::; ;'t •;W !;:fcji1:1: iiilii T1T: r* •_• ". il'-Jj• _:.* „-^«"^*$*5F\ * NLM 00107375 3 ... ./i*" V "^>t '■ ■■»¥ >•-' SURGEON GENERAL'S OFFICE LIBRARY. Section, ^ ^^n t NLM001073723 lb.. Lea's Series of Pocket Text-Books. Diseases of the Eye, Ear Nose and Throat. ByW.L. Ballenger, M.D.,Lecturer on Rhinology and Laryngology, and A. G.Wippern, M.D., Clinical Instruc- tor in Diseases of the Nose and Throat, College of Physicians and Surgeons, Chicago. Anatomy. By Frederick J. Brockway, M.D., Assistant Demonstrator of Anatomy, College of Physicians and Surgeons, New York. Bacteriology and Hygiene. By \V. E. Coates, Jr., M.D., Instruc- tor in Bacteriology and Pathology, College of Physicians and Surgeons, Chicago. Diagnosis. By C P. Collins, M. D., Attending Physician to St. Luke's Hospital, New York. Physiology. By H. D. Collins, M. D., Assistant Demonstrator of Anatomy, and W. H. Rockwell, Jr., A. B., M. 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Idea's Scries of Pocket Text=l}ool{s. PRACTICE OF MEDICINE. A MANUAL FOR STUDENTS AND PRACTITIONERS. BY ' GEORGE E. MALSBARY, M.D., Assistant to the Chair of Practice, Medical College of Ohio, University of Cincinnati; Assist- ant to the Lectureship of Clinical Medicine, Good Samaritan Hospital, Cincinnati. SERIES EDITED BY BERN B. GALLAUDET, M.D., Demonstrator of Anatomy and Instructor in Surgery, College of Physicians and Surgeons, Columbia University, New York; Visiting Surgeon, Bellevue Hospital, New York. ILLUSTRATED WITH FORTY-FIVE ENGRAVINGS. LEA BROTHERS & CO., PHILADELPHIA AND NEW YORK. \890 Entered according to Act of Congress, in the year 1899, by LEA BROTHERS & CO., In the Office of the Librarian of Congress, at Washington. All rights reserved. WESTCOTT & THOMSON, ELECTROTYPERS, PHILADA. PREFACE. Medical progress is so rapid in our day that Manuals have special value, in that they may be published in the shortest possible time, and thus place before the reader the most recent advances in Medicine. Moreover, a brief epit- ome presents the subject to the busy practitioner and student in a form more readily accessible than is possible in a lengthy treatise. All the standard authors of the day have been consulted in the preparation of this book, and the author trusts that it will prove a valued assistant to the student. GEORGE E. MALKBARY. Cincinnati, Ohio. 3 CONTENTS. CHAPTER I. PAGE Infections....................... 17 CHAPTER II. Diseases of the Organs of Digestion........168 CHAPTER III. Diseases of the Organs of Respiration......250 CHAPTER IV. Diseases of the Organs of Circulation......293 CHAPTER V. Diseases of the Blood................335 CHAPTER VI. Diseases of the Genito-Urinary Organs......364 5 PRACTICE OF MEDICINE. CHAPTER I. INFECTIONS. DISEASES CAUSED BY VEGETABLE PARASITES. SEPTICEMIA (Pyaemia; Septico-pyaemia; Sepsis). Definition: Septicaemia is a septic infection, due to the presence of the products, toxins, of pyogenic (pus-produc- ing) micro-organisms in the blood and tissues of the bod}-. Pyaemia is an infection of the blood and tissues of the body bv pyogenic micro-organisms. In septicaemia the symptoms of blood-poisoning predominate ; in pyaemia, the symptoms of metastatic abscesses. A combination of septicaemia and pvaemia constitutes scptico-pyamiia. Usually alt these condi- tions are included under the term septicaemia when there is general infection of the blood. Localized infections or in- flammations have received special names—e. g., meningitis, pleuritis, peritonitis, arthritis, metastatic abscess, etc. The condition caused by the absorption of toxins only, from a local- ized septic infection, is known as septic foxccmia. Etiology: The micro-organisms most frequently encountered in septicemia are the staphylococcus pyogenes aureus, which produces chiefly circumscribed abscesses, and the streptococ- cus pyogenes, which produces extensive suppuration. Puer- peral septicaemia {jjuerperal fever) is usually caused by the streptococcus pyogenes. Other micro-organisms which act as etiological factors are the staphylococcus pyogenes albus, the staphylococcus pyogenes citreus, and the micrococcus pyo- 2—P.M. 177 18 IXFECTTONS. genes tenuis. More rare are the pneumococcus, the bacillus coli communis, and the bacillus of malignant (edema. The micro-organisms gain entrance to the circulation through some break in the surface of the body, which may be caused by traumatism (wounds, parturition), or through a lesion produced by some other infection (tuberculosis, small- pox, dysentery, gonorrhoea), thus constituting a secondary in- fection. Cases of cryptogenetic sepsis are those in which the local depot of infection may not be discovered. Cases of dis- coverable lesion are phanerogenetic. Infection may be conveyed by insects—e. g., bedbugs, roaches, and flies (Coplin). In order that septicaemia may be produced the resistance (immunity) of the body to the invasion of micro-organisms must be overcome, as in other infections. Special obstacles to infection are found in the skin, mucous membranes, the serosae, in the small-cell infiltration, lymph-structures, lymph-vessels and -glands, the thymus gland, and bone-marrow ; in the ex- cretory organs, kidneys, liver, and intestine ; and in the blood, where resistance is offered by both the corpuscles and the serum. No protective principle has been isolated from the blood. It has been proved experimentally that the immunity to infection depends largely upon the degree of alkalinity of the blood. Immunity is lessened by fatigue, starvation, ex- posure to cold, more especially to impure air, bad hygiene, and by toxaemia (Bright's disease) and amemia. Septicaemia—symptomatology There may be a preceding infection or traumatism. Infection by the pyogenic micro- organisms is announced by chills and fever, 103°—104° F.; and these are repeated with each new invasion. The eleva- tion of temperature is accompanied by nervous symptoms, de- pression, headache, dizziness, and sometimes vomiting. There is profuse sweating. The fever recurs daily or evcrv other day, in chronic cases often at longer intervals, with varying intensity, and is characterized by its irregularity, constituting the "streptococcus-curve" (Fig. 1), and by its resistance to treatment with quinine or the salicylates. The temperature may be above or below normal during the intervals. Exami- nation of the blood sometimes reveals the micro-organism caus- SEPTICAEMIA. 19 ing the disease, and usually shows an increase of white blood- corpuscles (leucocytes), a decrease of red blood-corpuscles (erythrocytes), and an increase of blood-plaques. Soon there is pain in the joints, which are swollen and tender. The spleen is enlarged. The skin, at first pale, becomes icteric. The Fig. 1. TIME F. 105 104 103 102' 101 100° 99 98° 97° M E M E M E M E M E M E M E M E \ \ — T j i 1 I ft A I \ \ N | \ \ \ \ A \ ' i h 1 1 \ . j . \ — , > V \\ I V 11 Streptococcus-curve from a case of phthisis. pulse is rapid, often 120-140 per minute, weak and irregular. The typhoid state ensues. Evidences of metastatic affection mav be found, especially in the organs having end-arteries— the skin, eves, heart, kidneys, and brain. Septicaemia—diagnosis: This rests upon the infection, chills and fever, the sweating, the frequency of the pulse out of proportion to the temperature, and the metastases. The differential diagnosis concerns chiefly : 1. Typhoid fever. Both diseases may show an eruption of rose-colored spots, fever, diarrhoea, enlargement of the spleen, and bronchitis. Typhoid fever has a characteristic tempera- ture-curve, very different from the sec-saw, irregular " strep- tococcus-curve." The typhoid state is present much earlier in typhoid fever than in septicaemia. The presence of the 20 INFECTIONS. diazo-reaction (Ehrlich) in the urine, and the positive re- action of the blood to the blood-test for typhoid fever (Widal), would make the diagnosis of typhoid fever almost, if not quite, absolute. An examination of the blood may reveal the micro-organism causing septicaemia; but such micro-organism may be present as a secondary infection in cases of typhoid fever. The diseases may co-exist. Retinal hemorrhages, arthritic affections, and mitral lesions would speak for septicaemia. '2. Malaria; in which there is a distinct periodicity of fever, usually not to be found in septicaemia. A therapeutic test may be made with quinine, which has absolute control over malaria but no permanent influence over septicaemia. The presence of plasmodium malar ice in the blood speaks positively in favor of malaria. 3. Miliary tuberculosis, which may sometimes be differenti- ated by rinding the tubercle bacillus in the secretions and excretions. Often there is tuberculosis of the lungs, lymph- glands, spine (caries), or hip-joint (hip-joint disease). Obscure c.ises may be cleared up by a test-injection of tuberculin. Sep- ticaemia often exists in cases of tuberculosis as a mixed in- fection. 4. Cerebrospinal meningitis: Opisthotonos, hyperesthesia, constipation, and the occurrence of the disease in the colder months, in soldiers and children, would speak for cerebro- spinal meningitis rather than septicaemia. 5. Endocarditis, which presents evidence of heart-disease in enlargement and bruit. Ulcerative endocarditis is an expres- sion of septicaemia. 6. Unemia, which shows more severe headache, with twitch- ings, convulsions, and coma. In uraemia, there are oedema, albuminuria, and tube-casts; there is often also hardness of the arteries. 7. Affections of the joints, rheumatic, post-scarlatinal, or gonorrhoea!. These furnish the evidence or history of rheu- matism, scarlatina, or gonorrhoea, in the absence of the " strep- tococcus-curve " or metastatic abscesses. Affection of the joints may be an expression of septicaemia as a secondary infection. SEPTICAEMIA. 21 Septicaemia—prognosis: The prognosis is grave in all cases; but even bad cases may recover. In general the prognosis depends upon the possibility of removing or destroying cen- tres or depots of infection. Mixed infection; or infection with streptococci, usually gives a more grave outlook than infection with staphylococci or pneumococci. The gravity of the case may be measured approximately by the height of the fever, the weakness of the heart, and the nervous symptoms. Prophylaxis: The prevention of septicaemia calls for asep- sis (surgical cleanliness) and antisepsis in the treatment of wounds. Pus, whenever and wherever recognized, should be evacuated. Septicaemia—treatment: Bichloride of mercurv solution (1 :1000 or 1 : 2000) or carbolic acid solution (1 :40 or 1 :60) may be used in the treatment of wounds. The actual cau- tery, thermo-cautery, or galvano-cautery is sometimes useful. Cryptogenic cases are sometimes cleared up by the deep ure- thral injection of a strong solution of protargol or nitrate of silver, gr. xx to 5J ; or by a curettement of the uterus or the removal of a diseased ovary ; or by the relief of a mastoid disease by operation. The entrance of infection through the respiratory tract may be combated by the use of antiseptics— boric acid, lactic acid, subsulphate of iron, etc. Intestinal antisepsis may be secured by the use of calomel, salol, /9-naphthol, or ichthalbin. The frequent failure of serum-therapy in the treatment of septicaemia is probably due to the fact that streptococcic scrum protects only against infection by the particular variety of streptococcus from the culture of which the serum has been immunized. This is only what should be expected, as a large number of organisms which differ widely in virulence and other characteristics are included under the term strepto- cocci. Protection has been secured against two or three varie- ties by immunizing against the two or three germs. The streptococcic serums rapidly deteriorate in the vials and soon become worthless. Marmorek reports results obtained from the use of antistreptococcic serum that are in a general way encouraging. Sometimes excellent results, and almost always temporary 22 INFECTIONS. improvement, may be obtained by venesection and infusion of normal saline solution. Alcohol, best in the form of whiskey or brandy, may be given in large quantities. In septicaemia alcohol docs not readily produce toxic effects. It is supposed to increase the number of leucocytes and to neutralize toxins. Quinine, gr. v, may be given every two to four hours. Toxins in the blood may be neutralized by the use of the salicylates, iodine, mercury, bromine, or arsenic. Fever and pain may be relieved by phenacetin, or in the presence of great weakness by laciophenin. Fever that be- comes dangerously high may be controlled by hydrotherapy, sponging with cold water. Affections of the heart, joints, meninges, pleura, or peritoneum call for application of the ice-bag. Obstinate pain and sleeplessness demand the use of opium. ERYSIPELAS (Saint Anthony's Fire; Rose, Wundrose, Rothlauf (German); Erysipele (French)). Definition: An acute infection caused by the streptococcus erysipelatis, characterized by inflammation of the skin and lymphatics, fever, gastric disturbance, and symptoms on the part of the nervous system. History: Erysipelas was recognized by Hippocrates and the early medical writers, but they did not know the cause of the disease. Henle (1840) attributed the disease to minute vege- table organisms. Trousseau (1.S48) pointed out that there must be a lesion as a starting-point of the infection. The organism now held to be the cause of the disease was discov- ered in the skin by Koch and Fehleisen (1ni(e crotiposce. These organisms are also pres- ent in the blood in some cases. The diplococcus intracellu- lars meningitidis is believed to be closely related to the micrococcus pneumoniae crouposie. These micro-organisms are sometimes associated with, or supplanted bv, secondary infec- tion by the streptococcus pyogenes, staphylococcus pyogenes aureus, bacillus coli communis, the bacillus proteus, and rarely by other organisms. The avenue of entrance of the infec- tious agent is probably through the upper respiratory tract. Cold, crowding, and childhood are predisposing factors. Cerebro-spinal meningitis—symptomatology : The period of incubation lasts from eight to ten days (Latimer). The symptoms come on suddenly, without prodromata, with chill, vomiting, headache, and prostration. Opisthotonos be- gins to show itself in stiffness of the back of the neck, with tenderness in thp course of a few hours. There is hyperes- thesia, usually in the lower extremities, which may become CEREBRO-SPINAL MENINGITIS. 27 general. Various eruptions, including petechiae, occur, but are not characteristic. Herpes may be observed as early as the third day, and continue until after recovery, as a rule appearing first about the face. The te\nperature shows an early rise, 102° to 104° F., and an irregular course. The pulse is rapid, and later, with the temperature and respiration, shows great irregularity. Headache is persistent, and may be associated with vertigo. Usually there is constipation. The abdomen is boat-shaped. The urine is scanty, the bladder paretic. Bad cases show enuresis. The urine presents the diazo-reaction in severe cases. The blood presents the changes found in suppurative in- flammations. Leucocytosis is well marked during the active stage of the disease, and the amount of haemoglobin is usually diminished. Epistaxis is frequently observed. Complications : Pneumonia, catarrhal and croupous ; various pareses and paralyses ; affections of the eye, photophobia, con- junctivitis, neuritis, atrophy of the optic nerve, blindness, keratitis with ulcer, iritis, irido-choroiditis, panophthalmitis, and antesthesia are the chief complications. Affections of the ear, suppuration of the middle and internal ear, perfora- tion of the membranes, deafness from inflammation of the labyrinth, are often present. Sometimes there is pleurisy, pericarditis, or parotitis. Cerebro-spinal meningitis—forms: (1) Malignant (foudroy- ant, siderant, fulminant, or apoplectic), in which death may take place in three and a half (Jewell) to thirty-six hours. (2) Abortive, including light cases, frequently unrecognized, in which convalescence begins after the symptoms have lasted from three to five days. (3) Intermittent, in which the inter- missions are not so regular as in malaria. The temperature bears a closer resemblance to the streptococcus-curve in some cases of septicaemia, which may show more or less periodicity. The usual duration is from one to three weeks. (4) A chronic form has been described, which some believe to be the most frequent type (Heubner). Cases have been reported to last as long as fourteen weeks (Worthington). In this form there is a scries of recurrences of fever. Cerebro-spinal meningitis—morbid anatomy: Malignant 28 INFECTIONS. cases, if the patient die before exudation takes place, may present no characteristic changes. Exudation is most abundant on the cortex. The membranes may be thickened and adher- ent. The spleen shows more or less enlargement, according to the duration of the disease. Diagnosis: The disease prefers winter, soldiers, and children (Pfeiffer). The diagnosis is usually easy when cerebro-spinal meningitis is epidemic. Cases of sudden death with symp- toms of profound toxaemia should excite suspicion of cere- bro-spinal meningitis in the malignant, foudroyant form. A sudden onset, with chill, and the presence of headache, opis- thotonos (often only rigidity of the muscles of the neck), and vomiting are characteristic. Sometimes most information is to be obtained by lumbar puncture (Quincke), which may reveal the specific cause of the disease. The disease should not be mistaken for tubercular meningitis, malaria, tetanus, hydrophobia, smallpox, or typhoid fever. Fig. 2. Contracture of the knee-joint in the position of flexion, not admitting, without violence, extension beyond 135° with the thigh, while the patient is in the sitting posture, but which may be readily extended when the patient is in the erect or recumbent posture, is characteristic of meningitis (Kernig) (Fig- 2.) RHEUMATISM. 29 Prognosis: The mortality varies with the epidemic—20 per cent, to 75 per cent, (Hirsch). Almost all malignant cases die. Abortive cases usually recover. The mortality in aver- age cases is about 50 per cent. The outlook in childhood is graver than in adolescence. Most of the deaths occur in the first week of the disease, especially during the first three or four days. The prognosis is not so favorable in protracted cases, although recovery is possible. Cerebro-spinal meningitis—treatment: The sick-room should be well ventilated ; light, noise, and unnecessary visitors must be excluded. The diet should be light and nutritious. It mav be necessary to use forced feeding. The bladder and bowels call for proper attention. The chief remedy is opium, one grain every hour or two (Stille), which may be given to relieve pain and spasm, and to protect the nervous system against the action of the poison of the disease. Large quantities of opium may be given without producing toxic effects. In eases of vomiting inter- fering with the administration of opium, morphine may be given subcutaneously, gr. \-\ for adults (v. Ziemssen). Later, cold (ice-bags) should be applied to the head and spine. Hot baths, 40° C, for ten minutes, give excellent results. Vomiting and hiccough may be relieved by the internal use of hot water, cracked ice, milk and lime-water, soda, creo- sote, bismuth, chloral, or by morphine hypodermatically. Chloral may be given by enemata, if necessary, to enable the patient to retain food. A failing heart calls for stimula- tion. Alcohol, best in the form of whiskey or brandy, is well borne. Bloodletting and blisters have their advocates. In extreme cases lumbar puncture or laminectomy and irri- gation are justifiable. RHEUMATISM. The term "rheumatism" (ps'jtm, pico, to flow) has come down to us from the humoral pathologists. The term ''ca- tarrh," which has the same derivation as rheumatism, with which it was synonymous, became confined to affections of the mucous membranes about the time of Ballonius (1600). " Rheumatism " became limited to diseases characterized by 30 INFECTIONS. pain about the bones, joints, and other structures than mucous membranes, which are not attributed to any special or specific cause. Later investigations have isolated gout, arthritis, trichinosis, syphilis, tuberculosis, and rickets. The term "rheumatism" is now used to cover at least five distinct affec- tions : Acute articular rheumatism, Chronic articular rheumatism, Gonorrhceal rheumatism, Muscular rheumatism, and Nodular rheumatism (see Arthritis Deformans). Acute Articular Rheumatism. Definition: An acute infectious disease, characterized by multiple arthritis. Etiology: The disease is almost limited to the period of adolescence, fifteen to thirty-five years, and prefers fall and winter, when the weather is most changeable ; but no season is exempt. The disease is rare before four or after forty vears. Individuals most frequently affected are those exposed to changes of temperature—drivers, servants, bakers, sailors, and laborers. The disease is frequently ascribed to taking "cold." Acute articular rheumatism often occurs in the course of the infections, especially scarlet fever, dysentery, and septicaemia (puerperal). The' disease is believed'to be due to some infectious agent, probably closely related to the strepto- coccus pyogenes. Often the infectious agent seems to gain entrance to the body through the tonsils. Symptomatology: The onset of the symptoms of acute ar- ticular rheumatism is often preceded by angina, especially tonsi/ifis, and malaise. Usually the disease begins suddenly with a chill and fever, reaching 102°-105° F. within a day. The pulse is usually above 100. There are more or less malaise and generaFlistress. Affection of the joints is usually observed within the first twenty-four hours. The disease shows a prefer- ence' for the nvdium-sized joints, especially the knee, ankle, and wrist; later the shoulder and elbow, and still later the fingers, and the vertebral and sterno-clavicular joints. Parely there RHEUMATISM. 31 may be involvement of the articulations of the maxilla, larynx, pelvis, and ribs. The joints become red and swollen. There may be subcutaneous (edema. The disease flits from joint to joint, often to return again to a joint previously affected. There is profuse sweating, which lowers the temperature for a time. The perspiration is acid in reaction and sour-smell- ing. Often there are sudamina, especially in the absence of cleanliness. Examination of the blood reveals marked anaemia and leucocytosis. The urine is usually reduced in quantity, con- centrated, of high color, acid in reaction, and loaded with urates. The chlorides are diminished, and sometimes absent. The saliva may show an acid reaction and an excess of sul- phoeyanides. Complications : The chief complication of acute articular rheumatism is usually on the part of the heart: pericarditis, endocarditis, or myocarditis. Some cases show hyperpyrexia, the temperature reaching 110°-118° F. Upon the part of the lungs there may be pneumonia or pleurisy. Some cases show delirium and coma ; less frequently convulsions, rarely menin- gitis. Often there is chorea. The presence of sudamina has been mentioned. There may be a red miliary rash, scarlatini- form eruptions, purpura, often urticaria, and erythema. Rheu- matic nodules are sometimes found upon the tendons and fasciae. Diagnosis: The affection of medium-sized joints, and espe- cially the flitting from joint to joint, are characteristic points. Atypical cases and eases that do not respond readily to treat- ment should arouse the suspicion that they are not cases of rheumatism. Acute articular rheumatism must be separated especially from other forms of rheumatism, involvement of the joints in septicaemia, and gout and sarcoma. Prognosis : Rheumatism has, in itself, a mortality of about 3 per cent. The remote effects are more dangerous. From one third to one-half of the cases have permanent heart- lesions. Sometimes the heart-lesions entirely disappear. Acute articular rheumatism—treatment: The patient should wear flannel and sleep between blankets. The best article of diet is milk, which may be diluted with alkaline mineral 32 INFECTIONS. waters. Thirst may be relieved by free ingestion of fluid. Often relief may be obtained by fixing the joint—sometimes simply by wrapping the affected joint in cotton or hot cloths. Various liniments may be used, and are of value chiefly through massage and the application of heat, Pain is sometimes relieved by the use of blisters or a light application of the Paquelin thermo-cautery. Salicin, salicylic acid, and the salicylates, for a time regarded as spe- cifics, relieve pain and probably neutralize toxins. The oil of wintergreen, Ttlxx in milk every two hours, often gives good results. The salicylates are probably best given with alkalies, potassium or sodium bicarbonate or iodide, in suffi- cient dosage to render and keep the urine alkaline in reaction. Severe pain may demand opium, best in the form of Dover's powder, or morphine. As a rule, antipyrin, or better phen- acetin, salipyrin, or salophen will suffice. Excessive fever (hyperpyrexia) may be controlled best by the cold bath. Tumultuous action of the heart may be relieved by application of the ice-bag. Chronic Articular Rheumatism. Occurrence and symptoms : Only exceptionally chronic rheu- matism may result from acute rheumatism. Asa rule, chronic rheumatism comes on insidiously, after the meridian of life, and remains confined to the joint or joints first affected. The disease is found especially among the poor—those most ex- posed to cold and damp. The affected joint is somewhat swollen, stiff, and painful. The pain is increased during damp weather or upon exposure to cold and damp. The joint may become ankylosed. Chronic rheumatism shows a preference for the larger joints—hip, shoulder, knee, wrist, and ankle. Diagnosis : The age of the individual, the number of joints affected, longer duration despite medication, and the absence of sweating, high fever, or complications on the part of the heart, are important points in diagnosis, and serve to differen- tiate chronic from acute rheumatism. Prognosis : Life usually is not shortened ; but the outlook as to cure is not good. The disease is exceedingly obstinate to treatment. RHEUMATISM. 33 Chronic rheumatism—treatment: Iodide of potassium is probably the best internal remedy. The salicylates may re- lieve the acute pain or exacerbations. Most may be accom- plished by the local application of heat and friction. All sorts of liniments are recommended. Sometimes the use of blisters affords relief. Often most may be accomplished by climato-therapy, espe- cially by prolonged residence in a warm climate, or at least by wintering in such a climate, to avoid cold, damp weather; but few patients can afford such treatment. Gonorrhoeal Rheumatism. Gonorrhoeal rheumatism prefers the period of adolescence, the male sex, and the knee-joint. There may be involvement of the ankle and joints of the foot. Usually the affection of the joints is observed within three months after the gonorrhoeal infection. The joints are greatly swollen. The specific cause is the gonococcus; or the pyogenic micro-organisms, as a sec- ondary process (see Septicaemia). The disease runs a chronic course, does not show sweating nor involvement of the heart, and when finally cured does not return nor leave deformity. Treatment: Chronic gonorrhoea should receive attention, to prevent continuous infection. In the treatment of gonor- rhoeal rheumatism, most may be accomplished with heat, elec- tricity, friction, and massage. Further treatment is the same as for chronic rheumatism. Muscular Rheumatism—Myalgia. Etiology: Many cases are caused by trauma, whereby mus- cular fibres are ruptured. Other cases are attributed to cold and exposure, which probably act by localizing some infection or poison. At least one infection, that by the trichina spiralis, is now described separately under Trichinosis. Symptomatology: The only characteristic symptom is pain, which may vary in all degrees of severity and character, and is confined to the voluntary muscles. The pain is usually re- lieved by pressure. 3—P. M. 34 INFECTIONS. The chief varieties of muscular rheumatism are : occipito- frontal rheumatism ; torticollis, cervical rheumatism, stiff neck; pleurodynia, which is chiefly an intercostal rheuma- tism ; and lumbago, one of the most frequent and painful forms. Affection of the muscles of the head is sometimes known as ceptudodynia. The pain may be localized in the muscles about the shoulder and upper part of the back— scapulodynia, omodynia, and dorsodynia. Diagnosis: Myalgia must be differentiated from the infec- tions, especially smallpox, tuberculosis, syphilis, and septicae- mia ; and aneurism, caries of bone, and tumors must be ex- cluded. The separation from neuralgia is sometimes difficult. Prognosis: Usually good. Treatment: The muscle should be put to rest—e. g., by strapping the chest with adhesive plaster in cases of pleuro- dynia. Heat, friction, and electricity are probably the best remedies. Pain may demand phenacetin, antipyrin, or mor- phine. Lumbago is sometimes relieved by acupuncture. Some cases may be cut short by a hot bath early in the course of the disease. In chronic cases iodide of potassium is the best single remedy. In all cases a careful search should be made for the cause, which should be removed or properly treated. INFLUENZA (Influenza (Italian, from influence); the Grip; La Grippe; Epidemic Catarrhal Fever; Chinese Catarrh (Rus- sian) ; the Eussian Disease (German and Italian); Italian Fever, Spanish Fever (French)). Definition: An acute infectious disease, caused by the influ- enza bacillus, characterized by catarrhal symptoms on the part of the organs of respiration and digestion, and nervous symp- toms, especially prostration. Influenza—history: The disease was probably recognized by Hippocrates (Parks), and epidemics of this nature were recorded in the ninth century. In 1173 the disease seems to have been epidemic throughout Europe. The first accu- rate description is of the epidemic of 1510, when it is said scarcely a person escaped. The epidemic of 1557 spread west- ward from Asia to Europe and to America. The epidemic of 1G47, which appeared first in Italy and France (162(J-27), INFLUENZA. 35 is the first epidemic of the disease mentioned in American records (Noah Webster). Influenza is now pandemic. Etiology : The specific infectious agent is the influenza bacil- lus. This organism has been found in all cases of influenza examined, often in pure cultures in the bronchial secretion, frequently in the pus-corpuscles. In fatal eases it has pene- trated into the peribronchial tissue and even to the pleura, where pure cultures have been found in the purulent exuda- tion. The influenza bacillus disappears, in cases of influenza, with the cessation of the purulent bronchial secretion. Pos- itive inoculation-experiments have been secured in apes and rabbits (Pfeiffer). The bacillus has been found in the blood. (Canon). Kaufman found the influenza bacillus in a large number of telephone-receivers examined. The influenza bacillus is aerobic, non-motile; grows upon glycerin-agar in the incubator, drop-like colonies developing in twenty-four hours, which are characteristic in that the drops do not coalesce (Kitasato). The bacillus may be stained best with dilute carbol-fuchsin, or Loffler's mcthylene-blue so- lution with heat. The ends of the bacilli are most deeply stained, which probably at first caused them to be mistaken for cocci. The influenza bacillus prefers a soil containing haemoglobin, and requires a temperature that liquefies gelatin. Influenza is highly contagious, and may be conveyed by fomites (clothing, third parties). Children seem somewhat less susceptible than adults. About one-fourth of cases occur in early life. Influenza has been reported in infants only a few days old, but is more frequent in the second half of the first year. The most susceptible period of childhood is from the eighth to the tenth year. Influenza—symptomatology: The disease may show the usual prodromal a of infection : malaise, languor, headache, etc. The period of incubation varies from a few hours to four davs. Usually the onset is sudden, with symptoms on the part of the respiratory tract, the gastro-intestinal tract, and the nervous system. The respiratory tract presents catarrhal symptotns, some fever, dryness, and swelling of the mucous membrane of the nose, increased secretion, and coryza. Often there is intense 36 INFECTIONS. bilateral bronchitis, and in children there is frequently pneu- monia. Influenza-pneumonia is an unfortunate complication. Photophobia and lachrymation are frequently present. On the part of the gastro-intestinal tract there are nausea, dyspepsia, vomiting, diarrhoea, and icterus, symptoms due to inflammation—catarrh—of the gastro-intestinal mucous mem- brane. The nervous symptoms are supposed to be largely caused by toxins. The spirits are depressed, the patient experiences sinking sensations, and there is prostration. Headache is a constant symptom, usually frontal—supraorbital neuralgia. There are pains in the back and legs and general soreness. There may be drowsiness and somnolence or insomnia. Ver- tigo may be persistent and severe. Rarely there is cerebro- spinal meningitis as a complication. Not infrequently tuber- culosis follows influenza, or is changed from a latent to an active process. Influenza—diagnosis : The respiratory, gastric, and nervous symptoms are characteristic. Symptoms on the part of the respiratory tract, the gastro-intestinal tract, or the nervous system may predominate in a given case or epidemic. In doubtful cases an attempt should be made to disclose the bacillus of influenza, which may be readily cultivated upon glycerin-agar in the incubating-oven. At the end of twenty- four hours small transparent drop-like colonies may be recog- nized, which are characteristic in that they do not coalesce. Prognosis: Death seldom occurs, except among the feeble, the aged, invalids, and young infants. The chief danger lies in the predisposition to other diseases, especially tuberculosis. Prophylaxis: If it were generally known by the laity that " colds " are contagious, there would probably be fewer cases of influenza. Isolation of influenza-cases, to be of value, must be more complete than is usually practicable. The debilitated should not be exposed to infection. Influenza—treatment: The strength of the patient should be supported and individual symptoms met. The disease is self-limited ; but one attack does not secure immunity for any considerable length of time. Early in the course of the disease, especially when gastro- WHO OPING-CO UGH. 37 intestinal symptoms predominate, calomel or the saline purga- tives may be used. A light "fever-diet"—milk, the gruels, beef-tea—should be observed. Individuals previously weak- ened by disease, age, or the abuse of alcohol may require the use of alcohol, whiskey, or brandy. In relief of symptoms, appeal may be made to the salicylates, salicylate of sodium, salol, best salipyrin, or the salicylate of cinchonidin, which causes less depression; lactophenin, phenacetin, antipyrin; morphine or opium, best in the form of Dover's powder. The oil of eucalyptus has been used, especially by the English. Ffirst, in the treatment of children, claims good results from the local use of the vapor of turpentine and menthol. Benzonapthol has been highly recommended by Huchard in the gastric form of influenza, 5 mgr. (gr. y1^) in pills, several times a day. Some advocate the use of quinine, gr. xv—xx, and others condemn its use. Excessive fever may call for hydrotherapy, the sponge- bath ; as a rule, however, hydrotherapy should not be used. WHOOPING-COUGH (Pertussis; Tussis Convulsiva; Keuchhus- ten, Kindhusten (German); Coqueluche (French); Tosse Ase- nine (Italian)). Definition: An acute infection, especially of childhood, characterized by paroxysms of convulsive cough, with usually a peculiar inspiratory " whoop," an inflammation of the nasal, laryngeal, and bronchial mucous membranes. History: At first not distinguished from bronchitis, influ- enza, and croup. Recognized by the Greeks (Mason Good). Definitely described by Baillou (Paris, 1578). First mono- graph published by Danz (1791). " Etiology: The catarrhal stage of whooping-cough is sup- posed to be due to the action of micro-organisms. The par- oxysmal stage (whooping) is probably caused by the poison (toxin) generated by the micro-organism. There is consider- able evidence in favor of the bacillus discovered in the sputum by Koplik, of New York, as the specific infectious agent. The bacillus is about the size of the influenza ba- cillus. 38 INFECTIONS. Cohn and Neumann found in the sputum, at the end of a spasm, after washing with distilled water and staining with carbol-methylene-blue, diplococci and small chains of cocci. Ritter found the diplococcus tussis convulsiva in all of one hundred and forty-seven cases in which the sputum was ex- amined. This diplococcus resembles the gonococcals, but differs from that organism in that it grows upon agar (Schloss- man). Neumann could find the organism described by Ritter in only one out of eighteen cases examined. A similar organism has been described by Heubner as the intracellular meningo- coccus. Some observers hold that the cause is an amoeba be- longing to the protozoa. Kurloff found, in fresh, unstained sputum, amoebae with fine granular protoplasm, provided with cilia and showing active movement. Kurloff believes these to be the infectious agent of the disease, and that the bacteria, which he also observed, are probably concerned in the secondary affections and complications of whooping- cough. Contagion is usually by contact; but may be through fomites, especially handkerchiefs. One attack usually confers immunity. The disease shows a preference for children, espe- cially the weakly, from six months to six years old. Whooping-cough—symptomatology: The period of incuba- tion varies from two days to two weeks. The symptoms of an acute catarrh of the air-passages then develop, and may last a few days or throughout the course of the disease. The paroxysm of cough is preceded by a distinct aura, which the patient soon learns to interpret as a forerunner of a spell of coughing. The cough is usually rewarded by the discharge of a small quantity of mucus. Vomiting is common. Soon there comes the characteristic " whoop" an audible inspiration following a spasmodic cough. The " whoop " is heard at the close of a series of coughs. Gilbert recommends recording on a chart the coughing- spells, in suspicious cases. The duration of the paroxyms is noted, and also the length of time between paroxysms. There is a coughing-spell about once every hour in the daytime, and every half hour at night. The paroxysms consist of six or eight coughs, " beginning with a big, loud cough, and tapering WHOOPING-CO UGH. 39 down to a mere l hack.' " Gilbert represents the whooping- cough diagramatically thus : CCCCcc-----CCCCcc-----Ccc Cc- —etc. The cough of simple bronchitis may be represented thus : c-c-c-c-cc-c-c-c-c-c- ccc -c-c-c-c-cc. In this way Gilbert claims to be able to make a diagnosis in the first week of whooping-cough, before the characteristic whoop is heard. An ulcer may frequently be found upon the frenum of the tongue, due to friction against the lower incisors. Sometimes the ulcer is found in the absence of whooping-cough, and it may be absent in cases of whooping-cough. The paroxysmal stage continues usually two to six weeks. The severity of the symptoms begins to diminish, as indicated by fewer paroxysms, and after ten days to several months health is restored. Complications: The most frequent complication of whoop- ing-cough is broncho-pneumonia. Less frequent is emphysema. Petechia, especially upon the forehead, ecchymosis of the con- junctivae, epistaxis, and haemoptysis may occur. Albuminuria may be found, but serious kidney-lesions are not common. Diagnosis : The history of exposure is often of value. The cough not only persists, but increases despite treatment. The "whoop" is characteristic. Gilbert claims to be able to make the diagnosis by the character of the cough (see Symptomat- ology), even in the absence of the " whoop." There is evi- dence of inflammation of the nasal, laryngeal, and bronchial mucous membranes. An ulcer on the frenum of the tongue, the result of friction against the lower teeth, may usually be found, but is not pathognomonic. In doubtful cases measles may be excluded if there be no eruption by the fifth day. Whoop- ing-cough often occurs during convalescence from measles. Prognosis : The prognosis is usually favorable ; not so good in the debilitated or in the negro race. Frequently tubercu- losis has been observed to follow whooping-cough. Prophylaxis: The patient should be isolated. Isolation is 40 INFECTIONS. difficult to secure in mild cases. At any rate, invalids and delicate children must not be exposed to contagion. The sputum should be destroyed. Whooping-cough—treatment: Mild eases may call for no treatment. Often it is only necessary to treat the associated catarrh. For the paroxysms a number of remedies have been recommended. Should the paroxysms not exceed half a dozen per day special treatment may not be necessary. Where the paroxysms are troublesome antipyrin, gr. ij-iij for a child two years of age, often acts very well. Acetanilid, phenacetin, and lactophenin may be used in individual cases. Bromoform, gtt. ij-iv three or four times a day for a child three to six years of age, on sugar or in alcohol, has many advocates. Belladonna, from two minums of the tincture or gr. y1^ of the extract up to tolerance, given three or four times a day at two years of age, has stood the test of time. Qui- nine, gr. j or more, every two or four hours, for a child two years old, is largely used. Opium (paregoric) relieves the cough, secures sleep, and protects the nervous system. Chlo- ral may be given to relieve vomiting and secure sleep. A change of climate sometimes becomes necessary. Raubitschek attempted to determine whether or not whoop- ing-cough is due to bacteria, by the local application of bi- chloride of mercury, 1 :1000, to the tonsils, uvula, epi- glottis, and adjacent mucous membrane. The application was made every day in severe cases, and every other day in mild cases. As a rule, improvement was noticed on the second or third day. In the paroxysmal stage the disease disappeared after four or five treatments. Naegely advises grasping the hyoid bone, over the two greater cornua, and the larynx, and holding them from sixty to ninety seconds, as a means of cutting short the paroxysms. He believes the action is due to the induction of an inhibitory reflex. Rothschild found the faithful use of tussol from the begin- ning of the disease caused the whooping-cough to be milder and shorter in duration. Some cases recovered in two weeks. Koroleff found the disease entirely disappeared in three days in four cases treated with naphthalin vapor; while in five MUMPS. 