, 85; morbid anatomy of, 81; period of incubation in, 81; prognosis of, 84; symptoms of, 81; treatment of, 84. Measly meat, examination of, 1098. Meat, poisoning by, 1069 ; tuberculous infection by, 211 ; inspection of, for trichina;, 1086. Mechel's diverticulum, 443. Median nerve, affections of, 875. Mediastino-pericarditis, indurative, 614. Mediastinum, affections of, 611; abscess of, 613; tumors of, 612; cancer of, 612; diagnosis of, 613; emphysema of, 615; pleural effusion in, 613; sarcoma of, 612; symptoms of, 612. Mediterranean fever, 287. Medulla oblongata, tumors of, 973. Megalo-cephalie, 1047. Megalocytes, 729. Megastrie, 390. Melsena, in duodenal ulcer, 400; in typhoid fever, 23; in tuberculosis of bowels, 262; neonatorum, 348. Melano-sarcoma of liver, 487. Melanuria, 776. Melasma suprarenale, 749. Meniere's disease, 861. Meningeal hasmorrhage, 941; in birth palsies,. 961. Meninges, affections of, 881, 932. Meningitis, acute, spinal, 883; in erysipelas, 124, 125; in gout, 316; in typhoid fever, 10, 26 ; occlusive, 934; posterior, 979; serosa, 978; syphilitic, 191 (see also Leptomenin- gitis, 883); tuberculous, 221. Meningo-encephalitis, chronic diffuse, 966 ; tu- berculous, 222. Mercurial, tremor, 984; stomatitis, 355. Merycismus, 388. Mesenteric artery, aneurism of, 455 ; embolism of, 455. Mesenteric glands, tuberculosis of, 228 ; tuber- culous tumors of, 260; in typhoid fever, 9. Mesenteric veins, diseases of, 455. Mesentery, chylous cysts of, 456 ; affections of, 454. Metallic, echo, 610 ; tinkling, 247, 610. Metallotherapy, 1025. Metastasis in mumps, 87. Metastatic abscesses, 130. Metatarsalgia, 1016. Meteorism in typhoid fever, 23; treatment of, 41. Micrococci, in dengue, 94 ; in Malta fever, 288; in vaccine virus, 64. Micrococcus lanceolatus, 545, 546, 573, 631. Micrococcus inelitensis, 288. Microcytes, 729. Micromelia, 333. Middle cerebral artery, embolism and throm- bosis of, 952. Migraine, 1011; treatment of, 1012. Miliary abscesses in typhoid fever, 9. Miliary aneurism, 941. Miliary fever, 289; epidemics of, 289. Miliary tubercle, 214; tuberculosis, acute, 217; tuberculosis, chronic, 235. Milk, and scarlet fever, 71; and typhoid fever, 5; products, poisoning by, 1071; sickness, 287; tuberculous infection by, 210. Mind-blindness, 928. Mind-deafness, 929. Miner’s, amemia or cachexia, 1090: lung, 587; nystagmus, 850; sarcoma of lung, 590. INDEX. 1129 Mitchell, Weir, treatment in hysteria, 1031. Mitral incompetency, 645; diagnosis of, 649 ; etiology of, 645; morbid anatomy of, 645; physical signs of, 648; symptoms of, 647. Mitral stenosis, 649; chorea and, 649; etiology of, 649; morbid anatomy of, 650 ; physical signs of, 651; presystolic murmur in, 651; rheumatism and, 649 ; symptoms of, 651. Moist sounds, 246. Molluscum contagiosum, parasites in, 1081. Monoplegia, 831, 924; facial, 855; in hysteria, 1023 ; in traumatic neuroses, 1037. Montaigne on renal colic, 808. Montreal General Hospital, autopsies in diph- theria, 109; in typhoid fever, 6; death-rate from typhoid fever at, 35. Statistics, of apex lesions in 1,000 autopsies, 271; of dysentery, 145 ; of haemorrhagic small-pox, 56 ; of pneu- monia, 561; of rheumatic fever, 292; of ty- phoid fever, 3. Montreal small-pox epidemic 1885-’86, 60, 69. Morbilli hsemorrhagici, 83. Morbus cseruleus, 697. Morbus, coxae senilis, 306, 308 ; errorum, 1108 ; maculosus, 343. Morbus maculosus neonatorum, 347. Morphia habit, 1061; treatment of, 1062. Morphinism, 1061. Morphiomania, 1061. Morphcea, 1048. Mortality, in cerebro-spinal meningitis, 102; in pneumonia, 561; in typhoid fever, 35 ; in whooping-cough, 91; in yellow fever, 142. Morton's painful foot, 1016. Marxian's disease, 913. Mosquitoes, relation of, to filaria disease, 1092. Motor, nuclei, chronic degeneration of, 919. Mountain, anaemia, 1090; fever, 288 ; sickness, 288. Mouth-breathing, 364. Mouth, diseases of, 351; dry. 357; putrid sore, 352. Movable kidney, 758 ; dilatation of stomach in, 760 ; symptoms of, 760; treatment of, 761. Movable liver, 491. Mucous colitis, 422. Mucous patches, 187. Muguet, 353. “ Mulberry ” calculi, 806. Multiple gangrene, 1042. Multiple sclerosis, 965. Mumps, 86, 357. Munich Pathological Institute, statistics of au- topsies in typhoid fever at, 6 ; of tuberculosis in children at, 254. Munich, reduction of typhoid mortality in, 35. Murmur, in aneurism, 710; brain, 335 ; cardio- respiratory, 247 ; in congenital heart-disease, 698; Flint's, 640; hsemic, 725; in endocar- ditis, 629 ; in lung cavity, 247 ; in subclavian artery in phthisis, 247 ; in valvular disease, 640, 644, 648, 651, 654. Musca domestica, 1110 ; M. vomitoria, 1109. Muscle callus in sterno-mastoid in infants, 868. Muscles, diseases of, 1050 ; degeneration of, in typhoid fever, 11, 30. Muscular atrophy, forms of, 1051 ; heredity in, 1051; atrophic and hypertrophic varieties, 1052; infantile form, 1052; juvenile type, 1053 ; progressive neural form, 1054 ; pero- neal type, 1054. Muscular atrophy, progressive spinal, 919 ; eti- ology of, 920 ; hereditary influence in, 920 ; morbid anatomy of, 920 ; symptoms of, 921. Muscular contractures in hysteria, 1023. Muscular exertion, coma after, 781. Muscular exertion in heart-disease, 637, 674. Muscular rheumatism, 303. Musculo-spiral paralysis, 874. Musical faculty, loss of, in aphasia, 929. Musical murmurs, 644, 698. Mussel poisoning, 1071. Myalgia, 303. Mycosis intestinalis, 176. Mycotic gastritis, 377. Myelin degeneration of alveolar cells, 525. Myelitis, acute, 889 ; acute central, 890 ; acute transverse, 891; compression, 914; in measles, 84; of anterior horns, 892 ; reflexes in, 891; transverse, of cervical region, 892 : syphilitic, 191, 193. Myelocytes, 738. Myelogenous leukaemia, 735. Myiasis, 1109 ; of nostrils and of ears, 1109 ; ot vagina, 1109 ; cutaneous, 1109. Myocarditis, 676; acute interstitial, 676 ; flbrous, 676 ; in rheumatism, 296 ; prognosis of, 680 ; segmenting, 20, 677; symptoms of, 678 ; in syphilis, 197 ; in typhoid fever, 19 ; treat- ment of, 680. Myocardium, diseases of, 675; lesions of, due to disease of coronary arteries, 675. Myoclonia, 1055. Myoclonies, 1056. Myopathies, the primary, 1051; diagnosis of, 1053. Myositis, 1050 ; ossificans progressiva, 1050. Myotonia congenita, 1054. Myotonic reaction of Erb, 1055. Myriachit, 997. Mytilotoxin, 1071. Myxcedema, 754; acute, 755 ; congenital form, 754; operative, 755. Nails, in typhoid fever, 17; in phthisis, 250. Nasal diphtheria, 113. Naso-pharyngeal obstruction, 364. Neapolitan fever, 287. INDEX. Neck, cellulitis of, 361. Necrosis, acute, of bone, 297 ; in typhoid fever, 29. Necrosis, anaemic, 675. Necrosis in tubercle, 215. Nematodes, diseases caused by, 1083. Nematoid worms in the common duct, 471. Nephralgia, 1016. Nephritis, 782; acute, 782; after diphtheria, 115; chronic, 787; chronic haemorrhagic, 789. Nephritis, chronic interstitial, 790; diagnosis of, 795; etiology of, 790; haemorrhages in, 795 ; increased tension in, 794; morbid anat- omy of, 791; prognosis of, 796 ; relation of heart hypertrophy to, 792; symptoms of, 793; treatment of, 796 ; urine in, 793; vomit- ing in, 795. N ephritis, chronic parenchymatous, 788 ; con- secutive, 799 ; in erysipelas, 125; in chronic suppuration, 788; in malaria, 163, 788 ; in scarlet fever, 75 ; in typhoid fever, 29. Nephritis, lymphomatous, 29 ; suppurative, 800. Nephrolithiasis, 806 ; symptoms of, 807. Nephro-phthisis (see Kidney, Tuberculosis of). Nephroptosis, 758. Nephrorrhaphy, 761. Nephrotomy, 803. Nephro-typhus, 29. Nerve-fibres, inflammation of, 833. Nerve-root symptoms, 914. “ Nerve-storms,” 1012. Nerves, diseases of, 833; diseases of cranial, 840; diseases of spinal, 871. Nerves, lesions of, 874; anterior crural, 876; circumflex, 874; external popliteal, 877; glu- teal, 876; internal popliteal, 877; long tho- racic, 874; median, 875 ; musculo-spiral, 874; obturator, 876; sciatic, 876; small sciatic, 876; ulnar, 875. Nervous diarrhoea, 415,1027. Nervous dyspepsia, 386. Nervous system, diseases of, 816. Nettle rash (see Urticaria). Neuralgia, 1013; causes of, 1013; cervico-bra- chial, 1014; cervico-occipital, 871,1014; in- fluence of malaria in, 1013 ; intercostal, 1015; lumbar, 