41 other cases, treated in the same way, the course of the disease was unaffected. Neumann used benzine vapor with good results; but found little value from the use of chloroform by inhalation. Reh- feld, on the other hand, used chloroform anaesthesia in a case of whooping-cough while setting a broken thigh-bone, and there was an immediate disappearance of the whooping-cough. Mohn found the inhalation of sulphur fumes was followed by a reduction of the duration of the disease to eight to four- teen days. The sleeping-room was charged with sulphur fumes. Two or three treatments were sufficient. Topical applications secure better results than inhalations. Bichloride of mercury solution, 1 : 1000, never fails to arrest the disease (Raubitscnek, Gentile, Fede). Oliphant secured good results from the local application of formalin. Ditel uses the bromides during the paroxysmal stage, fol- lowed in a few days by the use of codein. For the fever Ditel uses antipyrin, and for the bronchitis terpin hydrate. Binz recommended the use of quinine. The remedy may be used per rectum. Unruh advises the insufflation of quinine into the nose and pharynx. Celli found vaccination sometimes followed by a cessation of whooping-cough. Bolognini believes vaccination justifiable as a therapeutic measure in children that have not been vaccinated. In cases complicated by broncho-pneumonia, when many of the remedies usually employed in whooping-cough are contra- indicated, the use of camphor has been advised. Good results may be secured in bad cases by the use of resorcin, 2 to 3 per cent, solution, applied locally. The patient should be in the open air as much as possible. Thorough ventilation of the apartments should be secured, even in cold weather. MUMPS (Epidemic Parotiditis; Epidemic Parotitis; Mompen (Danish); Schafskopf, Ziegenpeter (German); Oreillons (French)). Definition: An acute, infectious, contagious, epidemic dis- ease, characterized by inflammation of the parotid gland, often 42 INFECTIONS. complicated by involvement of the testicle in the male; and of the breast, ovaries, and external genitals in the female. History : Mumps was recognized in the earliest times. The disease was described by Hippocrates. Etiology : Many observers have cultivated micro-organisms found in cases of mumps. Michaelis found diplococci resem- bling the gonococcus and meningococcus, but smaller. Inocu- lation-experiments have not succeeded in producing the dis- ease. Infection probably occurs through the duct of Steno. Most cases are preceded by, or associated with, inflammation of the mucous membrane of the mouth or throat. The epidemic nature of mumps is well known. Contagion usually requires close contact, although infection may be carried by third par- ties (fomites). Mumps show preference for the period of cJiifdhood and early adolescence, especially from the fifth to the fifteenth years. The disease seldom appears under two years; age is almost exempt. It has been suggested (Soltmann) that the exemption of infancy and age may be attributed to the duct of Steno being small in infancy and atrophied in age. The exemption of age may be largely due to the exhaustion of susceptible material, few reaching advanced age without protection by previous attack. Males are attacked more frequently than females. Mumps prevails especially during the cold months. The disease may affect animals (dogs). Mumps—symptomatology: Incubation may be as short as three days (Leitzen), or as long as six weeks (Nicholson); usually about two weeks. This period presents no symptoms, at least no characteristic symptoms, of the disease. Prodromal symptoms of infection,—malaise, headache, neuralgic pains, anorexia, slight fever, less frequently diarrhoea, vomiting, con- vulsions,—are present in about one-third of cases (Rilliet and Barthez). These symptoms last from a few hours to a few days, usually two to eight days. With the onset there is usually a chill or chilly sensations; then fever, as a rule 101 ° F. or less, reaching during the course of the disease 102° F., exceptionally as high as 104° F. Evidence of affection of the parotid gland is one of the MUMPS. 43 earliest and most characteristic symptoms. Usually there is pain in one of the parotids. The gland soon begins to swell; the swelling becomes extensive, causes the ear to be displaced upward, outward, and forward, and may cause the head to lean to one side. As a rule, the infection extends to involve both parotids. Often there is involvement of the testicle— orchitis—in the male. In females affection of the breast— mastitis—is common, also of the external genitalia, rarely of the ovaries, oophoritis. Sometimes the attack is announced by otalgia, especially in children (Comby). Complications are rare. Affection of the labyrinth may cause deafness. Other complications, especially on the part of the brain, may be caused by interference with the circulation or by toxaemia. Mumps—diagnosis: The presence of an epidemic is an aid in diagnosis, which is usually easy. The onset of the disease with enlargement of the parotid, indicated by swelling ad the angle of the jaw and with displacement of the ear, sometimes of the head, with pain, tenderness, and more or less fever, characterizes the disease. In some cases, such as those marked only by orchitis without the development of other symptoms of mumps, an absolute diagnosis may be difficult or impossi- ble. Prognosis: As a rule, good. Uncomplicated cases do not die. According to Laveran, the chief danger in the adult male is orchitis, which occurs in about two-thirds of the cases, and results in atrophy seven times out of ten. Thus impo- tence may follow double orchitis, which, however, is rare. Other unfortunate complications are mastitis, nephritis, otitis, and permanent deafness. Mumps—prophylaxis: This calls for isolation, three weeks to a month, and disinfection (steam, formaldehyd) of the sick- room and of all articles which come in contact with the pa- tient. Prophylaxis is exceedingly difficult, since the disease is often so mild in character, and since it may be disseminated durino" the period of incubation and for some time after the disappearance of symptoms. Mumps—treatment: The treatment is symptomatic. The patient should be kept in the house, in bed, if the fever 44 INFECTIONS. is high. Sometimes aconite is given for fever. _ The diet should be fluid or such as may be swallowed without dip- tress. The tension caused by the enlargement of the parotid may be relieved by hot or cold applications, as the patient may prefer, usually best by hot poultices, lard, vaseline, olive oil, or cocoa-butter. Gargles, as with hot salt water, are of very great value. If orchitis develop, the testicle must be supported, and later treated with the faradic current. The bowels should be kept open, best with a saline laxative or calomel. Often the patient may be made more comfortable by the use of Dover's powder or phenacetin. Complications must be met by special treatment. MEASLES: Morbilli (Italian); Rubeola (Sauvages); Rougeole, Ruber (French); Masern (German); Masura (Sanscrit)). Definition: A very contagious acute infection, characterized by early catarrhal symptoms, coryza, and bronchitis, and later by a peculiar eruption. Etiology: Doehle (1891) described bodies resembling proto- zoa in eight cases of measles. The observation lacks con- firmation ; but many believe that measles, scarlet fever, and smallpox may be due to organisms of this character. Canon and Pielicke (Berlin, 1892) discovered a short, thin bacillus in the blood of measles patients in fifty-six cases. The bacil- lus varies from 0.5 p to the diameter of a red blood-corpuscle in length, and in culture is found in long threads. The dis- covery has been confirmed by some observers (Czajkowski, Grigorieff), while others (Barbier, Warschovsky) have failed to find the bacillus in cases of measles. Some observers be- lieve the cause is a micro-organism that is too small to be recog- nized by the strongest known power of the microscope. Measles shows a preference for winter and spring. The dis- ease is very contagious, which explains the apparent liability of childhood, especially from one to five years. Comparative exemption of the first six months of life is probably due to freedom from exposure to infection. Individuals in later life are protected largely by previous attack. The children of mothers with measles show marked exemption from the dis- ease. MEASLES. 45 Measles may be communicated through the nasal secretion, which explains the general belief that measles is contagious through the breath. The disease may be conveyed by third parties, clothing, etc. Measles is contagious throughout its course; probably during incubation, certainly during the pro- dromal stage. Measles—symptoms: The period of incubation lasts from seven to eighteen days, during which there are no symptoms characteristic of the disease. Inoculation-experiments have placed the incubation at ten days. The eruption appears about two weeks after exposure. Invasion: The patient has a shivering fit, possibly a chill. At this time there may be no noticeable fever, but soon the temperature rises to 100°-104° F., with symptoms on the part of the stomach and nervous system. There is inflamma- tion of the mucous membrane of the eyes, nose, pharynx, and larynx, with severe coryza, cough, and photophobia. The mucous membrane of the cheeks is swollen to show the im- print of the teeth. There is bronchitis. Usually during the second day the eruption appears, first as an enanthem upon the mucous membrane of the mouth, from one to five days before the exanthem appears on the skin. The former reaches its height just as the eruption on the skin is appearing, and then fades. Koplik describes the enanthem as minute bluish-white specks on a reddish punctuate area in beginning measles, and on a more diffused background in advanced cases. Microscopic examination of the spots reveals diplococci and epithelial cells. This enanthem is believed to be pathognomonic of measles. The breath has the odor of sour paste. The patient suffers gen- eral malaise and thirst. In some cases, especially in certain epidemics, dulness and somnolence appear among the prodro- mata. From the third to the fifth day, usually about the fourth day, the exanthem appears, as a rule, first on the forehead, at the edge of the seal}), or behind the ears; later, around the eyes and mouth, and on the chin and neck. The eruption may be at first red and punctiform, or only a diffuse redness; but in a few hours small rounded red spots appear, separated by ap- 46 INFECTIONS parently healthy skin. At first the spots disappear on press- ure, to reappear when the pressure is removed. Later the spots no longer disappear on pressure. The eruption gradually spreads from the forehead and sides of the face downward over the trunk and upper ex- tremities by the seventh day, and over the lower extremities by the eighth day. Within about twenty-four hours after the first appearance of the exanthem, the eruption begins to dis- appear. Thus the eruption may vanish from the face before it appears on the lower limbs. With the disappearance of the eruption there is an improvement in the general symp- toms, usually with a return to health in ten to fourteen days. After the eruption there is a desquamation, usually fine and branny. Desquamation is sometimes absent, especially in light cases. In the absence of complications, an average case of measles presents approximately ten to fourteen days' incubation, three days' invasion, three days' progress, and three days' decline. Measles—forms : In severe cases, rubeola siderans, the indi- vidual may be overwhelmed with the poison of the disease and die during the stage of invasion. On the other hand, in very light cases the patient may show little evidence of ill- ness. Almost any of the symptoms may be present or absent in a "given case. Thus there may be none of the symptoms of catarrh, rubeola sine catarrho; the eruption may be absent, rubeola, sine eruptione, although probably some eruption is present in every case; or there may be little or no fever, rubeola afebrilis. Hemorrhage may take place under the skin or from the mucous membrane of the urethra, vagina, nose, intestine, and other mucous membranes, or into the muscles and serous membranes, rubeola nigra, black measles. Such cases rarely occur in private practice, but may be found under bad hygienic surroundings. The more important complications and sequelae of measles are: bronchitis, broncho-pneumonia, croupous pneumonia, catarrhal pneumonia, tuberculosis, pleurisy, stomatitis, noma, laryngeal stenosis, diphtheria, enterocolitis, endocarditis, peri- carditis, headache, convulsions (especially in children), delirium, MEASLES. 47 tubercular meningitis, paralyses, chronic conjunctivitis, iritis, blepharitis, keratitis, catarrhal or purulent otitis, and nephritis. Measles—diagnosis: Diagnosis is usually impossible during the period of invasion, and is often very difficult during the prodromal stage of the disease. The absence of previous attack and the presence of other cases of the disease may aid in some cases. In measles there is a long prodromal stage, with fever and catarrh, and later a peculiar eruption. The spots described by Koplik in the enanthem (see Symptomatology), are of especial value in the differentiation of measles from scarlet fever, simple aphthae, rubella, and influenza. One of the most characteristic signs is the early pliotophobia, which is often of value in the differentiation from influenza. Measles should be differentiated, especially from simple catarrh or coryza, hay-fever, scarlet fever, rubella, variola, typhus, roseola, papular erythema, and drug-eruptions (co- paiba, quinine, antipyretics). Prognosis: The prognosis of measles would be excellent if it were not for the complications and sequelae of the disease. Should the temperature continue high after the appearance of the eruption on the fourth or fifth day, complications may be expected. The most dangerous of these is tuberculosis, which is often changed from latent to active. Bronchitis and pneumonia are responsible for many deaths. Prophylaxis: One of the chief difficulties in prophylaxis is the fact that measles is contagious before the appearance of characteristic symptoms. The child should be isolated upon the first suspicion of the disease. Widowitz believes that epidemics of measles could be prevented by closing the school- room in which the first case occurs, from the ninth to the fourteenth day after the first appearance of symptoms, during which time all children from the room should be isolated from other children. The children could then return to school upon presenting the certificate of a physician. The disease may be carried by third parties and things (fomites). Quarantine should be continued two or three weeks after the onset of symptoms. The patient should then receive a bath and put on clean clothing. The room, and all articles which 48 INFECTIONS. have come in contact with the patient, should be sterilized. As a rule, exposure to fresh air is sufficient to destroy the con- tagious principle of measles. Measles—treatment: The subcutaneous injection of serum obtained from convalescents from measles has been practised by a number of observers (H. Thompson, AVeisbecker, Hubert, Blumenthal), with results more or less encouraging. Weis- becker injected serum, obtained from a convalescent, into a child nine months old, showing the prodromal stage of measles and whose brothers and sisters were taken with the disease. Ten grammes of serum were injected, with the result that the eruption was confined to certain parts. In four cases of pneumonia following measles two cases received the same dose, ten grammes, and the other two twelve and eighteen grammes. In each of these cases resolution occurred in a few days. In two of the cases there was a rapid disappearance of the fever ; in six hours in one case; in twenty-four hours in the other. The use of the serum of convalescents is believed to confer immunity, to cause the disease to run a milder course, to shorten the duration of illness, and even to cause a rapid disappearance of general symptoms. Distressing symptoms or complications should be met, and the patient placed under good hygienic surroundings and sup- ported until the disease has run its course. Mild cases may call only for the relief of thirst, cough, and photophobia. Thirst may be relieved by water, simple or acidulated, lemon- ade, or raspberry vinegar. Milk is the best food, diluted with water, soda-water, mineral water. Cough may be con- trolled by codein or small doses of Dover's powder. Laryn- gitis, stomatitis, and pharyngitis may be treated with antiseptic solutions. Severe laryngitis may call for the application of hot fomentations to the front of the neck. In membranous laryngitis, intubation, or tracheotomy is sometimes necessary. Bronchitis may call for expectorants, best apomorphin. Pho- tophobia is relieved by shading the eyes with smoked glasses or screens, and the irritation may be reduced by the local application of solutions of morphine or atropine. The edges of the lids should be anointed with vaseline to prevent them RUBELLA. 49 adhering during sleep. Earache is relieved by the evapora- tion of chloroform near the meatus, or by the instillation of hot water or a grain-to-the-ounce solution of atropine. Slight fever may be disregarded; fever above 103° F. may be met with the warm bath or, though more unpleasant, the cold bath (Fodor, Dieulafoy). The desired result may often be obtained by the use of antipyrin, phenacetin, and similar remedies in small doses, with beneficial effect upon the nervous symptoms so often present. Nervous symptoms may call for the bro- mides; sleeplessness, for trional, chloral. Diarrhoea may be controlled by bismuth and opium. Constipation should be carefully treated to avoid diarrhoea, best by enemata, some- times by small doses of castor-oil or calomel. RUBELLA (Rotheln; German Measles; French Measles). Definition: A contagious acute infection of short duration, presenting mild catarrhal symptoms and a characteristic erup- tion. Etiology: Rubella occurs especially at from five to fifteen years of age, although adults are often attacked. Previous attacks of measles or scarlet fever do not protect against rubella. Micro-organisms have been found in the blood (Klamann, Fdwards), but have not been proven to be the cause of the disease. Rubella—symptoms: Incubation lasts from five days to three weeks, probably the most variable of any of the acute infectious diseases. The prodromal stage is short, one-half to one day, often scarcely perceptible. During this period there may be some symptoms of inflammation of the mucous membrane of the respiratory tract, some malaise, headache, vomiting, diarrhoea, or constipation ; but as a rule these symp- toms are not marked. Often the period of eruption sets in without previous symptoms. Forchheimer attaches importance to the enanthem of rubella, which lie believes to bo present in all cases as a macular, distinctly rose-red eruption upon the velum of the palate and uvula, extending to, but not onto, the hard palate. The spots are arranged irregularly, not eresccntically, are the size of 4—p. M. 50 INFECTIONS. large pinheads, at the largest, and are very little elevated above the level of the mucous membrane. During the process of involution, especially in mouths having a pale mucous membrane, there are sometimes left pigmented deposits, usually of a yellowish-brown color, in spots or streaks. The eruption extends from the face to the feet in a day. The eruption of rubella may resemble the eruption of measles or of scarlatina—rubella morbillosa, rubella scarlatinosa. The eruption may fade from one part before attacking another part, or it may cover the entire body at one time. The color is usually a pale red. The ma cuke are more or less elevated, smaller, and not arranged in groups as in measles. The red points seen in scarlatina are absent in rubella. The erup- tion lasts at the longest only three or four days. There is little or no fever. Desquamation may be absent, and when present is slight and resembles that of measles. (implica- tions are rare. Diagnosis: Rubella is distinguished by its mildness, the absence or slightness of prodromata and fever, the enanthem, the diffuse rose-red rash, and the enlargement of the cervical lymphatics early in the course of the disease. Rubella should be differentiated especially from measles, scarlatina, syphilis, and drug-eruption. Prognosis: Excellent. Prophylaxis calls for isolation. Treatment: Little or no treatment is required. Usually it is difficult even to keep the child in bed. Any unpleasant symptoms should be treated symptomatic-ally. SCARLET FEVER (Scarlatina; Scharlach (German); Scarlatine (French); Scarlatto (Italian)). Definition: An acute, highly infectious disease, exhibiting a peculiar rash, angina, and fever. Etiology: Scarlet fever is generally believed to be due to some micro-organism, probably a coccus—micrococcus, strepto- coccus, diplococcus—but as yet this has not been proven. Many observers would attribute; the failure to find the specific infectious agent to the limited magnifying power of the micro- scope. The pus-formers are commonly present in the local SCARLET FEVER. 51 inflammatory processes, in the exudate in the throat, and in secondary affections and suppurations. A denuded surface, sore throat, wound, the puerperium, predispose to infection. Scarlet fever may be conveyed directly or by third parties, clothing, milk, mail (fomites). The vast majority of cases occur under the age of ten years. Liability to attack is greatest at five years; the greatest mortality is at three (Gresswell). The disease has been observed as early as the second day of life (Cortes). The geographical distribution and the indi- vidual susceptibility are less in scarlet fever than in measles and smallpox. One attack confers immunity. Fleming believes scarlet fever to be a local disease of the throat, and that the nephritis and dermatitis result from the attempt at excretion of the toxin. Behle, of Frankfort, in a district in which " pigs' scarla- tina" (English)—Rothlauf (German), Rouget (French)—had been previously unknown, found a severe epidemic of scarlet fever among children followed or accompanied by a disease among the pigs, marked by the symptoms of scarlet fever, including erythema, angina, albuminuria, and uraemia. Death in these cases was usually due to uraemia or angina. Charac- teristic lesions were found post-mortem in the kidneys. A previously healthy pig inoculated with the blood of a child suffering from severe scarlet fever, died a week later, and presented symptoms and post-mortem appearances identical with those of scarlet fever in man and the disease present in the other animals. The animals had probably been infected from children or from one another. Scarlet fever—symptomatology: Incubation lasts from one day to one week. The period of invasion, lasting one or two days, usually sets in suddenly. As a rule, there are chilly sensations rather than a true chill. Fever (Fig. 4) often reaches 104° or 105° F. on the first day, with pallor and prostration. Frequently there is vomiting early in the course of the disease, and convulsions, especially in young children. The skin is dry and the tongue furred. Even on the first day there may be' some dryness of the throat; inspection soon reveals the characteristic angina. Cough and catarrhal symptoms are not common. INFECTIONS. The enanthem is found first, as a rule, upon the anterior pillars of the fauces, the uvula, and the palate, possibly extend- ing over the mucous membrane of the cheeks and gums upward into the nose. The enanthem disappears much in the same way as it appears, by desquamation, leaving a coating that Fin. 3. DAY OF DISEASE 1 2 3 4 5 G 7 IO/f '03° 102° IOI° IOO 99° TEMP., M E M E M E M E M E M E M E A il r \a / / / J VI / V l/ V / V ^ ... —- .... ... .... K- Iiiitiul fever. Eruption. Temperature in measles. Fig. 4. DAY OF DISEASE 1 2 3 4 5 c 7 8 !> 10 11 12 M E 13 14 ir. 105° 1040 •03° 102° IOl' 99 TEMPV M E M E M E M E M E M E M E M E M E M E M E M E M E M E h A / \l V A 1/ /I V /l l/ / V 1/ / S / Eruption. Temperature in scarlet fever. " A comparison of the temperature in Scarlet Fever and Measles." may be confused with that of diphtheria. Usually the enan- them is at its height when the exanthem appears. The exanthem appears on the first or second day, usually first on the nech, chest, and back, especially in the region if the clavicles, and may spread over the body within forty-eight hours. The mouth is usually spared. The color of the erup- tion is lighter than that of measles—a scarlet—which has SCARLET FEVER. 53 given the name to the disease. The eruption disappears from the face, neck, chest, and body within a week—four to six days—with dcsf/uamtdion, frequently in the form of casts, espe- cially of the hands and feet. The appearance of the swollen papilhe protruding through the white coating of the tongue has given rise to the term, " strawberry" tongue. This may be found in other conditions. The sore throat varies greatly in intensity in different cases. Scarlet fever—complications: Nephritis is the most impor- tant complication, and is much more frequent in some epidem- ics than in others. Albuminuria early in the disease may be due to the accompanying fever; but later, from the second to the fourth week, may indicate acute nephritis, which causes (edema, especially puffiness of the eyes, nervous symptoms, neuralgia, headache, vertigo, insomnia, convulsions, coma, through the effect of irritant products upon the nervous system. Affection of the ear is common, and may extend to cause meningitis. Joint-effect ions are sometimes present, probably through secondary infection. Scarlet fever—forms: The symptoms are sometimes very light and the course of the disease short, constituting the abortive form of scarlet fever. The eruption of scarlet fever sometimes remains localized, being found only in the face (Braun, Lemoine). Such cases may pass unrecognized and convey the disease. Sometimes the poison is so intense as to take life during the period of invasion, the fulminant form ; or the symptoms may be exceedingly severe, the malignant form. The angina may assume special prominence, the anginose form. Scarlet fever—diagnosis: The presence of an epidemic, the history of exposure, and of absence of previous attach may aid in the individual case. The sudden onset of the disease, often with vomiting, one day to one week after exposure; the peculiar angina; the characteristic eruption on the first or second day ; the " straiv- bcrry" tongue, later the desquamation, "casts," especially of the hands and feet, and the complications on the part of the kidneys, ear, and joints, mark the disease. Scarlet fever should be differentiated especially from diph- 54 INFECTIONS. theria, measles, rubella, septicaemia, acute exfoliating dermati- tis, and drug-rashes (belladonna, quinine, iodide of potassium). Scarlet fever—prognosis: The prognosis varies greatly in different epidemics, 3 per cent. (Hirsch) to 90 per cent. (Johan- nessen). A mortality of 10 to 13 per cent, is considered normal, although in private practice the rate is not so high. The prognosis in the individual case depends upon the nature of the prevailing epidemic, the character of the infec- tion, and the existing complications. Fulminant and malig- nant forms always give a grave prognosis. Recovery from nephritis is the rule in scarlet fever. Persistent anuria is ominous. Early in the course of scarlet fever severe nervous symptoms would point to a bad prognosis. Should complica- tions cause the eruption to disappear, to be " driven in," the mortality is increased. An unusually high or low tempera- ture is to be looked upon with suspicion. Other complica- tions that increase the danger of scarlet fever are : severe inflammations about the neck, phlegmonous processes, oedema of the glottis, pneumonia, pleurisy, peritonitis, endocarditis, pericarditis, and meningitis. Prophylaxis: Isolation of the patient should be absolute. Scarlet fever may be conveyed by contact, either direct or in- direct, through third persons, clothing, dishes (fomites). Sus- ceptible children should be sent away from a house in which there is scarlet fever. Children who are nursing women sick with scarlet fever rarely contract the disease, and then usually only in a mild form. In all cases quarantine should be con- tinued until desquamation is complete. A collective investi- gation in English hospitals showed the minimum duration of the infectious period of scarlet fever to be eight and the maximum thirteen weeks. The sick-room should be kept well ventilated, and the patient should be bathed frequently. After recovery is complete the patient should receive a full- length bath and a change of clothing. The sick-room and all articles with which the patient came in contact must be disinfected or destroyed by fire. The nasal mucous mem- brane should be thoroughly cleansed before the case is dis- charged. Gonzales reports good results from the prophylactic use of SCARLET FEVER. 55 sodium sulphocarbolate, where isolation was incomplete or not practised, and claims to have prevented contagion in sev- enteen families, protecting one hundred and thirty-nine chil- dren exposed to scarlet fever. Scarlet fever—treatment: Good results have been secured by the injection of the blood of recent convalescents; but such treatment is not generally practicable. The patient should be placed under good hygienic sur- roundings, in a room where thorough ventilation may be se- cured and an equable temperature maintained, 65° to 70° F. at the head of the bed. The patient must be kept abed. The best single article of diet is milk. The meat soups afford an agreeable change. Acidulated, mineral, or plain pure water should be offered at regular intervals. A daily full-length warm bath contributes to both cleanliness and comfort. Tem- perature over 103° F. calls for the application of cold, spong- ing with cold water, the use of the cold pack, or the cold bath. It is more comfortable to the patient not to have the bath too cold ; or, to have the temperature of the water re- duced gradually after entering the tub. The bath may be substituted by antipyrin, or more safely by lactophenin or phenacetin, which may also relieve the nervous symptoms, especially headache. Itching of the skin is relieved by the application of lanolin, cocoa-butter, or lard, which should be renewed after each bath. Mild throat symptoms may not demand treatment; more severe symptoms on the part of the throat call for the appli- cation of cold to the neck or the inhalation of steam and the use of antiseptic solutions. In general the local treatment of the throat symptoms in scarlet fever is the same as in diphtheria. When the inflammation extends to the middle ear puncture of the drum-membrane may become neces- sary. Turpentine, hypodermatically or internally, is recommended for the prevention of nephritis in scarlet fever. Fauva found the injections to be perfectly harmless. Children may receive one gramme ; adults as much as three grammes. Two or three injections are usually sufficient. The digestive organs must be watched, and if necessary the turpentine may be suspended a 56 INFECTIONS. couple of days and salines given. To prevent local irritation, sodium bicarbonate may be added to the turpentine. The treatment of nephritis will be considered under acute nephritis. Cardiac weakness may call for heart-stimulants : alcohol, digitalis, nitroglycerin. SMALLPOX (Variola). Definition: An acute infectious disease, characterized by sudden onset with chills, headache, pains in the lumbar and sacral regions, sweating, vomiting, epigastric tenderness, a typical temperature, and peculiar eruption. History: The disease was probably recognized long before the time of Christ, in India, China, and Central Africa. Smallpox first reached America (the West Indies) in 1507, and the United States (Boston) in 1649. Etiology: Numerous micro-organisms have been described. Many observers believe the disease to be due to sporozoa. Others believe that the specific cause of smallpox has not been isolated because the microscope is not capable of suf- ficient magnification to detect the micro-organism. The cause is in the skin, as is evidenced by inoculation ; and in the blood, as suggested by infection of the foetus and as proven by inoculation-experiments. The disease shows a preference for the cold season. Smallpox was formerly considered a disease of childhood. Since protection by vaccination has become general smallpox has become so rare that children are seldom exposed to the infection. All ages are susceptible to the disease, with the possible exception of early infancy. Second attacks are rare, as are also attacks after vaccination. Smallpox—symptoms: Incubation lasts eight to fourteen days, usually ten to twelve days. There are no symptoms during incubation, except possibly some malaise late in the period. The period of invasion, lasting two or three days or longer, usually sets in suddenly and violently, with chill, rigors, fol- lowed by fever, rising often to 103° or 104° F. on the first day, SMALLPOX. 57 and possioly 105° to 107° F. on the second or third day. The pulse may reach 100-130; in children 160. Prostration is marked. There are thirst, loss of appetite, often constipation. The tongue is coated and the breath offensive. Some claim that the odor of the breath at this time is characteristic. Very frequently there is gastric irritation, sometimes accompanied by epigastric tenderness. Among the nervous symptoms are headache, which is almost always present in greater or less degree; delirium, especially when the temperature is high; coma, convulsions, especially in children, and pain in tlie back, especially in females. Hettdaefie, pain in the loins, and gastric irritation usually continue from the onset of the dis- ease until the eruption appears. The urine is diminished in quantity, there is a diminution of the chlorides, and in severe cases albumin may be present. A large quantity of albumin in the urine, if not due to chronic disease of the kidney, would probably point to the malignant type of smallpox. The spleen may be enlarged in unmodified smallpox. Often on the second day of the invasion there is an initial eruption, a roseola, lasting not longer than two days, which has been variously described as presenting the appcaranee of erythema, scarlet fever, and measles. Cases in which this eruption is marked have been observed to run a milder course. Sometimes an initial eruption appears in one of Simon's tri- angles as petechiae. (Simon's "triangles" arc in the groin, hypogastric region, inner surface of thigh, axilla, and inner surface of arm.) This eruption is found most frequently in a triangle, the apex of which is at the knees, and the base on a line extending transversely across the body at the level of the umbilicus. Petechiae have no diagnostic import. The eruption appears usually on the third day, first on the forehead and temples, near the margin of the scalp, and on the wrists. The eruption shows preference for the cutaneous and mucous surfaces exposed to the atmosphere, spreading rapidly to the scalp, ears, forearms, hands, and to the body and lower extremities in twenty-four hours. At first the eruption appears as little red points, macules, which be- 58 INFECTIONS. come indurated papules in twenty-four hours. The papules feel like shot in the skin. At first discrete, the papules become confluent as they increase in number. About the fifth day of the disease, after the eruption has lasted some three days, the papules which appeared first, will contain serum, at first clear (vesicles), becoming cloudy and milky (pustules), by the fourth or fifth day. The vesicles become umbi/ictded. By the sixth day the contents of the vesicles have become distinctly purulent (pustules). The vesicles and Fig. 5. DAY OF DISEASE 1 2 .'! 4 5 c 7 8 9 10 1! M E M E 13 14 15 1G 17 IS in 20 io6 i°5° 104° '°3° 102" IOI° iocf 99° NORM'L TEMP. 1—qS^ M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E M E / / V / A \/\ / V \ " V / V / / / \/ 1/1 / V l/ V\ V ^ \ Initial fever. Eruption. Secondary fever. Temperature in smallpox. pustules appear first upon the face and extend in the order of appearance of the rash over the body and extremities. With the exanthem there appears an eruption upon the mucous membranes that are exposed to the external air, espe- cially the mucous membrane of the mouth, nose, and pharynx, sometimes in the vagina, rectum, and urethra. The temperature, which often reaches 10(>° F., usually falls when the eruption appears, but may continue until the third or fourth day of the eruption (Welch). The temperature then falls, to become normal or even subnormal, usually within twelve to eighteen hours. At the same time there is a reduction in the pulse, respiration, and symptoms of gastric irritation. With the pustular stage the tempercdure at/ain rises, reaching 102°, frequently 104°, rarely 106° or 1076 F., with morning remissions. This secondary fever (Fig. 5) is a SMALLPOX. 59 part of the disease, but later shows, as a rule, the "strepto- coccus-curve" of sepsis (see Septicemia). During this stage there may be disturbances of the cerebral functions, particu- larly delirium in various degrees. Desiccation begins on about the eleventh or twelfth day of the eruption, with improvement in all the symptoms. With the drying up of the pustules there is often considerable itching, and frequently it becomes necessary to restrain the patients, especially children, from scratching and thus pro- ducing unsightly scars. The process of desiccation requires three or four weeks. During this time the fever disappears by lysis. Smallpox—complications: The skin may show multiple ab- scesses, erysipelas, boils, bedsores, pigmentation from derma- titis, acne pustulosa, and swelling of the hands and feet. The eyelids show oedema, possibly with sloughing, and some- times contain abscesses. Upon the part of the eyes there may be conjunctivitis, pustules, keratitis. The chief ear complication is deafness, partial or complete. The following are the more common complications on the part of the various organs. The respiratory organs: inflammation of the nasal mucous membrane, epistaxis, laryngitis, tracheo-bronchitis, pneumonia, pleuritis. The circulatory organs: pericarditis, endocarditis, myocarditis, hemorrhage, venous thrombosis. The digestive organs: glossitis, stomatitis, haematemesis, diar- rhoea, colitis, peritonitis. The urinary organs: albuminuria, haematuria, acute nephritis, cystitis. The nervous system: delirium, meningitis, acute mania, paraplegia, peripheral neuritis, disseminated spinal scleroses, epilepsy, anterior poliomyelitis. The genital organs: phimosis, from oedema of the prepuce, orchitis, ovaritis. The most important complica- tion is secondary infection (see Septicaemia). Smallpox—diagnosis: The prevalence of an epidemic, the history of a previous attack, inoculation, or vaccination, are points that aid in diagnosis. The onset of the disease sud- denly, with chills or rigor, followed by fever, headache, pain in the back, epigastric tenderness, and vomiting, is suggestive. The appearance of the eruption on the third day, first upon the upper part of the face, extending rapidly over the body, 60 INFECTIONS. changing from macules and papules to vesicles, which are um- bilicated and later become pustules, stamps the disease. The differential diagnosis has to do chiefly with measles, scarlet fever, typhus fever, lumbago, simple fever, syphilis, chicken-pox, erysipelas, drug-eruptions, ptomaine-poisoning, herpes, glanders, acne pustulosa, pemphigus, acute rheuma- tism, meningitis, malignant or ulcerative endocarditis with erythematous or purpuric rash, and cerebro-spinal fever. The prognosis of smallpox depends largely on the protection of the individual by previous attacks of the disease, inocula- tion, or vaccination; the form of the disease, hemorrhagic, purpuric, confluent, discrete, abortive (varioloid) ; the sur- roundings of the patient regarding hygiene, and the complica- tions that may arise in the individual case. The mortality is about 50 per cent, among the unvacci- nated, 26 per cent, among the badly vaccinated, and only 2.3 per cent, among the efficiently vaccinated (Moore). Infants and age show a large mortality. The prognosis is not good among drunkards. Prophylaxis: Vaccination is most important. Suspected cases should be quarantined eighteen days. Smallpox pa- tients should be isolated until all the scabs and scales have fallen off. They should then be sponged with a solution of bichloride of mercury, 1 : 2000, and given a full-length bath and change of clothing, after which they may safely come in contact with susceptible individuals. The room to which the patient with smallpox is confined should first be cleared of all unnecessary articles, pictures, curtains, etc. Precautions must be taken that contagion be not conveyed by the physician, attendants, letters, and dishes (fomites). In case of death the body is wrapped in a sheet soaked with bichloride of mercury, 1 : 1000, placed in a hermetically sealed casket, and should be buried as soon as possible. It would be better still to cremate the body. In the disinfection of the sick-chamber and furniture all articles of little value should be burned. Linen and other things of like nature may be boiled at least half an hour or exposed to a high degree of dry heat. Articles which cannot be subjected to moist or dry heat must be spread out in the SMALLPOX. 61 room, which is then thoroughly disinfected with formaldehyde gas, chlorine gas, sulphurous acid gas, mercuric chloride, or thiocamf. The apartments should then be well aired. Smallpox—treatment: Early vaccination, within the first four days, may lessen the severity of the disease. Bcclere has reported the successful treatment of sixteen cases of smallpox with injections of the serum of a vaccinated calf. One and a half liter of the serum was injected under the skin of the abdomen, in three doses. All the cases re- covered. Otherwise the treatment is symptomatic. The patient should be kept in bed, in a well-ventilated room with a tem- perature of 05° F. The diet should be light—milk, soups, gruels—and the patient should be given plenty of pure water to drink. Pain calls for opium ; fever above 103° F. for baths, phenacetin, salipyrin, antipyrin. The throat symptoms may require inhalations of steam, antiseptic gargles or sprays. Ice is grateful. The nervous symptoms may be met with chloral or Dover's powder. Pitting may be limited, before the formation of pustules, by touching the vesicles with pure carbolic acid. Some prefer anointing with oil or vaseline and covering the parts, especially the face, with lint soaked with a solution of bichloride of mercury, 1 : 5000 or 1 : 10,000; a 1 per cent, solution of creolin, or a dilute solution of carbolic acid. The object is to prevent infection of the vesicles, and consequent destruction of tissue. Varioloid. Mild cases of smallpox—varioloid—appear most frequently in individuals Avho have received a certain degree of im- munity or protection through vaccination, inoculation, or previous attack of smallpox. Varioloid assumes special im- portance since infection from cases of varioloid may cause unmodified smallpox. Vaccinia; Vaccination; Cowpox. Definition : "Vaccinia is the name given the disease produced in man by inoculation (vaccination) with cowpox. 62 INFECTIONS. History: Vaccination in prophylaxis against smallpox was introduced by Edward .Tenner, 1798. Etiology : As in smallpox, many micro-organisms have been described in vaccinia, but the etiologic relationship of none of them has been definitely established. Kent believes the spe- cific organisms of vaccinia to be a diplobacillus. Inoculation of susceptible animals with pure cultures of this organism causes vesicles that may not be distinguished from those pro- duced by vaccine lymph, and the animals so inoculated are immune to the action of vaccine lymph. The vesicles pro- duced by inoculation contain the diplobacilli in large num- bers. The supposition that cowpox is a bovine smallpox, as well as the belief that cowpox is identical with horscpox and sheeppox, remains without final proof, although no one will deny the close relationship of these affections. Cowpox will protect man against smallpox, and inoculation with small- pox will protect cattle against cowpox. The immunity against smallpox, in man, begins on the fourth day after vaccination, and is highest by the ninth day, but does not remain complete for life. Revaccination, in order to secure the most perfect immunity, should be repeated as often as it will " take." Virus from the cow or from cases of vaccinia in man may be used. The chief danger from the use of humanized lymph lies in the possibility of syphilitic infec- tion, which may be avoided by the use of virus from a healthy individual, or more absolutely by the use of bovine virus, best in the form of so-called glyeerinated lymph. Susceptibility to vaccination is universal, premising no previous attack of smallpox or vaccinia. Failure of the virus to "take" calls for another attempt. Vaccination—method: The virus should be rubbed into abrasions of the skin, made most conveniently by scarification or incision, which should cause the exudation of lymph through exposure of the superficial lymphatics, and little or no flow of blood. The point of selection, as a rule, is the left arm, near the insertion of the deltoid muscle, but usually there is no objection to vaccinating on the leg or some other part of the body. VARICELLA. 