1015; of nerves of feet, 1015 ; phrenic, 1015; plantar, 1015; reflex irritation in, 1013; treatment of, 1016; trifacial, 1014; visceral, 1016. N eurasthenia, 1032 ; etiology of, 1032; symp- toms of, 1033; traumatic, 1035; treatment of, 1039. Neuritis, 833; arsenical, 837; fascians, 834; in- terstitial, 833; lipomatous, 834; localized, 833,834; parenchymatous, 834; multiple, 833, 835 ; alcoholic, 836; diagnosis of, 838; en- demic, 838; in diphtheria, 116; in chronic phthisis, 249; in the infectious diseases, 837; in typhoid fever, 27; recurring, 836; satur- nine, 837; traumatic, 835 ; treatment of, 839; optic, 844. Neuroglioma, 970. Neuroma, plexiform, 840. Neuromata, 839. Neurons, 816. Neuroses, occupation, 1017. Neutrophiles, 738. New-born, haemorrhagic diseases of, 347. New growths in the bowel, 445. Night-blindness, 843; in scurvy, 340. Night-sweats in phthisis, 245 ; treatment of, 276. Night-terrors, 366. Nipple, Paget's disease of, 1081. Nitric-acid test for albumin, 769. Nits, 1108. Nodding spasm, 870. Nodes, Jleberden's, 306. Nodes, symmetrical, in congenital syphilis, 190. Nodules, rheumatic, 297. Noma, 354; in scarlet fever, 77; in typhoid fever, 30, 32. Normoblasts, 729. Nose, bleeding from (see Epistaxis), 516. Nose, diseases of, 512. Nose-bleeding in typhoid fever, 11. Nucleo-albumin, 769. Nummular sputa in phthisis, 240. Nurse’s contracture of Trousseau, 1019. N utmeg liver, 462. Nyctalopia, 843; in scurvy, 340. Nystagmus, 850 ; in Frederick's ataxia, 912; in insular sclerosis, 966 ; of miners, 850. Obesity, 1077. Obsession, 997. Obstruction of bowels, 443; acute, 446 ; chronic, 447. Obturator nerve, 876. Occipital lobes, tumors of, 972. Occupation neuroses, 1017. Ocular palsies, treatment of, 853.- Oculo-motor paralysis, recurring, 849. Odor, in small-pox, 63 ; in typhoid fever, 17. (Edema, angio-neurotic, 1043; collateral, in lungs, 540; febrile purpuric, 345; hereditary, 1044; of lungs, 539 ; malignant, 175; of brain in uraemia, 779, 940. (Edematous laryngitis, 519. Oertel's method in obesity, 681, 1078. (Esophageal bruit, 371. (Esophago-pleuro-cutaneous fistula, 373. (Esophagismus, 370. (Esophagitis, acute, 369 ; chronic, 370. (Esophagus, diseases of, 369 ; cancer of, 372; INDEX. 1131 dilatations of, 373; diverticula of, 373; pa- ralysis of, 370; post-mortem digestion of, 373 ; rupture of, 373; spasm of, 370; stric- ture of, 371; syphilis of, 197; tuberculosis of, 261. Oidium albicans, 353. Olfactory nerve, 840. Omentum, tuberculous tumor of, 259; tumor of, in cancer, 507. Omodynia, 304. Onomatomania, 997. Onychia, in arthritis deformans, 307 ; in loco- motor ataxia, 907 ; syphilitic, 187, 189. Operation per se, effects of, in epilepsy, 1011. Operation, tuberculosis after, 213. Ophthalmia, gonorrheal, with arthritis, 298. , Ophthalmoplegia, 852; externa, 852; interna, 853. Opisthotonos, cervical, in infants, 934; in tetanus, 182. Opium, poisoning, diagnosis from uraemia, 781; habit, 1061; smoking, effects of, 1061. Optic nerve atrophy, 844; hereditary, 844; in ataxia, 905; primary, 844; secondary, 844. Optic nerve and tract, diseases of, 841, 844. Optic neuritis, 844; in abscess of brain, 975; in brain-tumor, 971; in tuberculous menin- gitis, 224. Orchitis, in malaria, 171; in mumps, 87; inter- stitial, in syphilis, 198 ; in typhoid fever, 29 ; in variola, 53; parotidea, 87; tuberculous, 266; value of, in diagnosis, 266. Oriental plague, 144. Orthotonos, in tetanus, 182. Osteitis deformans, 1047. Osteo-arthropathy, hypertrophic pulmonary, 1047. Osteo-myelitis simulating acute rheumatism, 297. Otitis media, in typhoid fever, 28; in scarlet fever, 77. Ovaries, tuberculosis of, 266. Over-exertion, heart affections due to, 674. Oysters and typhoid fever, 5. Oxalate-of-lime calculus, 806. Oxaluria, 774. Oxygen, inhalations of, in diabetic coma, 330. Oxyuris vermicularis, 1084. Oysters, poisoning by, 1071; and typhoid fever, 5. Oziena, 514. Pachymeningitis, 932. Pachymeningitis cervicalis hypertrophica, 882. Pachymeningitis hemorrhagica, of cerebral dura, 932; of spinal dura, 881. Paget's disease of the nipple, 