63 VARICELLA (Chickenpox; Waterpox). Definition : An acute infection of childhood, occurring espe- cially from two to six years of age, characterized by an erup- tion of vesicles, waterpox. Chickenpox is a common name for the disease, but varicella is not known to have any con- nection with chickens. Etiology: The specific agent of infection, probably a micro- organism, has not been demonstrated. Usually one attack confers immunity. So far as we know, there is no relation- ship between variola (smallpox) and varicella (chickenpox). Varicella shows a decided preference for children, especially under ten years, and very rarely attacks adults. Varicella—symptomatology : Incubation lasts eight to seven- teen days. The invasion is marked by fever with possibly a chill, vomiting, and pain in the back and legs, rarely con- vulsions. The eruption, first seen on the trunk, back, or chest, develops in a day. At first the eruption is papular, the little red papules becoming vesicles in a few hours. The vesicles may show umbilication, though this is usually not the case. Within two days the vesicles become purulent, and a day or two later the eruption dries up, the crusts falling off, to leave as a rule no scar. The eruption appears in successive crops. Varicella—diagnosis: The symptoms are usually much milder than in smallpox. Prodromata are rare in varicella. The pocks rarely present a feeling as of shot under the skin, such as is found in smallpox ; they appear especially upon the trunk, rarely become confluent, do not present so great infiltration around them, and are apparently more superficial. Prodromal rashes are more common in smallpox than in chickenpox. Above all, varicella occurs in childhood, some- times as an epidemic, but never appears as an epidemic among adults. Further, varicella shows no respect for vac- cination. Prognosis : Good. Complications do not often occur. Varicella—treatment: The patient should be confined to the house, if not to bed. The diet should be light. As a rule little or no treatment is required. Irritation of the skin 64 INFECTIONS. may call for the application of cocoa-butter or a dilute solution of carbolic acid. DIPHTHERIA. Definition: An acute infectious disease, caused by the Klebs- Loffler bacillus, characterized by a fibrinous exudate, false membrane, occurring especially upon the mucous membrane of the throat, occasionally upon other mucous membranes and wounds. Diphtheria—history: The disease was recognized by the older physicians—Aretaeus, Galen—but was not dissociated from other forms of sore throat. Early in the nineteenth century diphtheria was recognized by Bretonneau as a separate affection. The bacillus of diphtheria was discovered by Klebs, 1883; isolated, cultivated, and its pathogenesis demonstrated by Lofner, 1884. Etiology: The specific infectious agent in true diphtheria is the bacillus dipidtierite, commonly known as the Klcbs-Loffler bacillus. Most cases of diphtheria show mixed infection with streptococci and staphylococci. Diphtheria is endemic in cities. Children from two to fifteen years of age are espe- cially liable to attack. Diphtheria—symptomatology : Incubation two to seven days. The period of invasion is announced by slight cfiilliness, fever, pains in the back and limbs. In mild cases the patient may not feel sick enough to keep abed. During the first day the temperature rises to 102°-103° F., possibly 104b F. Some- times in childhood there are convulsions. In pharyngeal diphtlieria, membranous croup, there is some inflammation about the tonsils, palate, and pharynx, consti- tuting the catarrhal stage. The patient complains of dryness, burning, and constriction of the throat, and difficulty in swallow- ing. Soon the fibrinous exudate appears as a false membrane, usually first upon the tonsils, extending by the third day to the fauces and uvula, possibly later to the posterior wall of the pharynx. The color of the membrane changes from a grayish-white to a dirty gray, possibly to a yellowish-white. At first the false membrane may be readily detached, but later the mucous membrane is so involved that the false membrane DIPHTHERIA. 65 may be removed only with difficulty, leaving a bleeding sur- face, which soon again is covered with fresh exudate. Later the false membrane may be readily removed, after mixed infection. Convalescence usually begins about the seventh to the tenth day. Occasionally the disease lasts longer. Jessen reports a case lasting for five months, in which there were virulent diphtheria bacilli. Such cases are rare. The diphtheritic process may involve; the nasal mucous membrane, nasal diphtheria; or the false membrane may extend to the larynx, laryngeal diphtheria; or to the bronchi, oesophagus, or Eustachian' tube. Cases of diphtheria may appear primarily in the larynx or nose. Diphtheria—complications: One of the most important complications is post-diphtheritic paralysis, of toxic origin, affecting especially the pidate, possibly the epiglottis or larynx, or the constrictors of the pharynx, interfering with deglutition ; sometimes involving the eye (strabismus, ptosis, and alterations of accommodation); sometimes affecting the face, or extremities, especially the legs, frequently with loss of the knee-jerk. Albuminuria is found in all severe cases. Albumin in the urine in considerable quantity, with casts, would indicate nephritis. The heart shows both functional and organic de- rangement, tachycardia, bradycardia, pericarditis, endocarditis, valve-lesions, and heart-failure. Capillary bronchitis and broncho-pneumonia are found in the more severe cases. Diphtheria—diagnosis: The presence of an epidemic, and the history of exposure to infection and absence of previous attack, are valuable aids in some cases. A false membrane mav be present in some recess, as in the nose, and not be visible. Mild cases sometimes escape recognition until they spread infection and the disease appears in a more severe form. The demonstration of the bacillus diphtheria?}* of the greatest value in diagnosis, since it differentiates diphtheria from pseudo-diphtheria and reveals the character of mild cases of diphtheria, which might otherwise pass unrecognized and become foci of infection. The value of the bacterio- logical examination in diphtheria is well indicated in the emphatic statement by Osier, that "Where a bacteriological 5—P. M. 66 INFECTIONS. 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." The occurrence of albuminuria with casts points to diphtheria. Examination for the bacillus diphtheria : The bacillus grows upon various media—milk, potato, alkaline bouillon, nutrient gelatin, glycerin-agar, etc. The growth is most rapid upon the blood-serum mixture recommended by Loffler: blood- serum, three parts; bouillon, one part; to which are added peptone and grape-sugar, each 1 per cent., and sodium chlorid I per cent. After sterilization the mixture is solidified at a low temperature. A test-tube containing Loffler's blood-serum mixture is inoculated from a swabbing of the throat, or a piece of the false membrane, and placed in the incubating-oven at a tem- perature of about 35° C. for twenty-four hours. If the case be one of diphtheria, large, moist, grayish-white, elevated colonies of the bacillus diphtherias will be present, usually without sufficient development of other micro-organisms to interfere with the examination. From one of the colonies a slide is prepared and stained with Loffler's alkaline methylene-blue solution: saturated solution of methylene-blue, 30 c.c. ; solution of caustic potash, 1 : 10,000, 100 c.c. Or a good double stain may be secured by using the modified Weigert's fibrin stain and picrocarmine, recommended by Welch and Abbott. The specimen should be examined under the microscope with an amplification of a thousand diameters or more. The bacillus diphtheria? is non-motile, grows either in the presence or absence of oxygen (facultative anaerobic); it does not liquefy gelatin and does not form spores. The pseudo-diphtheria bacillus is often found associated with the true bacillus diphtherias, which it may closely re- semble. Sometimes the pseudo-diphtheria bacillus may be differentiated only by the lack of virulence. Diphtheria—prognosis: Usually good in private practice in cases that are seen early. A greater mortality occurs in hos- pital practice, since many cases are far advanced when they apply for treatment. Some epidemics give a higher mortality DIPHTHERIA. 67 than others. In general the prognosis is very much better since the introduction of the antitoxin treatment. Koenig and Moxter used antitoxin successfully in an infant five days old. Prophylaxis : For the protection of the community, a patiod with dij)htheria should, be isolated as long as cultures reveal the presence of the bacillus diphtherias. Thus it may be neces- sary to prolong isolation far into convalescence. This applies to mild as well as severe cases. Infection may be conveyed by third parties—fomites. When the disease has terminated the sick-room and all articles that have come in contact with the patient should be sterilized. In cases exposed to infec- tion an injection of antitoxin may prevent the disease. Such immunity lasts from two to four weeks. Infants at the breast rarely contract diphtheria from an infected nurse. In such cases Schmid and Pflanz have demonstrated, in Escherich's clinic, that the nurse's milk contains diphtheria antitoxin. If for any good reason the prophylactic dose of antitoxin cannot be given subcutaneously to nursing infants, it may be administered internally pure or mixed with eggs or milk. When given internally the prophylactic action of antitoxin is not so reliable as after subcutaneous injection in infants, and is of no value in adults. The internal use of anti- toxin cannot be depended upon in the treatment of diphtheria. The use of antiseptic sprays, in cases that have been exposed to diphtheria, is of value. Diphtheria—treatment: The diet should be light, consist- ing chiefly of milk, eggs, carbohydrates, butter, and light meats. Antitoxin should be used as early as possible in all cases, after a diagnosis of diphtheria has been made. In doubtful cases it is better to make the injection of serum before a bacteriological examination is made, if such an examination cannot be made promptly, especially in cases not seen until the third or fourth day Of the disease. Patients over two years of age may receive from 1500 to 2000 units; infants under two'years,' 1000 to 1500.1 The serum may be obtained 1 An antitoxic unit (Behring-Ehrlich) is ten times the amount of anti- toxin which, when mixed with ten times the minimum fatal dose of toxin 68 INFECTIONS. either in the liquid or solid form. The solid antitoxin is soluble in ten parts of water, and is of such strength that one gramme represents 5000 immunity units. If no im- provement follows the first injection of antitoxin, the dose should be repeated in eighteen to twenty-four hours, and again after a similar interval, if necessary. Antitoxin has complete control over the infection by the bacillus diphtherias, but not over the secondary infection by other micro-organisms (see Septicaemia). Local applications should be made of the subsulphate of iron. Some advise the use of the tersulphate or the per- chloride of iron, fuming hydrochloric acid, carbolic acid, bichloride of mercury, creosote, or creolin. The surface is best touched or painted with the remedy, with a cotton- wrapped sound, care being taken that none of the fluid drops into the larynx. Comfort is sometimes secured by the inhalation of steam. The nasal passages may be kept moist with yellow oxide of mercury ointment and vaselin, 1 : 6, introduced several times a day. Antiseptic sprays may be used ; but, as a rule, these accomplish more in the prevention than in the cure of diph- theria. The toxic symptoms are best met with alcohol. A weak heart may be supported with digitalis, best in the form of the fresh infusion. Quicker results are secured with nitro- glycerin. Severe cases may demand the use of camphor, ether, alcohol, or musk subcutaneously. In all cases, espe- cially in adults, the patient should be kept abed, that undue strain may not be thrown upon the heart. Paralysis calls for the use of electricity and strychnin. Severe dyspmea, indi- cating obstruction of the larynx, may demand intubation or tracheotomy. Complications should receive proper attention. for a 250-gramme guinea-pig, and injected subcutaneously, will neutralize the poisonous effect of the toxin and permit the test-animal to remain ap- parently unaffected. The guinea-pig must not vary in weiglit over 15 grammes from 250 grammes, and on the seventh day alter the injection must be alive and within 20 grammes of the original weight. QUINSY. 69 Croup. True croup is characterized by a peculiar crowing inspiration, due to the presence of a false membrane in the larynx. In true membranous croup the most common cause is the bacillus diphtherias (see Diphtheria). In other cases the spe- cific etiological factor is some other micro-organism, most fre- quently the streptococcus, especially in cases that are secondary to the acute infectious diseases, measles, scarlet fever, whoop- ing-cough, rotheln, smallpox, typhoid fever, less frequently after simple catarrh. Exceptionally cases may depend upon mechanical or chemical irritation, excessive heat and dry- ness, ammonia, chlorine, bromine, and the fuming mineral acids. As a rule croup occurs in children from two to seven years of age, although infancy is not exempt, and exceptionally the disease appears later in life. False Croup—Laryngismus Stridulus. False croup is characterized by a peculiar crowing inspira- tion, due to a laryngeal spasm. There is no false membrane in the larynx, such as is found in true croup. Sometimes there is a light catarrh of the larynx. The disease is found most frequently between six months and five years, especially in children that are confined in badly ventilated apartments. The attacks depend upon spasm of the adductors of the cords. QUINSY (Epidemic Tonsilitis; Suppurative Tonsilitis; Paren- chymatous Tonsilitis). Definition: An acute infection of the fauces, pharynx, and tonsils, probably contagious, that tends to go on to suppura- tion. The disease prefers fall and winter, and is found most fre- quently in adolescence, from fifteen to thirty years. Symptomatology: The symptoms of quinsy are marked by their severity. The disease comes on with chill and fever, 103°-105° F.; pulse 110-130. There are anorexia, some- 70 INFECTIONS. times nausea, pain in the back and limbs, headache, and extreme prostration. The throat is sore and dry. There is difficulty in swallowing. One or both tonsils may be affected. The tonsils are enlarged and oedematous, sometimes to such a degree as to meet in the median line, or one tonsil may be enlarged so as to extend beyond the median line. The swell- ing may be detected on the outside of the neck. Deglutition is painful. The tonsils are tender and soon show evidence of the presence of pus. Pus is recognized early by palpation. Extreme enlargement of the tonsil and surrounding tissue impairs hearing by blocking the Eustachian tube, and inter- feres with the use of the voice. Prognosis: Good. Death may be caused by the abscess bursting and inundating the larynx, or rarely by opening into the internal carotid artery. But recovery is the rule. Some individuals seem peculiarly liable to repeated attacks. Quinsy—treatment: Moist heat should be applied in the form of poultices, hot water, or steam. Pain may be con- trolled best with Dover's powder, internally. Suppuration calls for evacuation of the pus. TUBERCULOSIS. Definition: An infection due to the bacillus tuberculosis, characterized by the formation of tubercles (nodules). Tuberculosis—history: The disease was recognized as a suppuration by the older clinicians. Later, after the birth of anatomy in the sixteenth century, nochdes were observed by the anatomists. Early in the present century Bayle and Laennec ascribed the disease to the deposit of tubercle, which they showed to be a specific product, independent of ordinary inflammation. Villemin (1865) produced tuberculosis experi- mentally by inoculation with tuberculous sputum, and declared the disease to be caused by a virus. Koch (1882) isolated the virus as the tubercle bacillus. Tuberculosis—etiology : The specific etiological factor is the bacillus tuberculosis, which gains entrance to the body through the inspired air (tuberculosis put'monum); or the food, especially the milk and meat (tuberculosis intestinalis); or by direct TUBERCULOSIS. 71 infection of wounds {lichen tubercle); and possibly through heredity (congenital tuberculosis). Cornet believed tuberculosis to be disseminated chiefly through the dried sputum. Fliigge has shown that the dis- ease is most frequently spread through the agency of minute droplets of fluid containing bacilli, ejected during coughing, sneezing, etc. Secondary infection by streptococci, in cases of tuberculosis, intensifies the virulence of the toxins to a higher degree than would be present in either infection alone. Among the factors predisposing the individual to infection, environment—exposure to infection—is the most important. Bad hygienic surroundings, especially crowding, exclusion from fresh air and sunlight, a sedentary life, and exposure to dust render the individual more liable to infection. Certain diseases, especially bronchitis, measles, whooping-cough, influ- enza, diabetes, chronic nephritis, cirrhosis of the liver, chronic heart-disease, arterio-sclerosis, aneurism of the aorta, and pos- sibly above all trauma, prepare the body for infection by the tubercle bacillus. Affection of the tonsil may be primary or secondary, in the latter case being due to infection carried by the return-flow of lymph (Schlesinger). Such an explanation is supported in some cases by finding the deposit at the base of the tonsils, away from the crypts. Tubercular stomatitis, more often tubercular ulcer of the intestine, depends especially upon the swallowing of tuberculous sputum or the ingestion of food (milk) containing the tubercle bacillus. Laryngeal tuberculosis is usually secondary to involvement of the lungs. Cases of primary tuberculosis of the larynx are occasionally reported. Sometimes tuberculosis presents the general appearance of pneumonia. Tuberculosis of the kidney is not infrequent. Lichen tubercles are caused most frequently by scratching with contaminated hands. Tuberculosis of the inguinal glands following circumcision has been reported in a number of cases. Ten such cases were inoculated by one operator, who himself later died of pul- monary tuberculosis (Ware). 72 INFECTIONS. Tubercular myositis has been reported in some sixteen cases. A number of investigators have observed branching forms of the tubercle bacillus with club-shaped extremities, resembling the ray fungus. These are believed by some to be degenerative forms, or a reversion to the type of organism from which the tubercle bacillus was originally evolved. Friedreich, Babes, and Levaditi found the branching forms with club-shaped extremities early in the course of experi- mental tuberculosis. Brons proposes the term " myco-bacte- rium of tuberculosis" for the tubercle bacillus. Tuberculosis—symptomatology : Most cases begin with bron- chitis, manifested by cough, at first dry and hacking, occurring especially in the morning and evening upon changing the posture. The expectoration, at first absent, becomes abundant; at first mucoid, later muco-purulent, and possibly containing blood. Microscopic examination of the sputum reveals the presence of the bacillus tuberculosis, later elastic tissue. Haemoptysis usually means tuberculosis. Frequently the first symptom noticed is dyspepsia, often associated with ancemia, chlorosis, amenorrhoea, and general degradation of health. These are regarded as symptoms of toxaemia. Only too often the onset is so insidious as not to cause the patient to seek medical advice until the disease is far ad- vanced. One of the early symptoms is shortness of breath upon ex- ertion. Later there is dyspnoea, due to cardiac weakness, sometimes associated with cyanosis. Pain in the chest is a common symptom, due to pleurisy, sometimes to neuralgia of the intercostal nerves, caused by toxaemia. The tempertdure at first may be normal or subnormal in the morning; but shows early a rise some time during the day, usually in the afternoon. With the fever there may be night-sweats. Later the temperature becomes higher, 103° F., possibly 104° F., with daily remissions of two or three degrees. After sec- ondary invasion by the pyogenic micro-organisms takes place, constituting the period of "hectic," the temperature varies from 103° to 105° F. in the evening, but is normal or sub- TUBERCULOSIS. 73 normal in the morning, constituting the " streptococcus- curve" (see Fig. 1). The night-sweats may be exhausting. The jtulse, at first corresponding to the temperature, with increased weakness becomes rapid, compressible, and readily influenced by exercise. Frequently one of the earliest symptoms is loss of weight, and in the later stages emaciation is so marked as to have been one of the first recognized signs of the disease. Hence the terms, phthisis, consumption (wasting). Laryngeal tuberculosis will receive separate consideration. Tuberculosis—physical signs : Physical signs at first are en- tirely absent. Inspection may reveal the characteristic long, narrow chest, and the winged scapulae, which have been aptly compared to folding doors or the wings of the eagle. The clavicles become prominent. The chest may show deformity. The habitus phltiisicus, marked by a long, flat chest, with emaciation and weakness, formerly believed to predisj>ose to tuberculosis, is now recognized as evidence of the existence of the disease. I'aij>ation shows lessened mobility, with defective expansion on one or both sides. With consolidation, vocal fremitus is increased. In cases of pleural exudate the vocal fremitus is diminished or absent. Percussion may reveal defective resonance, especially in the region of the clavicle. In ad- vanced cases percussion will show dulness from consolida- tion, the so-called fibroid change; or a cracked-pot sound may be caused by the presence of cavities. Auscultation, a* a rule, shows prolonged expiration early in the course of the disease. Later all sorts of rales may be heard. Tuberculosis—diagnosis : In cases far advanced the physical signs leave little doubt as to the character of the disease. Advanced cases often show elastic tissue in the sputum ; but this may appear in other diseases, especially in abscess or gangrene of the lung, and sometimes is not present even late in tuberculosis. As a rule, an earlier diagnosis may be made by the discovery of the tubercle bacillus (Fig. 6). Examination for the bacillus tuberculosis: Some sputum is collected in a clean vessel. From the specimen a suspicious yellowish or whitish particle is selected, or a film is spread on a 74 INFECTIONS. slide or cover-glass with a camel's-hair brush. If the sputum is very tenacious, it may be better to add some caustic soda or potash and precipitate the bacilli with the centrifuge. The film is allowed to dry, and is then fixed by passing through a flame, specimen side up, three times. The specimen is now ready for the stain. Probably the most satisfactory stain is the Ziehl carbol-fuchsin solution: fuchsin, 1 c.c; absolute alco- hol, 10 c.c.; carbolic acid crystals, 5 c.c.; distilled water, 100 c.c. The specimen is covered with, or floated upon, this solution, under gentle heat, just sufficient to cause steam Fig. 6. ___' <-m,^>. -^ W- - Tubercle-bacilli. Sputum of a man suffering from tuberculosis of the lung, spread in a thin layer on a cover-glass and stained with fuchsin and methylene-blue (Ziegler). to rise, usually three to five minutes. Decolorize everything but the tubercle bacillus by the use, for about thirty seconds, of acid alcohol: hydrochloric acid, 1 c.c; 70 per cent, alcohol, 100 c.c. Wash with absolute alcohol and then with water. Countersfain with a saturated aqueous solution of methylene- blue. Wasfi off the surplus stain with water, dry and mount, best in glycerin or balsam. The tubercle bacilli appear red upon a blue background. Tuberculin test: Still earlier in the course of tuberculosis, before bacilli are thrown off through the sputum or when they are so few in number as to be difficult to find, the diag- nosis may be made by a test-injection of one milligramme of Koch's old tuberculin, which causes a rise of fever in tuberculosis, but no temperature-reaction in non-tubercular TUBERCULOSIS. 75 cases. This method is of especial value, since it discloses tuberculosis not only of the lungs, but anywhere in the body. The cases in which other diseases (actinomycosis, leprosy) have been reported to give the reaction were probably cases in which a coincident tuberculosis in some part of the body was overlooked. Pronounced agglutination and bactericidal power have been found in the serous fluid from local tuberculous lesions. In non-tubercular cases there is no such reaction. Tuberculosis—prognosis : The spontaneous cure of tuber- culosis is not uncommon. In fully one-third of autopsies (Mossini, 3!) per cent., quoted by Osier) upon individuals who have died of some disease other than tuberculosis there is evi- dence of pre-existing tuberculosis. in a general way it may be said that two-thirds of man- kind have tuberculosis, and that two-sevenths succumb to pulmonary tuberculosis, and fully one-third to tuberculosis in some form, including affections of the intestine, bones, glands, etc. Much depends upon the environment, especially as regards autoinfection of patients from their own sputum. The symp- toms of sepsis are ominous. When treatment is begun before the development of septic symptoms the outlook is not so bad. Froebelius, in the post-mortem examination of 18,569 in- fants, found the cause of death to be tuberculosis in 416, about 0.4 per cent. Tuberculosis—prophylaxis: The community as well as the individual should be protected by destruction of the sputum, best by fire. Promiscuous expectoration should be absolutely prohibited. Cuspidors must contain water or some antiseptic solution. Crowding, especially in a tuberculous atmosphere, favors contagion, as do also the inhalation of dust and the exclusion of fresh air and sunshine. It would be better for society if all tuberculous patients could be isolated. After a case of tuberculosis the sick-room and everything that has come in contact with the patient should be disinfected. For the protection especially of infants, dairies should be 76 INFECTIONS. inspected systematically with reference to the presence in the milk of tubercle bacilli. Tuberculous animals should be killed. Tuberculosis is found less frequently by far among the cadtle of Colorado than among the cattle raised in less elevated portions of this country. Gardiner concludes that in a drink of milk taken in a city below 2000 feet above the sea-level the risk of tuberculosis intestinalis is about 30 per cent, greater than in an elevated region such as Colorado. Tuberculosis—treatment: In the way of specific medication, the new tuberculin of Koch (T. P.) is of the greatest value, especially in cases of pure tuberculosis, but it has no control over the " sepsis " of phthisis.1 The remedy is given hypodermati- cally, preferably in the back, beginning with 0.001-0.002 mg. and gradually increasing up to 20.0 mg. The tuberculin is usually dissolved in 20 per cent, glycerin, to which 0.6 per cent, sodium chloride has been added. A solution containing 5F0 m£- °f tuberculin to 1.0 c.c. is used at first, the injections being given every day, sometimes every second or third day, beginning with 1.0 c.c. of the solution, or, in very bad cases, 0.5 c.c, and increasing 1.0 c.c. each injection until the dose reaches 10.0 c.c The solution is then increased in strength and the injections again gradually increased from 1.0 c.c. to 10.0 c.c. Again the solution is increased in strength, and so on until pure tuberculin is used, gradually increasing the in- tervals between injections as the injections increase in size, so that when the large doses are reached, the patient receives 'Besides Koch's new tuberculin, commonly known as T. R., prepared from whole tubercle bacilli pulverized in a mortar, the following have been recommended to address the specific cause of tuberculosis: Tuberculin (Koch), a glycerin extract of the tubercle bacillus, commonly known as Koch's old tuberculin, which is used chiefly for diagnostic purposes; tuber- culocidin (Klebs), a modification of tuberculin; antiphthisin (Klebs), prac- tically same as above; tuberculinum purificatum (v. Ruck), practically ditto; purified tuberculin (Whitman), practically ditto, made from the culture-fluid in which the tubercle bacilli have grown; oxy tuberculin (Hirschfelder), a 5 per cent, solution of tuberculin saturated with peroxide of hydrogen under protracted heat; V. Ruck's aqueous extract of dead tubercle bacilli. Serums: Maragliano's serum; antitubercle serum (Paul Paquin); Cran- dall's immunized serum ; Mulford's ass' serum, antituberculin serum ; anti- phthisic serum (Fisch). TUBERCULOSIS. 77 one injection in one or two weeks. The injections should cause; no fever, and are of most value when there is no, or but little, fever. The solutions of tuberculin must be kept where it is cool but not damp; and should they become cloudy they must not be used. This caution is important. For the laryngeal ulcers perhaps nothing is better than the local application of lactic acid. Fever and night-sweats, evidences of the sepsis of phthisis, disappear when the individual remains in the open air day and night. Night-sweats may be controlled with atropine, gr. _^__i_. Aromatic sulphuric acid combined with gallic acid is also highly recommended. Diarrhoea may be controlled for a time with bismuth, best in combination with Dover's powder, or by enemata of starch and laudanum, or acetate of lead and opium in pill, or by tannalbin or tannigen. Hemop- tysis, when the hemorrhage is from the lungs, may be relieved by morphine and atropine, at first hypoderniatically, later per os, with rest in bed and the application of an ice-bag over the heart. Among other remedies recommended for haemoptysis are : ergotin, sclerotinic acid, aconite, aromatic sulphuric acid, tannic acid, lead, and gallic acid. For the relief of the septic symptoms, aside from life in the open air, probably nothing equals the aromatic oils containing sulphur. Of these the oil of garlic is especially beneficial, but its use is seldom practicable because of the odor. Intrapulmonary injection with iodoform in oil has been suggested by the success attending the use of iodoform in surgical tuberculosis, as of the joints, and deserves a further trial. Alexander recommends campor subcutaneously. The rem- edy is antihydratic, antipyretic, and a cardiac stimulant, and lessens the suppuration and cough. Sanitaria are of value in the management of tuberculosis chiefly in so far as such institutions may secure the proper climatic, hygienic, and dietetic treatment of cases. Frequently good results may be obtained by the use of cinnamic acid, or, better, the cinnamate of sodium, given by intravenous injection. 78 INFECTIONS. Nebulization of the various essential oils has been recom- mended. These remedies may exert a beneficial effect, espe- cially upon the sepsis of phthisis, but are not a satisfactory substitute for the open-air treatment. Recovery from tubercular meningitis has followed lumbar puncture. In tubercular laryngitis pain may be relieved by insuffla- tions of orthoform, gr. v, or by painting the surface with a 10 per cent, solution of the hydrochlorate of orthoform (Nau- mayer). Tubercular pleuritis which does not show a tendency to undergo resolution promptly may demand thoracentesis and possibly the resection of one or more ribs. LEPROSY (Lepra; Elephantiasis Graecorum; Aussatz (German)). Definition: A chronic infectious disease, due to the bacillus lepra?, characterized by changes in the skin (tubercular leprosy), and in the nerves {ancesthetic leprosy), and also in the bones and other tissues. History: Probably reference was made to leprosy by Moses. The disease was described in detail by Celsus, 25 a. d. His- tory shows the gradual extension of leprosy westward, from Egypt to the Orient, India, Persia ; to Greece, Italy, later to Spain, France, and Germany ; to England and Scotland in the tenth century. It was spread all over En rope by the Crusades in the eleventh and twelfth centuries, to be brought under control by segregation in the fifteenth to the seventeenth century. Leprosy is endemic in northern and eastern Africa, Mada- gascar, Arabia, Persia, India, China and Japan, Norway and Sweden, Italy, Greece, France, Spain, and the islands of the Indian and Pacific Oceans. The disease is found in Central and South America, Mexico, the West Indies, Hawaii, Aus- tralia, and New Zealand, and also in New Brunswick, Canada. In the United States most cases occur in Louisiana and Cali- fornia, occasionally in Florida, New York, Ohio, Pennsyl- vania, Minnesota, Missouri, North and South Carolina, and in Texas. LEPROSY. 79 Etiology: The bacillus leprae is generally accepted as the specific cause of leprosy, although this has not been demon- strated by the production of the disease in man through inocu- lation with a pure culture of the bacillus. The bacillus lepras bears a marked resemblance to the tubercle bacillus, from which it may be differentiated by bac- teriological methods, especially by its affinity for acid stains, such as eosin and acid fuchsin. Leprosy may be communicated through inoculation. The disease is probably not contagious except upon close contact. As a rule, cases do not present open ulcers ; and when there are ulcers the superficial bacilli are usually dead. Hereditary transmission has not been proven. Kaposi has reported a case in which a leproma developed where an individual had been bitten upon the finger by a mosquito. Sommcr has observed that leprosy is more frequent where mosquitoes occur in large numbers. Leprosy—symptomatology: The period of incubation has been stated to be from a few weeks to as long as twenty or even forty years, probably most frequently from three to five years. Among the jurmonitory symptoms are irregular fever, mal- aise, anorexia, dyspepsia, epistaxis, drynes of the nasal pas- sages and respiratory tract, vertigo, headaches, neuralgias, rheumatic pains, articular pains, exaggerated functions of the kidneys and sweat-glands, anxiety, pruritus, and hyperesthesia of the skin. Erythematous eruptions may appear in various parts of the body, constituting the macular stage. Bullae may appear over the articulations of the fingers and toes, knees, elbows, wrists, and ankles. The appearance of nodules, especially upon the forehead, eyelids, nose, lips, chin, cheeks, and ears, constitutes the so-called tubercular leprosy. The nerve-trunks are thick- ened. Anaesthetic leprosy may start as an ulcer, appearing usually as the result of numerous bullae re-forming in the same locality. Patches of anesthesia, sometimes hyperesthesia, may appear in various parts of the body. Amesthesia of the little finger is said to be one of the most 80 INFECTIONS. constant symptoms, often appearing before other lesions in the hand. The tendon reflexes are exaggerated. Later there are marked trophic changes, atrophies, paralyses, etc. Usually the disease appears first as the tubercular form of leprosy, sometimes as the anesthetic form, and later takes on the symptoms of the other variety. Leprosy—diagnosis: Usually the history and symptoms are sufficient to make the diagnosis. In case of doubt, the body, including the suspicious macule, may be rubbed with fuchsin methyl-violet in powder, then covered with absorbent cotton, and perspiration caused by the injection of pilocarpin : the sound skin will be colored, while the leprous spots, which do not perspire, will not be stained (Baelz). Or the tissue may be searched for the bacillus lepre. Leprosy should be differentiaded from morphcea, syphilis, iodism, sarcoma, molluscum fibrosum, lichen planus, dysidro- sis, and Morvan's disease (if this be not, indeed, a variety of leprosy, or leprosy a causative factor of Morvan's disease). Leprosy—prognosis: The average duration of life, about eight years, is greatly exceeded in some cases. Prophylaxis: Segregation will prevent spread of the disease. In all cases absolute cleanliness should be observed, including destruction of all excreta and the protection of open sores. The patient should use individual utensils and occupy a sepa- rate sleeping-apartment. Leprosy—treatment: Probably the remedy of most value is gynocardia (chaulmoogra) oil, Gynocardia odorata, given internally, beginning with gtt. ij in capsule or milk and in- creased to tolerance, usually about two drachm doses, half an ounce a day. Among many other remedies which have been highly rec- ommended may be mentioned gurgun oil (dipterocarpus tur- biuatus), TTLv-x internally with lime-water; ichthvol, inter- nally and externally ; pyrogallic acid and resorcin, externally ; salol and salicylate of sodium, internally ; morphine and oil, hypodermatically; potassium chlorate, internally in large doses (gr. 180-380 per day, Dyer) ; oxygenated muriate of potassium ; the bites of venomous snakes ; the serum obtained from leprous lesions; the use of tonics, stimulants,and pallia- SYPHILIS. 81 five measures. Various baths are recommended In many cases an appeal must be made to surgery. SYPHILIS (Pox; Lues Venerea). Definition: A chronic infectious disease, transmitted through heredity [congenital syphilis) or through inoculation (acquired syj)fii/is). In acquired, syphilis, a sore at the site of inoculation, after an incubation of two or four weeks, constitutes the primary lesion. Two or three months later the secondary lesions develop : affections of the skin and mucous membranes, sore throat, cutaneous eruptions, and condylomata. The third. stage of the disease develops after a period of three or more years, with falling of the hair, gummatous growths in the viscera, muscles, bones, or skin—so-called tertiary lesions. Etiology : From a bacteriological standpoint the etiology of syphilis is not clear. Micro-organisms have been described by Lustgarten (1884); Eve and Lingard (18K(>); Disse and Taguchi'(1886); Golasz (1894); and Van Niessen (189S). One difficulty encountered by bacteriologists is the fact that animals are not subject to syphilis. It is known that syphilis may be conveyed by inocuhttion, and that the abrasion need be but slight. Thus infection is transmitted through sexual intercourse, kissing, and through the use of common utensils and vessels for eating and drinking. Physicians have frequently been inoculated in the examination or treatment of cases of syphilis, especially in surgical and obstetrical practice. Occasionally syphilitic in- fection occurs during circumcision. Hereditary syphilis may be transmitted from either parent, in whom the disease may be either manifest or latent at the time. Syphilitic infection of a mother at the seventh month of u'estation usually does not affect the foetus, although the fo'tus has been reported to be affected as late as the eighth month of gestation. The mother need not necessarily be affected bv syphilis transmitted to the offspring from the father, and may afterward nurse the child without becoming 6--P. M, 82 INFECTIONS. infected, probably through having received a protective inocu- lation without the development of the disease. The child may convey syphilis to a wet-nurse who has received no such protection. Hereditary syphilis is usually found in the first three months of life, often at the time of birth. Not infre- quently abortion or miscarriage is due to inherited syphilis in the foetus. A distinction should be made between syphilis acquired with conception and syphilis acquired during intra-uterine life ; but for practical purposes hereditary syphilis is usually considered synonymous with congenital syphilis. Symptomatology: After an incubation of two to four weeks the primary sore, ulcus durum, appears at the point of inocula- tion, first as a small red papule, which later breaks down in the centre to form an ulcer. The ulcer has an indneeded base; hence the term hard chancre. The primary sore varies in size, and when small may be overlooked, particularly when located in the urethra. In the female the sore is usually on the inner side of the labia or on the vaginal portion of the cervix. The lymphatics in the neighborhood of the primary sore are enlarged, and suppuration may occur both in the primary sore and in the adjacent lymphatics. The early symptoms of hereditary syphilis are peevishness and irrita- bility at night, harsh and difficult breathing, snuffles, sore mouth, and impaired digestion, with emaciation and the "old man appearance." There may be characteristic eruptions. Second stage: Usually in from six to twelve weeks consti- tutional symptoms are observed: fever, ancemia, cutaneous and mucous lesions (macules, papules, and pustules ; squamous syphilides, condylomata, fading of the hair, mucous patches, stomatitis, and sore throat), and affections of the eye (iritis, keratitis, and affections of the optic nerve), sometimes affec- tions of the ear, and occasionally epididymitis and parotitis. Third stage: After a period of several years the so-called tertiary symptoms appear. These are chiefly skin-erujjtions, gummtdous growths in the viscera, and amyloid degeneration. Other characteristic symptoms of syphilis are the pains in the bones, especially at nigfd ; the su)d:en bridge of the nose, and the notched teeth. The bone-lesions in congenital syphilis SYPHILIS. 83 are usually found after the sixth year. Sometimes syphilis involves the kidneys and lungs. Congenital syphilis may or may not be present at birth. Among the most characteristic symptoms are those due to a syphilitic rhinitis, which has given the name " snuff es" to the disease. The symptoms of congenital syphilis, when not present at birth, as a rule become manifest within the first three months, and resemble those of acquired syphilis, except that the primary sore is not present. P. Silex recognizes in congenital syphilis three character- istic signs: 1. A choroidea areolaris, in which there are scattered over the fundus of the eye, especially in the neigh- borhood of the macula, black points and patches, with here and there white spots of various sizes and larger areas with a black border. These represent atrophic colonies in the choroidea, and pigment-patches from the pigment of the stroma and epithelium Vision is impaired from involvement of the retina. 2. A central crescent-shaped excavation in the permanent upper incisors denuded of enamel. 3. Pseudo- scars radiating from the corners of the mouth to the cheek and chin. Cases of syphilis hereditaria tarda, in which the disease was acquired by heredity, but did not become manifest until a long time after birth, have been reported. The existence of such cases is doubted by many, who are inclined to believe that they are really acquired, and that the initial lesion has been overlooked. Syphilis affects the bloodvessels (endarteritis obliterans) and precipitates the changes of age (arterio-sclerosis). In the liver syphilis may cause cirrhosis, or the formation of gum- mata. The testicle may be involved in a sarcocele, marked by the absence of pain and fluid, and usually of slow growth. Diagnosis : A negative history is of little value in diagnosis. Frequently the primary sore is not recognized. A history of an eruption, failing of tfie hair, iritis, sore ttiroat, or repeated miscarriages or abortions, may be obtained, and is suggestive. Superficial bone-surfaces (tibia) may be examined for nodes. Copper-colored cicatrices may be found on the legs, or a scar 84 INFECTIONS. may indicate the site of the primary sore. The testicles may show atrophy or hardening. Usually enlargement of the lymphatic glands may be detected. Depressed nasal bones or the presence of ozcena may throw light upon a case. The notched teeth of syphilis—the so-called Hutchinson teeth— are due to a disturbance of nutrition, and are not pathogno- monic of syphilis, although frequently present in that disease. Congenital syphilis shows early snuff es and a skin-msA. About three-fourths of cases develop symptoms of syphilis within the first three months of life ; but a negative diagnosis should not be made within less than a year after birth. Doubtful cases may be cleared up by the therapeutic test with mercury and iodides. Prognosis : Although syphilis is a chronic disease, the prog- nosis under proper treatment is usually good. In hereditary syphilis the chances arc more favorable for the child in cases of infection from the father in which the mother remains healthy. In 1700 pregnancies destruction of the ovum or foetus oc- curred in about one-third of the cases; 1121 children were born alive, and of these children 966 died during the first year of life (Hyde). Prophylaxis : Segregation would be effective, but is imprac- ticable. Promiscuous sexual intercourse, the habit of kiss- ing, and the use of common drinking-vessels are largely responsible for the propagation of syphilis, and should be prohibited. Sexual relations should not be permitted until after at least two years' active treatment of syphilis. Founder has wisely remarked that nothing is so dangerous to the surroundings as a syphilitic infant (Bulkley). In cases of hereditary syphilis the father may be treated ; the mother must be (Sturgis). Syphilis—treatment: Some advise excision of the primary sore, since it is a focus of infection. When this is done, medicinal treatment is begun at once; but usually active treatment is deferred until the second stage. In the treatment of the second stage, mercury, in the form of the ointment, may be given by inunction, a drachm a day SYPHILIS. 