1081. Palate, paralysis of, in diphtheria, 116; in fa- eial paralysis, 857; perforation of, in scarlet fever, 77. Palate, tuberculosis of, 261. Palpable kidney, 758. Palpitation of heart, 684. Palsies, cerebral, of children (see Hemiplegia of Children), 958. Palsy, lead, 1065. Paludism (see Malarial Fever), 155. Pancreas, diseases of, 492. Pancreas, cancer of, 496; lesions of, in diabe- tes, 322; cysts of, 495; haemorrhage into, 492 ; influence of, in diabetes, 321. Pancreatic diabetes, 323 ; calculi, 497. Pancreatitis, acute haemorrhagic, 493 ; chronic, 495; fat necrosis in, 494; gangrenous, 495; suppurative, 494. Papillitis, 844. Paraesthesia (numbness and tingling), in neu- ritis, 836; in locomotor ataxia, 906; in tumor of brain, 972; in primary combined sclerosis, 902. Parageusis, 863. Paralysis, acute ascending, 896; acute spinal, of adults, 896 ; acute, of infants, 892; agitans, 982; alcoholic, 836; Bell's, 855; bulbar, acute, 922; chronic progressive, 923 ; of blad- der, in myelitis, 890 ; of brachial plexus, 873; in chorea, 990; of circumflex nerve, 874; crossed or alternate, 925, 946 ; “ crutch,” 874; Cruveilhier's, 919; diverts, 888; of diaphragm, 872; after diphtheria, 116; Du- chenne's, 922; following epilepsy, 1006; of facial nerve, 855; of fifth nerve, 853; of fourth nerve, 850; general, of the insane, 966; of hypoglossal nerve, 870; hysterical, 1023 ; infantile, 892 ; labio-glosso-laryngeal, 922 ; Landry's, 896 ; of laryngeal abductors, 864; of adductors, 865; in lateral sclerosis, 898; from lead, 1065; in locomotor ataxia, 908; of long thoracic nerve, 874; in menin- gitis, 223, 936; of median nerve, 875; of musculo-spiral nerve, 874; of oculo-motor nerves, 849 ; of olfactory nerve, 841; period- ical, 1039; in progressive muscular atrophy, 921 ; radial, 874; of rectum, in myelitis, 890; of recurrent laryngeal nerve, 864; secondary to visceral disease, 835 ; of sixth nerve, 851; of third nerve, 849 ; of ulnar nerve, 875; of vocal cords, 864. Paramyoclonus multiplex, 1055. Paraphasia, 930. Paraplegia, from alcohol, 836; from anaemia of spinal cord, 886; from compression of cord, 914; dolorosa, 916; from haemorrhage into cord, 887; from ergotism, 1072; hereditary form of, 900; hysterical, 1023; in lathyrism, 1072 ; from myelitis, 890 ; in pellagra, 1073; spastic, 898, 962; spastica cerebralis, 900; 1132 INDEX. secondary, 616; symptoms of, 618, 620; treat- ment of, 623 ; with effusion, 619. Pericardium, adherent, 624; Friedreich's sign in, 625. Pericardium, diseases of, 616; tuberculosis of, 256 ; air in, 626. Perichondritis, laryngeal, in typhoid fever, 25 ; in tuberculosis, 522. Perihepatitis, 475, 505. Perinephric abscess, 814. Periodical paralysis, 1039. Periosteal cachexia, 341. Peripheral neuritis, 834. Peristaltic unrest, 388, 1027. Peritonaeum, diseases of, 498. Peritonaeum, fluid in, 507, 511 ; cancer of, 506 ; new growths in, 506. Peritonaeum, tuberculosis of, 258; acute mil- iary, 258 ; chronic, 258 ; chronic fibroid, 258. Peritonaeum, tumor formations in tuberculosis of, 259. Peritonitis, acute general, 433, 438, 498, 509; appendicular, 438, 504; chronic, 505, 511 ; chronic haemorrhagic, 506 ; diffuse adhesive, 505 ; hysterical, 501; idiopathic, 498; in in- fants, 502; in typhoid fever, 24; leukaemic, 737 ; local adhesive, 505 ; localized, 433, 502 ; pelvic, 504 ; perforative, 498 ; primary, 498 ; proliferative, 505 ; pyaemic, 498 ; rheumatic, 498 ; secondary, 498 ; septic, 498; subphrenic, 502 ; tuberculous, 258, 506. Peritonitis, tuberculous, effects of operation on, 511. Perityphlitis, 429. “ Perles ” of Laennec, 533. Pernicious anaemia, 726. Pernicious malaria, 161,169. Peroneal type of muscular atrophy, 1054. Pertussis (see Whooping-Cough), 88. Pesta magna, 50. Petechiae in epilepsy, 1006; in relapsing fever, 48; in scurvy, 339; in small-pox, 57; in typhus fever, 45. Petechial fever, 96. Petit mal, 1002, 1006 ; in general paresis, 968. Peyer's patches in typhoid fever, 6 ; in measles, 81; in tuberculosis, 262. Phagocytosis in erysipelas, 124; in malaria, 161; in tuberculosis, 215. Pharyngitis, 359 ; acute, 359; chronic, 359 ; retro-pharyngeal abscess of, 361; sicca, 360. Pharynx, acute infectious phlegmon of, 360; haemorrhage into, 358; hyperaemia of, 358 ; oedema of, 359 ; paralysis of, 864; spasm of, 864; tuberculosis of, 261; ulceration of, 360. Pharynx, diseases of, 358. Philadelphia Hospital, relapsing fever at, 1844, 48 ; typhoid and typhus fever at, 2; typhus epidemic in 1883, 44; statistics of cerebro- from spinal caries, 914 ; syphilitic, 898 ; from tumor of the cord, 918 ; in tabes, 908. Paraplegie fiasque, 898. Parasites, diseases due to animal, 1080. Parasitic gastritis, 377. Parasitic stomatitis, 353. Parasyphilitic affections, 188, 967. “ Parchment crackling ” in rickets, 333. Parenchymatous nephritis, 788. Parieto-occipital region, brain tumors in, 972. “ Paris green,” poisoning by, 1067. Parkinson's disease, 982. Parosmia, 840. Parotid bubo, 357. Parotitis, epidemic, 86 ; deafness in, 87 ; delir- ium in, 87 ; chronic, 358; orchitis in, 87 ; spe- cific, 358. Parotitis, symptomatic, 357; after abdominal section, 358 ; in pneumonia, 558 ; in typhoid fever, 21; in typhus fever, 46. Paroxysmal haemoglobinuria, 766. Parrot's ulcers, 353. Patellar-tendon reflex (see Knee-jerk). Pectoriloquy, 247. Pediculi, 1108; relations of, to tache bleuatre, 16, 1108. Pediculosis, 1108. Pediculus capitis ; P. corporis, 1108. Peliomata, 16. Peliosis rheumatica, 344 ; in chorea, 992. Pellagra, 1073. Pelvis of kidney, affections of (see Pyelitis), Pemphigoid purpura, 344. Pemphigus neonatorum, 189. Pennsylvania Hospital, 1073, 1076. Pennsylvania Institution for Feeble-minded Children, 958, 1002. Pentastomes, 1106. Peptic ulcer, 394; dyspepsia in, 397; haemor- rhage in, 397; pain in, 397 ; tenderness on pressure in, 397. Peptones in the urine, tests for, 770. Peptonuria, 770. Perforating ulcer of foot, 907. Perforation of bowel in dysentery, 152; in ty- phoid fever, 8, 24. Periarteritis, gummatous, 198; nodosa, 719. Pericardial friction, 618. Pericarditis, 616; acute plastic, 617; acute tuberculous, 256; aphonia in, 620; chronic adhesive, 624; chronic tuberculous, 257 ; de- lirium in, 621; diagnosis of, 619, 622; dyspha- gia in, 620; epidemics of, 617 ; epilepsy in, 621; from extension of disease, 617; from foreign body, 616 ; in chorea, 991; in foetus, 617; in gout, 316; in rheumatism, 295; haem- orrhagic, 257, 620 ; hyperpyrexia in, 618, 621; physical signs of, 618, 621; primary, 616; prognosis of, 622; pulsus paradoxus in, 620; 16, 1108. 1NDEX. 1133 spinal fever, 99; of delirium tremens in, 1060. Philadelphia Infirmary for Nervous Diseases, statistics of chorea, 985; of hemiplegia and diplegia in infants, 958 ; of epilepsy, 1002. Philadelphia, tuberculosis in city wards, 210; yellow-fever epidemic in, 1793, 139. Phlebitis of portal vein, 480. Phlebo-sclerosis, 703. Phosphates, alkaline, 775 ; earthy, 775. Phosphatic calculi, 806. Phosphaturia, 775. Phosphorus poisoning, similarity of acute yel- low atrophy to, 461. Phrenic nerve, affections of, 871. Phthiriasis, 1108. Phthirius pubis, 1108. Phthisical frame, Hippocrates's description of, 211. Phthisis, 228; chronic ulcerative, 234; acute pneumonic, 229 ; arterio-selerosis in, 253; basic form of, 235 ; Bright’s disease in, 250 ; of coal-miners, 213, 587 ; chronic arthritis in, 253 ; cough in, 240 ; endocarditis in, 238,248 ; diagnosis of, 250 ; distribution of lesions in, 234; erysipelas in, 252 ; fatal haemorrhage in, 255 ; fever in, 242 ; forms of cavities in, 236 ; gastric symptoms of, 248; haemoptysis in, 242 ; modes of death in, 255 ; modes of onset in, 238 ; physical signs of, 245; pneumonia in, 253; relation of fistula in ano to, 262; sputum in, 240 ; summary of lesions in, 235 ; symptoms of, 239; typhoid fever in, 253; vomiting in, 249. Phthisis, fibroid, 251, 566 ; florida, 231; renum, 264; syphilitic, 194; of stone-cutters, 213, 587 ; unity of, 216 ; ventriculi, 378. Physiological albuminuria, 767. Pia mater, diseases of, 883, 933. Pica, 389. Picric-acid test for albumin, 769. Pigeon-breast, in rickets, 335 ; in mouth- breathers, 366. Pigmentation of skin, from arsenic, 1068 ; in