85 for six days, with a bath on the seventh day, the inunction being begun again on the eighth day and continued as before. The patient should be directed to make the applications suc- cessively to the forearms, arms, chest, abdomen, thighs, and legs, upon different nights. ()r mercury may be given internally, in the form of calomel, or the hydrargyrum cum creta (chalk-mixture, gray powder), with Dover's powder, one grain of each in pills, four to six times a day ; or the biniodide of mercury, gr. -^, or the prot- iodide of mercury, gr. ^, three times a day. Mercury may also be given by injection into the muscles, bichloride, gr. ^ in gtt, xx of water, or calomel, gr. j-ij in Tu_xx of glycerin, injected once a week. Mercury may also be given by fumigtdiou. Infialation of mercury often gives excellent results ; indeed, it is believed that when inunctions of mer- cury are used the mercury must enter the system through the organs of respiration, since it is well known that very little of the mercury is absorbed through the skin. During mercurial treatment, salivation should be guarded against by keeping the teeth and mouth clean, avoiding acids, green vegetables, and fruit. Should symptoms of salivation supervene, manifested by tenderness of the gums, the use of mercury may be suspended, or potassium chlorate may be given, a teaspoonful of the saturated solution every two hours. Congenitad syphilis may be treated with mercury by in- unction or internally, in the form of the hydrargyrum cum creta. Later manifestations may call for the " mixed treat- ment," Gilbert's syrup (biniodide of mercury, gr. j ; iodide of potassium, half an ounce ; water, two ounces), gtt, v-x three times a day, gradually increased to tolerance. Syphilis in infants may be treated indirectly through the administration of mercury and the iodides to the nurse. Children with hereditary syphilis almost invariably die if taken from the breast. This has generally been attributed to decreased nutrition, but possibly may be due to some sub- stance of therapeutic value in the mother's milk. In the treatment of the third stage the iodides, especially the iodide of potassium, takes the place of the mercury used 86 INFECTIONS. in the second stage. The patient may begin with gr. x, gradually increased to gr. xxx or more, largely diluted, in milk or water three times a day. In all cases it is advised to continue treatment ad least two years. Some believe that this length of time may be made shorter by the use of injections of mercury. CHANCROID (Soft Chancre ; Ulcus Molle). A venereal sore, that appears within a day after infection as a red spot upon the glans penis. At first a papule, it be- comes a day or two later a vesicle. Rupture of the vesicle forms an ulcer, characterized by a profusely suppurating base. The ulcer causes infection of contiguous structures, and often spreads through the lymphatics to cause suppuration of the lymphatic glands—bubo. Inoculation-experiments are suc- cessful in apes and man. Diagnosis : The rapid onset, the absence of induration of the base of the ulcer, and the fact that there is no general infec- tion, differentiate soft chancre (chancroid) from the hard chancre (true syphilis), and make recognition of the disease easy. Treatment: When seen early the ulcer should be destroyed with the cautery or strong caustics, caustic potash or zinc chloride, or with fuming nitric acid. Later, mild treatment is best. The ulcer may be cleaned and covered with iodoform, europhen, dermatol, calomel, or bismuth. GONORRHOEA (Blennorrhcea; Urethritis Specifica; Clap; Tripper (German)). Definition: Infection of the urethra by the gonococcus. Etiology: The specific cause is the gonococcus, micrococcus gonorrhoeas, a diplococcus discovered by Neisser (1879). In- fection occurs usually through impure intercourse, to cause greater or less involvement of the genito-urinary system. Thus there may be produced a specific urethritis, affecting sometimes the posterior urethra ; prostatitis, adenitis (bubo), orchitis; salpingitis, oophoritis, metritis, peritonitis; cystitis, GONORRHOEA. 87 ureteritis, pyelitis, and nephritis. Careless manipulations may permit inoculation of the anus, condylomata; or of the eye, conjunctivitis. During parturition from an infected mother a child may be inoculated, to cause most frequently affection of the eve, conjunctivitis, blennorrhea neonatorum; less fre- quently, vaginitis or stomatitis. The gonococcus has been found in the blood and upon the valves in cases of gonorrhoeal endocarditis. Pericarditis, pleurisy, and myocarditis are rare. Gonorrhoeal arthritis is more frequent. Sometimes pure cultures of the gonococcus may be obtained from infected joints. The knee-joint is the more frequently involved. Often the gonococcus opens the way for secondary invasion by other micro-organisms (see Septicemia). Gonorrhoea—symptomatology: Incubatiim, two or three days. The symptoms come on with dysuria, painful erections (chordee), a muco-purulent discharge, becoming later a more or less continuous discharge of pus—pyuria. In bad cases there may be a bloody discharge, due to the destruction of tissue. As a rule there is fever, probably caused by the absorption of toxins. Infection of the lymphtdics may cause enlargement of the glands in the groin. Sometimes there is affection of the testicle, especially of the epididymis, with effusion into the tunica vaginalis. Condylomata may appear upon the glans penis or perineum. Infection of the glands of Cowper is announced by a sense of weight and pain, and the appearance of a tumor, in the median line of the peri- neum. Suppuration with discharge into the urethra may lead to the formation of fistule. Among the nervous phenomena are insomnia, headache, priapism, and emotional disturbances; the individual becomes irritable, sometimes dejected. The chief complications and sequelae are prostatitis, adenitis, peri-urethral and prostatic abscess, orchitis ; vulvitis, vagin- itis (leucorrhcea), metritis, salpingitis, oophoritis, sometimes peritonitis; cystitis, ureteritis, pyelitis, nephritis; arthritis, endocarditis, septicaemia, conjunctivitis, iritis; pericarditis, pleurisy ; synovitis, and stricture. Diagnosis: The symptoms, especially dysuria and pyuria, 88 INFECTIONS. may arouse suspicion; but a positive diagnosis may be made only upon disclosure of the gonococcus (Fig. 7). Examination for the gonococcus: The gonococcus is a "bis- cuit-shaped" or kidney-shaped diplococcus, arranged with its concavities in apposition, separated by a narrow zone. The organism is found within pus-cells and upon epithelial cells, and is decolorized by Cram's method. Cultivation is difficult, Fig. 7. Gonococci in the secretion from the urethra in recent gonorrhoea. Cover-glass preparation stained with methylene-blue. a, mucus with separate cocci and diplococci; b, pus-cells with diplococci; c, pus-cells without diplococci (Ziegler). but may be accomplished upon human blood-serum, or upon the ordinary nutrient agar to which urine has been added. The gonococcus shows an affinity for the basic aniline dyes, especially methyl-violet, gentian-violet, and fuchsin. Prob- ably methylene-blue is the best stain when searching for the organism in pus. Beautiful double staining may be done with methylene-blue and eosin, or with Ziehl's solution of fuchsin and methylene-green. Prognosis: Good, under proper and persistent treatment. The occurrence of complications makes the outlook less favorable. Gonorrhoea—treatment: The bowels should be kept open. A light diet is best. Fluids, but not alcohol, should be taken in abundance. Rest in the recumbent posture is advisable. The testicles should be supported in a light bandage. Pria- pism calls for sponging of the organ with cold water and the internal use of the bromides, camphor, lupulin. Dysuria may be relieved by salol, the salicylates, phenacetin, or in severe cases by suppositories of opium or belladonna. After subsidence of the acute symptoms oil of copaiba GLANDERS. 89 or sandalwood may be given internally. Later the urethra may be treated locally with mild solutions of the acetate of lead or zinc, nitrate of silver, protargol, chloride of zinc, or alumnol. Posterior urethritis calls for the deep prostatic injection of nitrate of silver with an Ultzman catheter; or iodoform may be injected, a 10 per cent, solution in pure glycerin. The odor may be disguised with vanillin or coumarin, 1:10. The remedy is injected, a syringeful at a time, immediately after the patient has voided the urine. Complications may need special treatment, Cystitis is best met by washing out the bladder with mild solutions of boric acid, permanganate of potassium, nitrate of silver, or protargol. Obstinate cases may sometimes be cleared up by the use of the endoscope, whereby a localized inflammation may be dis- covered and treated directly by local applications. Buboes may be treated by the injection in two places of a 1 per cent, solution of the benzoate of mercury. This treat- ment will sometimes prove successful when incision has failed, and has been reported to succeed even after suppuration has begun. GLANDERS (Farcy; Rotz (German); Morve (French)). Definition: An infectious disease, acute or chronic, com- municated to man from the domesticated animals, especially the horse, and characterized by nodules, particularly in the nose and beneath the skin. The disease does not affect cattle nor swine. Etiology: Glanders is caused by the bacillus mallei, dis- covered by Loffler and Schiitz (1882). The disease occurs in man chiefly through inoculation from diseased animals; occa- sionally from man. The infection is disseminated through the lymphatics. Glanders—symptomatology: Incubation, usually three or four days. The point of inoculation shows swelling and red- ness with inflammation of the lymphatics. Nodules form in the nasal mucous membrane and break down to form ulcers, from which there is a muco-purulent discharge. Papules, which 90 INFECTIONS. soon become pustules, appear on the face and over joints. The patient experiences chilly sensations, fever, headache, and prostration. Chronic glanders present nasal ulcers, and often also laryn- geal symptoms. The disease may be mistaken for chronic coryza. Farcy, in animals, presents a phlegmonous inflammation of the skin at the point of inoculation. With inflammation of the lymphatics there are formed enlargements along their course, to constitute the farcy "butts." These usually soon show suppuration. As a rule this form of the disease reaches a fatal termination in about two weeks. In the chronic form farcy shows localized tumors, which break down, sometimes forming deep ulcers. There is not much involvement of the lymphatics. The duration of this form of the disease may be for months or years. Glanders—diagnosis: The occupation of the patient—possi- bility of contact with diseased animals—may lead the phy- sician to suspect the disease in the presence of a nodular eruption or ozena. Mallein, a product of the glanders bacillus, is used in the diagnosis of glanders, much as tuberculin is used in the diag- nosis of tuberculosis. This is of especial value when the disease is located in some recess of the body, as in the lungs, where it may not be brought under direct observation. Should mallein not be accessible, a male guinea-pig may be inoculated, or better several of them. The inoculation is made into the abdominal cavity. Two to five days after inoculation the testicles and their sheaths become swollen and purulent. Prognosis : Cases of acute glanders usually terminate fatally in about eight or ten days. Chronic glanders may last for months, and sometimes results in recovery. Glanders—prophylaxis: Diseased animals should be killed, and as far as possible individuals should be protected from the danger of inoculation. To this end, after death cremation of the bodies of both men and animals is advisable in all cases. Treatment: As far as possible, especially in early cases, the FOOT-AND-MOUTH DISEASE. 91 diseased tissue should be removed by the knife or cautery, and the parts treated antiseptically. The value of mallein as a therapeutic agent has not been definitely determined. FOOT-AND-MOUTH DISEASE. Definition: A disease, involving especially the mouth and extremities, sometimes the udder and teats, that occurs most frequently in cattle, sometimes in other animals, and is occa- sionally communicated to man through the ingestion of milk and otlier dairy-products from diseased animals, or directly by inoculation. Some believe that aphtha is an expression of this disease in man. Foot-and-mouth disease—symptomatology: Incubation, two to ten days. The chief prodromcda are pains in the head and limbs; fever, 100° to 103° F.; malaise; vertigo; and fre- quently a sensation of formication in the hands and feet. An eruj>tion then appears upon the mucous membrane of the mouth and nose, consisting of vesicles with at first clear contents, which later become turbid. The vesicles may burst and crusts form. There is swelling of the tongue, lips, nose, and evelids. Often vesicles appear upon the fingers. An eruption of vesicles, discrete or confluent, may appear upon various parts of the body or become general. With appearance of the eruption the temperature usually falls. The affection of the mouth causes difficult deglutition and speech, sometimes difficult respiration. The disease may last from five to eight days in mild cases; as long as eight weeks in severe cases. The principal complications are diarrhoea; hemorrhages from the mouth, bowels, or kidneys; sometimes bronchitis and catarrhal pneumonia; occasionally spasms and paralyses. Foot-and-mouth disease—diagnosis: The diagnosis rests on the evidence of direct or indirect transmission of the disease from infected animals, in conjunction with the symptoms of the disease. A positive diagnosis may be made by inoculating an animal, best a goat, with the contents of the vesicles from a 92 INFECTIONS. suspected case. As the name indicates, the disease is peculiar in that the eruption usually appears o)dy upon the mouth and extremities. The differential diagnosis concerns chiefly other forms of stomatitis, scurvy, measles, typhoid fever, septicemia, and rarely syphilis. Prognosis: Usually good. Death may occur in delicate children, the aged, or individuals weakened by disease or other cause. Foot-and-mouth disease—prophylaxis: Diseased animals should be isolated. Individuals who have abrasions of the skin should not come in contact with diseased animals or in- dividuals. The dairy-products and meat from infected ani- mals should not be used, or should at least be subjected to sterilization by heat before being used. Treatment: Largely symptomatic. Siegel uses salicylate of sodium internally. Among the many remedies used locally are chlorate of potassium, borax, alum, lead, nitrate of silver, salicylic acid or zinc paste, dermol, creolin, lysol, and per- manganate of potassium. The patient should be kept com- fortable by the use of opium, best in the form of Dover's powder, chloral, the salicylates, and phenacetin. TYPHOID FEVER (Typhus Abdominalis; Enteric Fever; Ner- venfieber (German)). Definition : An acute infectious disease, due to a special bacillus, characterized by hyperplasia and ulceration of the intestinal lymph-glands (Peyer's patches), and enlargement of the mesenteric glands and of the spleen. Nervous symptoms are marked. There are headache and hebetude, a cloud about the brain, constituting the sttdus typhosus. The disease shows more or less characteristic fever, eruption, stools, and meteorism. Sanarelli defines typhoid fever as an infection of the lymphatic system by the typhoid bacillus. History: First recognized as 'a separate disease by Pierre Bretonneau (1813); named "Tvphoide" by Louis (1829); separated^ from typhus fever by Gerhard,"of Philadelphia (1837). The bacillus typhosus tibdominalis was described by Eberth, and observed and photographed by Koch (1880). TYPHOID FEVER. 93 Etiology: The bacillus typhosus abdominal is is generally recognized as the specific cause of typhoid fever. Typhoid fever seems to show preference for the temperate climate and prevails especially in the fall months. Hot, dry weather seems conducive to a dissemination of the dis- ease, probably through greater contamination of the water- supply. The bacillus of typhoid fever gains entrance to the body chiefly through the water-supply and milk. Typhoid bacilli, when mixed with fat, oil, or butter, are not killed by fresh gastric juice, and thus may pass into the in- testine. The disease occurs especially in youth and adolescence; rarely in infancy and age. Typhoid fever—symptomatology : Incubation, four to twenty- three days; usually about two weeks. Often during incu- bation there are lassitude, early fatigue, and especially lack of concentration. The onset of typhoid fever is insidious. Among the pro- dromal symptoms are languor, headache, coated tongue, ano- rexia, nausea, epistaxis, pain in the back anil legs, sometimes in the abdomen ; chilly sensations, rarely rigor, and sometimes vertigo. These symptoms continue to increase until the patient is forced to his bed, which is usually reckoned as the first day of the disease. Often during the first week of the disease the temperature (Fig. 8) shows the so-called step-ladder rise, being a degree or more higher in the evening than the previous evening, and a degree higher in the morning than the previous morning, reaching by the fifth to the seventh day 103° to 104° F. The pulse is quickened, 100 to 110, of full volume but low tension, sometimes becoming dicrotic. With the high fever there may be delirium. By the latter part of the first week the spleen is noticeably enlarged and the rose-colored lenticular spots are first seen on the skin, as a rule, in the region of the diaphragm. The tongue is coated white, with clean, bright- red margins and tip. There are usually meteorism and diar- rtava, sometimes constipation. After the discharge of the normal contents of the intestine the stools assume the "pea- soup, ochre-colored" appearance, sometimes colored with 94 INFECTIONS. Ul " e © ©i £ 2* ul e 3 5 ,■> ul •w © E »t- « UJ X X E SB t- s HI x o e CO eo UJ © 2 £ " Ul S x E Ul ■3" X E e Ul c e £ oo es a Ul ce e E t- es CO ul 2 2 S - u eig £ * M * Ul ~v ■* X S » - Ul « o S M Ul X x £ > f X W Ul -~~ ~- 9) © E "5r - Ul S E T •v 2* 8 a 53 0) - blood. Blood may be found with the microscope in almost all cases. The urine is diminished in quantity, the urea TYPHOID FEVER. 95 Fig. 9. &r.. -='.3 ''Vifr. V^'3' Typhoid bacilli from a section of the human spleen, tenth day of enteric fever (Charcot). increased, chlorides diminished, and frequently there is a trace of albumin. There may be a slight cough, a symptom of bronchitis, very early in the course of the disease. Fig. 10. *>;$ H 96 INFECTIONS. During the second week the fever continues on a high plane with slight morning remissions. The other symptoms become more pronounced. The pulse varies, 90-120, and is less dicrotic. Headache gives way to mental torpor and dulness. Fto.11. Human liver, tenth day of enteric fever (Charcot). The tongue is dry and covered with sordes. Toward the end of this week there is danger of perforation and hemorrhage. In mild, cases the symptoms may begin to improve bv the end of the second week. As a rule the symptoms continue during the third week much the same as during the second week, only more severe. There may be low muttering delirium, stupor, coma-vigil, and picking at the bedclothes in bad cases. The emaciation and loss of strength are more marked. The fever shows oreater morning remissions, a beginning lysis. Pulse, 110-130. During this week perforation and hemorrhage, bedsores, pneu- monia, and heart-failure are the complications to be 'most feared. Usually during the fourth week the temjwrafure reaches the normal by a gradual descent—lysis—and all the other symp- TYPHOID FEVER. 97 toms show improvement. In severe cases the picture presented during the third week may be continued into the fourth or even the fifth week, only becoming worse through the weak- ness of the patient. As a rule a marked improvement in the patient's condition occurs during the fourth week and conva- lescence begins. With the beginning of convalescence the patient shows a considerable increase in appetite. The more important complications of typhoid fever are perforation, peritonitis, fiemorrhage, and parenchymatous de- generations of muscles. Thus the heart-muscle may be affected so as to cause heart-failure; or the diaphragm may be rendered incompetent. Many, if not most, cases are affected secondarily by septictemia. Typhoid fever—diagnosis: In cases that come under obser- vation early the anorexia, headache, weakness, epistaxis, diarrhoea, gradual rise of temperature, and roseola, and later tympanites and enlargement of the spleen, are usually sufficient for diagnosis in typical cases. The hlood-test for typhoid fever (Widal test) is almost, if not absolutely, pathognomonic of infection by the typhoid bacillus. Unfortunately, the reaction is found sometimes for along time after recovery from typhoid fever. Apple and Thornbury report a case in which the reaction persisted thirty- one years. But usually the reaction disappears within a year. The history should not be implicitly relied upon in excluding a previous attack, since typhoid fever may have been mis- taken for some other disease. Further, in a few instances infection by the typhoid bacillus has occurred in other parts of the body than the alimentary tract. But as a rule the his- tory is clear, and the blood-test remains the best single sign we possess. Method: The best and simplest way to make the test (Widal) is with dried blood. A drop of blood is collected, from the finger-tip or lobe of the ear, upon a piece of glass and permitted to dry. When the examination is to be made a particle of the dried blood is added to just sufficient water to cause indistinct coloring. Of this an ordinary platinum loopful is added to a similar quantity of an emulsion of the typhoid bacillus in a hanging drop under the microscope. 7—P. m. 98 INFECTIONS. The culture of the typhoid bacillus should be twelve to twenty-four hours old, made from a stock culture a month old The emulsion of the typhoid bacillus is made by adding to a drop of normal salt solution (0.6 per cent.) a trace of the culture of the typhoid bacillus. Reaction: When diluted tvphoid blood is added to an emulsion of the typhoid bacillus, the bacilli are observed under the microscope to become agglutinated together in little clumps, and to lose their motility. To be positive, the reaction should be present within fifteen minutes. The diazo-reaction of Ehrlich does not furnish so reliable evidence as the blood-test, but is more readily made and often sheds a valuable side light upon a doubtful case. The reagents necessary are(l) a 0.5 per cent.solution of sodium nitrite; (2) sulfanilic acid solution, composed of a 5 per cent, solution of hydrochloric acid in distilled water and sulfanilic acid to sat- uration ; (3) ammonia. Method: To 3 c.c. of urine add one drop of the sodium nitrite solution. Shake. Add 3 c.c. of the sulfanilic acid solution. Shake. Add an excess of ammonia. The reaction, when positive, is marked by a rose-red to a dark-red color, which persists also in the foam. A brownish- yellow color is negative. In typhoid fever the diazo-reaction is present from the middle of the first week up to the ninth day and longer, but not after the third week. Absence of the reaction before the ninth day excludes typhoid fever, at least in an average or grave form. The typhoid hacillus may be isolated from the urine, feces, or blood, especially blood withdrawn from the spleen, rarely from the rose-colored spots. But the withdrawal of blood from the enlarged and friable spleen, in which the bacilli may most frequently be found, is not without danger, through rupture of the spleen and hemorrhage. During the first week typhoid fever should be differentiated especially from febricula, influenza, and the exanthematous diseases common among children. When a case first comes under observation late in the course of the disease the differ- ential diagnosis concerns especially malaria, acute miliary TYPHOID FEVER. 99 tuberculosis, appendicitis, peritonitis, trichinosis, and, espe- cially in children, entero-colitis. Typhoid fever—prognosis : The treatment with cold baths has reduced the mortality from about 30 per cent, to about 5 per cent. The mortality is especially high in the intem- perate, gouty, and corpulent. Recovery is the rule, with very few if any exceptions, in cases that are seen early and treated faithfully with the cold bath whenever the temperature reaches 103° F. in the rectum. The prognosis will depend upon the height and duration of the fever, the presence of complications, the time the patient comes under treatment, especially the time the patient takes to his bed, and the degree of toxaemia, as manifested by the strength of the heart and the presence of nervous symptoms. Prophylaxis: The ingesta, especially the milk and water, should be clean—/. e., not contaminated by the excreta of typhoid-fever patients. Or if such food and drink must be used, it should first be subjected to the temperature of boiling water. The excreta (stools and urine) of the patient should be dis- infected, best by fire, or carbolic acid (1 : 20), or bichloride of mercury (1 : 1000). Clothing contaminated by the dis- charges should be sterilized. Typhoid fever—treatment: Proper nursing is of the greatest value. The patient must remain in bed, and under no cir- cumstances arise from the recumbent posture until the tem- perature has remained normal at least three successive days. This implies the regular use of the bed-pan and urinal. The food should be fluid, chiefly milk, which may be given raw or boiled, hot or cold, sometimes coagulated with rennet or in the form of koumvss, kephir, or matzoon ; occasionally buttermilk or wine-whey", milk-punch, or egg-nog. The milk-diet may be varied with clear soups and broths, made from beef, mut- ton, veal, or chicken ; or consomme, with or without vegeta- bles, rice, or barley, carefully strained. The patient may receive also oyster-soup, clam-juice, strained barley-gruel, and meat-juice. At any rate, the diet must be liquid. To guard against continued infection, it may be necessary to boil the water and milk or to secure these articles from a different source. 100 INFECTIONS. The patient should be placed under good hygienic sur- roundings, with plenty of fresh air and sunshine, and secluded from society. During convalescence the visits of friends may at first be limited both in number and duration. Throughout the illness small quantities of food and drink should be offered at definite intervals, usually every two or three hours. Of drinks pure water is best, sometimes in the form of iced tea, lemonade, or barley-water. At times the juice of an orange or lemon is very grateful. Various " specifics " have been recommended from time to time; among them guaiacol, calomel, bichloride of mercury, carbolic acid, sulphuric acid, iodine, chlorine, quinine, salol, the salicylate of bismuth, boric acid, turpentine, oil of euca- lyptus, thymol, camphor, and beta-naphthol, but none of these has been generally accepted. Early in the course of typhoid fever it is best to administer calomel or castor-oil to empty the intestinal tract, especially when there is constipation. In the way of specific medication, the transfusion of blood from convalescents has been practised by Hammerschlag; injections of blood-serum from convalescents by Hughes and C-arter; the scrum of animals rendered immune through inocu- lation by Beumer and Peiper (sheep); and Klemperer and Levy (dogs), with results sufficiently satisfactory to call for further experimentation along this line. Frankel and Manchot, in fifty-seven cases, obtained prom- ising results by injection of sterilized thymus bouillon- cultures of the typhoid bacillus deep into the muscles of the back. The cases in which the injections were continued showed an amelioration of the constitutional symptoms, with an early fall of temperature, increase in the quantity of urine, and a cessation of diarrhoea. Rumpf reported somewhat similar results in the treatment of thirty cases of typhoid fever with similar cultures of the bacillus pyocyaneus. Loss of appetite and strength may be met probably best with the tincture of mix vomica before meals. In the pres- ence of fever the gastric juice is not formed so readily, and it is best to give dilute hydrochloric acid after meals. Slight fever may be let alone; higher fever, above 103° F TYPHUS FEVER. 101 in the rectum, calls for#ie cold bath, which lowers the tem- perature and strengthens the heart. The bath should be at a temperature of 68° F.; or may be begun at a higher tempera- ture and gradually lowered. The duration of the bath (five to twenty minutes) must be sufficient to lower the temperature of the patient two degrees. The bath may be repeated every two hours should the temperature reach 103° F. in the rectum. Cold sponging, the application of cold compresses or of ice, the cold pack, etc., are poor substitutes for the cold bath ; but are often useful. Beneficial results may sometimes be obtained by the judicious employment of antipyretic drugs, of which lactophenin is probably the safest. Tympanites and abdominal pain may be relieved by tur- pentine stupes. For meteorism, in the presence of a dry tongue, sordes, and muttering delirium, turpentine may be given internally or by enema. Excessive diarrhoea—more than three or four stools a day— may be controlled by enemata of starch and opium, or the administration per os of bismuth and Dover's powder, or a combination of tincture of opium, hydrochloric acid, and cam- phor-water. Constipation may be relieved by enemata re- peated every three or four days if necessary. Hemorrhage calls for absolute rest, restricted diet, ice both internally and externally, the administration of opium and acetate of lead. Collapse may be met by the injection of the physiological salt solution, 0.6 per cent., into a blood- vessel, the rectum, or the subcutaneous tissue. For peritonitis morphine may be given hypodermatically. Perforation may demand laparotomy, which has saved three cases out of seventeen reported. Weakness of the heart calls for stimulation with alcohol or digitalis internally ; camphor, strychnine, or ether hypoder- matically, to bridge an impending collapse. During convalescence, after the temperature has been normal ten days, the patient may gradually return to a solid diet. TYPHUS FEVER (Typhus Exanthematicus). Definition: An acute infectious disease, probably due to a specific micro-organism, characterized by sudden onset, a 102 INFECTIONS. peculiar eruption, which is usually present, and, as a rule, termination about the fourteenth dav by crisis. History: "Typhus fevers" were recognized by the older clinicians; but they did not separate typhus fever from a number of other fevers, notably typhoid fever and relapsing fever. Typhus was differentiated from typhoid fever by Gerald and Pennock, of Philadelphia (1836), and the non- identitv of the diseases confirmed by Jenner, of London (1849-51). Etiology: Various micro-organisms have been found in typhus fever, but none of them has been proven to be the cause of the disease. Balfour and Porter found a diplococcus in several cases post-mortem ; and in fifteen out of nineteen cases of typhus fever examined during life, in which the diplo- coccus was the only organism present. Among the predisposing causes are overcrowding, bad ven- tilation, poverty, famine and scarcity of food, and intemper- ance. Typhus fever—symptomatology: The period of incubation, variously given at from a few hours (Huss) to as long as thirty-one days (Hutchinson), is usually about twelve days. The invasion is short, one to three days, and abrupt, begin- ning with chilly sensations, sometimes with a distinct chill. There are malaise, later great prostration, headache, vertigo, anorexia, general soreness of the body, and pains in the loins and extremities, especially the lower extremities. The tongue, large and pale, presents at first a white coat, which later becomes darker in color. The face is flushed and dusky ; the conjunctiva} show a well-marked uniform congestion. Usually the hands show tremor. The urine is small in quan- tity and high-colored, specific gravity possibly 1030. The temperature reaches 102°-105° F. within a day." The pulse is rapid and compressible. Usually the abdomen presents noth- ing abnormal. Constipation is the rule. Sometimes there is nausea, more rarely vomiting. _ The eruption appears on the third, sometimes as late as the sixth day, first as a dark punctate measly rash, which disap- jtears on pressure, to reappear when the 'pressure is removed. The eruption is found first upon the abdomen, later on the TYPHUS FEVER 103 arms and thighs, more rarely on other parts of the body, the face, and neck. An eruption under the skin, in addition to the rash just referred to, constitutes the mulberry rash of Jenner. Later, about the fifth day, the measly rash becomes darker in color and does not disappear on pressure, due to capillary hemorrhage and the deposit of pigment. About the tenth day true petechiae appear, which do not disappear after death. The eruption usually disappears in eight or ten days. The temperature rises rapidly during the first week, often reaching 103° F. or more in a day or two, and remains high, Fig. 12. 105° 104° 103" 102° 101° 100° 99° 98° 11 I u. 5 10 11 12 13 14 15 Hi § % §3: I % I Hi! 18 I** Typhus fever. sometimes with gradual descent, until about the end of the second week, when the temperature drops suddenly, by crisis, to normal or subnormal. In uncomplicated cases a remission occurs early in the second week. As in typhoid fever, the temperature in typhus fever shows a slight diurnal variation. Diagnosis: The knowledge of the existence of the disease in the neighborhood is of value. Isolated cases may present great difficulties in diagnosis, especially in the absence of eruption. The sudden onset, great prostration, with the dense 104 INFECTIONS. cloud about the brain, and peculiar eruption, appearing about the third day and sparing the face, and the crisis at the end of the second week, are characteristic. Typhus fever should be differentiated especially from typhoid fever, cerebro-spinal meningitis, pneumonia, small- pox, unemia, and severe cases of yellow fever. Prognosis: Children rarely die of typhus fever; the mor- tality among the aged and intemperate is high. Different epidemics have given a mortality of from 12 to 20 per cent. Much depends upon the strength of the heart and the degree of toxaemia. Prophylaxis: There should be early isolation of typhus fever patients, and later thorough disinfection, with fire, for- maldehyd, bichloride of mercury, or sulphur, of the room and of all articles with which the patient came in contact. Treatment: The treatment of typhus fever is much the same as of typhoid fever. Special stress should be laid on hydrotherapy, especially cold baths. The heart must be supported, best with alcohol, digitalis, and nitroglycerin. RELAPSING FEVER (Recurrent Fever). Definition: An acute infectious disease, caused by the spirochieta Obermeieri, characterized by an intermission "at the end of the first week, with the disappearance of the fever and symptoms, followed by one or more relapses. Etiology: The specific infectious agent of relapsing fever is the spirochaete (spirillum) discovered by Obermeier, in the blood during fever, in 1873. Relapsing fever is contagious directly and possibly indirectly through fomites. The predis- posing causes are similar to those in typhus fever. Relapsing fever—symptomatology: 'incubation one to four- teen days, usually five to seven days. For a day or two there may be anorexia, lassitude, headache, and vertigo. Invasion as a rule is abrupt, with a chill followed by a rise of temperature, frequently 104° F., which in a day or two reaches 105°-106°. The pulse becomes rapid, 110-130, full and strong. The spleen shows early en/argemad. There are giddiness, headache, and severe pain in the muscles of the RELAPSING FEVER. 105 trunk and extremities, especially in the calves of the legs. S«mie cases begin with nausea and vomiting. The face is flushed, the tongue coated white. The patient complains of thirst. Often there is jaundice. Some cases show an eruption of petechiae. The urine is scanty, dark colored, albuminous, with high specific gravity, containing bile when there is jaundice, sometimes blood. With the crisis the temperature falls suddenly to normal or subnormal. The pulse drops to 70 or less. Often just before Fig. 13. Relapsing fever (Murchison). the crisis the temperature becomes higher and there are sweat- ing, diarrhoea, and epistaxis, sometimes an appearance of the menstrual flow, sometimes delirium. Rarelv does convalescence proceed uninterruptedly. As a rule about a week, four to fourteen days, after the crisis there is a relapse, resembling the original attack, but somewhat shorter in duration, the second crisis appearing usually in 106 INFECTIONS. three to five days. Recovery may now take place, or there may be as many'as three or even four relapses. Diagnosis: The diagnosis of relapsing fever rests upon the discovery of the spirochteta Obermeieri, which is found upon microscopic examination of the fresh blood during the fever. Spirochaetes of relapsing fever in the blood. Differential diagnosis, especially during the onset of the disease, concerns typhus fever, yellow fever, and smallpox. Cases seen later may be confounded with typhoid fever. The intermissions and relapses are characteristic. Prognosis: Death rarely occurs, except through collapse or complications, especially pneumonia. Treatment: Lowenthal treated 131 cases of relapsing fever with antispirochcetic serum. Thirty-four of the cases were thoroughly treated, with but one death. Compared with 152 cases not subjected to specific treatment, the use of the serum lowered the mortality about one-half, markedly lessened the number of relapses, and shortened the duration of the dis- ease. Symptomatic treatment: Pain may call for opium; a threat- ened collapse for stimulants—alcohol, camphor, ether, strych- nine, ammonia, digitalis. YELLOW FEVER. 107 YELLOW FEVER. Definition: An acute infectious disease, caused by a specific micro-organism, characterized by icterus and hemorrhage from the mucous membranes. Etiology: The specific infectious agent is the bacillus icte- roides (Sanarclli), which resembles closely and is possibly identical with the micro-organism described by Sternberg as the bacillus X. The bacillus icteroides is a slender bacillus, 2-4 p long, motile, ciliated, facultative, anaerobic. The bacillus is decol- orized by Gram's method, grows in the usual culture-media, causes fermentation when grown upon a culture-soil contain- ing sugar, and is pathogenic, producing in man, monkeys, and dogs the symptoms of yellow fever. In many cases the ba- cillus is not found, probably because it is overrun by sec- ondary infection, especially by the pyogenic streptococci and staphylococci. The bacillus seems to thrive better and show greater virulence in the presence of a certain fungus, an asper- gillus. This fungus thrives only in warm weather, which may explain the prevalence of yellow fever during the warm season (Lacerda). The bacilli occur in small numbers, but produce a powerful toxin, the amaril poison of Sanarelli. Yellow fever prevails especially along the sea-coasts and prefers unsanitary conditions and a hot climate. The bacillus icteroides resists well both drying and the action of sea water, and its growtli seems to be favored by the moulds. One attack of yellow fever usually confers immunity. Yellow fever—symptomatology : Incubation lasts from a few hours to five days. Preceding the attack there may be some malaise, anorexia, lassitude, headache, vertigo, and indisposi- tion, both physical and mental; or all these symptoms may be entirely absent. As a rule the attack begins suddenly with a chill or chilly sensations. Sometimes the onset is insidious. There are fearer and more or less pain in the head, especially in the fronted and supraorbital regions. The eyeballs are painful, and there may be photophobia. The patient complains of pains in the loins and ctdves of the legs. After the chill the 108 INFECTIONS. temperature rises rapidly. The face is flushed, often con- gested and swollen. The conjunctivae are injected. The skin is dry and hot, and there may be considerable restlessness and jactitation. Typical cases usually present three stages. The first stage begins with the initial paroxysm and lasts two to five days. This stage includes the high temperature, which is usually highest on the first day. The second stage, beginning after the fall in temperature, shows often subnormal temperature and great prostration, lasting a few hours or days. The third stage is the period of convalescence, during the early part of which there is a remittent fever. Jaundice, which is not present in all cases, begins toward the end of the first stage, is most intense during the second stage, and may last far into convalescence. Sometimes jaun- dice does not begin until the second or third stage, when it usually lasts longer. The urine, scanty and high-col- ored, earlv shows albumin. There may be urtemia. There are gastric distress, vomiting, and haematemesis (black vomit), due to toxaemia. Sometimes the " black vomit" is absent throughout the course of the disease, even in severe cases. Yellow fever—diagnosis : In the blood-test, with the bacillus icteroides, the reaction of paralysis and agglutination is pres- ent as early as the second day of the disease. Albuminuria is usually present by the third or fourth day, and with the temperature and pulse is of value in diagnosis. Later the appearance of icterus, without enlargement of the spleen, helps in differentiation. The history of the patient, especially regarding the place of residence and absence of previous attack, and the knowledge of the presence of an epidemic, may aid in the individual case. The prognosis of yellow fever is more favorable among the natives of regions where the disease exists continuously than among those not " acclimatized," and is better for women and children than for men. The prognosis may said to be favor- able when the temperature does not rise above 103° V. by the end of the second day, and assumes gravity in proportion to the height of the fever at this time. The mortality varies in YELLOW FEVER. 109 different epidemics. The majority of deaths occur during the first week of the disease. Yellow fever—prophylaxis: Patients should be isolated. The excreta, and all articles coming in contact with the patient, should be thoroughly disinfected, best by fire. Susceptible individuals, as far as practicable, should avoid infected re- gions. Yellow fever—treatment: Fitzpatrick (1899), working at the instance of Doty, injected horses with the filtrate of cult- ures of the bacillus icteroides. The blood-serum of the horses was then found to prevent the lethal effects in guinea- pigs of inoculations with the bacillus icteroides, that proved fatal in control-animals. Early in the course of the disease, best on the first day, the use of a cathartic is recommended, preferably castor oil, calomel, or a saline cathartic. Fever may call for the ex- ternal application of cold water and evaporating lotions so long as the skin is hot and dry and the temperature elevated (Sternberg). Later tepid water should be used. A hot mus- tard foot-bath may be repeated several times during the first day. Cold enemata are recommended. The patient should be protected from cold draughts or sudden lowering of tem- perature. During the height of the fever antipyrin may be advantageously given. Aconite has been recommended dur- ing the first day or two of the disease. Later digitalis may be used, with acetate of potassium or ammonium (Bemis), or sodium bicarbonate in ice-cold water (Sternberg). The acid secretions would seem to call for the use of alkalies. The following alkaline and antiseptic mixture, pro- posed by Sternberg, has been largely used : B/. Sodii bicarbonatis, 10.00. Hydrargyri chloridi corros., 0.02. Aquae puree, 1000.00. M. Sig.—Two or three tablespoonfuls every hour; to be given ice-cold. A weak heart calls for stimulation. Stimulants, as a rule, need not be given before the fourth day, and then they must be administered in small quantities in order not to cause vom- 110 INFECTIONS. iting. Champagne, brandy, later milk punch, English ale, and Rhine wine may be used. During the height of the fever no food is required. \\ itli the fall of temperature there is usually a return of the appe- tite. The diet should then consist of milk in small quantities, possibly with lime-water, and chicken-broth, which may be given every two hours. Excessive vomiting may demand rectal alimentation. The return to the normal diet should be gradual. CHOLERA (Asiatic Cholera; True Cholera). Definition: An acute infectious disease, caused by the spirillum cholera: Asiaticie, characterized by onset with diar- rhoea and vomiting, later showing great prostration, severe cramps or spasmodic contractions of the muscles, with char- acteristic stools, resembling rice-water, and a cyanotic appear- ance of the skin. History: In the southern part of Bengal cholera is endemic. From this region epidemics of cholera have in- vaded Asia, Africa, Europe, and America. Cholera was described in India several centuries before Christ, by Charaka (Macnamara). Koch believes, however, that true cholera was not endemic in India before 1817, although epidemics of cholera, or a disease resembling cholera, are recorded as early as 1543. Cholera first reached the United States in December, 1832, by way of Quebec and New York. The disease appeared again'in 1835-6; 1848; 1849; 1854; 1866-7 and 1873. Since then emigrants from Europe have; brought cholera to America, but quarantine has prevented the disease becoming epidemic. The spirillum choleras Asiaticce was discovered by Koch (1884). Etiology: Asiatic cholera is now generally recognized as a water-borne disease (Hart), due to the spirillum cholerce Asiaticce, the "comma bacillus" of Koch. The spread of the disease is favored by bad hygiene, especially poor sewerage. Cholera is contagious through the ingestion of the exereta of infected cases. The disease shows a preference for age, and for CHOLERA. Ill individuals debilitated by disease or intemperance. The river population, those who work and live on the water, are pre- disposed to infection. Epidemics of cholera avoid cold weather. Cholera—symptomatology: Incubation, one to five days. Often cholera begins with diarrhwa, sometimes accompanied by vomiting, frequently coming on during the night. There are pain in the abdomen, headache, and depression. These symp- toms increase in severity. Diarrhoea may be severe in the beginning, with pain and tenesmus. The patient suffers cramps in the calves of the legs, later in the arms and abdomen. There is great prostration. Vomiting may be more or less continuous. The stools, at first muco-purulent and stained with bile, early assume the rice-water character. The skin is cyanotic and cold. There are extreme anxiety, thirst, sometimes heart-failure. These symptoms continue from a few hours to a day. Should the patient survive this stage, a reaction sets in, the cyanosis disappears, the skin becomes warm, the diarrhoea improves, and the prostration is relieved. There is always danger of relapse. Cases of cholera, showing various degrees of severity, have been called choleraic diarrhoea, cholerine, and cholera gravis. Diagnosis: The knowledge of the prevalence of the disease, or of exposure to the possibility of infection, is of value in diagnosis, which can be made positive by finding the spir- illum cholerce Asiaticce in the stools in a case presenting the symptoms of cholera, which are indicative of intense intoxi- cation. Bacteriological examination: A hanging-drop or cover-glass preparation made from the suspected excreta may reveal the presence of spirilla. The cholera spirillum is motile, decolor- ized by Gram's, method, and stains with the ordinary dyes, probably best with a solution of fuchsin. Upon the surface of diluted bouillon in the incubator colonies appear in ten to twelve hours as a wrinkled film. Gelatin in plates, Petri dishes, or tubes, may be inoculated both from the excreta and from the bouillon cultures. The gelatin begins to be fluidified in a day, and presents under the lens an appearance as if the surface were strewn with glass. The gelatin tubes show a 112 INFECTIONS. distinct funnel shaped depression, with the apex downward, from the fluidification of the gelatin. The so-called " cholera red " or indol reaction may be obtained by adding to bouillon cultures that have been in the incubator ten to twelve hours, or to gelatin cultures in which fluidification has occurred, pure sulphuric acid. A reddish-violet or purplish-red color quickly appears. Cultures in litmus bouillon, made in the incubator, show decolorization within a day. Pfeiffer has shown that when a trace of cholera serum is added to a culture of cholera spirillum and injected into the peritoneal cavity of a guinea-pig, or when the spirilla are injected into immunized guinea-pigs, the cholera vibrios are quickly destroyed. This is the so-called Pfeiffer phenomenon. Blood-test: The blood of cholera patients causes paralysis and agglutination of the cholera spirilla (see Typhoid Fever). This method promises to be of value both in the diagnosis of cholera and in the differentiation of the cholera spirillum from simulating organisms. The prognosis of cholera, which should always be guarded, depends largely upon the gravity of the symptoms. Com- plication with pregnancy, abortion, pneumonia, or typhoid fever, makes the outlook more grave. Prophylaxis demands quarantine at sea of infected indi- viduals, the destruction of the stools in all cases, best bv heat, and the abandonment of contaminated water-supplies. Water may be safely used if thoroughly boiled. The patient must be isolated and all articles that come in contact with him should be sterilized. Cholera—treatment: We know no specific. " We may look for advance in this direction, above all, to modern bacteri- ology" (Rumpf). The mortality was decreased in a series of 193 cases of cholera treated in Japan, by Xahagawa, with Kitasato's cholera antitoxin. Klebs's anticholerin has been tried with results that would seem to justify a further trial of the remedy. Cases of cholera without marked symptoms need little or no treatment, aside from prophylactic measures. Diarrhoea calls for rest in bed and the use of opium. In cases threatened with cyanosis, Reiche injected hypo- CHOL ERA MORB US. 113 dermically the fluid extract of opium with good results. The intestinal canal should be emptied with castor oil, or possibly better with calomel, which has the advantage that it may at the same time exert some antiseptic influence. As a rule purgation may be continued only a day or two. Cantani (1870) introduced the use of tannic acid enteroclysis. The intestine is irrigated several times a day with one or two quarts of a 1 per cent, solution of tannic acid at 104° F. This method has been modified by v. Genersich, in what he calls diaclysmus, using from five to fifteen quarts of a 0.1 per cent, to 0.2 per cent, solution of tannic acid at about 104° F. The fluid is gradually passed per rectum until there occurs copious vomiting of the irrigating fluid. Remarkable results are claimed for this method, which would seem to be justi- fiable in very severe cases. Vomiting may be controlled by cocaine, or better by mor- phine hypodermatically. Elimination by the skin, as well as warmth, may be secured by the use of the warm bath, the temperature of which may be increased to 113° F. for fifteen minutes. Three or four ounces of mustard may be added to the water. Should the pulse not show improvement or should syncope supervene, the bath must be discontinued. In most cases the bath does good. Drink in the form of hot or cold water should not be denied the patient. Alcohol in small quantities may do some good, but in large quantities acts unfavorably. Evidence of cardiac weakness calls for subcutaneous or intravenous infusions of normal salt solution, 0.6 per cent., or the use of camphor in oil, 1 : 8 or 1 :10, internally or hypo- dermatically. CHOLERA MORBUS (Cholera Nostras; Cholera Infantum). Definition : An acute infectious disease, occurring especially during the summer in temperate climates, characterized by diarrhoea and in severe cases presenting symptoms identical with those of true cholera. Etiology: The disease is due largely to the absorption from the alimentary canal of toxic substances, the result of the 8—P. M, ] 14 INFECTIONS. action of bacteria. A number of micro-organisms have been isolated from the stools. Among other bacteria, spirilli have been found, but not the spirillum cholera? Asiaticae. Indis- cretions in diet are predisposing causes. The disease shows a preference for summer-time, in temperate regions. Cholera morbus—symptomatology: The symptoms vary from a simple diarrhoea to severe diarrhoea, sometimes with rice-water stools, vomiting, cramps, cyanosis, collapse, possibly death. Diagnosis : Cholera morbus is to be differentiated especially from true cholera (Asiatic cholera). Young children seem to be more susceptible to cholera morbus than to cholera Asiatica. The persistence of normal stools in severe cases would point to cholera morbus rather than to cholera Asiatica, in which we usually find rice-water discharges. Cholera morbus may so closely resemble true cholera that the differential diagnosis can be made only by bacteriological methods (see Cholera). Cases may simulate poisoning by arsenic, solanine, and colchicine, when the differential diagnosis may be made by a chemical examination of the contents of the stomach. Prognosis: Usually good. The mortality is greatest in children and among the aged, invalids, and intemperate. Cholera morbus—treatment: Offending material should be removed from the alimentary canal. Material remaining in the stomach may be removed by lavage. Usually the material has passed into the intestine before the patient is seen^ by the physician, when it may be removed by the administration of castor oil, or calomel, gr. iij for an adult, Sv- T~i f°r children, in one dose or repeated. In cases of persistent vomiting it may be prudent to wash out the intes- tine with water, to which may be added soap, castor oil, sweet oil, glycerin, siij-vj, or tannin, 1:1000, best by means of the rectal tube. Obstinate vomiting may sometimes be relieved by enemata of chamomile tea, 80 c.c. to 100 c.c. con- taining tincture of opium, gtt. v (Liebermeister). Vomiting may usually be stopped by swallowing pieces of ice or by the administration of chloral. In general the treatment is the same as for true Asiatic ANTHRAX. 115 cholera (see Cholera). Severe cases may call for salt water infusion. ANTHRAX (Malignant Pustule; Carbuncle; Wool-sorters' Disease; Splenic Fever; Milzbrand (German); Charbon (French)). Definition : An acute infectious disease, caused by the bacillus anthracis, occurring among animals, especially cattle and sheep, and occasionally in man through accidental inoculation. Etiology: The specific infectious agent is the bacillus anthracis. The bacillus anthracis—Milzbrand bacillus (Ger- man), Bacteridie du charbon (French)—is 1-1.25// broad and 5-20/i long, sometimes growing into long filaments in favorable culture-soil. The ends of the bacilli are concave, so that when joined together, end to end, there is a distinct lenticular interspace between the bacilli. The bacillus is non-motile, forms spores, stains with the usual dyes and by Gram's method, and grows upon the usual culture-media. Gelatin is liquefied. The bacillus does not seem to be strictly aerobic, since a growth takes place all along the line of inoculation in stick-culture. The spores are very resistant to drying, and may be preserved in a dry condition for years without losing their vitality or virulence. A dry temperature of 140° C. will kill them in three hours (Koch and Wolff hugel); or moist heat at the boiling-point, 100° C, in four minutes (Sternberg). The bacilli, in the absence of spores, may be destroyed by a temperature of 54° C. in ten minutes (Chauveau). When ingested the bacilli are killed by the gastric juice; but when the spores are ingested they resist the action of the gastric juice and almost invariably cause infection. The action of the bacillus is due largely to a toxin. Martin made a chemical study of filtered cultures of the anthrax bacillus and found: (1) protoalbumose, deuteroalbumose, and a trace of peptone ; (2) an alkaloid ; and (3) small quantities of leucin and tyrosin. Cattle and sheep are infected by the ingestion of spores. Spores are not formed in the body, but only during the saprophytic existence of the organism. The soil becomes infected largely through the discharges of infected animals. 116 INFECTIONS. Animals or men (wool-sorters' disease) may be infected through the respiration of air containing anthrax spores sus- pended in the form of dust. Exceptionally infection may pass from the mother to the foetus, possibly through some lesion of the placenta. Man is infected chiefly through contact with diseased animals, either alive or dead. Thus anthrax is found most frequently among butchers, liverymen, shepherds, tanners, wool-sorters, glue-makers, etc. Insects have been accused of spreading the infection, and the disease has been actually pro- duced by inoculation with the stomach, legs, and feelers of carnivorous flies (Bollinger, Raimbert, and Davaine). Anthrax—symptomatology: Two general clinical forms of anthrax are recognized : (1) external anthrax, including malig- nant pustule and anthrax oedema; (2) internal anthrax, including pulmonary and intestinal infection. Malignant pustule appears especially on the hands, arms, or face, surfaces most exposed, to infection. Within a few hours after exposure there are itching and uneasiness, sometimes tickling, burning, stinging, at the point of inoculation, and soon there appears a small papule, which later becomes a vesicle. The vesicle bursts, discharging a bloody fluid, pre- senting the appearance of a red papule with a reddish-brown or black central crust. In mild cases the vesicle may dry up and disappear in a few days. In severe cases the inflamma- tion and induration become extensive, the inflammation involving neighboring lymphatics. At first there is fever; later the temperature becomes less elevated, often subnormal. The case may end in death in three to five days. Recovery is possible. Anthrax oedema is characterized by extensive oedema of the eyelids, head, hand, and arm, resulting in gangrene. The papilla and vesicle are absent. The pulmonary form of anthrax is commonly known as wool-sorters' disease and rag-pickers' disease. The infection probably takes place from inhalation of dust containing an- thrax bacilli or spores. The attack comes on with chill, pros- tration, pains in the back and legs, and fever (102°-103 F.). The pulse is rapid and feeble. Rapid breathing and pain in ANTHRAX. 117 the chest are prominent symptoms. Death may close the scene within twenty-four hours. The intestinal form of anthrax occurs usually through the ingestion of infected milk. Wool-sorters' disease sometimes shows affection of the intestine, probably through swallowing dust ladened with anthrax bacilli. The attack begins with a chill, with later vomiting, diarrhoea, fever, pains in the back and legs. There may be dyspnoea, cyanosis, restlessness, anxiety, and even convulsions and death. There is enlarge- ment of the spleen ; sometimes hemorrhage from mucous mem- branes. The skin may show petechiae or phlegmonous inflam- mation. Affection of the brain is rare. Anthrax—diagnosis : Knowledge of the occupation of the individual, in a suspicious case, is an aid in diagnosis. The bacillus anthracis may be found in the pustules; later in the blood. The bacillus can be separated hy inoculation, best of a mouse or guinea-pig. In intestinal or pulmonary anthrax the bacilli may be found in the faeces or sputum, respectively, before they appear in the blood. Prognosis : Grave. Usually good results may be secured in cases of external anthrax that come under treatment early. The outlook is bad in late cases of external anthrax and in all cases of internal anthrax. Prophylaxis calls for the avoidance of the cause (see etiology). Peterman (1892) injected into the veins of a susceptible animal large quantities of a culture of the anthrax bacillus in ox-serum filtered through porcelain, and thus obtained tem- porary immunity lasting not longer than a month or two. Anthrax—treatment: The point of inoculation should be treated with caustics or the cautery. The pustule may be excised, or incised, and dressed with strong antiseptics. Men- thol, 2 per cent, solution in alcohol, applied on a gauze strip, with which the cavity may be packed after cleansing as thor- oughly as possible, has been found very effective (Braun). The cavity is packed with the saturated gauze, then covered over air tight, and a compress applied. The gauze is left in twentv-four to forty-eight hours. Subcutaneous injections of solutions of bichloride of mercury or carbolic acid around 118 INFECTIONS. the pustule, repeated two or three times a day, are recom- mended. In internal anthrax active purgation may be resorted to, and quinine is recommended ; but treatment is of little avail. TETANUS (Lockjaw; Trismus; Opisthotonos; Wundstarrkrampf (German)). Definition: An acute infectious disease, caused by the tetanus bacillus, characterized by tonic spasm of certain mus- cles, marked by trismus and opisthotonos. Etiology: Due to infection by the bacillus tetani. The tetanus bacillus appears to be a widely distributed micro- organism in the superficial layers of the soil in temperate and especially in tropical regions (Sternberg). Inoculation occurs chiefly through traumatism, especially wounds, however slight, caused by splinters or nails contaminated with earth or manure. The tetanus bacillus is attenuated by exposure to oxygen and sunlight, and the virulence is increased by passage through the intestines of animals. The more virulent tetanus bacilli are found in the superficial soil that comes in contact with the dung of animals. Asepsis and antisepsis has diminished the number of cases of tetanus after surgical operations. Not infrequently tetanus occurs after lacerated wounds. The wound through which the tetanus bacillus gains entrance to the body may heal before the disease is recognized, constituting eryptogenetic or "idiopathic" tetanus. So-called idiopathic tetanus is much less frequent than tetanus neonatorum. Other varieties of tetanus are puerperal, rheumatic, and traumatic. The spores of the tetanus bacillus are very resistant. Hen- rijean, quoted by Park, caused tetanus experimentally in an animal by inoculation with a piece of splinter which eleven years before had caused the disease. The symptoms of tetanus are due to the toxins of the teta- nus bacillus rather than to the bacillus itself. Mixed infection is common. Tetanus—symptomatology: Incubation varies from one to twenty-two days, usually one to two weeks. The symptoms of tetanus are due chiefly to a poison (toxin) produced by the TETANUS. 119 tetanus bacillus. From what has been said about the etiology it is not strange that the wounds through which the tetanus I'll- bacillus gains entrance to the body are usually situated on those parts of the body which come most frequently in con- tact with the earth—the feet and hands. The patient usually first complains of stiffness of the mus- cles of the neck and jaw. Sometimes the first symptom is a spasm of the muscles near the point of inoculation. With the spasm there is pain. The stiffness of the muscles of the neck and jaw extends so as to prevent opening the mouth (trismus, lockjaw); and to cause retraction of the head, sometimes com- plete opisthotonos, arching of the body backward ; rarely einprosthotonos, arching of the body forward ; or pleurothoto- nos, arching of the body to one side. The spasms are con- stant, except during sleep or narcosis (chloral, opium, and chloroform). There is difficulty in swallowing. Affection of the muscles of the face causes the sardonic grin, risus sardonicus, de- scribed by Hippocrates. There may not be fever. There is free perspiration. There may be difficulty of breathing and cyanosis. Diagnosis: Stiffness of the muscles of the neck and jaw, especially following trauma with liability of infection with the tetanus bacillus, should lead to suspicion of tetanus. The differential diagnosis concerns strychnine-poisoning, which shows no period of incubation, and in which the muscles of the extremities are most frequently affected ; and hydrophobia, in which there is early difficulty in respiration, from attempts to swallow. Tetanus—prognosis: Always grave. Rarely cases may show only stiffness of the muscles of the neck and jaw, but the diagnosis of such cases is doubtful. In severe cases death may occur within two or three days. As a rule death takes place in eight to twelve days, or recovery in three to six weeks. Death usually occurs through spasm of the mus- cles of respiration or through heart-failure. Tetanus—prophylaxis : Infected wounds should be treated antiseptically. Nails or splinters removed from wounds should be examined for the bacillus tetani ; and if this is 120 INFECTIONS. found, excision of the infiltrated area or the amputation of a member may be considered. In cases in which the spasm first appears in the muscles near the point of inoculation, resection of the nerve leading to the area of the wound has in some cases appeared to pre- vent the development of the disease. Tetanus—treatment: Most is promised by the antitoxin treatment. The subcutaneous use of the tetanus antitoxin has given a mortality of 50 per cent, or less. Better results have been secured by the intracerebral injection of the anti- toxin. It is believed that the tetanus toxin reaches the brain and cord through the nerves and blood. Knorr made an emul- sion of the cerebrum of a guinea-pig, to which he added tetanus toxin. The mixture was then centrifugalized. Thus there was secured a precipitate, consisting of the cerebral matter, evidently in intimate association with the toxin, since the upper layer of fluid was found to contain none of the toxin. When the tetanus toxin is injected into the brain-substance the union between the poison and the cerebral matter is so prompt that the action of the toxin may be limited to certain groups of cells (Roux and Borrel). Different symptoms are produced by the injection of the toxin into various parts of the brain. Animals, whose blood shows the presence of the antitoxin of tetanus, may succumb to intracranial injections of the toxin. Antitetanic serum is much more effective when injected into the brain than when used subcutaneously. The antitoxin is of little value in treatment after the de- velopment of symptoms. Such treatment is better in subacute than acute cases. In all cases, 20 to 50 c.c. of the antitoxin should be given as early as possible. In tetanus the phagocytes not only destroy the tetanus bacilli, as far as they are able, but they'also absorb the toxin. Baccelli has secured good results by the subcutaneous injec- tion of carbolic acid, 2 per cent, solution, beginning with grs. iij in the twenty-four hours and increasing to gr. vj-ix in the twenty-four hours. There is remarkable tolerance to carbolic acid in tetanus. HYDROPHOBIA. 121 General treatment: The patient should be kept quiet, and secluded from light and noise as well as from unnecessary visitors. Feeding should not be neglected. The diet should be light and nutritious, and if necessary may be given per rectum. Various remedies have been used, among them the bromides, Indian hemp, chloral, opium, chloroform, atropine, calabar bean, curare, and carbolic acid. HYDROPHOBIA (Rabies (Latin); Wuth, Hundswuth, Tollwuth (German); La Rage (French)). Definition: An acute infectious disease, communicated to man from the lower animals, especially the dog (" mad dog "), by inoculation, usually through bites, and characterized in man by fear of water, or rather by inability to swallow, a symptom that is absent in animals. Etiology: The disease is found in the dog, fox, wolf, cat, and skunk, and may be communicated to other animals or to man by inoculation. Hydrophobia maybe communicated at any time in the course of the disease, even during the period of incubation. Hydrophobia — symptomatology: Incubation usually lasts from six weeks to two months, but is very variable. The premonitory stage is dominated by disturbances in the psychical sphere. There are depression and melancholia, headache and anorexia, insomnia and irritability, increased sensibility, and a feeling of impending danger. The larynx is injected, and there may be some difficulty in swallowing. The point of inoculation may show irritation, pain, or numb- ness. The stage of excitement, which lasts from a day and a half to three days, is marked by great fiyj>ertesthesia, excitability, restlessness, and inability to sivalloiv. Water or liquid food is more dreaded because it more readily suggests the act of swallowing. Mania, or general convulsions, may be present. Sometimes there is satyriasis or nymphomania. There is usually some fever, 100° to 103° F. Paralytic stage: Gradually the spasms disappear, and the 122 INFECTIONS. patient becomes quiet, and later unconscious. The hearts action becomes feeble, and death by syncope may occur in from six to eighteen hours. The diagnosis of hydrophobia is easy in the presence of typical symptoms, especially spasm of the muscles of degluti- tion and'respiration, and the history of exposure to infection, most commonly a dog-bite. The differential diagnosis concerns especially lyssophobia, hysteria, Landry's paralysis, tetanus, and uraemia. Prognosis: Bad. Recoveries from hydrophobia have been claimed; but with our present knowledge, the positive demon- stration of the disease would be difficult in cases that recover. Dogs have recovered from rabies. Much is claimed for the treatment recommended by Pasteur. Hydrophobia—prophylaxis: Rabid animals should be killed and all dogs should be muzzled or confined. Bites of animals, especially of those suffering from rabies, should be thoroughly cauterized and kept open. Keirle gives a mortality of 30 per cent, following cauterization, against 80 per cent, in cases that were not cauterized. Where cauteriza- tion may not be resorted to at once, it may be advantageous to ligate above the wound ; to suck the wound or apply cups, or open up the wound, or even to resort to amputation. In all cases it is best to make free use of antisepsis. Where practicable, the individual should receive the prophylactic inoculations recommended by Pasteur. Pasteur found the virus of hydrophobia located in the central nervous system, especially the spinal cord. Inoculation from rabbit to rabbit increased the virulence and decreased the period of incubation. The virus used as a standard will cause the symptoms of hydrophobia after an incubation of seven days. The virus is attenuated by desiccating the spinal cords in sterilized glass jars containing caustic potash. After two weeks' desiccation, the spinal cord is perfectly innocuous. Beginning with the injection of an emulsion of such a non- virulent cord, successive injections are made of the emulsions of more virulent cords—that is, cords that have not been des- iccated so long—until the individual is able to receive an in- jection of the emulsion of a cord that has been desiccated DENGUE. 123 only five days. At this point the greatest protection is se- cured. Hydrophobia—treatment: The patient should be kept in a darkened room and visitors excluded. The spasms may be allayed by inhalations of chloroform and the use of morphine hypodermatically. The patient should be fed. Liquid food may sometimes be given after the throat is cocainized. If necessary, food may be given per rectum. DENGUE (Break-bone Fever). Definition: An acute infectious disease of short duration, characterized by severe pains in the head, eyeballs, and joints; inflammation of exposed mucous surfaces, swollen salivary glands, and a peculiar eruption. The disease often occurs in epidemic form, and is in some places endemic, as in Calcutta. The etiology is not clear. McLaughlin (1886) claimed to find micrococci in the blood in cases of dengue, but the ob- servation lacks confirmation. Dengue—symptomatology: Incubation, two to five days. The onset is sudden, with chilly sensations, headache, con- gested conjunctivae, and pains in the eyeballs, muscles, and joints. The mucous membranes exposed to the air become inflamed. There are sore throat and swelling of the submax- illary glands. The fever rises gradually to 103° to 107° F.; pulse 100 to 120; respiration hurried. A scarlatiniform rash appears within one or two days, usually first upon the face, sometimes on the chest, back, abdomen, and knees, and lasts about a dav. From three to four days later the terminal rash appears, usually first on the palms 'of the hands, sometimes followed by desquamation. This rash may be so slight as to be scarcely observed, or so severe as to cause ecehymoses. There may be some fever. Convalescence is tedious. The severity of individual symptoms varies in different epidemics, as well as in different cases. Diagnosis : At first dengue may resemble scarlatina or rheu- matism, but later the differentiation is easy. The resemblance between dengue and mild cases of yellow fever is more marked. Suspicious cases should be isolated until the differ- 124 INFECTIONS. entiation is absolute. Dengue should be differentiated also from influenza, typhoid fever, and malaria. Prognosis: Adults rarely die. Death occasionally occurs through some complication, such as septicaemia following abortion. Children may suffer convulsions and death. Dengue—treatment: The patient should have good hygienic surroundings, thorough ventilation, and isolation. The intes- tinal canal should be cleansed, best with calomel, rhubarb, or colocynth ; but the use of active purgation or emesis is un- called for. Temperature above 105° F. calls for hydrother- apy, the cold bath, or cold sponging. Tincture of belladonna, gtt. x-xv, gives great relief. When there is pain opium may be given, especially to secure sleep. Opium is probably best given in the form of Dover's powder. Complications call for appropriate treatment. PLAGUE (Bubonic Plague; the Pest). Definition: An infectious disease, due to a specific bacillus, characterized by swelling of the inguinal and other lymphatic glands (buboes), often with the appearance of carbuncles and hemorrhages. History : The disease probably existed before the beginning of the Christian era, but the first reliable account is of an epidemic in Constantinople, 542 a. d. The bacillus was dis- covered by Kitasato and Yersin, during an epidemic in China, in 1894, when the disease prevailed especially in Hongkong and Canton. The plague has never appeared in America. Etiology : The bacillus of bubonic plague, the bacillus j>estis of Kitasato, is found in all cases of plague, and has been proven by inoculation of pure cultures to be the specific cause of the disease. Bad hygienic surroundings are supposed to be predisposing causes. Plague—symptomatology : Incubation, two to eight days. Usually the symptoms come on rather suddenly, with lassi- tude, loss of strength, mental anxiety, sometimes with head- ache and vertigo, pain in the back and limbs, fever, and deli- rium. There is an invasion of the lymphatics in two or three days, which ends in resolution or suppuration, sometimes ACUTE INFECTIOUS ICTERUS. 125 gangrene. Carbuncles, petechia, or purpuric spots may ap- pear upon different parts of the body. Diagnosis : Pains in the regions of the lymphatics, ('specially the inguinal, with later tenderness, swelling of the glands, and the formation of buboes, with the appearance still later of carbuncles and hemorrhages, stamp the disease, in doubt- ful cases the bacillus should be isolated. The plague should be differentiated from lymphadenitis due to other causes—tuberculosis, syphilis, typhus fever, and anthrax. Prognosis : Should be guarded. Death may occur within a few hours. Much depends upon the severity of the symptoms. Prophylaxis: Calls for proper sanitation, especially regard- ing sewage and water-supply. Patients should be isolated until at least a month after recovery. The dead should be buried at a depth of three meters, or preferably cremated (Kitasato). The excrement and all articles that come in con- tact with the patient should be burned or thoroughly steril- ized. Plague—treatment: With the serum treatment Yersin, in cases treated with strong serum, had only two deaths in twenty-six cases. Further treatment is symptomatic. ACUTE INFECTIOUS ICTERUS (Acute Febrile Icterus; Weil's Disease). Definition: An acute infectious disease, characterized by fever, prostration, icterus, and gastro-intestinal disturbances. Etiology : Probably due to the bacillus proteus fluoreseens (Jaeger). The disease seems to show a preference for summer and the male sex. Acute infectious icterus—symptomatology: Prodromata are usually absent. The onset is usually sudden, often with a chill. On the fourth or fifth day the fever may remit and recur in two or three days, lasting eight to ten days. There are intense prostration and marked jaundice, mental dulness, sometimes delirium and coma. The urine, diminished in quantity, contains bile, and in about half the eases albumin and casts, sometimes blood. 126 INFECTIONS. Diagnosis: The absence of prodromata, the sudden onset, the remissions, and the duration of the disease are more or less characteristic. The disease should be differentiated, from simple catarrhal jaundice and from typhoid fever with jaundice. Prognosis : Usually good. Death has occurred, but recovery is the rule. Acute infectious icterus—treatment: A milk-diet is best. Active purgation should be avoided. Small doses of calomel or castor-oil may be given early in the disease. Carlsbad water or the Carlsbad salt is used. Irrigation of the large intestine is recommended. MALTA FEVER (Mediterranean Fever; Rock Fever; Neapoli- tan Fever). Definition: An infectious disease of long duration, caused by the micrococcus melitensis, characterized by fever, prostra- tion, constipation, relapses, enlargement and softening of the spleen, often by rheumatic or neuralgic pains, sometimes by swelling of the joints and orchitis. Etiology: The micrococcus melitensis (Bruce, 1887) has been proven to be the specific infectious agent, by inoculation of animals and by an accidental inoculation in man. The disease is endemic upon the island of Malta, and appears also in Naples and other Mediterranean ports; is more prevalent during the hot months—May, June, especially July. The disease has appeared in the United States. Malta fever—symptomatology: Incubation six to thirty days, usually about two weeks. The early symptoms are malaise, anorexia, nausea, some- times vomiting, sleeplessness, epistaxis, coated tongue, conges- tion of the pharynx, as a rule constipation, sometimes diarrhoea from indiscretion in diet, the stools sometimes containing blood, with enlargement of the spleen and liver, profuse per- spiration, sudamina, usually a slight cough with scanty expec- toration and moist crepitant rales which last a week or ten days, sometimes a month. The symptoms clear up and the patient apparently enters convalescence. Sooner or later there is a recurrence of symptoms. There are considerable pros- MILIARY FEVER. 127 tration and marked weakness. The number of red blood- corpuscles is diminished. Temperature 101°-104° F., and irregular. There are pains in the joints, which show swelling; intercostal neuralgia, sciatica; and orchitis. After some weeks' duration the fever gradually subsides, the number of red blood-corpuscles returns to the normal, the strength im- proves, and the weight increases. The symptoms may occur in all grades of severity. In some cases the symptoms may be so slight that only a rise in temperature will be noticed. The disease usually lasts about two or three months. Diagnosis: Malta fever is to be differentiated especially from typhoid fever, which it often simulates so closely as to be recognized only by the clumping of the micrococcus meli- tensis upon the addition of the serum, should the case be Malta fever; or by the paralysis and clumping of typhoid bacilli, in the blood-test, in cases of typhoid fever. Malaria may be ruled out by a search for the plasmodium. Prognosis : The mortality is about 2 per cent. Malta fever—prophylaxis: If possible, the region of the Mediterranean should be avoided, especially during the hot months. Where this is not possible special attention should be paid to hygiene, especially with regard to sanitation and personal cleanliness. Fatigue and intemperance should be avoided. Malta fever—treatment: The diet, consisting largely of milk, eggs, beef-tea, and brandy, must be continued for several weeks. Fresh lemonade or lime-juice should be added, to prevent scurvy. After the temperature has remained normal two weeks the patient may return to ordinary diet. The treatment is symptomatic. High temperature calls for the cold bath, which must be repeated whenever the tempera- ture reaches 103° F. MILIARY FEVER (Sweating Fever). Definition: An infectious disease, occurring especially in France, Italy, Germany, and Austria, characterized by fever, profuse sweating and a miliary eruption of vesicles, 128 INFECTIONS. History: The disease was first described in London, 1485, as sudor Anglicus; Leipsic, 1652; France, Montbehard, 1712, and Abbeville, 1718. The etiology is obscure. Miliary fever—symptomatology: There may or may not be prodromata, lassitude, anorexia, and headache. Perspiration is profuse and persistent. There is great thirst; the mouth is dry ; the tongue is coated. Usually there is constipation. About the third day, as a rule, the miliary eruption appears, preceded by a pricking sensation and itching of the skin, first as papules, which later become vesicles. The eruption lasts two or three days, and the symptoms disappear within a week or ten days from the onset of the disease. The nervous phenomena are prominent: constriction or oppression in the epigastric region with mental anxiety; palpitation; sometimes cardialgia and constriction of the pharynx. Occasionally there are delirium, less constantly general malaise, fatigue, headache, pains in the joints, vertigo, and insomnia. Diagnosis : In the presence of an epidemic the diagnosis is usually easy. Miliary fever should be differentiated espe- cially from scarlet fever, puerperal sepsis, and measles. The prognosis varies greatly in different epidemics. Prophylaxis calls for sanitation, isolation, disinfection. Treatment is symptomatic. BERIBERI. Definition: An infectious disease, occurring especially in tropical and subtropical regions, characterized by motor pare- sis, beginning in the lower extremities, with oedema and sensory disturbances, visceral disorders, especially of the heart and lungs. The disease is of long duration, and fre- quently shows acute exacerbations. Etiology: Various micro-organisms, chiefly micrococci, have been described. Beriberi—symptomatology: The disease shows almost in- finite variations and combinations of symptoms. The symp- toms most frequently present depend upon paresis, atrophy, numbness, and oedema. There may or may not be fever. GLANDULAR FEVER. 129 The pulse varies greatly in different cases. Usually there is palpitation. Perspiration may be diminished or absent, or greatly increased. Diagnosis: Usually easy in regions where the disease is endemic. Beriberi should be differentiated especially from locomotor ataxia, progressive muscular atrophy, paralysis, myelitis, poly- neuritis, diseases of the heart, anaemia, malaria, and Bright's disease. Prognosis: Should be guarded. Mortality varies greatly in different epidemics. Prophylaxis : Demands isolation, proper attention to hygiene, especially sanitation and disinfection. Treatment is symptomatic. GLANDULAR FEVER. Definition: An acute infectious disease, characterized by adenitis and the absence of eruption. Etiology: The disease occurs most frequently in childhood, sometimes in infancy, rarely in age. The specific cause is unknown. Glandular fever—symptomatology : Incubation, five to fifteen days, usually six or seven days. The onset is sudden with malaise, nausea, sometimes vomiting. The tongue is coated. Temperature 101°-103° F. Constipation is the rule. The anterior cervical glands are most frequently affected, usually first on the left side. There is apparently stiffness of the neck, since movement causes pain. The glands show enlarge- ment about the second or third day, when the temperature is highest. Uncomplicated cases do not show suppuration. Usually the liver is enlarged. Enlargement of the spleen is found in about half the cases. The beginning of conva- lescence is usually marked by the passage of thin green stools containing mucus. The glands begin to diminish in size from two to five days after they begin to swell. As a rule the fever and symptoms continue five to ten days, sometimes as long as two weeks, when there is a successive involvement of different groups of glands. The patient is depressed and anaemic. Convalescence requires one or two months. 9—P. M. 130 INFECTIONS. Diagnosis: Tonsilitis and pharyngitis should be excluded. Glandular fever should be differentiated especially from irreg- ular cases of rubella and mumps. Prognosis : Good. Death may occur in the case of delicate children. Treatment is symptomatic. SIMPLE CONTINUED FEVER. Definition : Cases characterized by an elevation of tempera- ture, more or less continuous, which may not be classified under any of the known diseases. Etiology : Probably due to a number of causes. The diag- nosis of "simple continued fever" frequently arises from a failure to recognize the true nature of the disease. Symptom: The only characteristic is the elevation of tem- perature, which may last from a few days to a few months. Diagnosis: Other diseases should be ruled out, especially tuberculosis, typhoid fever, malaria, and intestinal ptomain- poisoning. Treatment symptomatic. Persistent cases call for change of residence. HAY FEVER (Autumnal Catarrh; Catarrhus iEstivus; Rhinitis Hyperaesthetica; Hay Asthma; June Cold; Summer Catarrh.) The disease occurs most frequently in the fall, and is marked by catarrh of the upper air-passages, especially of the nose, with coryza, sometimes inflammation of the eyes, conjunc- tivitis, and lachrymation. Etiology : Hay fever has for a long time been ascribed to an irritability of the nervous system, and it has been observed that the attacks are apparently caused most frequently by the pollen of ragweed (Ambrosia artemesifolia) and golden rod (Solidagoodora); more rarely by wheat, barley, oats, rye, and Indian corn. Dust and the odor of animals and flowers some- times cause the disease. The disease is probably due to some micro-organism that finds a favorable soil in the pollen. Often there is hyperesthesia of the nasal mucous membrane. Symptoms: Hay fever is most frequent in middle life, but HAY FEVER. 