Basedow's disease, 753; from phthiriasis, 1108; in Addison's disease, 748; in chronic pulmonary tuberculosis, 250; in melanosis, 749 ; in peritoneal tuberculosis, 259. Pigmentation of viscera in pellagra, 1073. Pigs, tuberculosis in, 203. Pin-worms, 1084. Pitch, in cavities, change of, 247. Pitting in small-pox, 55 ; measures to prevent, 62. Pituitary body in acromegalia, 1046 ; in gigan- tism, 1046. Pityriasis versicolor, 250. Plaques a surface reticulee, 7. Plaques jaunes, 950. Plastic bronchitis, 536. Pleura, diseases of, 592. Pleura, echinococcus of, 1104; tuberculosis of, 256. Pleural effusion, Baccelli's sign in, 596, 598 ; compression of lung in, 593; diagnosis of, 601; haemorrhagic, 600; in scarlet fever, 76; position of heart in, 594; pseudo-cavernous signs in, 596; purulent, 597 ; serous effusion, constituents of, 593 ; Sudden death in, 597. Pleural membranes, calcification of, 606. Pleurisy, acute, 592; diaphragmatic, 600 ; en- cysted, 601; etiology of, 592, 597; fibrinous, 592; interlobular, 601; in typhoid fever, 26; pain in side in, 594; plastic, 592; pleural friction in, 596; pulsating, 599, 713; sero- fibrinous, 592; treatment of, 603; tubercu- lous, 256, 593, 600. Pleurisy, chronic, 605 ; dry, 605 ; primitive dry, 606; vaso-motor phenomena in, 607; with effusion, 605. Pleurodynia, 304. Pleuro-peritoneal tuberculosis, 255. Pleurosthotonos in tetanus, 182. Plexiform neuroma, 840. Plica polonica, 1108. Plumbism, 1063; and gout, 310; as a cause of renal cirrhosis, 791; paralysis in, 1065. Plymouth, epidemic of typhoid fever at, 5. Pneumaturia, 324. Pneumogastric aurye, 1004. Pneumogastric nerve, affections of, 863 ; cardiac branches of, 866 ; gastric and oesophageal branches of, 867; laryngeal branches of, 864; pharyngeal branches of, 864; pulmonary branches of, 866. Pneumonia, acute croupous, 545; abscess in, 561; acute delirium in, 555; bleeding in, 564; clinical varieties of, 558; colitis, croupous, in, 550 ; complications of, 556 ; crisis in, 551; delayed resolution in, 561; diagnosis of, 562; diagnosis from acute pneumonic phthisis, 231; diplococcus pneumoniae, 545, 546; en- docarditis in, 550 ; engorgement of lung in, 548; epidemics of, 546, 559 ; etiology of, 545 ; fever of, 551; fibroid induration in, 561; gangrene in, 561; gray hepatization in, 549; herpes in, 555; immunity from, 547 ; in dia- betes, 559; in infants, 559; in influenza, 559; in old age, 559 ; meningitis in, 550; morbid anatomy of, 548; mortality of, 561; pericar- ditis in, 550; physical signs of, 553; prog- nosis in, 560 ; pseudo-crisis in, 551; purulent infiltration in, 549; recurrence of, 558; red hepatization in, 548 ; relapse in, 558; resolu- tion of, 560; serum-therapy in, 548; symp- toms of, 551; terminations of, 560 ; treatment of, 563. Pneumonia, acute syphilitic, 195; apex pneu- 1134 INDEX, monia, 559 ; aspiration or deglutition, 571; “ cerebral,” 556; chronic interstitial, 566, 568; chronic pleurogenous, 607 ; contusion, 546; double, 559 ; fibrinous, 545 ; hypostatic, 539; in malaria, 163; interstitial, of the root, in syphilis, 194; in typhoid fever, 25; lar- val, 559 ; lobar, 545 ; massive, 559 ; migra- tory, 559 ; pleurogenous interstitial, 567 ; ty- phoid pneumonia, 559 ; white, of the foetus, 194. Pneumonitis, 545. Pneumonokoniosis, 568, 587. Pneumo-pericardium, 626. Pneumorrhagia, 540. Pneumothorax, 608; after tracheotomy, 615; causes of, 608; chronic, 611; Hippocratic suc- cussion in, 610 ; morbid anatomy of, 609 ; in phthisis, 238; from muscular effort, 609; Skoda's resonance in, 609 ; symptoms of, 609; treatment of, 611. Pneumotoxin, 548. Pneumo-typhus, 25. Podagra, 309. Pododynia, 1015. Poikilocytosis, 729. Poisoning, by leucomaines, 1069; by lead, 1063; by meat, 1069; by ptomaines, 1069 ; by sewer- gas, 285. Poliomyelitis, acute and subacute, in adults, 896. Poliomyelitis anterior, acute, 892 ; epidemics of, 892 ; etiology of, 892 ; morbid anatomy of, 893 ; prognosis of, 894 ;* symptoms of, 893. Poliomyelitis anterior chronica, 919. Polyadenomata, 410. Polysemia, 735. Polyneuritis, acute febrile, 835; recurrens, 836. Polyphagia, 