131 infancy and old age are not exempt. The disease shows a pecu- liar periodicity, in that the attacks recur each year upon about the same day, sometimes at the same hour. There are noticed early tickling and irritation of the conjunctivae and of the mucous membrane of the upper respiratory passages, espe- cially of the nose. Soon there are sneezing, coryza, and lachrymation. There may be two or three degrees of fever and some increase of the pulse-rate. With the local symp- toms there is more or less malaise and prostration. Some- times there is pain in the muscles, eyes, and occipital region. The general symptoms seem to be due to a tox- aemia. Sometimes early, usually after the disease has existed two or three years, asthmatic attacks assume prominence. These usually appear late in the season, but may begin early in the attack. The attacks usually cease after a few hard frosts. Diagnosis: The coryza, often with lachrymation, sometimes with asthma, comes on suddenly, about the same time on succeeding years. Differential diagnosis has to do chiefly with acute nasal catarrh, influenza, and spasmodic asthma. Prognosis: Hay fever is not a fatal malady. Almost all cases may be relieved, many may be cured, but some cases persistently recur year after year. Hay fever—treatment: A change of place of residence, especially to a cooler climate, will relieve many cases. Some- times it is only necessary to take a trip at the time of the expected attack. Some cases may be benefited bv tonics. In the way of palliative treatment most relief is afforded by opium and belladonna, or morphine and atropine, but these remedies should not be used indiscriminately as a routine treat- ment. The local application of cocaine may give great but only temporary relief. Nasal spurs or adenoids should be removed, which is sometimes followed by a cure of the hay fever. Sensitive areas, which are most frequently found upon the nasal septum, may sometimes be cured by cauterization, after which the hay fever may disappear. Probably the best single remedy is arsenic, Fowler's solu- tion, gtt. ij-v three times a day up to tolerance. Quinine may be given, gr. v, morning and evening. A boraeic acid oint- 132 INFECTIONS. ment in vaseline, 5 per cent., is useful. Conjunctivitis is relieved by the instillation of cocaine, 4 per cent, solution, or morphine,*l-2 percent, solution. Chlorate of potassium may be given internally, a teaspoonful of the saturated solution every two hours. The asthma is sometimes relieved by chloral, gr. v, or the iodides. Headache and fever are relieved by phenacetin and the salicylates. ACTINOMYCOSIS (Big Jaw; Swelled Head; Holzzunge, Knochen- krebs, Kinnebeule (German)). Definition: A disease, found especially in cattle, sometimes in man, caused by the ray fungus, actinomyces. Etiology: In the pus or granulations the fungus appears as whitish, more often yellowish, granules, which under the microscope are seen to consist of threads radiating from a centre and ending in club-shaped extremities. Bostroem would classify the parasite among the polymorphous bacteria, since the masses contain cocci and bacilli, some of which are branched and show club-shaped extremities (Ponfick) (see Tuberculosis). The organism has been cultivated outside of the body, and inoculation-experiments upon animals have been successful. The disease may occur in man by direct transmission from infected animals or from foreign bodies, especially cereal grains with sharp extremities, more rarely isinglass, splinters, etc., which may contain growths of the parasite. Infection may occur through carious teeth, and Ponfick has reported infection from barbers' utensils. In man, actinomycosis is found most frequently in the head (jaw, tongue), neck, air-passages (lungs), alimentary canal (small intestine), and skin. Actinomycosis — symptomatology: The infection runs a chronic course. The symptoms, at first obscure, increase insidiously, and show variations according to the location of the actinomycotic process. As a rule, wherever the process develops there is the formation of granulation-tissue, abscesses, and fistuhe. The infiltration is peculiar, and has been de- scribed by Ponfick as " tough." Bones, when attacked, are A CTIN OM YCOSIS. 133 expanded and eroded. Affection of the lungs may cause cough, expectoration, irregular fever, emaciation, night-sweats, and the formation of cavities closely resembling pulmonary tuberculosis, and life may be terminated by tuberculosis or amyloid degeneration. In the intestine the process is slow, permitting protection of the general peritoneal cavity by the adhesion of coils of intestine. Frequently the first suspicion of the disease may be afforded and verified by the discharge of the peculiar granular pus containing the jmrasite, from a sinus which may be in the lumbar, more rarely in the gluteal or perineal, region; sometimes in some other part of the abdominal wall, communicating with the intestine or bladder. Diagnosis, to be absolute, depends upon the detection of the parasite, ray fungus, which not infrequently is to be found in granular pus discharged from a sinus; sometimes in the sputum, in cases of involvement of the air-passages (lung). Suspicion may be aroused by the insidious onset and chronic course of the infection, the presence of granulation- tissue, -fistuhv, and abscesses. Karlowski gives, as a point in differential diagnosis, that dulness is found below the clavicle in actinomycosis of the lungs, and not at the apex of the lung as in tuberculosis. Prognosis: Depends upon the location of the process, especially upon the accessibility of the infectious foci to sur- gical treatment. Prophylaxis : Care should be taken of the teeth and mouth. Animals should receive good food, not containing thorns. The parasite should be destroyed, best by fire. Actinomycosis—treatment: Wherever possible the deposits of the fungus should be thoroughly removed or destroyed with the knife or cautery. Where this is not practicable, Ponfick advises repeated injections of bichloride of mercury, 1 : 500. Further treatment is symptomatic. Karlowski successfully treated a case of pulmonary actino- mycosis by incision, resection of a rib, the use of the Paquelin thermo-cautery, and the application of iodoform- gauze. The internal use of iodide of potassium has been recommended in visceral affection, but was found ineffectual 134 INFECTIONS. by Poncet in 18 out of 25 cases. The remedy is useful only in the earliest stages. DISEASES CAUSED BY ANIMAL PARASITES. MALARIA (Intermittent Fever; Chills and Fever; Ague; Swamp Fever; Marsh Fever; Miasmatic Fever; Wechselfieber (Ger- man)). Etymology: Malaria, from mal'aria (Italian), meaning bad air. It has been suggested that mal aqua would be a better name for the disease. Definition: An infectious disease, acute or chronic, caused by the haematozoon (plasmodium) malariae; appearing some- times as a pernicious fever; usually as a fever of intermittent or remittent type; frequently as a chronic cachexia with anaemia and enlargement of the spleen. History: Malaria was known in the remotest antiquity. The disease was described by Hippocrates. Celsus and Galen recognized the quotidian, tertian, and quartan types. Perni- cious paroxysms were described by Mercatus, toward the end of the sixteenth century. Cinchona bark was introduced into Europe, in the treatment of malaria, by the Countess del Cinchon and her body-physician, Juan del Vega, 1640. The malarial parasite was discovered by Laveran in Novem- ber, 1880. Golgi described some of the varieties of the para- site found in quartan and tertian types of the disease, 1885-6. Marchiafava and Celli described varieties of the parasite in aestivo-autumnal fever, 1889. Etiology: The specific cause of malaria is now generally recognized to be the malarial parasite, the osciUaria malariae of Laveran, more commonly known as the plasmodium mala- riae (Marchiafava and Celli), more properly the htematozodn, or better the htemocytozoon malar ice. The term hcemosporidium has been recommended, but not generally adopted. The malarial parasite belongs to the protozoa, a class of unicellular animals, and to the group fuemocytozoa, since it develops within a red blood-corpuscle. There is a difference of opinion as to whether the different forms of malaria (tertian, quartan, and autumnal) are due to the same organism MALARIA. 135 or to different varieties of the malarial parasite. It is known that certain appearances of the parasite are peculiar to the different forms of malaria. Fig. 15. Plasmodium malariae of a febris tertiana in various developmental stages (after Golgi). a, first step in development; b, c, enlarged Plasmodia with pseudopods ; d, Plasmodia before the formation of spores—blood-corpuscle decolorized ; e, for- mation of spores ; /, free parasite with flagella. In the tertian form of malaria the parasite (Fig. 15) appears first as a small hyaline amoeboid body, becomes pigmented with granules in active motion, and grows to about the size of a Fig. 16. 6 c d Plasmodium malariae of a febris quartana in various stages of development (after Golgi). a, red blood-corpuscle with a small, non-pigmented plasmodium; b, c, d, e, pigmented, variously sized Plasmodia inside of red blood-corpuscles; /, Plasmodium at the commencement of segmentation, with pigment collected in centre; g, segmented plasmodium; h. plasmodium divided into separate glob- ules; i, k, two differently shaped, free Plasmodia. red blood-corpuscle. The corpuscle becomes expanded and decolorized. The parasite then breaks up into fifteen or twenty segments (spores). 136 INFECTIONS. In the quartan fever (Fig. 16) the amoeboid movements are slower than in the tertian form, and the granules of pig- ment arc coarser and present less active motion. The cor- puscle contracts around the parasite and shows a somewhat Fig. 17. Plasmodium malariae of a febris quotidiana in various stages of development (after Celli and Sanfelicc). a, first step in the development; 6, plasmodium with pseudopods ; c, Plasmodium which has become round and provided with pig- ment before segmentation; d, formation of spores; e, intraglobular crescent form ; /, gr, free Plasmodia. deeper color. The parasite breaks up into only five or ten segments, arranged in the form of rosettes around a central clump of pigment. The testivo-autumnal parasite is still smaller, reaching only half the size of a red blood-corpuscle, and presents less pig- Fig. 18. t- - __ ' 1-4- 4T —-h - -It- - r- 4V 4^U Jt I it _ It Cla_ _L L It L t. - f l&u—- ~.„^J \-/^\,J \y\vsr\l\ ^/OTSi— ±A±~ - ±± - ::::± :: Temperature-curve in man after injection of blood from patient affected with mala- rial (quartan) fever. X 12, noon, injection of four cubic centimetres of blood : + injection of two grammes of muriate of quinine (Baccelli). ment. The corpuscles become contracted around the parasite, often crenated. After about a week the characteristic cres- centic, ovoid, and round bodies appear, containing central clumps of coarse pigment-granules. The round bodies of this MALARIA. 137 form of the parasite, as well as the full-grown tertian and quartan parasites, may present flagelli, which show active movement and may become detached from the corpuscles and appear free in the blood. MacCallum has shown that the flagelli are the male elements of reproduction. Malaria has been transmitted by subcutaneous inoculation with blood, the disease appearing in the same form as in the case from which the inoculation was made. It is supposed that infection may also gain entrance to the body through the respiratory tract, but this has not been proven. Nothing is known of the life-history of the parasite outside of the body. Attempts at cultivation upon artificial media have been unsuccessful. A peculiarity of malaria is that it may prevail in a region for an indefinite length of time and suddenly disappear, seem- inglv without cause, to reappear at some future time. The disease seems to prefer a low, swampy country and to avoid altitude. Often the occupants of the ground floor of dwell- ings may be attacked, while those in the upper stories escape. An exception to the rule seems to be found in Quetta, India, which is almost 6000 feet above the level of the sea, and upon which some hills reach 12,000 feet above sea-level. Quetta is affected periodically by malaria, especially during Septem- ber and October (Birch). The mosquito plays a prominent role in carrying the infec- tion, producing the disease in man by direct inoculation. Grassi believes the species of mosquito that acts most fre- quently as purveyors of malaria are the following: tniopheles e/avit/es (Fabr), culex penieillaris (Roudani), and culex horten- sis (Ficalbi). Malaria—symptomatology: The period of incubation is not accurately known, but probably varies from one to two weeks. In cases where malaria has been produced experimentally the incubation has lasted in the quartan type from eleven to fif- teen davs; in the tertain type, six to twelve days; and in the (estivo-autumnaf type, two to five days. The regular intermittent types, tertian and quartan, are char- acterized by regularly recurring paroxysms of chill followed 138 INFECTIONS. Fig. 19. SSHK 18 h IS (h 20 b 21st 106° 105° 104° 103° 102° ror 100° 99° 98° En E E -E E s s. 2' s- Si- Cfcr 0.- E- s- <■ <■ -<■ a: <- -^ ol- ct-'d- a- £- < -< <- Qr or Q-- orS- CO *■■ 07° PULSE g o S s g " s § s p s fi 2 g S ? s S ? S S RES P. S S 3 s s a s s - - 2 - £ ?. s 2 s 3 3 S Tertian fever (Seguin). bv /crcr, later sweating. The paroxysms are often preceded by uneasy sensations, especially in the epigastrium, and some- Fig. 20. MV OF MONTH lSth 19th 8()t»i 21s TEMP. 107 108° 105° 104 103' 102" tof 100° 99° 98° 97° 35 E E E S % S S: 7 EfsiE sh= s. S S: < £ rg S E 5: E: -•_ ? *ft* E E E * = ? <' <■ 1 I .j*. IN | JN 5t. | § | i | -~ '=" 5 | | PULSE 96 22 10 w w 8! 7b 72 7i 10 7! 7. 8, 08]] w'i RESP. 24 i_ 20 _ •M 2( IS 1'' L 20 IB 20 21 20 20 20 J', _i_ 2J2, 24 Quotidian fever (Seguin). times by headache. "With the onset of the paroxysm there are lassitude, headache, sometimes nausea and vomiting a MALARIA. 139 slight rise in temperature, and a pronounced chill, the skin becoming cold and blue. The temperature rises, and may reach 105° or 106° F. The pulse is rapid, hard, and non- compressible. There is headache. The chill may last from CO CO CO OOOO O O O 2 |? j | j Ul || 11 'III Ml 1111111 6 aJm C fill 1 I 1 1 8 A.M i H> | 0 A.M jMJ-LLL 7 l2l \ioor> 11111111 III TfTn- t 2 F>.M ill lljlIN 1 71 IT IhTRTtV w 4 P M -mtfl t r p.|m llllllllllllil 1 8 f M 1 | 1 f? ff M 1 II 1 1 1 ■ i 1 1 ! 1 1 1 ' III 7*1 1 ' ' 1 ! ' III 7 2 M ■I 1 ll 1 11 \jf[[\ ] 111 2 A. M A. M~ 00 N p. ivv p]m P.'M P.|m: p. |iyi| M.| ^ I fHll Pm T I4 M ■4111 II11IIIIII ||| 1 6 iJiiiiiiinpn 2 4 """b 8 i^tmflmr f III ill M : 1 m 1 '2 A.;M a 4 A. M r A. M 8 A M | 10 a] M I 7 2! Vooi i Ii pU 4 ? r in 1TTT | i 7 8 P.M film mj i 8 p.|iyi W tj 10 p.Jm til 111' 111 12 Mj-] \- ra^ m 1' 7 2 a.'m 3* 1 nffli In 4 aJm ii Ttl 11II 7 6 A. M II 8 1- M T |\, Hill 7 10 A.M III II Wm 1' 111111 11 I 111 hi I 2 us. A proc- titis may extend to constitute a periproctitis, with the forma- tion of abscess, which by bursting may cause an external rectal, recto-vesical, or recto-vaginal fistula. The subjective symptoms of chronic catarrh are similar to those of acute catarrh. The general symptoms may be more pronounced. The mucous membrane is sometimes destroyed, or undergoes atrophy, to cause persistent chronic diarrhoea, anaemia, and debility. When this is combined with atrophy of the stomach, there may be the picture of pernicious anaemia (Osier, Noth- nagel, Ewald). Diagnosis: Catarrh of the duodenum is often caused by ex- tensive burns of the skin. The condition may be recognized by the presence of icterus, tenderness in the right hypochon- drium following catarrh of the stomach, anol the passage of large quantities of mucus. ('tdarrh of the small intestine shows indican in the urine, which may be recognized by the Burgundy-red reaction of Rosenbach. Boil the urine in a test-tube, adding nitric acid drop by drop. A Burgundy or peony-red color, which is retained on further boiling and which may be extracted with ether, is indicative of a disturbance of the metabolic processes in the small intestine. Catarrfi of the large intestine, especially of the rectum, is indicated by anal itching and burning sensations, tenesmus, pain in the left iliac fossa, the passage of mucus, sometimes of blood, and considerable pain on digital examination, espe- cially when the lower part of the large intestine is affected. Chronic catarrfi of the intestine may show constipation. The passage of mucus is especially prominent, A careful differentiation should be made between primary and secondary catarrh of the intestine. Most important is the discovery of the cause of the catarrh. Prognosis is more serious in infancy and old age, but de- pends largely upon the cause. In cases of long duration the INTESTINAL CATARRH. 211 outlook becomes more unfavorable through the danger of atrophy or ulcer. In secondary catarrh of the intestine the prognosis depends chiefly upon the gravity of the primary disease. Treatment: Mild cases of intestinal catarrfi may require no treatment further than the removal of the cause, with absti- nence from food for a short time and later a light diet, begin- ning possibly with diluted milk and gradually returning to the normal diet. Offending material must be removed from the intestine, best by calomel or castor oil internally and by cleansing enemata. Some prefer the biniodide of mercury. Abdominal pain and tenesmus may be relieved by warm or hot applications, or opium in the form of laudanum inter- nally or the extract in suppositories. An excellent formula, given by Whittaker, is: B/ Tincturae opii, gtt. xl-lx ; Acidi hydrochloric! diluti, gtt. xl; Aquae camphorae, aol £iv. M. S. A teaspoonful to a tablespoonful every two to four hours. Antiseptic and astringent remedies may be used internally and by enemata. Ewald recommends : B/. Rcsorcin, (5-0) gr. lxxv ; Bismuthi salicylat., Tannigen, da (15.0) sss; Sacchari albi, Sodii carbonatis, da (7.5) 3ij. M. ft. pulv. S. Small even teaspoonful to be taken every two hours. The intestine may be irrigated with a solution of nitrate of silver, with boric acid, tannic acid, or alum. Ewald prefers : 212 DISEASES OF THE ORGANS OF DIGESTION. R/. Chloral, (3.0-5.0) gr. Ixv-lxxv ; Acidi tannici, (E5) gr. xxiv; Lime water, ad (500.0) Oj. M. S. One-quarter to one-third of this quantity is to be mixed with 12 ounces of warm water or thin starch-water, and of this 5 or 6 ounces or more may be injected into the bowel and should be retained as long as possible. Carlsbad salt is one of the best laxatives. Chronic catarrfi of the intestine—treatment: Diet is most important. The drinking-water should be pure (boiled). In addition the treatment recommended for acute catarrh of the intestine may be indicated. Constipation frequently needs treatment, Sometimes a stay at one of the mineral springs may be necessary. Catarrh of the intestine in infancy and early childhood: Food should be withdrawn for a time. During the interval the patient may be given boiled water, to which may be added a pellet of salt. Cases of chronic catarrh sometimes call for a change of diet, Lavage is often of value. Irritant material must be removed from the intestine, usually best by the administration of calomel or castor oil. Diarrhoea often is relieved by the administration of bismuth subnitrate, or tannalbin. More persistent cases may be relieved by a com- bination of ipecac and opium. Sometimes persistent vomiting is relieved by creosote. ULCER OF THE INTESTINE. Typhoid ulcer (see Typhoid Fever). Tuberculous ulcer (see Tuberculosis). Catarrhal and follicular ulceration have been treated of under Catarrh of the Intestine. Round Duodenal Ulcer (Ulcus Duodeni Pepticum). Ulcer of the duodenum is found in men more frequently than in women. It is believed that the gastric juice enters INTESTINAL HEMORRHAGE. 213 the duodenum and causes corrosion when there has been a local circumscribed disturbance of circulation. Ulcer of the duodenum frequently appears after severe burns of the skin. Some attribute such cases to toxic material eliminated by the bile (Hunter) ; others believe it to be due to the liberation of the fibrin-ferment causing thrombosis of the duodenal veins. Duodenal ulcer—symptomatology: Sometimes there are no symptoms. Some three hours after meals there may be pain in the region of the duoolenum radiating toward the epi- gastrium and sacrum, sometimes very closely simulating gall- stones. The pain is not increased by food. Usually there is diarrhoea. More characteristic is hemorr/iage, appearing as mehena, sometimes with haematemesis, very rarely as haemat- emesis alone. There are tenderness and anorexia. Sometimes induration may be detected. Diagnosis: Duodenal ulcer should be differentiated from ulcer of the stomach, gall-stone colic, carcinoma of the duode- num, and the gastric crises of locomotor ataxia. Ulcer of the stomach may be eliminated by the location of the circumscribed point of tenderness, the time of occurrence of the pain after taking food, the examination of the contents of the stomach, showing an absence of hyperchlorhydria, and an examination of the urine for peptone. The time of occur- rence of pain and hemorrhage would speak against gall-stone colic. Carcinoma runs a shorter course, and frequently presents the symptoms of stenosis, and is accompanied by cachexia and more marked degradation of health, and often a tumor may be detected. The gastric crises of locomotor ataxia may be ruled out by the absence of symptoms on the part of the central nervous system, indicative of locomotor ataxia. The prognosis is not favorable. Treatment: Special attention should be paid to the diet and all indiscretions avoided. Sometimes it is necessary to resort to rectal alimentation. Otherwise the treatment' is symp- tomatic. INTESTINAL HEMORRHAGE (Enterorrhagia). Etiology: Ulceration of the intestines is the most common local cause of intestinal hemorrhage. Other conditions to 214 DISEASES OF THE ORGANS OF DIGESTION. which hemorrhage may be due, are : inflammation of the in- testinal mucosa, inflammation and ulceration following burns of the skin; intussusception; obstruction of the portal circu- lation; disease of the heart, lungs, bloodvessels, and liver; obstruction of the mesenteric arteries, and rupture of an aneurism into the intestine. Hardened faeces or foreign bodies passing through the intestine may cause slight hemorrhage. Hemorrhage may be caused by foreign bodies passed into the rectum by accident or design, as frequently occurs among the insane. The excessive use off purgatives or the ingestion of caustic or corrosive poisons may produce hemorrhage. The infections may cause hemorrhage either through an action upon the mucosa of the intestine, as in the ulceration of typhoid fever, syphilis, and dysentery ; or through an action upon the blood and vascular system, as in typhoid fever (before ulceration), yellow fever, plague, septicaemia, malaria, scurvy, purpura, haemophilia, uraemia, and cholaemia. Hemorrhage from the intestine is sometimes an expression of vicarious menstruation. Hemorrhoids, ulcers, polypi, carcinomata, and tuberculosis intestinalis may be marked by hemorrhage. Intestinal hemorrhage—symptomatology: 4'here may be only collapse, without the passage of blood, sometimes with- out preceptible distention of the abdomen. Blood from the upper part of the intestines is sometimes regurgitated into the stomach anol discharged by ha'matemesis. As a rule blood ap- pears in the stools. The amount may be so small as to be detected only with the microscope, and sometimes blood may be discovered in this way before the appearance of gross hem- orrhage (thirty-six hours before, Nothnagel). Hemorrhage high up in the intestinal canal may appear as black (tarry) stools. In hemorrhage from the colon, the passages may be covered or streaked with blood anol mucus. When retained for a long time the blood may become inspissated. Diagnosis: The stools should be carefully examined to detect the presence of blood. In doubtful cases an exami- nation may be maole with the microscope or spectroscope. Next the source of the hemorrhage should be determined, whether from the mouth, nose, pharynx, larynx, lungs, oesoph- agus, stomach, or intestine. Swallowing of bloool is found TYPHLITIS. 215 especially among malingerers, the new-born, and infants nursing from bleeding nipples. Examination of the anus anol rectum may reveal hemorrhoids, ulcers, or polypi. Sud- den collapse should awaken the suspicion of latent hemor- rhage. The prognosis depends largely upon the cause. A copious anol persistent hemorrhage is always dangerous. Intestinal hemorrhage—treatment: The foot of the bed should be raised. The diet may consist of milk, ice, and cold drinks. Cold applications—the ice-bag—should be placed over the abdomen. Opium may be given to restrain peristalsis. Liquor ferri persulphatis or pernitratis, tannic acid, o>r gallic acid, may be given internally. Ergotol, the aqueous extract of ergot, ergotin, or sclerotinic acid, may be injecteol subcutaneously. Astringent solutions, tannic aciol, gr. j : 5j of ice-water, or nitrate of silver, gr. \ : sj, may be injected into the bowel, when the hemorrhage comes from the rectum or lower part of the intestine. Any underlying con- dition should be properly treated. Thus malaria may call for quinin. Collapse demanols the use of the analeptics. Lyman recommends— B/. Moschi, Pulv. camphorae, Pulv. capsici, ad gr. j. M. Fiat pilula No. j. Sig. Give one such pill every two to four hours. Bad cases call for the use of camphor hypodermatically, best dissolved in olive oil or ether. Salt water infusion may rescue even desperate cases. TYPHLITIS (Perityphlitis; Paratyphlitis). Typhlitis (caecitis) is a colitis limited to the wall of the caecum. The chief causes are improper food and trauma, gall- stones, enteroliths, foreign bodies, and the infections, typhoid fever, tuberculosis intestinalis, syphilis, olysentery, intestinal 216 DISEASES OF THE ORGANS OF DIGESTION. oliphtheria, carcinoma, and actinomycosis. When due to irri- tation from masses of faeces, the condition is known as typhlitis stercoralis. Typhlitis—symptoms: The onset of symptoms is gradual. There is pain in the ileo-o:aecal region, dull in character, some- times paroxysmal, increased by pressure or movement, some- times radiating to the umbilicus, right hypochondrium, or the epigastrium. The usual symptoms of dyspepsia, eructations, nausea, rarely vomiting of foool or bile, are more or less marked. There are constipation, and usually some distention of the abdomen. A soft sausage-shaped tumor may be found in the right iliac fossa. The temperature usually is not very high, but frequently reaches 102° F. The urine, diminished in quantity anol high colored, may contain small quantities of albumin and indican. The prognosis of typhlitis is good. In the treatment of simple typhlitis the bowels should be moved thoroughly with an enema of water or oil, combined if necessary with the internal use of castor oil. In simple typhlitis stercoralis the enema may be repeated, if necessary, with the administration of castor oil, calomel, or Carlsbad salt. Perityphlitis, an inflammation of the peritoneal covering of the caecum, and paratyphlitis, an inflammation of the perito- neum and connective tissue behind the caecum (retrocaecal), as a rule, accompany appendicitis rather than typhlitis, although their relationship with typhlitis in some cases may not be denied. "' Perityphlitis belongs to the surgeon,' has been until lately an assertion defended with emphasis by many sur- geons, but which has never received the assent of the general practitioner, and never will. According to the experience off general practice, and the statistical results of Sahli, Renvers, Guttmann, Leyden, Fiirbringer, Hollander, Rotter, and the majority of French physicians, from 90 to 91 per cent, of all cases of perityphlitis, taken in the widest sense, recover with- out any operation. It would, therefore, smack of insanity to subject every case of perityphlitis to the uncertainties of an operation " (Ewald). APPENDICITIS. 217 APPENDICITIS. Appendicitis: Inflammation of the vermiform appendix is usually not confined to the appendix, but extends to consti- tute a perityphlitis, or more correctly a peri-appendicitis. Etiology: The infectious agent is usually the bacillus coli communis, sometimes associated with the streptococcus pyo- genes or the staphylococcus pyogenes aureus or citreus or other bacteria, especially diplococci, usually as a secondary infection. Causes predisposing to such infection are : irrita- tion due to arrest of the contents of the intestine, the con- tinued retention of faecal matter in the caecum, bending or twisting of the appendix, and muscular relaxation of the wall of the appendix; excesses in eating, violent exercise soon after eating, and the ingestion of substances of an irritating (mechanical or chemical) character. Bacteria grow readily in the mucus, sometimes mixed with faecal matter, contained in the appendix. The appendix may be occluded or irritated by inspissated masses of faecal mat- ter, gall-stones, enteroliths, rarely foreign bodies, suo:h as the eggs of ascarioles, fish-bones or other small bones, bristles, hairs, and seeds. Sudden perforation may occur from necrosis of the wall of the appendix. Appendicitis—symptomatology: Most cases occur between fifteen and thirty years of age, rarely before the third year, although the disease has been reported as early as the seventh week of life. Males are probably most frequently affected. There are often repeated relapses or recurrences. A simple catarrhal appendicitis may show no symptoms. Pain, dull, boring or stabbing, may appear in the ileo-ccecal region, sometimes at the umbilicus or epigastrium, as repeated attacks of colic, which may occur in mild cases only when peristalsis is increased. A careful physical examination may reveal the swollen appendix. More severe cases of appendicitis may show dulness, more or less marked, over the region of the appendix, and palpa- tion may detect resistance resembling a tumor near the border of the right ilium. There are pain, abdominal distention, dyspeptic symptoms, sometimes vomiting of food, bile, medi- 218 DISEASES OF THE ORGANS OF DIGESTION. cine, possibly stercoraceous vomiting, with constipation and some fever. The urine is scanty, high colored, gives the Burgundy-red reaction, and may contain indican. In a third class of cases of appendicitis there is bacterial invasion of the peritoneum, sometimes but not always through perforation (necrosis, ulceration). There is violent abdominal pain after intestinal disturbances, trauma, the swallowing of some foreign body (bone, seed), sometimes without apparent cause. The pain later becomes localized in the region of the appendix. The temperature may rise above 102° F. Hic- cough is a prominent symptom in many cases. Constipation is the rule; occasionally there is diarrhoea. Movement causes pain. There may be the symptoms of collapse. Phys- ical examination may reveal a large perityphlitic accumu- lation. In chronic cases the pus may burrow, to find exit in the most various ways. Diagnosis: In the presence of typical symptoms the diag- nosis is easy. Of most importance, as a rule, are the previous history and the presence of a tumor or olulness in the region of the appendix. Tenderness may be elicited at MeBurney's point. The differential diagnosis calls especially for the separation of renal colic, hepatic colic, and in chronic cases cancer and tuberculous peritonitis. Often appendicitis is tubercular. The inflammation may not be confined to the usual region of the appendix, so that it may be necessary to rule out peri- nephritic inflammation, haematocele, salpingitis, pyosalpinx, cholelithiasis, or disease of the liver; or to recognize an appendicitis occurring in a hernial sac in the scrotum or else- where. Confusing symptoms may sometimes be caused by constipation from opium, invagination, or strangulation. Some- times a positive diagnosis can be maole only upon exploratory incision. Appendicitis—prognosis: When appeal is to be made to surgery, the earlier such treatment is instituted the better will be the prognosis. Suppurative peritonitis gives a bad outlook. The occurrence of complications increases the gravity of the case. The prognosis is unfavorable when the peritonitis INTESTINA L OBSTR UCTION. 219 becomes general, or in the presence of a suppurative pleurisy, pylephlebitis, or abscess of the liver. Prophylaxis : The bowels should be regulated. Especially must constipation be remedied. Fooid is to be avoided that would cause constipation or leave a large residue in the bowel. The meals should be eaten slowly and thoroughly masticated. The patient should rest for a while after meals. Indigestible substances, such as the seed of fruit, should not be swallowed. The danger of trauma, as far as possible, must be avoided. Appendicitis—treatment: During the attack the patient must observe absolute rest in bed. The diet should be light; best nothing but boiled water and crackeol ice for the first twenty-four to thirty-six hours. Later milk may be given, eolol or lukewarm; then small quantities of oatmeal, farina soup, or bouillon made from white meat. The return to the normal oliet should be very gradual. Pain calls for the use of opium, with applications of cold (colol compresses, ice-bag), or of heat (hot compresses, poul- tices), and infusions of chamomile, valerian, etc. Constipation, even when obstinate, may be allowed to run several days during the acute stage of an attack without treatment. The bowels may then be gently moved by small enemata carefully given. Should these fail, high injections may be given of water containing castor oil, made into an emulsion with the yolk of an egg. When necessary, purga- tives may be administered internally, best castor oil; later calomel or Carlsbad salt may be given. Operation may be demanded by perforation, suppuration, recurrence of attacks with increasing severity, when the opera- tion should be made between attacks, and in cases of chronic appendicitis with indefinite and obscure symptoms. It is not infrequent to find an apparently healthy appendix at opera- tions in o'ases in which the clinical symptoms have been those of appendicitis (Ramm). INTESTINAL OBSTRUCTION (Ileus; Intestinal Occlusion). Etiology: Obstruction of the intestine may be caused by abnormal conditions of the intestine, of the intestinal con- 220 DISEASES OF THE ORGANS OF DIGESTION. tents, or by compression from tumors, misplaced organs, etc. Chronic or habitual constipation may be present even when there is the history of daily stools. The condition may be due to atony of the bowel or a weakening of the muscle- fibres of the intestine through inefficient efforts to overcome some chronic obstruction of the bowel; irregular habits of defecation ; leaving too much or too little residue to pass through the intestine, or a diet without variety, such as an exclusive meat-diet, or food containing too little water, or the loss of water through the skin (profuse perspiration), lungs, or kidneys; abuse of purgatives, fatiguing the mus- cular fibres; change from an active outdoor to an indoor sedentary life ; mechanical pressure (pregnancy); preoccupa- tion of the mind by business or domestic cares, melancholia, insanity. Intussusception, or intestinal invagination, may occur physio- logically during the so-called death-agony, anol possibly at other times. Intussusception oo;curs pathologically most fre- quently in children, half the cases before the tenth year; in males more frequently than in females. The condition occurs, in the order of frequency, as ileo-caecal invagination, enteric invagination, anol colic invagination. Invagination of the duodenum is rare. Internal strangulation usually affects the small intestine, the lower part of the ileum, and is most frequent under forty. Stricture may result from cicatrization following ulceration (dysentery, less frequently typhoid fever, tuberculosis). More often stricture is due to syphilis or carcinoma and may be recognized by rectal examination. Obturation of the intestine may occur from the lodgment of gall-stones, more rarely from enteroliths, as a rule having as a nucleus some foreign body. Calculi may be causeol by the continued medicinal use of mineral substances, such as calcium carbonate, calcined magnesia, or magnesium carbonate. Volvulus, a turning of the intestine around its mesentery or upon its own axis, occurs most frequently after forty, usually at the sigmoid flexure. Volvulus is causeol as a rule by chronic constipation, sometimes by chronic peritonitis, and may be, rarely, congenital. Twisting of the intestine has INTESTINAL OBSTRUCTION. 221 been ascribed to violent irregular movements of the intestine, jumping, trauma, and the use of high injections. In such cases peritonitis may occur early, but perforation is rare. With- out operation oleath usually occurs in two to six days. One case is reported to have lived twenty days (Treves). Twist- ing of the intestine upon its own axis occurs only in the caecum and ascending colon. Volvulus of the ileum or jejunum is rare. ( hltapse may supervene suddenly. There is violent pain, often intermittent, with vomiting, slight in quantity but faecal in character. The convolution above the volvulus is dis- tended and fixed. It is impossible to introduce water or air through the rectum past the obstruction. There is early tenesmus. The urine does not contain indican. There may be only half a turn of the bowel, constituting an incomplete volvulus. In addition to the causes already enumerated, obstruction of the intestine may be caused by compression from a tumor or from some other organ : displaced uterus, dislocated spleen, floating kidney. Cases in which no other cause can be found are supposed to be due to a circumscribed intestinal paralysis, so-called cases of paralytic ileus. The condition may be only an arrested peristalsis or an actual paralysis, anol may be olue to trauma, appearing sometimes after the reduction of a hernia; inflammation, peritonitis, or to other causes which may not be easily oliscovered. Symptomatology: The onset of the symptoms of ileus may be gradual or sudden. Where the obstruction is complete, the constipation may amount to obstipation. Usually there is pain, which may be present in every grade of severity, and either intermittent or constant, There are tormina and tenes- mus. The pain comes on earlier and is more marked when the small intestine is involved. The pain is not always referred to the point of obstruction. There are singultus; eructations; later vomiting, which is at first, or soon becomes, stercoraceous. The abdomen is more or less distended and tenoler. Percussion reveals meteorism in cases of acute ob- 222 DISEASES OF THE ORGANS OF DIGESTION. struction, which is absent in the occlusion from constipation. The urine is diminished in quantity, of high specific gravity, and contains urates. Indicanuria appears early in obstruc- tion of the small intestine, and late or not at all in obstruction of the large intestine, and is small in amount when the obstruc- tion is in the upper part of the small intestine. tbmpIications: The chief complications are peritonitis, perforation, and fistula. Ileus—diagnosis: Usually easy. The condition must be differentiated especially from general peritonitis, acute typh- litis and perityphlitis, appendicitis, and coprostasis; occasion- ally from Asiatic cholera, strangulation of a floating kiolney, renal calculus, lead-colic, displacement of the uterus, and ovarian tumors. It is often more difficult to reco>gnize and locate the cause of the obstruction. When the obstruction (tumor, carcinoma, syphilis) is in the lower part of the large intestine, it may be detected by rectal examination. Obstruction in this part of the bowel will permit the introduction of only a small quan- tity of water or air per rectum. Sometimes only small enemata may be useol in patients who are nervous or neuras- thenic, or who are not accustomed to such injections, even when there is no obstruction. Cases of obstruction in the lower part of the large intestine show an absence of indi- canuria. In such cases the symptoms of ileus come on later, there is considerable meteorism, and there is not so great collapse. When the obstruction is in the jejunum or upper part of the ileum, there is early vomiting of bile (not stercoraccous), sudden collapse, and absence of general distention of the abdomen. Indican is absent from the urine, the same as when the obstruction is in the rectum. The location and character of the pain may be deceptive, but often will give a clue to the location of the obstruction. Prognosis: Depends upon the cause, whether the occlusion is complete, and the conolition of the patient. In severe cases the prognosis is baol, and even in cases less severe the mortality is high. Ileus—treatment: An uncomplicated faecal obstruction ENTEROPTOSIS. 223 may be relieved by purgatives. In other cases all pur- gatives may do harm. Intestinal irrigation not only cleanses the bowel, but may relieve strangulation before the for- mation of adhesions. Rectal injections often suffice to re- duce a volvulus or intussusception. The introduction of air into the bo>wel increases peristalsis anol causes disten- tion of the intestine, but does not remove the contents so well as when water is used. Repeaton! lavage of the stomach may relieve the symptoms by lessening the tension on the intestine, and has been reported to effect a cure by exciting reflex movements in the intestine, in cases of an incarcerated convolution, intussusception or volvulus. Opium in suppositories, or morphine subcutaneously, may be given to overcome peristalsis anol pain. While administer- ing o>piates the physician should not underrate the gravity of the case. Intestinal convolutions distended by gas may be relieved by puncture, under strict asepsis; but, especially in cases of intestinal paralysis, there is danger of some of the contents of the intestine getting into the peritoneal cavity through the puncture and causing peritonitis. Sometimes the paralysis causeol by the passage of foreign bodies may be relicveol by massage and electricity. Excessive thirst may be relieved by rectal injections of water anol permitting the patient to drink all the water he wants, with lavage of the stomach. Infusion of salt solution may be called for. Many cases can be relieveol only by surgery. When an operation is decided upon, the earlier it is done the less will be the danger. A primary enterostomy or colotomy should be made, if the patient is not in condition to undergo a more pro- longed operation, and a secondary operation may follow when the patient is in better condition. ENTEROPTOSIS. The term, enteroptosis, is w^ca to indicate a descent or dis- placement of any of the abdominal viscera, as well as a down- ward displacement of the intestine. A descent of the trans- verse colon, coloptosis, is the most frequent intestinal displace- 224 DISEASES OF THE ORGANS OF DIGESTION. ment. Prominent causes are constipation and violent exertion. There are frequently emaciation and indigestion. Enteroptosis is most frequent in cases of anaemia and neurasthenia, which conolition it aggravates. The diagnosis may be made by percussion of the bowel after it is distended with air. Treatment calls for the relief of constipation, attention to the general health, especially the treatment of anaemia and neurasthenia, and the support of the abdomen by a well-fitting bandage or supporter. HEMORRHOIDS (Piles). Etiology: Hemorrhoids occur most frequently from thirty to fifty years of age. Hemorrhoids may be caused by any- thing which interferes with the return of blood from the hem- orrhoidal veins. Prominent causes are constipation, obstruc- tion of the portal circulation (cirrhosis of the liver), chronic proctitis, stricture of the rectum, pelvic or abdominal growths or tumors, pregnancy, enlargement of the prostate, and diseases of the heart and lungs that may cause congestion off the hem- orrhoidal veins by interference with the circulation of the blood. Symptomatology: The patient feels as if a foreign body were in the rectum, which causes burning anol smarting, often painful defecation, sometimes painful micturition. In cases of internal hemorrhoids there may be a muoious or muco-puru- lent discharge, sometimes mixonl with blood. Diagnosis: External hemorrhoids may be revealed by in- spection ; internal hemorrhoids, by inspection through the rectal speculum or by oligital examination. Prognosis : Asa rule goo>ol as far as life is concerneol. Rarely the hemorrhoids may become strangulated or gangrenous. Re- lapses are frequent, except when thorough surgical treatment is resorteol to. Hemorrhoids—treatment: As far as possible the cause should be removed. Constipation shoulol be relieved ; exer- cise shoulol be prescribed for the indolent anol those engaged in sedentary occupations. The patient should abstain from INTESTINAL NEOPLASMS. 