325. Polysarcia, 1077. Polyuria (see Diabetes Insipidus), 330. Polyuria, in abdominal tumors, 331; in hys- teria, 332, 1022. Pons, lesions of, 925 ; tumors of, 973. Poor-man’s gout, 310. Popliteal nerve, external, 877 ; internal, 877. Porencephalus, 959. Pork in relation to trichinosis, 1087. Portal vein, 462 ; thrombosis of, 462 ; suppura- tion in, 480. Post-epileptic conditions, 1006. Post-hemiplegic chorea, 960; epilepsy, 960, 1004; movements, 960. Post-mortem movements in cholera bodies, 135. Post-pharyngeal abscess, 361. Post-typhoid, anaemia, 18; elevations of tem- perature, 15. Pott's disease, 914. Poumon, ulceres du, 569, 589. Pregnancy, and acute yellow atrophy, 459 ; and chorea, 986 ; and phthisis, 269 ; and typhoid fever, 32. Presystolic murmur, 651. Priapism in leukaemia, 737. Prickly heat (see Urticaria). Procession caterpillar, effects of, 1110. Professional spasms, 1017. Proglottis of taenia, 1096. Progressive muscular atrophy, 919. Progressive pernicious anaemia, 726 ; blood in, 728; diagnosis of, 731; etiology of, 726; mor- bid anatomy of, 728; prognosis of, 731; symp- toms of, 728 ; treatment of, 733. Propepton, 770. Prophylaxis, against cholera, 137 ; against scurvy, 340 ; against tuberculosis, 269 ; against taenia, 1098 ; against trichina, 1089 ; against typhoid fever, 35; against yellow fever, 142. Prosopalgia, 1014. Prostate, tuberculosis of, 266. Protozoa, diseases caused by, 1080; parasitic, 1080. Prune-juice expectoration, 591. Prurigo, in Hodgkin's disease, 745. Pruritus in diabetes, 325; in uraemia, 780; in obstructive jaundice, 457 ; in gout, 316. Pseudo-angina pectoris, 693,1028. Pseudo-apoplectic seizures in fatty heart, 679. Pseudo-biliary colic, 467. Pseudo-bulbar paralysis, 923. Pseudo-cavernous signs, 248, 596, 602. Pseudo-cyesis, 1024. Pseudo-diphtheritic processes, 106. Pseudo-hydrophobia, 180. Pseudo-leukaemia, 742. Pseudo-ptosis, 849. Pseudo-rheumatic affections, 301. Pseudo-sclerose en plaques, 966. Psilosis, 421. Psoriasis, buccal, 356. Psorospermiasis, 1080; cutaneous, 1081; in- ternal, 1080. Ptomaine poisoning, 1069. Ptosis, forms of, 849 ; hysterical, 849 ; in ataxia, 905; pseudo-, 849. Ptyalism, 355, 357. Puberty, harking cough of, 1026. Pulex, irritans, 1109 ; penetrans, 1109. Pulmonal-cerebral abscesses, 975. Pulmonary (see Lungs). Pulmonary apoplexy, 542. Pulmonary artery, sclerosis of, 703 ; perforation of, 712. Pulmonary haemorrhage, 540 ; treatment of, 543. Pulmonary orifice, congenital lesions of, 697 ; valves, lesions of, 655. INDEX. 1135 Pulmonary osteo-arthropathy, hypertrophic, 1047. Pulsating pleurisy, 599, 713. Pulsation, dynamic, of aorta, 713. Pulse, alternate, 686; anastomotic, 704; di- crotic, 18 ; under influence of digitalis, 660; intermittent, 685 ; irregular, 686 ; bigeminal, 686, 687 ; recurrent, 704. Pulse, capillary (see Capillary) ; Corrigan's, 641; water-hammer, 641. Pulse, slow, in tuberculous meningitis, 223; in jaundice, 464 (see Brachycardia, 688). Pulsus paradoxus, 620, 625, 685. Pupil, Argyll-Robertson, 850. Pupillary inaction, hemiopic, 847. Pupils, unequal, 850; in general paresis, 968. Purpura, 343 ; arthritic, 344 ; cachectic, 343 ; diagnosis of, 346 ; fulminans, 346; Henoch's, 345; infectious, 343; mechanical, 344; neu- rotic, 344 ; peliosis rheumatica in, 344 ; hasm- orrhagica, 345; simplex, 344; symptomatic, 343 ; toxic, 343 ; treatment of, 347 ; urticans, 344; variolosa, 56, 57. Purpuric oedema, 345. Pustule, malignant, 174, 175. Putrid sore mouth, 352. Pyaemia, 126 ; arterial, 634; idiopathic, 129. Pyaemic abscess of liver, 481, 483. Pyelitis, 799; diagnosis of, 802; intermittent fever in, 801; morbid anatomy of, 800 ; prog- nosis of, 803; pyuria in, 801; symptoms of, 801; treatment of, 803 ; in typhoid fever, 29. Pyelonephritis, 799. Pylephlebitis adhesiva, 462. Pylephlebitis, in dysentery, 152; in pyaemia, 130 ; suppurative, 463, 481. Pylorectomy, statistics of, 393. Pyloroplasty, statistics of, 393. Pyonephrosis, 799. Pyo-pneumothorax, 256, 608. Pyo-pneumothorax subphrenicus, 395, 503, 610. Pyuria, 771; in typhoid fever, 9, 29. Quarantine