225 irritating food and drink, such as strong spices, alcoholic drinks, strong coffee and tea, acid articles (pickles), and food that contains much material that will be left as a residue in the intestine. Upholstered chairs and feather beds are to be avoided. After defecation the anus shoulol be sponged, best with a weak solution of carbolic acid or some antiseptic, and drieol with lint. For symptoms of irritation, especially after excoriations, the application of an ointment of vaseline, lanoline, or cocoa- butter, containing morphine, extract of belladonna, or cocaine, may give relief. The hemorrhoids may be touched with a 2 per cent, solution of cocaine, or a 1 percent, solution of ni- trate of silver. Inflammation may be relieved by ice-water or ice bags, poultices, or hot baths. Pain may be relieved by ointments (unguentum gallae cum opii), or suppositories of opium or morphine and atropine. Hemorrhage may call for the administration of calomel and bicarbonate of sodium, or the local application of ice plugs, tampons, or injections of hot water, anol astringent solutions, tannic acid, alum, acetate of lead, or nitrate of silver. Prolapse and strangulation or very great discomfort call for the inter- vention of surgery. Injections of carbolic acid, 1 : 3 of glyc- erin, gtt. v into each pile, may be repeated at intervals of a few days. 44icse injections may be preceded by injections of a 1 per cent, solution of cocaine or the Schleich fluid. Care should be taken not to make the injection into the cellular tissue, because of the danger of abscess. INTESTINAL NEOPLASMS. Carcinoma is the most frequent intestinal neoplasm, but does not occur as often as carcinoma of the stomach. Most cases occur from forty to sixty years off age. Only one-seventh of cases occur before thirty (Maydl). From an examination of the statistics regarding the location of carcinoma of the in- testine, Ewald found the rectum involved 874 times, the large intestine 148 times (the transverse colon 12 times), the caecum including the appendix 64 times, the ileum 26 times, the duo- denum 19 times, and the jejunum 17 times. 15--P. M. 226 DISEASES OF THE ORGANS OF DIGESTION. Symptoms: Often carcinoma may exist some time before symptoms are noticed. The most characteristic symptoms are the peculiar cachexia, the presence of a tumor, malnutrition, and obstruction of the bowel. The obstruction of the bowel may disappear under treatment to reappear again later. The condition is chronic. Other symptoms will depend upon the location of the carcinoma. Sometimes a tumor may not be detected. Diagnosis: In the presence of a complete array of symp- toms, especially cachexia, tumor, and intestinal obstruction, the diagnosis is easy. Sometimes a piece of the neoplasm may be removed, through a rectal speculum or endoscope, or through an incision, and examined microscopically, to make the diagnosis absolute. Intestinal carcinoma shoulol be dif- ferentiated from tuberculosis, syphilis, olysentery anol typhoid fever, carcinoma of the pylorus or of the gall-bladder, pan- creas or omentum, echinococcus of the omentum, retroperitoneal neoplasms, neoplasms of the uterus and its adnexa, intestinal concretions (gall-stones, faeces), appendicitis, anol tumors of the kidney or spleen. The prognosis is unfavorable. Such patients may live for a number of years. The duration of life is usually longest when the carcinoma is situated in the rectum. The treatment is surgical, and should be resorted to as soon as a diagnosis is made. The results are not so good after the formation of metastases or adhesions. Often marked im- provement follows colotomy. Sarcoma and lymphosarcoma of the intestine are rare. The most common site is the small intestine. There is a marked tendency to metastases, and the course is more rapid than in carcinoma of the intestine. Among the benign neoplasms of the intestine are adenomata, fibromata, lipomata, papillomata, angiomata, myomata, fibro- myomata, myxomata, and fibro-myxomata. Most important are the intestinal polypi, tumors having a pedicle, which may cause intestinal obstruction. In the small intestine they may cause invagination. Rectal polypi may be ACUTE PERITONITIS. 227 detected by digital examination. All such tumors may cause diarrhoea, with the discharge of mucus, pus, or blood, or in- testinal obstruction anol hemorrhage. DISEASES OF THE PERITONEUM. ACUTE PERITONITIS. Etiology: Acute inflammation of the peritoneum is caused chiefly by bacterial infection, most frequently by the bacillus coli communis, streptococcus pyo>genes, staphylococcus pyo- genes aureus, citreus and albus, sometimes by the micro- coccus pneumoniae crouposae, bacillus lactis aerogenes, bacillus typho-abdominalis, and the proteus vulgaris. These bao;teria may gain access to the peritoneum through solutions of con- tinuity (perforating ulcers, wounds) of the stomach, intestine, or abdominal wall, or through the intact walls of the stomach, intestine, or other abdominal or pelvic organ covered by peri- toneum, when injureol (trauma); or through extension of in- flammation of abdominal or pelvic organs (appendicitis, genito-urinary oliseases). Peritonitis, due to the micrococcus pneumoniae crouposae, is found most frequently in girls. When localized, the process is found in the pelvis. Boulay found the micro-organism in the uterus, which would seem to indicate that the channel of infection of the peritoneum is from the uterus, through the lymphatics or tubes (F. Brim). Pernio:e produoeol peritonitis experimentally, in rabbits and guinea-pigs, by injecting chemical substances (concentrated mineral acids, acetic acid, phenol, nitrate of silver) into the peritoneal cavity. Sternberg failed to produce peritonitis in rabbits by the introduction of sterilized powdered glass into the abdominal cavity. Other causes of acute peritonitis are general septicaemia, miliary tuberculosis, malaria, dysentery, nephritis and suppu- rative inguinal adenitis (Fitz). Symptomatology: The principal symptoms of acute peri- tonitis are abdominal pain and tenderness, constipation (some- times diarrhoea), nausea, often vomiting. Usually the tern- 228 DISEASES OF THE ORGANS OF DIGESTION. perature is high and the facial expression anxious. Thirst is often distressing. There is singultus. The abdomen is at first retracted, later distended and tympanitic. The abdominal muscles are firmly contracted. Respiration becomes largely or altogether costal. The pulse is rapid, small, anol wiry. Frequently there is retention of urine. Sometimes there is collapse. Pain anol tenderness may be absent, especially in septic (puerperal) peritonitis. Sometimes the peritonitis is limited to a part of the abdominal or pelvic cavity to which the symptoms are confined, constituting a localized peritonitis. Complications and sequelae of peritonitis: There may be tympanites, from paralysis of the bowel; obstinate vomiting, probably reflex through the pneumogastric nerve ; retention of urine, through extension of inflammation from the peritoneal covering to the muscular wall of the bladder; bronchitis, pneumonia, pleurisy, or strangulation of the bowel. Diagnosis: The abdominal pain anol tenderness, board-like rigidity of the abdominal muscles, anol constipation, form a characteristic group of symptoms of acute peritonitis. More difficult to diagnosticate are the cases in which abdominal pain anol tenderness may be absent. Acute peritonitis shoulol be differentiated from obstruction of the bowel, acute hemorrhagic pancreatitis, hysterical peritonitis, gall-stone and renal colic, anol subphrenic abscess. The prognosis should be guarded. Acute peritonitis—treatment: If possible, the cause shoulol be found and removed, if necessary by the intervention of surgery. The medical treatment consists in the relief of pain and vomiting by the administration of opium internally or mor- phine hypodermatically. Turpentine stupes and mustard plasters may be applied to the abdomen. Some cases may be relieved by high rectal injections, which may contain turpen- tine and milk of asafetida. Alcohol, best in the form of wine, whiskey, or brandy, is sometimes useful. In the absence of vomiting, foool may be given bv the mouth; but usually it is best to give the stomach a rest. The patient may be sustained for a few days by nutritive enemata. TUBERCULAR PERITONITIS. 229 The judicious use of saline purgatives is often of very great value. Sometimes the cause may be found and removed by an ex- ploratory incision. As in so many other conditions, when an operation is olemanoled the earlier it is performed the better are the chances for recovery. TUBERCULAR PERITONITIS. Definition: An infection of the peritoneum by the tubercle bacillus. Etiology: The tubercle bacillus infects the peritoneum most frequently by direct extension from the intestine, next in frequency from the female genital organs. The disease occurs especially in early adolescence, but infancy and old age are not exempt. Symptomatology (see Symptomatology of Acute Peritoni- tis) : Usually the symptoms of tubercular peritonitis are not so acute, and the course is more chronic. Abdominal disten- tion and rigidity, emaciation, anol the streptococcus fever-curve are present. There may be symptoms on the part of the organs primarily affected, especially the lungs, intestine, and genital organs. The temperature may be subnormal for days at a time (Osier, Musscr). Sometimes tubercular nodules are recognized by palpation, especially upon vaginal or rectal examination (HegeiM. There may or may not be ascites. The disease may continue for months or years, or early show the symptoms of miliary tuberculosis or acute peritonitis. Diagnosis: Sometimes tubercle bacilli may be found in the ascitic fluid. Often a test-injection of tuberculin will clear up a doubtful case. Differential diagnosis has to do chiefly with chronic peri- tonitis (not tubercular) anol cirrhosis of the liver. Prognosis: Some cases may be rescued only by operation anol the exposure of the peritoneum to the air. Cures have resulted from puncture and aspiration, and spontaneously. Man\' o'ases terminate favorably under medical treatment. Tubercular peritonitis—treatment: Many cases may be res- 230 DISEASES OF THE ORGANS OF DIGESTION. cued by the use of tuberculin R, climatotherapy, cod-liver oil, and massage. Laparotomy, with the removal of the primary focus in the intestine or female genital organs (Fallo- pian tube), sometimes gives the best results. It may be nec- essary to make repeated laparotomies. Aspiration and the injection of air and other substances into the peritoneal cavity have been unsatisfactory. CHRONIC PERITONITIS. The most frequent form of chronic peritonitis is tubercular peritonitis, which has already been discussed. The etiology of chronic peritonitis, aside from tubercular peritonitis, is obscure. Exposure to cold has been invoked as a cause, as have also the causes of acute peritonitis in the presence of sufficient resistance to prevent an acute attack. Localized chronic peritonitis is most frequently due to sub- acute pelvic inflammations in which the irritation is not suf- ficient to produce an acute peritonitis. Sometimes cases may be caused by repeated paracentesis abdominalis (tapping). Symptomatology and diagnosis: The symptoms resemble those of acute peritonitis, but are, as a rule, less intense. The distinction between tubercular peritonitis and peritoneal neo- plasms is sometimes impossible. Most important is the dis- covery of the cause. The prognosis is usually good. The greatest danger arises from complications, especially strangulation of the bowel and pressure upon important abdominal organs. The treatment is the treatment of peritonitis in general (see Treatment of Acute Peritonitis). Ascites may be relieved by paracentesis. PERITONEAL NEOPLASMS. Carcinoma rarely occurs in the peritoneum primarily. Sec- ondary-involvement of the peritoneum is not uncommon. The treatment is purely surgical Hydatid cysts occur most frequently in the abdominal organs, but may occur in the peritoneum. Diagnosis often ICTERUS. 231 rests upon exploratory incision. Aspiration is dangerous. The treatment is surgical. It is better to remove the cyst without puncture. Other tumors of the peritoneum are sarcoma, lipoma, and fibroma. More rare are myxoma, endothelioma, haemangioma and chylangioma, papillary cystoma, dermoiol and teratoid cysts. The treatment of neoplasms, when active treatment is ole- manded, belongs to surgery. Otherwise the treatment is largely symptomatic. DISEASES OF THE LIVER. ICTERUS (Jaundice). Icterus: Jaundice, is a yellowish color of the tissues and fluids of the body. Etiology: Icterus may be caused by anything that inter- feres with the flow of bile. Such interference with the flow of bile may be causeol by occlusion of the bile-ducts through swelling of the mucous membrane of the ducts, the presence of inspissated mucus, the impaction of a gall-stone, or by the pressure that may be caused by ouincer of the stomach, liver, pancreas, omentum ; or by sarcoma ; or by the cicatrization of an ulcer in the duodenum or bile-ducts, or by abdominal tumors, vertebral caries, aneurism, etc. Symptomatology: The skin and mucous membranes present a change in color varying from a light yelloivisfi tinge to a dark yellow. Itching, pruritus, is usually noticed after jaundice has existed for some time, but may even precede the appear- ance of the change in color. There may also be various cutaneous eruptions. There is interference uith intestinal digestion and absorption. Eat appears in the stools in large amounts. The fceces are pale, from the presence of fat and the absence of bile. The absence of the normal stimulus of the bile upon the intestine results in a lessened peristalsis and consequent constipation. The absence off the antiseptic action of the bile permits abnormal fermentation and putrefaction of the faeces and causes meteorism. 232 DISEASES OF THE ORGANS OF DIGESTION. The secretions and excretions, urine, perspiration, milk, sometimes the sputum, may contain bile-pigments. The presence of bile in the blood, cholaemia, o;auses auto- intoxication. The ^(Y.s-e-rate is lowered (bradycardia), but in long-continued cases of grave icterus the pulse may be normal or quickened (tachycardia). Sometimes the pulse is irregular, The number of red blood-corpuscles is reduced, especially when icterus has existed for some time. The temperature is subnormal, unless elevated by some cause other than the icterus. Long-standing cases may show hemorrhages from the mucous membranes, especially epistaxis, gastrorrhagia, and enterorrhagia. The chief nervous symptoms that may occur are delirium, coma, convulsions, muscular tremors, anol paralysis of the sphincters. Often the patient is in a typhoid condition. Sometimes there is a bitter taste in the mouth, and often the tongue is coated. Diagnosis: In light cases the change of color may be observed in the conjunctivae as a slight yellowish tinge. In marked cases the yellow color of the skin is obtrusive. Bile-pigments may be detected in the urine. For this pur- pose various tests have been proposed. Gmclin's test consists in floating a layer of urine upon nitrosonitric acid, when at the point of contact there will be observed a distinct green color, representing the oxidation of bilirubin into biliverdin. Other colors may be present, but are not indicative of the presence of bile-pigment. Rosen bach has modified this test by filtering the urine anol placing upon the filter-paper thus used a drop of fuming nitric acid, when the color will appear as above. V. Jaksch remarks that the only caution to be observed in this moolification is that the filter-paper must be pure and white. Pure white blotting- paper may be used and is quite satisfactory. The blotting- paper is soaked with the urine and a drop of the acid added. The green color forms a distinct ring. A simple test suggested by Marcchal consists in adding to the urine a few drops of the tincture of iodine. An emerald- green color indicates the presence of bile. The bile-acids may be detected by Pettenkofer's test, best as GALL-STONES. 233 modifieol by Strassburger. A piece of cane-sugar is dissolved in the urine, with which a piece of blotting-paper is then moistened. After drying, this is touched with pure concen- trated sulphuric acid. A positive reaction consists in the development, at the point of contact, of a carmine-violet- purple color. Icterus should be differentiated from Addison's disease, cachexia, and a normal yellow color of the skin. 44ie prognosis is that of the disease causing the icterus. Icterus—treatment: As far as possible, treatment should address the underlying disease, usually catarrh of the bile- ducts, gall-stones, syphilis, malaria, or carcinoma. The diet should consist of articles that will not irritate the liver : milk, soft-boileol eggs, bouillon, meat soups, and thoroughly cookeol fruit. Alcoholic beverages and foods con- taining fat shoulol be withheld. In the way of medicines, the salicylates, salol, phosphate of sodium, benzoate of sodium, benzoic acid, calomel, anol hydro- chloric acid are useful. In some cases hepatic stimulants may be used, especially podophyllin, jalap, and colocynth. Among the mineral waters in common use are Carlsbad, Vichy, Ems, Selters, Hathorn, Saratoga, and for some cases Marienbad, Kissengen, anol Homburg. The salicylates not only act antiseptically, but also increase anol liquefy the flow of bile. Inspissated ox-gall may be given internally as a purgative anol antiseptic, or fresh ox-gall may be used in enemata. Large enemata of hot water (Bouchard) have been recommended in cases of threatened uraemia anol may be of value in chohemia. GALL-STONES (Cholelithiasis; Biliary Lithiasis). The concretions found in the gall-bladder anol biliary pas- sages varv in size, shape, color, anol composition. The chief constituents are cholcstcrin, bile-pigment (bilirubin, associated with biliverdin, bilievanin, and bilifuchsin), and salts of lime and magnesia. The nucleus is sometimes a foreign body (bacillus coli communis ; mercury). The stones are frequently laminated. Usually they are faceted. 234 DISEASES OF THE ORGANS OF DIGESTION. Etiology: About two-thirds of the cases occur in women. Cases are more frequently encountered after forty, rarely under twenty, although gall-stones have been found in the new-born. Conditions which interfere with the flow of bile, sedentary habits, old age, baol hygiene, oliabetes, carcinoma of the stomach and liver, are predisposing causes. Morgagni has observed that gall-stones anol kidney-stones are frequently found in the same individual. Patients with gall-stones are often subjects of obesity, rheumatism, gout, lithaemia, and atheroma. Catarrhal inflammation of the bile-ducts may be a pre- disposing cause, and the cholesterin may be precipitateol on the necrosed epithelium. It is possible that typhoid fever may play a role in etiology, and many times cases have been attrib- uted to the drinking-water. Gall-stones have been observed more frequently in some countries (Hanover, Sweden, Hun- gary) than in others (Holland, Finland). Symptomatology: Calculi in the gall-bladder may produce no symptoms. Post-mortems show gall-stones in about one- tenth of all cases, most frequently in the female sex. The most obtrusive symptom is pain, gall-stone colic. An over- distended gall-bladder may be painful. The attack of gall- stone colic begins with a feeling of discomfort, which gradually increases to absolute, often excruciating, pain, in the right hypochondrium or epigastrium. There is interference ivith di- gestion,, sometimes vomiting. Often the patient complains of pain at the angle or inner margin of the scapula. There are obstipation and tympanites. There is a slight rise of tempera- ture, 99°-99.5° F. Usually there is no icterus. As a rule, gall-stones do not cause colic, except when there is impaction of the stone in the cystic duct. When the gall-bladder is enlarged it may be felt as a tumor. Diagnosis: Gall-stones should be differentiated especially from ulcer of the duodenum and ulceratiom or malignant dis- ease of the pylorus, hepatic carcinoma, and obstructions of the bile-olucts from other causes. Prognosis: The duration of an attack of biliary colic due to gall-stones is usually three to six days. Frequent recurrence is the rule. The advances in surgery have made the outlook GALL-STONES. 235 much more favorable. Surgery may give a mortality not ex- ceeding 5 per cent,, except in cases of jaundice and malignant disease. The prognosis of malignant cases is bad. Prophylaxis: High living, rich diet (brains, yolks of eggs), anol stimulants (ale, porter, wine) should be avoided. The use off tight-fitting waistbands and corsets should be aban- doned. Bicycling and horseback-riding are forms of exercise highly recommended. In the way of medicinal prophylactics, salicylic acid, cholate of sodium, the sulphate anol phosphate of sodium an hour before meals, deserve mention. Gall-stones—treatment: Pure olive oil, a wineglassful at bedtime every night, may do good in some cases. If necessary, the oil may be substituted by glycerin. Sometimes the sali- cylate of sodium may be of value. Sulphuric ether and chloro- form have been used ; they probably act as antispasmodics rather than as solvents of the calculi. Duramie used a mixt- ure composed of three parts of sulphuric ether and two parts of oil of turpentine, a drachm each morning. Graham suggests that gtt, xx three times a day would be better tolerated by the stomach. Large quantities of water, hot water with or without bicarbonate of sodium, 5j-ij : Oj, or mineral water, especially Carlsbad and Vichy, are often beneficial. Sodium sulphate has been recommended, 3j-ij, taken before breakfast in a bitter infusion, with sodium bicarbonate, gr. xx-xxx at bedtime (Harlow). For the indigestion caused by the cutting off of the bile from the intestine, ox-gall, cholate of sodium, acetic acid, anol citric acid have been reox)mmended. Pain may call for the hypodermatic use of morphine, to which belladonna or atropine may be added. Sometimes re- lief is obtained by the loK'al application of heat, or better by the hot bath. Severe pain may demand chloroform or ether. Surcp-ry offers the most hope'for absolute cure. The opera- tion to be selected will depend upon the conditions present in the individual case. Among the operations commonly per- formed for gall-stones are : cholecystostomy, in which the gall- bladder is opened, the stones removed, and the gall-bladder stitched to the abdominal wall; cholecystectomy, complete removal of the gall-bladder; cholecystenterostomy, in which a direct communication is established between the gall-bladder 236 DISEASES OF THE ORGANS OF DIGESTION. and intestine; choledochotomy, choledocholithotomy, in which the common duct is opened for the removal of a gall-stone. Operations less freopiently performed are chofecystendysi.s, re- moval of stones from the gall-bladder by incision, closure of the incision by suture, and return of the gall-bladder to the abdominal cavity; choledocholithotripsy, in which the gall- stone is crushed in the common duct; and puncture of the gall-bladder. , Calculi have been forced from the common I>i 1 e- duct by external pressure, a procedure not devoid of danger, especially of rupture. ACTIVE HYPEREMIA. Hyperaemia of the liver occurs physiologically during diges- tion, and may become excessive after indulgence in food of an irritating nature (alcohol, spices), or which may o-ause intes- tinal fermentation. Persistence in such indiscretions may cause a permanent pathologic hyperaemia of the liver. Hyperaemia of the liver is common in the infections, espe- cially typhoiol fever, malaria, and dysentery. Gout is a fre- quent cause. Some, cases are due to syphilis. Among the toxic causes are alcohol, carbonic oxide, mer- cury, carbolic acid, phosphorus, arsenic, nicotine, etc. Tropical hyperaemia of the liver is probably largely due to infection. Some cases are attributed to nervous causes acting through the vaso-motor nerves. Hyperaemia of the liver—symptomatology : The onset may be gradual, with a feeling of tension in the epigastric region and dyspeptic symptoms. Usually the symptoms begin rather suddenly, with a slight chill and fever followed by pain anol a feeling of tension in the region of the liver, radiating to the right shoulder. Dyspeptic symptoms appear early, sometimes before there is pain, anol become pronounced. There are nausea, vomiting, and diarrluea. Slight icterus appears in two or three days, and may become severe. The feces are coloreol (pleo- chromatic). The urine is reduced in quantity, with high specific gravity, contains bilirubin or urobilin, anol an in- creased amount of urea, 40-50 grammes in the twenty-four hours. Severe cases may show some enlargement of the PASSIVE HYPERMMIA. 237 spleen. More prominent is the enlargement of the liver, palpa- tion of which is usually painful. Diagnosis: The chief diagnostic points are the severity of the symptoms, the elevation of temperature, the general con- dition of the patient, and the course of the disease. Most important is the determination of the cause, and the separation of active hyperaemia from cirrhosis of the liver and ab-eess of the liver. The prognosis is usually good when the cause can be re- moved. Hyperaemia of the liver—treatment: Shoulol first address the cause. The diet must be regulated, alcohol withheld, and gout, malaria, or other infectious disease properly treated. Usually a milk-diet is best. An initial dose of calomel may be fol- loweol by the use of saline purgatives or mineral waters. Carslbad and Vichy are recommended as watering-places for chronic cases. Cold is applieol to the region of the liver, in the form of an ice-bag or cloths wrung out of ice-water. In- testinal antiseptics are used. PASSIVE HYPEREMIA. Passive hyperaemia of the liver is causeol chiefly by obstruc- tion of the general circulation, which may be due to val- vular disease of the heart, myocarditis, pericarditis, arterio- sclerosis, aneurism, marasmus, pleurisy, empyema, asthma, bronchitis, emphysema, or pneumonia. Alcoholism and the infections, especially malaria, may account for these causes producing passive hyperaemia of the liver in some inolividuals and not in others. Some cases are due to obstruction in the hepatic veins. Symptomatology : There is enlargement of the liver, sometimes with persistent pain, which may be increased by palpation. There mav be anorexia, vomiting, eructations, and constipation alternating ivith diarrluea. Obstruction off the hepatic circula- tion mav cause hemorrhoids and hemorrhage from the intestine. Often there are ascites and the formation of the caput J fed usee. The urine is diminished in quantity, high colored, off high specific gravity, and usually contains urobilin and uroerythrin, 238 DISEASES OF THE ORGANS OF DIGESTION. and in marked cases of jaundice pure bile-pigment. Urea may be diminished or increased with a diminution or increase in the volume of urine voided. Uric acid and the chlorides are decreased ; the phosphates are increased. There may be gly- cosuria, sometimes albuminuria. The diagnosis, in the preseno'.e of enlargement off the liver, is easy when an etiological factor, such as a pulmonary or caroliac lesion, is obtrusive. The prognosis depends largely upon the cause, the condition of the patient, anol the severity of the case. Treatment: A failing heart must be stimulated. A milk- diet should be adopted. In the way of medicines, calomel, the saline purga ives, anol mineral waters are most important. Calomel and oliuretin may be used as diuretics. Cases which resist other treatment may be subjected to para- centesis, repeated as often as necessary, from which very good results may be obtained. ABSCESS OF THE LIVER (Suppurative Hepatitis). Etiology: The principal causes are pyaemia, inflammation of the bile-ducts, dysentery, appendicitis, suppurating glands, ulceration from gall-stones, suppurative pylephlebitis, umbili- cal phlebitis (in the new-born), tuberculosis, foreign bodies, and parasites. Tropical abscess in some cases depends upon the presence off the amoeba coli, but in many cases the amoeba may not be found. The pus-producers, especially the staphylococcus pyogenes aureus anol staphylococcus pyogenes albus, are fre- quently present. It is supposed that alcohol, through the production of acute hyperaemia of the liver, is a predisposing cause. Some cases may be due to toxins. The absence of micro-organisms may be due to their destruction by the liver. Abscess of liver—symptomatology : Symptoms may be absent or indefinite, or overshaolowed by sepsis or trauma. The acute form, found especially in hot countries, begins with malaise, chills, and fever, sometimes remittent or inter- mittent, higher in the evening anol at night. The region of the liver becomes painful, especially upon pressure, with a feel- ABSCESS OF THE LIVER 239 ing of tension anol weight. There are dyspwea and cough, described by Galen as the hepatic cough, slight, dry, and harol. The cough is supposed to be olue to an impulse trans- mitted along the phrenic and vagus nerves. There may be icterus and vomiting of bile. The symptoms continue to increase for eight or ten days. Fever persists anol there is profuse perspiration. Death may result, or at this time the abscess forms and there is a slight improvement in the general symptoms, with increase of the local symptoms on the part of the liver. In the subacute form, which is the most frequent in the temperate climate, the symptoms are less severe and the local symptoms of abscess come on more gradually. The chronic form shows the greatest variations in symp- tomatology. Some cases show about the same symptoms as the acute anol subacute forms, but not so severe, anol the formation of the abscess is slower. With the formation of abscess the liver shoivs increase, in size, and a tumor may be visible. When the abscess is super- ficial the thoracic walls may be oedematous. The liver-dul- ness extends farther upward than normal. Often there is pain radiating to the right shoulder. There may be jaundice (frequently absent), sometimes ascites (even more rare than jaundice). There is fever as a rule, which varies in type and elevation. Examination of the urine shows at first an increase of urea, Later there is hypoazoturia (Semmola and Gioffredi). Diagnosis : Sometimes easy; sometimes exceedingly diffi- cult. Malaria, typhoiol fever, and tuberculosis must be ruled out, More difficult often is the differentiation from hyper- aemia of the liver, echinococcus of the liver, and neoplasms. Some cases may be decided only upon puncture or inci- sion. The prognosis depends largely upon the form of the disease, better results being secured when there is a single abscess than when there are metastatic abscesses. The prognosis of met- astatic abscess depends largely upon the primary disease. The prognosis should always be guarded. Spontaneous cure very seldom occurs. 240 DISEASES OF THE ORGANS OF DIGESTION. Treatment is surgical. The medical treatment is symp- tomatic. CIRRHOSIS OF THE LIVER (Chronic Interstitial Hepatitis; Hobnail Liver; Gin-drinkers'Liver; Contracted Liver). Cirrhosis of the liver is characterized by general prolifera- tion of the hepatic connective tissue. Etiology: The most frequent cause is alcohol. Other toxic causes are lead, mussels (Segers), anol spices and highly sea- soned food (Buold), gout and diabetes, rickets and dyspepsia. Among the infections syphilis, tuberculosis, anol malaria are causes. Some cases are probably due to toxins, especially the toxins of typhoid fever, measles, and scarlatina. Senility is a cause of cirrhosis of the liver associated with arterio-sclerosis and endarteritis. Some authorities believe that cirrhosis of the liver may result from retention of bile. Adami found diplococci, sometimes resembling gonococci and sometimes appearing more like short bacilli, in the liver- cells and new connective tissue. Similar organisms were found by Adami in the Pictou cattle disease, an infective cirrhosis of o'attle. As a rule alcoholic cirrhosis is found in middle life. Bar- low found cirrhosis of the liver, post-mortem, in a child eighteen months old who had received alcohol as food in the form of beer and gin. Cirrhosis of liver—symptomatology : The early symptoms are tfiose of a gastro-intestinal catarrfi: eructations of gas, gastric pain, coateol tongue, nausea and vomiting, and diarrhoea alter- nating with constipation. There are hepatic tenderness and pain radiating toward the right shoulder. The patient is pale, emaciated, anol experi- ences early fatigue. At first the fiver may be larger than nor- mal, but with the contraction of the cicatricial tissue the liver becomes reduced in size and the surface uneven (hobnailed). Ascites comes on gradually anol is frequently the symptom that causes the patient to seek medical advice. The ascites may be olue to peritonitis (Hanot). Usually there is enlarge- ment of the spleen, which often is difficult to oletect. CIRRHOSIS OF THE LIVER. 241 The subcutaneous abdominal veins become dilated, especially on the right side, and there is dilatation off the capillaries along the margin of the ribs and around the umbilicus {the caput Mcdmce). The urine may at first be increased in quantity, but soon be- comes scanty, high o:oloreol, and of high specific gravity. The reaction is strongly acid and urates are present in abundance. The amount of urea is olecreased ; urobilin and uric acid are increased. Semmola has observed a constant inverse ratio between the amount of urea anol urobilin eliminated. There are peptonuria, sometimes glyo',osuria anol albuminuria, from passive congestion and cachexia. With great diminution in the quantity of urine there may be symptoms of toxamia. Jaundice more or less markeol appears especially late in the course of the olisease. Hemorrhage is present in the majority of cases. Epistaxis is frequent. Hemorrhage from the gastro-intestinal mucous membrane, usually appearing as haematemesis, may be so great as to be fatal. Fever may be present in acute cases, or may be caused by perihepatitis or catarrh off the bile-ducts. Diagnosis : The history of long-continued indulgence in alcoholic beverages, with the presence of the symptoms of gastro-intestinal catarrh and ascites, would lead to the sus- picion off cirrhosis of the liver. Confirmatory evidence would be furnished by physical examination. The liver is dimin- ished in size, the surface nodulated ; the spleen is increased in size, and there is cachexia. The surface-vessels are enlarged. Cirrhosis off the liver should be differentiated especially from pylephlebitis, pyelothrombosis. thrombosis, hypertro- phic cirrhosis, diffuse chronic peritonitis, hyperaemia, amyloid liver, syphilis, carcinoma of the liver, and the simple atrophy off marasmus. Males are affected more frequently than females. Prognosis is unfavorable as far as ultimate recovery is con- cerned. The usual duration of life is one or two years, although in some cases with judicious treatment life may be prolonged for a number of years. The course may be ab- ruptly terminated by hemorrhage, pleurisy, bronchopneu- monia, or tubercular peritonitis. 16—P. M, 242 DISEASES OF THE ORGANS OF DIGESTION. Cirrhosis of liver—treatment: The cause, if possible, should be removed. Alcohol, spices, highly seasoned food, and coffee must be withheld. The diet should consist of milk, broths, farinaceous foods in moderation, cooked fruits and vegetables, except potatoes. Carlsbad salt is useful for the relief of the gastro-intestinal catarrh. In the treatment of ascites appeal is made to the diuretics. Digitalis may be given in combination with acetate of potas- sium. Hydragogue cathartics, compound jalap powder, gam- boge, and elaterium may be used. Sooner or later tapping (paracentesis abolominis) becomes necessary, and should be repeated as often as required. The withdrawal of the fluid must not be too rapid, or the dis- tended peritoneal vessels may rupture and syncope result from cerebral anaemia. Further medical treatment is purely symptomatic. Hypertrophic cirrhosis of the liver: This variety of cirrhosis of the liver occurs especially between twenty-two and thirty- five, rarely after forty (Graham), most frequently in males. Differing from the ordinary cirrhosis of the liver, hyper- trophic cirrhosis shows an enlargement of the liver, the surface of which remains smooth or is roughened only from a peri- hepatitis ; absence of ascites, except in the later stages, when it is usually causeol by peritonitis; absence of enlargement of the subcutaneous abdominal veins, except late in the course of the disease; a good appetite, only slight emaciation, and a somewhat lessened secretion of urea. The duration of the disease is usually longer than in the ease of ordinary cirrhosis, frequently eight or ten years. The faeces contain bile, in the presence of icterus. Treatment: The diet shoulol be the same as in ordinary cirrhosis. Constipation must be overcome, best with the mild salines. Intestinal decomposition calls for calomel, hydro- naphthol, and salol. Diuretics anol the ingestion of milk increase the action of the kidneys and thus eliminate the poison that accumulates in the body through the disability of the liver. ACUTE ATROPHY OF THE LIVER. 243 Simple atrophy of the liver occurs in age anol marasmus, is not a disease, and is not accompanied by characteristic symp- toms. ACUTE ATROPHY OF THE LIVER (Acute Yellow Atrophy; Icterus Gravis). An atrophy of the liver characterized by destruction of the hepatic cells and severe jaundice. Etiology: The disease is rare. Women are more frequently affecteol than men. The disease occurs frequently during pregnancy. It may occur at any age, from less than a year to over sixty, but is most common between twenty and thirty. Symptomatology: The early symptoms are those of gastro- intestinal catarrh: loss of appetite, nausea, vomiting, constipa- tion, pain anol tenderness over the liver; later, jaundice, in two-thirds of the cases, beginning in the face anol graolually extending over the body. Sometimes there is an initial rigor. There may be general weakno'ss, pains in the muscles, a tremulous tongue, and epistaxis. Later there are cardiac asthma and an irregular pulse with increased tension. Later marked nervous symptoms supervene—restlessness, delirium, coma, irregular breathing, which becomes stertorous, anol death. The liver, which at first may show some increase in size, becomes greatly atrophied^ with diminished dulness from below upward and from left to right, Death may supervene before there is marked atrophy of the liver. Sometimes atrophv of the liver cannot be detected when there is an accompanying hyperplasia of the connective tissue. Hemorrhages occur in more than half the cases, usually in the form of haematemesis. Diagnosis : The early symptoms are those of catarrhal jaun- dice. The characteristic symptoms begin later: severe jaun- dice, hemorrhage, anol nervous symptoms. Leucin and tyrosin are usually to be found in the urine. The objective symptoms, with the decreased hepatic dulness and increased size of the spleen, make the diagnosis clear. The prognosis is unfavorable, although cases of recovery have been reported (Frerichs and Sehnitzler). 244 DISEASES OF THE ORGANS OF DIGESTION. The treatment is symptomatic. Cases off recovery have followed the use of aconite (Teissier) and benzoic acid and musk (Lebert). Weil's disease : A severe relapsing febrile infectious icterus, believed by some to be a olistinct disease. Others consider the disease only a form of febrile icterus. In some cases the typhoid bacillus has been found, which led to the belief that the disease is a " hepato-typhoid," but this view seems to have been disproved by finding the typhoid bacillus in cases which did not show the symptoms of Weil's olisease (Dupr£). In some cases a bacillus has been found, the proteus fluorescens, which Jaeger believes to be the specific infectious agent (see also under Infections). FATTY LIVER. Definition : The liver in the normal condition contains more or less fat. An abnormal deposit of fat in the liver is termed fatty infiltration, except when it is formed at the expense of the albumin of the organ, when it is known as fatty degenera- tion. Fatty infiltration anol fatty degeneration may not al- ways be readily differentiated, and often are associated. Etiology: The amount of fat in the liver may be increased by eating fat anol sugars, anol by sedentary habits. Fat often accumulates in the liver in alcoholism anol in many of the acute infections, very frequently in tuberculosis. Fatty de- generation takes place in acute yellow atrophy, phosphorus- poisoning, anol has been produced experimentally in animals by the injection of the toxins of the bacillus pyocyaneus (Charrin), anol by the injection of variola-poison (Roux and Yersin). There may be a localized fatty degeneration in cases of carcinoma. Fatty liver—symptomatology: Light cases may show no symptoms. Pronounced cases show some enlargement of the liver, which does not present the normal solidity upon palpa- tion. The surface of the liver is smooth and the border rounded. The increaseol weight of the liver may cause displacement downward. There is little or no bulging of the thorax. AMYLOID LIVER. 245 Marked cases may show anorexia, vomiting, diarrhoea, and hemorrhoids. The diagnosis of fatty liver is rendered probable by the presence off a uniform enlargement of the liver, with a smooth surface anol rounded border, and with lessened resistance to pressure; and the absence of ascites, enlargement of the spleen, and jaundice. The history and physical examination may dis- close the etiological factor. Fatty liver should be differentiated especially from amyloid liver and leukaemia. Fatty liver frequently exists in com- bination with cirrhosis of the liver. The liver is then more solid upon percussion and the surface roughened, and there are ascites and enlargement of the spleen. The prognosis depends largely upon the cause, and is greatly influenced by complications, especially fatty heart and fatty kidnev. Except in the cases due to poisons or infections (acute yellow atrophy), life may not be cut short. Fatty liver—treatment calls for removal of the cause, where this is possible. The treatment is largely symptomatic. Murchison recommends the internal use of large quantities of common salt. AMYLOID LIVER. Amyloid liver is usually associated with a similar involve- ment of the spleen, kidneys, and intestines. Amyloid matter is believed to be an albuminoid substance, which upon disin- tegration yields leucin anol tyrosin. Etiology: Amyloid liver has been observed at various ages, from two to seventy years, usually between twenty and thirty, more frequently in men than in women. The process is usually secondary to some chronic suppurative disease, espe- cially tuberculosis and syphilis, and may follow malaria, leuco- cythaemia, pseudo-leukaemia, rickets, or gout. Amyloid liver—symptomatology: As a rule the liver is en- larged and firm upon pressure, and the surface is smooth. The bile is diminished in quantity and poor in quality, with consequent intestinal disturbance and tympanites. There are always some anaemia and leucocytosis. There may be numerous symptoms 246 DISEASES OF THE ORGANS OF DIGESTION. from affection of the spleen, kidneys, and intestines, and from the primary disease. Diagnosis: Suspicion may be aroused by amyloid disease in other organs, especially the spleen, kidneys, or intestine. Characteristic of amyloid liver is the great enlargement of the liver, with firmness on pressure, rounded border, freedom from pain or tenderness upon pressure, except when pain is caused by perihepatitis or syphilis; and the presence of a chronic suppurative olisease, tuberculosis, or syphilis. The prognosis is unfavorable as a rule, but better where the liver alone is involved. Treatment shoulol adolress the cause, and is otherwise symp- tomatic. NEOPLASMS OF THE LIVER. Carcinoma of the liver: According to Eichhorst, carcinoma occurs, in the order of decreasing frequency, in the uterus, stomach, breast, and liver. Occurrence : Carcinoma of the liver occurs most frequently at from forty to sixty years of age. The disease has been found in early life, even in the new-born child (Siebold). Carcinoma of the liver occurs more frequently in women, secondary to involvement of the uterus, ovaries, or breast. The disease is less frequent in hot than in cold countries. Usually carcinoma of the liver is secondary to carcinoma of the uterus or gastro-intestinal tract, especially the pylorus, caecum, sigmoid flexure, or rectum; sometimes of the spine or right innominate bone. Carcinoma of the liver often follows traumatism from external violence or the irritation of biliary calculi. The symptoms of carcinoma of the liver may be slight anol indefinite, sometimes overshadowed by other disease. The onset is often insidious. Emaciation is marked, sometimes intense. Often there is cachexia. As a rule, the liver is en- larged, especially in young persons. The enlargement is sometimes sufficient to cause bulging of the thorax. The liver may feel harder tfurn normal. Sometimes nodules may be detected by palpation. Often there is pain radiating DISEASES OF THE PANCREAS. 