against yellow fever, 142; against cholera, 137. Quartan ague, 167. Quebec, cholera at, in 1832, 132. Quincke's lumbar puncture, 937, 979. Quinine rash, 72, 78. Quinsy (see Tonsillitis, Suppurative). Quotidian ague, 167. Rabies, 177; etiology of, 177 ; morbid anatomy of, 179 ; preventive inoculation in, 179; symptoms of, 178 ; treatment of, 179. Rachitic bones, 333. Rachitis (see Rickets), 332. Radial paralysis, 874. Rag-picker’s disease, 176. Railway brain, 1035. Railway spine, 1035. Rainey's tubes, 1080. Rapid heart, 687. Rashes, from drugs, 78, 343 ; in glanders, 281; in measles, 82; in relapsing fever, 48; in rubella, 85; in scarlet fever, 73; in small- pox ; 55; in syphilis, 187; in typhoid fever, 16 ; in typhus fever, 45; in pyaemia, 130; in vaccination, 67 ; in varicella, 70. Raspberry tongue in scarlet fever, 73. Ray-fungus (actinomyces), 282. Raynaud's disease, 1041; aphasia in, 1043 ; and scleroderma, 1049 ; epilepsy in, 1043 ; hemo- globinuria in, 1042; pathology of, 1043. Reaction of degeneration, 829,838, 857. Recrudescence of fever in typhoid fever, 15. Rectal crises in tabes, 907. Rectum, irritable, 1027 ; stricture of, 197 ; syph- ilis of, 197 ; tuberculosis of, 262. Recurrent laryngeal nerve, paralysis of, 864. Recurrent pulse, 704. Recurring multiple neuritis, 836. Red softening of brain, 950. Reduplication of heart-sounds, 686. Redux crepitus, 554. Reflex epilepsy, 1004. Reflexes in ascending paralysis, 897; in cere- bral haemorrhage, 947; in locomotor ataxia, 905; in polio-myelitis acuta, 894; in spastic paraplegia, 899; in hysterical paraplegia, 901, 1023 ; in progressive muscular atrophy, 921. Regurgitation, tricuspid, 653. Reichmann's disease, 387. Relapse in typhoid fever, 32. Relapsing fever, 47; spirillum of, 48. Remittent fever, 167. Renal calculus, 806. Renal, colic, 808; sand, 806; syphilis, 198; sclerosis, 790. Rendu's type of tremor, 1025. Ren mobilis, 758. Resolution in pneumonia, 560. Resonance, amphoric, 247,609; tympanitic, 247, 595, 609. Respiratory system, diseases of. 512. Rest treatment, 1031; in aneurism, 714. Retina, lesions of, 841. Retinal hyperassthesia, 843. Retinitis, albuminuric, 842; in anaemia, 842; in malaria, 842 ; leukaemic, 842 ; pigmentosa, 842; syphilitic, 187, 842. Retraction of head in meningitis, 223, 936. Retro-collie spasm, 869. Retroperitoneal abscess, 434. Retroperitonae um, haemorrhage into, 53. Retro-pharyngeal abscess, 361. Retropulsion in paralysis agitans, 983. Revaccination, 65. Rhabditis Nielly, 1092. 1136 INDEX. Bhabdo-myoma of kidney, 811. Ehabdonema intestinale, 1095. Ehagades, 189. Eheumatic fever, 292; age in, 292; cerebral complications of, 296 ; diagnosis of, 297 ; en- docarditis in, 295; etiology of, 292; fibrous nodules in, 297 : germ theory of, 293; hered- ity in, 293; hyperpyrexia in, 295 ; metabolic theory of, 293; morbid anatomy of, 293; nervous theory of, 293 ; pericarditis in, 295 ; purpura in, 296; sex in, 292; symptoms of, 294 ; treatment of, 298. Eheumatic gout (see Arthritis Deformans). Eheumatic nodules, 297. Eheumatism, chronic, 300; etiology of, 300; morbid anatomy of, 300; prognosis of, 300; symptoms of, 300 ; treatment of, 300. Eheumatism, muscular, 303. Eheumatism, subacute, 295. Eheumatoid arthritis (see Arthritis Defor- mans). Ehinitis atrophica, 513; fibrinosa, 113 ; hyper- trophica, 513; simplex, 513; syphilitic, 189. Eibs, resection of, in empyema, 605. Eice-water stools, 136. Eickets, 332; acute, 336, 341; etiology of, 332 ; foetal, 332; morbid anatomy of, 333; progno- sis of, 336 ; symptoms of, 334; treatment of, 337. Riga’s disease, 352. Eigidity, early, in hemiplegia, 943. Eigidity, late, in hemiplegia, 947. Eigors, in abscess of brain, 975 ; in abscess of liver, 482 ; in ague, 163; in pneumonia, 551; in pyaemia, 130; in pyelitis, 801; in tuber- culosis, 239 ; in typhoid fever, 15. Eisus sardonicus, 181. Eiverside Hospital, New York, typhus epi- demic, 1881, 44. Eock-fever, 287. Romberg's symptom, 906. Eoot-nerve symptoms in compression para- plegia, 914. Eosary, rickety, 334. Eoseola (see Eose Eash of Typhoid), 16; epi- demic, 85.