247 toward the right shoulder, through the connection between the phrenic and the fourth and fifth cervical nerves; and in the lumbar region. Among the early symptoms are anorexia, nausea, vomiting, anol sometimes constipation. Diarrhoea may be present later. There may be jaundice, tympanites, anol ascites. Diagnosis: Differentiation between primary and secondary carcinoma of the liver may be difficult or impossible. The course of primary carcinoma of the liver is usually rapid and the enlargement of the liver more pronounced. The differential diagnosis concerns hydatid cyst, sarcoma, abscess, anol amyloid liver ; syphilis of the liver ; carcinoma of the pylorus, pancreas, mesentery, colon or kidney ; and downward displacement of the liver. The prognosis is unfavorable. Treatment is palliative. Adenoma of the liver resembles carcinoma in symptoma- tology, but the duration of life is longer. The prognosis is unfavorable. Surgery offers the only hope of cure. Sarcoma of the liver occurs rarely as a primary disease, more frequently secondary to sarcoma elsewhere, especially in the region of the portal vein. As in sarcoma in other parts of the body, young persons are most frequently affected. The symp- toms are similar to those of carcinoma of the liver. Angiomata of the liver are small. In children they may attain some size. Usually they do not cause serious disturb- ance, anol surgical treatment is unnecessary. Troublesome cases may demand resection of the liver. Fibromata, lipomata, gliomata, and cysts occur occasionally in the liver. DISEASES OF THE PANCREAS. Hemorrhage into the pancreas may occur in acute pancrea- titis or necrotic inflammation of the pancreas. Extensive hemorrhage may destroy the pancreas anol invade the retro- peritoneal tissue ; or through a break in the peritoneal cover- 248 DISEASES OF THE ORGANS OF DIGESTION. ing of the pancreas the hemorrhage may find its way into the lesser peritoneum. The symptoms come on in the midst of apparent health, with severe pain in the upper part of the abdomen, with nausea anol obstinate vomiting. Soon the patient becomes anxious, restless, and olepressed. There are epigastric tenderness and sometimes marked tympanites. The temperature may be normal or subnormal. There may be constipation. These symptoms continue and the patient soon falls into collapse. Treatment: Death is probably due to shock through the solar plexus (Zenker), and not to the loss of blood ; and there- fore it has been suggesteol that probably the best treatment would be to expose the pancreas and thereby relieve the pressure. Pancreatic cysts are often due to traumatism or inflamma- tion ; but both these factors may be absent. Cyst of the pan- creas has been observed in an infant six months old (Kailton); but the great majority of cases occur between thirty and forty years of age. The symptoms come on gradually, sometimes suddenly, as after traumatism, with attacks of colicky pain, nausea, and vomiting, and often with progressive enlargement of the ab- domen. There may be glycosuria. Jaundice anol dyspnoea may be caused by pressure. So-called pancreatic salivation, an increased secretion of saliva, is rare. Emaciation is some- times marked. Transitory disappearance of the cyst has been reported. Diagnosis: As a rule the cyst lies below the stomach and above the colon, and is affected little or not at all by respira- tion. The cystic fluid is alkaline in reaction ; specific gravity, 1010-1020. Most important is the presence of ferments. The digestion of both fibrin and albumin is characteristic of the pancreatic secretion. Treatment, is surgical. Korte reports 101 cases in which the cyst was openeol anol drained, with a direct loss of only 4 cases. In 14 extirpations there were 12 recoveries. Tumors of the pancreas: Carcinoma is the most frequent new growth. Much more rare are sarcotma, adenoma, and DISEASES OF THE PANCREAS. 249 lymphoma. The most important .sipnptoms are epigastric pain, often paroxysmal in character; icterus, olue to pressure; the presence of a tumor in the epigastrium, which may be difficult to detect; emaciation and cachexia, nausea and vom- iting. Fatty diarrhoea and glycosuria are not common. Treatment is surgical. Six recoveries in ten operations have been noted by Korte. Pancreatic calculi, pancreatic lithiasis, is rare. The stones are white and usually numerous, as a rule composted of car- bonate of lime, sometimes with phosphate of lime. Severe colic, glycosuria, and fatty diarrhoea were observed by Licht- heim in a case in which the oliagnosis was confirmed by autopsy. CHAPTER III. DISEASES OF THE ORGANS OF RESPIRATION. DISEASES OF THE NOSE. Diseases of the exterior of the nose belong rather to the domain of dermatology or surgery. Those most o'ommonly met are boils (furuncles); warts (verruca); acne; hyper- trophy, which is sometimes wrongly termed lipoma, but resem- bles elephantiasis elsewhere; sebaceous tumors; naevus; rodent ulcer; lupus; rhinoscleroma; epithelioma; and in- juries. Of more interest to us are the diseases of the interior of the nose. ACUTE CATARRH OF THE NOSE. Acute rhinitis: An acute inflammation of the nasal mucous membrane, sometimes due to mechanical or chemical irrita- tion, is usually caused by the action of bacteria or toxins. Iodine internally may cause iodism, manifested by coryza and the usual symptoms of a "cold." Attacks of acute nasal catarrh are frequently precipitated by changes of temperature, especially by the exposure of a portion of the body to cold and moisture. Bad ventilation is one of the most prominent causes. Chronic inflammation of the nasal mucous membrane may predispose to acute attacks of nasal catarrh. The symptoms of acute nasal catarrh, coryza, commonly known as a " cold," are too well known to need description. Asiole from the local symptoms, there are general symptoms, usually ascribed to toxaemia. The diagnosis of acute rhinitis is easy; but sometimes we may not readily locate the cause. The attack comes on 250 ACUTE CATARRH OF THE NOSK 251 Fig. 29. Vertical section of head, slightly diagrammatic. 1, superior turbinated bone; 2, middle turbinated bone : 3. lower turbinated bone; 4, floor of nasal cavity ; 5, vestibule- 6 section of hyoid bone; 7, ventricular band: 8, vocal cord; 9, section of thyroid cartilage ; 10, •23, and 24, section of cricoid cartilage ; 11, sec- tion of first tracheal ring;" 12, frontal sinus : 13, sphenoidal cells : 14, pharyngeal opening of Eustachian tube; 15, Rosenmuller s groove; 16, velum palati; 17, tonsil -18 epiglottis : 19, adipose tissue behind tongue ; 20, arytenoid cartilage; 21, tub'ercie of epiglottis; 22, section of arytenoid muscle (Seiler). 252 DISEASES OF THE ORGANS OF RESPIRATION. with malaise and chilliness; later there are some fever, loss of appetite, and pains in the joints. The swollen mucous membrane causes occlusion of the nasal passages. There may be frontal headache anol affection of the owes in severe cases. Soon there appears an acid discharge from the nose, usually with sneezing, sometimes with excoriation of the lip. With the beginning of the olischarge the occlusion of the nose becomes less. Later the olischarge changes to muco-purulent. The duration of the attack is about a week. The prognosis is almost always good, but depenols upon the cause. Prophylaxis: As a rule "colds" are contagious. Feeble individuals should not be exposed to the danger of infection. Many cases would be prevented by attention to hygiene, especially personal cleanliness and proper ventilation. Coryza due to the administration of iodine (iodism) may be relieved by the discontinuance of the drug, or, where this is undesirable, by the administration of morphine. Acute rhinitis—treatment: If possible, the cause should be discovered and removed. Defective hygiene must be cor- rected. The body should be kept clean. The number of remedies is legion ; space forbids even their enumeration. The nasal mucous membrane may be cleansed with an alkaline or astringent douche or spray, or with a cotton-wrapped sound. Increased nasal secretion may call for atropine. The toxic symptoms may be relieved by one of the coal-tar products, or opium in some form, best as Dover's powder. Often very great relief is afforded by the hot bath. CHRONIC CATARRH OF THE NOSE. Chronic rhinitis: Chronic nasal catarrh may be caused by an acute catarrh of the nose becoming subacute anol later chronic. Thus the causes of acute catarrh of the nose, when long continued, may produce a chronic catarrh of the nose. Common causes are bad ventilation, dust, tobacco, and snuff. The symptoms are less intense than in acute catarrh of the nose, and o>f longer duration. As in acute catarrh, the mucous membrane is swollen. NON-MALIGNANT NEW GROWTHS IN THE NOSE. 253 Diagnosis calls for differentiation from acute catarrh, poly- pus, and syphilis. Inspection reveals the mucous membrane swollen, especially over the turbinated bones, and covered mo e or less by secretion. There may be ulcers or erosions of the mucous membrane. Prognosis: Sometimes chronic catarrh is quite obstinate to treatment, but persistence is usually rewarded by a cure. Prophylaxis demands gooxl hygienic surroundings anol the avoidance of dust and the use of tobacco and snuff, things which play a prominent part in the causation of rhinitis. Chronic rhinitis—treatment: The mucous membrane should be carefully cleansed. At first it is usually best to use an alkaline wash, anol later an astringent solution. Bad cases may require a change of climate. Syphilitic rhinitis: Sypfiilitic catarrfi of the nose is charac- terized by lesions involving the deeper structures as well as the mucous membrane. Frequently there are evidences of syphilis elsewhere. Doubtful cases justify the therapeutic test, NON-MALIGNANT NEW GROWTHS IN THE NOSE. Polypi (myxomata) are the form of tumor occurring most frequently iii the nose. The appearance of these growths Fig. 30. Adenoid hypertrophy at vault of pharynx (Lefferts). has been likened to the pulp of a grape. At first they may cause sneezing and a thin, watery discharge. They cause more 254 DISEASES OF THE ORGANS OF RESPIRATION. or less occlusion of the nose and diminish or destroy the sense of smell. Numerous and diverse reflex disturbances are attributed to them. The voice is deadened. Frequently there are bronchitis and laryngitis. The diagnosis is made by inspection, best after the applica- tion of cocaine. The treatment is surgical. Other non-malignant tumors which may be found in the nose are fibromata, papillomata, angiomata, chondromata, osteo- mata, rarely cystomata. It is doubtful whether pure adeno- mata occur in the nose. Adenoids of the naso-pharynx (Pig. 30) may be mentioned. The treatment of all these tumors belongs to surgery. DISEASES OF THE LARYNX. ACUTE CATARRHAL LARYNGITIS. Acute inflammation of the laryngeal mucous membrane is usually due to infection, which is favored by some disturbance in the nose, obstruction, chronic inflammation ; or pharynx, acute or chron'c pharyngitis. Frequently mouth-breathing plays an important role in etiology. Other causes are the inhalation of impure air, dust, irritating fumes or vapors, excessive use of the voice, anol certain exanthemata, especially measles and scarlet fever. Symptoms: The voice becomes hoarse, there is dysphonia, sometimes aphonia. Cough may be present. General symp- toms are absent or mild, unless there is at the same time in- volvement of other parts of the respiratory tract, Diagnosis: Hoarseness, dysphonia, or aphonia should lead to a laryngoscopic examination, to find the cause of these symptom-. Such an examination would reveal a symmetrical inflammation of the mucous membrane of the larynx, bright red in color and swollen, the vocal cords pink ; and would exclude other affections of the larynx, especially syphilis, tuberculosis, paralysis, and tumors. Prognosis : As a rule, the disease lasts about a week ; from five to eight days (Bosworth). Prophylaxis calls for pure air, the proper treatment of dis- CHRONIC CATARRHAL LARYNGITIS. 255 eases of the nose anol pharynx, anol the avoidance of mouth- breathing. Singers anol public speakers should avoid over- taxing the voice. Acute laryngitis—treatment: Rest of the voice should be enjoined. Any nasal or pharyngeal disease shoulol receive proper attention. It is better to confine the patient to a room that is comfortably warm, the air of which is kept moist with steam. The larynx may be cleanseol with an alkaline solution and then treated with an astringent solution, such as a 1 per cent, solution of the liquor ferri persulphatis, or a 0.5 per cent, solution of nitrate of silver. These solutions are intro- duced upon a cotton-wrapped sound or in the form of a spray. Relief may be secureol by the use of the steam atomizer. The application of cold to the neck, in the form of cold compresses, the ice-bag, or Leiter's coil, may be of value. The bowels should be kept open. CHRONIC CATARRHAL LARYNGITIS. Chronic catarrhal laryngitis may be due to a continuance of the causes of acute catarrhal laryngitis. Many cases depend upon deflection of the nasal septum or hypertrophic rhinitis. The diso>ase is frequently found in individuals who use the voice excessively, anol among those who indulge in alcoholic beverages. Symptoms : The voice becomes husky anol hoarse, especially upon exercise, singing, or speaking. There are numerous attempts at clearing the throat. As in acute catarrhal laryn- gitis, there mav be cough. The absence of cough would indi- cate that the disease has not extended below the larynx. Rarely there is aphonia, which is usually temporary. Diagnosis : The altered character of the voice, huskiness and hoarseness, should lead to a laryngoscopic examination, which would reveal a chronic inflammation of the larynx. The mucous membrane of the larynx is red and swollen, the blood- vessels injected. The vocal cord-, instead of being glistening white, will appear grayish or pinkish, and will not approxi- mate as well as in health. The differential diagnosis is not always easy. Many cases 256 DISEASES OF THE ORGANS OF RESPIRATION. are due to tuberculosis and syphilis, and will be considered in connection with those diseases of which they form a part. Prognosis: Spontaneous recovery does not occur, as in acute catarrhal laryngitis. Under treatment, which should include attention to any ao'companying disease in the nose or pharynx, the affection may disappear anol the voice return to its normal strength and clearness. Prophylaxis is the same as for acute catarrhal laryngitis. Chronic laryngitis—treatment: Diseases or malformations on the part of the pharynx or tonsils, which may have a causative relation to the laryngitis, shoulol be removed. After clo'ansing the larynx with an alkaline wash, upon a cotton- wrapped sounol or in the form of a spray, a 4 per cent, solu- tion of ichthvol, a 1 per cent, or 2 per cent, solution of nitrate of silver, or some other astringent may be used. The value of resting the voice should not be overlooked. Erosions on- chronic thickening of the mucous membrane may call for the local application of Lugol's solution anol glycerin, 1 : 3, after the use of cocaine, 4 per cent., or a mixture of equal parts of cocaine, 4 per cent., and antipyrin, 10 per cent,, which gives a more lasting anaesthesia. Tho'se applications may be repeateol twice a Meek for a month or so. Obstinate cases may require curetting and the application of lactic aciol under cocaine anaesthesia. GZDEMA OF THE LARYNX. Etiology : The most frequent causes of oedema of the larynx are those which may cause dropsy elsewhere. Most important is disease of the kidney. Sometimes oedema of the larynx is caused by iodism, aneurism, or by a tumor pressing on the cervical veins. Symptoms : The onset is usually sudden. The most striking symptom is inspiratory dyspnoea, which may become extreme in a few hours. Deglutition may be painful and difficult. Diagnosis: The symptoms point to stenosis of the larynx. Upon laryngoscopy examination the laryngeal mucous mem- brane is found to be ceolematous. The prognosis depends upon the cause. In the absence of LARYNGEAL PERICHONDRITIS. 257 treatment a case may terminate fatally in a few hours, from suffocation. Treatment: CEdema of the larynx clue to kidney-disease or cirrhosis of the liver may be relieved by free catharsis, which may be secured quickly by the administration of croton oil, gtt. j, or elaterium, gr. ss ; and by free diaphoresis, which may be readily causeol by the hypodermatic use of pilo- carpine, gr. -|, best given with alcohol internally to avoid de- pression. A weak heart may need stimulation, best with the fluid extract of oligitalis or tincture of strophanthus subcutane- ously. The patient shoulol be kept in a warm room, the air of which is kept moist with steam. Tumefaction of the larynx may be relieved by scarification, which should be repeateol if necessary. Severe cases may de- mand intubation or tracheotomy. LARYNGEAL PERICHONDRITIS. Laryngeal perichondritis is frequently found in connection with carcinoma, tuberculosis, syphilis, typhoid fever, diph- theria, pneumonia, erysipelas, anol traumatism. Most cases are ascribed to exposure to colol or abuse of the voice. Symptoms: After more or less malaise and chilly sensa- tions, the attack comes on with headache, anorexia, sometimes with pain in the bones, anol fever, 100°-101° F. Respira- tion, the use of the voice, and deglutition may be interfered with. Laryngoscopic examination reve>als affection of the laryngeal cartilage. Diagnosis: There are dyspnoea anol the symptoms of acute inflammation. Laryngoscopic examination shows not only an acute inflammation of the larynx, but also an irregular swelling, usually upon one side. The cases due to tuberculo- sis run a chronic course ; those due to syphilis are marked by pain and respond to the therapeutic test, Laryngeal perichondritis should be differentiated especially from croup and acute submucous laryngitis. Croup shows an exudate. In submucous laryngitis the swelling is generally symmetrical and involves both sides. 17_p. M. 258 DISEASES OF THE ORGANS OF RESPIRATION. Prognosis: The chief danger is through stenosis of the larynx, which may demand intubation. Cases due to tuber- culosis or carcinoma have a baol prognosis. In all cases the course of the disease is long and tedious. Laryngeal perichondritis—treatment: Cold may be applied to the neck and ice given internally. Sometimes relief is secured by scarification of the endolaryngeal tissues. Bain is relieved bv the application of cocaine or the adminis- tration of morphine. The bowels should be kept open. Cases due to syphilis call for the use of the iodides. Bos- worth advises the use of iodide of potassium during the acute stage, even in the absence of a history of syphilis. Dyspnoea may call for intubation or tracheotomy, or better laryngotomy. Sequestra should be removed, adhesions liberated, and strict- ures dilated. SYPHILIS OF THE LARYNX. Primary syphilitic lesion of the larynx occurs so rarely as to be considered a medical curiosity. The secondary lesions of syphilis may appear in the larynx as an erythema or a mucous patch, in four months to two years, usually within a year after the primary lesion. More frequent in the larynx are the tertiary manifestations of syphilis: gummata, deep ulcerations, and cicatricial stenoses. Prognosis: Under treatment the olisease may be arrested ; but destruction of tissue will be followed by cicatrization, which may lead to stenosis of the larynx. The medical treatment is that of syphilis in general. Steno- sis may demand dilatation, intubation, or tracheotomy. TUBERCULOSIS OF THE LARYNX. Laryngeal tuberculosis is usually secondary to pulmonary tuberculosis; but tuberculosis may be primary in the larynx. Here, as elsewhere, tuberculosis is due to infection by the tubercle bacillus. Symptomatology: The voice becomes altered, weak, some- times aphonic. The use of the voice requires great effort. CARCINOMA OF THE LARYNX. 259 There may be an involuntary change from a low tone to a falsetto noto, which may be maintained for a short time (Moure). The emaciation caused by the pulmonary tubercu- losis, which usually precedes the affection of the larynx, is increased, and the expression of the patient becomes anxious. With extension of the disease, deglutition becomes difficult anol painful. Destruction of the epiglottis may permit food to enter the larynx. Diagnosis : A reaction to tuberculin or the presence of the tubercle bacillus in the sputum would be of little value in diagnosis, since in most cases there is tuberculosis of the lungs before involvement of the larynx. Cases of pulmonary tuberculosis may show alterations of the voice, due to non- tubercular affection of the larynx. Of most value in diag- nosis is the laryngoscopic examination. Tuberculosis of the larynx should be differentiated espe- cially from syphilis anol carcinoma. The prognosis is grave. Eleven recoveries in fifteen cases have been reported by Heryng. The cases usually succumb to pulmonary tuberculosis. With improvement in the treat- ment of tuberculosis of the lung we may hope to save more cases of laryngeal tuberculosis. Treatment: Probably of most value is the application of lactic aciol or nitrate of silver. Orthoform may be used locally for the relief of pain. Climatotherapy and the use of tuberculin are important. Further than this the treatment is largely symptomatic (sec Treatment of Tuberculosis). Opera- tion may be justifiable, especially in the absence of pulmonary tuberculosis. Pain should be relieved by morphine and cocaine. CARCINOMA OF THE LARYNX. Carcinoma rarely affects the larynx. Men are affected more often than women. The disease occurs most frequently after Symptomatology: The voice shows early impairment. rl here is dyspnoea. Cough is caused by the mucous or sero mucous discharge. The breath is offensive (the odor has been de- scribed as musty), and there is more or less hemorrhage. As 260 DISEASES OF THE ORGANS OF RESPIRATION. a rule there are pain, sometimes difficult oleglutition. Cachexia comes on late or may be absent. Early diagnosis is difficult or impossible. Later the symp- toms, the peculiar laryngoscopic appearance, and the pro- gressive course of the disease may render the diagnosis more or less absolute. In doubtful cases a positive diagnosis may be made by a microscopic examination of a portion of the growth. Prognosis : The disease is almost absolutely fatal. Cases of apparent cure by operation have been reported (Billroth, Butlin). Bosworth gives the fatality of operation at over 90 per cent. Treatment: Early and complete removal of the growth is important. It must be remembered that the process extends beyond the apparent infiltration of the lymphatics. A great obstacle to operation is offered by the difficulty experienced in making an early diagnosis. Otherwise the treatment is symptomatic. SARCOMA OF THE LARNYX. Sarcoma occurs in the larynx very rarely. The majority of the reported cases have occurred in men. The ao-es of the patients have ranged from nineteen to seventy-four years, most of the cases occurring between forty and sixty. Symptomatology: The voice becomes hoarse, sometimes aphonic. There are dyspnoea, cough, sometimes dysphagia. There may be slight hemorrhage and some pain. Late in die course of the disease there may be some cachexia. Diagnosis : Suspicion of malignancy may be aroused by the symptoms anol laryngoscopic examination. A positive diag- nosis may be made by microscopic examination. A point in the differential diagnosis from o;arcinoma is the involvement of the cervical glands late in carcinoma, which is usually absent in sarcoma. The prognosis is grave. Very few recoveries have been reported. Treatment: The only hope of cure lies in operation. All other treatment is palliative. BENIGN TUMORS OF THE LARYNX. 261 BENIGN TUMORS OF THE LARYNX. Benign tumors are found in the larynx much more fre- quently than malignant growths. Bosworth gives the order of frequency as follows : papillomata, fibromata, cystomata, myxomata, adenomata, lipomata, angiomata, enchondromata, and mixed tumors. It is doubtful whether pure adenomata occur in the larynx. The chief symptoms are interference with phonation and respiration. The diagnosis is made with the laryngoscope. Differential diagnosis may call for the use of the microscope. The prognosis is usually good. These tumors rarely offer serious interference to respiration. Treatment, where necessary, is surgical. Neuroses of the larnyx: The chief neuroses of the larynx are : paralysis, spasm of the glottis (laryngismus stridulus), muscular incoordination, neuralgia, hyperesthesia, paraes- thesia, anaesthesia, and hysterical aphonia. DISEASES OF THE TRACHEA AND BRONCHI. The trachea and bronchi are rarely affected primarily. Diseases of the trachea and bronchi usually come from above, the larynx ; or from below, the bronchial tubes; anol in most instances the disease of the trachea or bronchi is overshad- owed by the primary affection. Malignant disease of the trachea and bronchi is usually secondary. Summary: The mucous membrane of the trachea may be inflamed to constitute an (wide or chronic catarrhal tractieitis. Diphtheria has been reported to occur primarily in the trachea ; but in the great majority of cases it is secondary to invasion of the larynx. The trachea or bronchi may show ulceration, acute or chronic, and stenosis. Tumors of various kinds may occur in the trachoma or bronchi ; or these organs may suffer comp>rcssion, due usually to diseases in the thyroid gland, the mediastinal glands, the vertebrae (tuberculosis), (esophagus, aorta (rarely due to large pericardial effusion). 262 DISEASES OF THE ORGANS OF RESPIRATION. The diagnosis of diseases of the trachea and bronchi may be difficult, In such cases the use of the laryngoscope may give valuable information, but the examination is much more diffi- cult than inspection of the larynx. BRONCHITIS. Etiology : Bronchitis is due to infection in the vast majority of cases, either directly through the invasion of the bronchial mucous membrane by micro-organisms ; or indirectly, through the elimination of toxins, as may be observed especially in typhoid fever and cerebro-spinal meningitis. Bronchitis may also be caused by the elimination of poisons other than the toxins referred to, especially iodine and alcohol. Many of the exanthemata, particularly measles anol smallpox, show bronchitis. Direct invasion of the bronchial mucous mem- brane usually is an extension of an inflammation from the upper respiratory passages, the mouth or nose, or may be caused by trauma. ACUTE BRONCHITIS. Definition: An acute inflammation of the bronchial mucous membrane. Etiology: Most cases are attributed to " catching cold." "Catching cold" usually occurs in badly ventilated apart- ments, rather than in the open air. Sometimes the disease is due to mechanical or chemical causes, dust, or irritating fumes. An acute bronchitis is often found in connection with the in- fections, especially measles and the respiratory form of influ- enza. The most prominent predisposing causes are tubercu- losis, syphilis, rheumatism, gout, diabetes, Bright's disease, cancer, and heart-disease. An acute bronchitis appears in some individuals following the use of even small quantities of iodide of potassium. Acute bronchitis occurs most frequently in the colder months, and especially at the extremes of life. The disease is very common among the users of alcoholic beverages, probably due to elimination through the bronchial mucous membrane. Acute bronchitis is often caused by too little exercise in the open air. ACUTE BRONCHITIS. 263 Acute bronchitis—symptomatology: Usually there are 'the general symptoms of an infection— chilly sensations, fever, in- creased pulse-rate, malaise, anorexia, headache, often a coated tongue, more or less constipation, and in severe cases there may be pain in the limbs. The last-mentioned symptom would seem to indicate a toxiemia. The early local symptoms are dryness and constriction in the region of the larger bronchial tubes, the bronchi and trachea, frequently with hoarseness and a dry cough, from involvement of the larynx and trachea. There may be dyspnoea. In a few days the exudation from the bronchial mucous membrane becomes more profuse. There is expectoration. Light cases may last but a week or two. In more severe cases there may be sleeplessness and prostra- tion. In the aged the temperature may be subnormal. As a rule the dyspnoea becomes greater the further the inflamma- tion extends toward the air-cells, amounting sometimes to orthopnoea. Children may have convulsions. The chief complications are inflammation of the upper air- passages, laryngitis and tracheitis, and atelectasis and broncho- pneumonia. Diagnosis and physical signs: Percussion maybe negative, or mav reveal dulness in the presence of atelectasis. Expira- tion is prolonged. Snbcrepitant rales may be found when the inflammation involves the smaller ramifications of the bron- chial tubes. These may be heard on both sides, especially at the base of the lungs. Differential diagnosis calls especially for the recognition of pneumonia or broncho-pneumonia. Of most importance as a rule is the recognition of the cause of the bronchitis, especially tuberculosis, syphilis, rheu- matism, gout, diabetes, Bright's disease, measles, and whoop- ing-cough. Prognosis: The mortality increases as we approach the ex- tremes of life, and also as the inflammation advances along the finer bronchial tubes toward the air-cells. More deaths occur in winter than in summer. Mild cases usually recover in a week or two A fatal result does not often occur among robust adults and children. The prognosis assumes gravity 264 DISEASES OF THE ORGANS OF RESPIRATION. with the cause, the condition of the patient, and the severity of the attack. Acute bronchitis—treatment: The patient should occupy a warm, well-ventilated room, exposed to the sun. The air of the room may be kept moist with steam, or the patient may obtain relief by the use of a .steam atomizer, or by inhaling steam from a kettle or pitcher. The compound tincture of benzoin may be added to the water. Catharsis should be secured by a mercurial or saline laxative. Diaplioresis is some- times of value. There are a large number of expectorants. As a rule the best are apomorphine, ipecac, and squills. Cough and insomnia may be relieved by the use of codeine, morphine, or opium, best in the form of Dover's powder, which may be given in a syrup. Hot applications may be made to the chest, or turpentine or a weak mustard plaster may be used. Rub- bing the chest with a liniment may secure some relief, at least of the mind of the patient. An emetic'is sometimes useful in the case of infants who may not be able to expectorate. The aged may require alcohol, senega, anol carbonate or chloride of ammonium. Inhalations of oxygen are recommended, espe- cially at the extremes of life. During convalescence, tonics, fresh air, and exercise are of value. Where the bronchitis is secondary to syphilis, rheumatism, or diseases of the lungs, heart, kidneys, etc., the treatment must address the primary disease. Capillary bronchitis: The term has been applied to an acute bronchitis affecting the finer bronchial tubes. Such a division of bronchitis is an over-refinement, It is difficult to imagine a case in which such an inflammation would not extend to the air-cells to constitute a broncho-pneumonia. CHRONIC BRONCHITIS. Definition : A chronic inflammation of the bronchial mucous membrane. Etiology: Chronic bronchitis may result from an acute bronchitis, especially when the attacks of acute inflammation are frequently repeateol. Chronic bronchitis is also found in CHRONIC BRONCHITIS. 265 tuberculosis, emphysema, asthma, disease of the heart, espe- cially stenosis or insufficiency of the mitral valve; rheumatism, gout, diabetes, alcoholism, or where almost any of the causes of acute bronchitis, such as the inhalation of dust, are long continued. To some of the causes of acute bronchitis toler- ance may be established before the production of chronic bronchitis. Chronic bronchitis is usually found in middle or advanced life. Chronic bronchitis—symptomatology: The onset is gradual. The symptoms improve in summer, to become aggravated in winter. As in acute bronchitis, there may be dyspnoea anol discomfort under the sternum. There is more or less cough, which in bad cases may become violent. The cough may cause insomnia. Sputum may be almost absent, or present in varying amounts, sometimes constituting a bronchorrhoea. There may be fetor, usually due to sputum retained in dilated bronchi. Sometimes the bronchi are not dilated. The physical signs resemble those of acute bronchitis. The duration of the disease is indefinite, but longer than in acute bronchitis. The principal complications are atelectasis, broncho-pneu- monia, emphysema, bronchiectasis, and dilatation of the heart, usually of the right side of the heart. Diagnosis: The history anol symptoms render valuable aid. Chronic bronchitis should be differentiated, especially from pneumonia and tuberculosis. Chronic bronchitis differs from pneumonia in being a bilateral affection without evidence of consolidation anol with little or no fever. Tuberculosis usually shows a more marked decrease of weight and greater weak- ness, and, as a rule, the tubercle bacillus may be found in the sputum. In doubtful cases the differential oliagnosis may call for a test-injection of tuberculin. Prognosis: Much depends upon the cause of the bronchitis, the severity of the disease, and the strength of the patient. Chronic bronchitis is most dangerous in the feeble and aged. The prognosis should be guarded in the presence of emphy- sema, bronchiectasis, or dilatation of the heart. Chronic bronchitis—treatment: The general or curative treat- ment of bronchitis must address the underlying cause, what- 266 DISEASES OF THE ORGANS OF RESPIRATION. ever that may be. All other treatment is palliative or symptomatic. Bronchitis due to cardiac insufficiency may be relieved by purgation, diaphoresis, anol the use of stimulants, digitalis, strophanthus, alcohol, anol nitroglycerin. Bronchitis due to pressure from an aneurism or tumor may be relieved by opium. Iodide of potassium may be of value. Rheumatism or gout should be properly treated with the salicylates, Carlsbad salts, colchicum, etc. (see Rheumatism and (lout). Where bronchitis is due to the inhalation of dust, irritating vapors or fumes, a change of occupation may be necessary. Tuberculosis, pleurisy, disease of the liver, or any other disease upon which the bronchitis may depend should receive proper attention. For the dry catarrh, the "catarrhe sec" of Laennec, opium, best in the form of codeine, morphine, paregoric, or Dover's powder, often affords great relief, but should not be used when there is high fever or great prostration. Chronic bronchitis is a disease of long duration, and opium may not be indefinitely continued. Heroin, or heroin hydro- chloride, in doses of 0.005-0.015 gm., diminishes the desire to cough, deepens and prolongs respiration, and relieves pain. Chlorate of potassium is a good expectorant. Various other sedatives, narcotics, and expectorants are recom- mended. Much relief may be obtained from the inhalation of steam. Where the secretion is excessive and the cough unavailing, stimulating expectorants may be useful, such as senega, which may be given in teaspoonful doses of the simple syrup of senega, or gtt. xxx of the compound syrup of squills ; car- bonate and chloride of ammonium, balsam of oopaiba, and the various preparations of turpentine; syrup, picis liq., 3ij-iv t. i. d.; myrtol, turpentine, terebene, and terpene hydrate, TTfv t. i. d. Cubebs may be given in cough-lozenges. Apo- morphine is an excellent expectorant, but shoulol not be given when there is a weak heart. Iodide of potassium may be given, gr. v-xxx ter die. Often very great comfort is secured from the use of the steam atomizer, in which various sub- FIBRINOUS BRONCHITIS. 267 stances may be used.1 Sometimes a change of climate is advisable. Cases of dry bronchitis are usually benefited most by a warm, moist climate, such as may be secured in the Bermudas, Nassau, Florida, Southern California, the Azores, or Madeira. FIBRINOUS BRONCHITIS (Plastic Bronchitis). Definition: An inflammation, acute or chronic, of the bronchial mucous membrane, characterized by the formation of a fibrinous exudate in the bronchial tubes. The disease has been found in the new-born child on autopsy (Hayn). Fibrinous bronchitis, is most frequent between ten and forty years. The condition is rare in the aged. The etiology of the disease is obscure. Escherich (1883) failed to find the bacillus of diphtheria in the exudate. Three varieties of micrococci were isolated by Picchini (1889). Many cases have been observed to follow traumatism or chemical irritation. Exposure to cold and moisture is fre- quently given as a cause. Among the predisposing or under- lying causes the following have been observed : tuberculosis, syphilis, alcoholism, rickets, pregnancy, and typhoid fever. Fibrinous bronchitis—symptoms: There are present the symptoms of an acute or chronic bronchitis. At times cough and dvsjmoea become intense, to be relieved by the expulsion of a fibrinous bronchial cast, These casts are branched like a tree, corresponding to the ramifications or branches of the bronchial tubes from which they are expelled and of which thev form a cast. The casts vary in size, usually an inch to an inch and a half in length, rarely reaching a length of four inches or over. Haemoptysis is a common symptom. 1 Mason, in the American Si/xtrm of Practical Medicine, gives the following list of substances that may be used with the atomizer, with the quantity of each to be added to one ounce of water: Tincturse opii camphoratse, 3J_nJ i Tinctune iodii, tt\,ij-x ; Acidi carbolici, gr. ij ; Creosoti, nijij ; Acidi tannici, gr. ij-x ; Alumini exsiccati, gr. iij—xv ; Liquoris ferri subsulphatis, gtt. v-xx ; Morphinae sulphatis, gr. ss-j ; Solut. cocainae hydrochlorici (4 per cent), n^xxx-lx ; Tincturae hyoscyami, rr^xxx-lx; Tincturae stramonii, TTl,xxx-xl; Tincturse opii, Hi,v-xxx ; I Tincture belladonnnse, ni,xxx-xl 268 DISEASES OF THE ORGANS OF RESPIRATION. Diagnosis: Finding the peculiar casts makes the oliagnosis. A localized subcrepitant rale may be suggestive (Flint). Blood-casts may appear in cases of haemoptysis, and should not be mistaken for the casts characteristic of fibrinous bron- chitis. Acute pneumonia and diphtheria also may show casts. Prognosis: Fibrinous bronchitis is most dangerous at the extremes of life. Death is most frequently caused by com- plications, or the underlying diseases which predispose to fibrinous bronchitis. Extension of the exudate into the trachea or inability to expel casts may cause death by suffoca- tion. Aside from other diseases of the lungs, especially tuber- culosis, the prognosis is usually good. Treatment: Of most value arc inhalations of steam and the use of expectorants, particularly after the cast becomes loose. Probably the best expectorant in these cases is apomorphine. Iodide of potassium seems to be of little or no value. BRONCHIECTASIS (Dilatation of the Bronchial Tubes). Etiology: Most of the cases are probably due to weakening of the walls of the bronchial tubes, caused by chronic bron- chitis. Many cases are caused by whooping-cough, measles, tuberculosis, asthma, and pleurisy. Sometimes cases may be caused by obstruction of the air-passages by foreign bodies, enlarged glands, tumors, aneurisms. Rarely the condition is congenital. The symptoms in cases of slight or moderate dilatation may not be characteristic. Marked dilatation of the bronchial tubes may be followed at times, especially in the morning, by expectoration of large quantities of muco-purulent sputum, often foetid in character. On physical examination percussion mav reveal the presence of cavities. The signs of bronchitis are usually present. Diagnosis: In slight or moderate cases of bronchiectasis diagnosis may be impossible during life. In doubtful cases the diagnosis may call for an exploratory puncture. Bron- chiectasis should be differentiated especially from tuberculosis, actinomycosis of the lung, pulmonary gangrene or abscess, and empyema. The diagnosis of tuberculosis or actinomycosis of ASTHMA. 269 the lung may be established by an examination of the sputum for the tubercle bacillus and ray fungus respectively. Gan- grene and abscess of the lung show more pronounced general symptoms than are present in bronchiectasis. Bronchiectasis, barring complications, shows little or no fever and only slight general symptoms, except in cases that are far advanced. An empyema that discharges through the lung may closely simu- late bronchiectasis, but usually shows fever, and sometimes pneumococci may be found in the sputum. The prognosis is best in childhood ; worst in the weak and aged, especially in the presence of consolidation or collapse (atelectasis) of the lung-tissue. Bronchiectasis—treatment: Some cases improve under the use of iodide of potassium, probably only when syphilis plays a role in etiology. Some relief may be afforded by inhalation or administration of turpentine, creosote, tar, menthol, euca- lyptus, myrtol. Some cases have been successfully treated surgically by incision and drainage; but surgery does not offer as much hope as in the treatment of abscess of the lung. In most cases of bronchiectasis that have been operated upon the operation has only hastened a fatal termination. ASTHMA. Definition: A peculiar dyspnoea, characterized by difficult and prolonged expiration, hyperaemia of the bronchial mucous membrane, more or less acute emphysema of the lung, and sibilant rales. The sputum often shows Charcot-Leyden crystals anol Curschmann spirals. Etiology : Depending upon the cause, asthma is divided into (1) primary asthma, sometimes called bronchial asthma or pulmonary asthma; and (2) secondary asthma, which is sub- divided into cardiac asthma, renal asthma, etc. With the advance of our knowledge of the etiology of asthma the num- ber of cases of primary asthma are diminishing, while the secondary asthmas are increasing. Asthma is supposed by some observers to be due to con- tracture of the bronchial muscles, through some affection of the nervous system, the cause of which is known in secondary 270 DISEASES OF THE ORGANS OF RESPIRATION. asthma and unknown in primary asthma. Asthma is more frequent in men than in women. Cases which have seemed to depend upon swollen tracheal or bronchial glands have been explained by the supposition that such enlargements cause irritation of the vagus nerve through pressure. An important role has been ascribed to a special susceptibil- ity of the nervous system that in some individuals causes an asthmatic attack to follow stimuli that in other individuals would be without such effect. In many cases heredity seems to play a part. Asthma may alternate with other neuroses, such as epilepsy, hemicrania, angina pectoris. Nasal polypi and other affections which interfere with the respiratory function of the nose are a frequent cause of asthma. Such cases have been ascribed to reflex irritation. In some instances the attacks are observed to occur only during the menstrual period. Cullen gives the account of an apothecary's wife who had an attack when ipecac was handled in the shop. Trousseau had an attack in the presence of a bouquet of violets. Itzig- son records the case of a merchant who would have an attack when fresh coffee was handled in his presence. Mackenzie reports the case of a lady who had an attack upon seeing a rose, even though it were artificial (psychic ast/rma). Most cases of asthma occur at night, often regularly at the same hour. In some cases the attacks will not appear if a light is left burning. Many cases of asthma seem to bear a relation to gout, and in some cases a seeming relation with chronic skin diseases (herpes, psoriasis, and eczema) has been reported. Symptomatology: Asthmatic attacks occur suddenly at irregu- lar, sometimes regular, intervals, usually in the night-time, with intervals of apparent perfect health. The attack is char- acterized by severe dyspntea, calling for the use of all the accessory muscles of respiration. The difficulty is with expiration, which is prolonged. The hunger for air causes the patient to assume a posture that will give freedom and power to the accessory muscles of respiration. There is cyanosis. The attack may continue for a few minutes to a few ASTHMA. 271 Fig. 31. hours, when the symptoms gradually, sometimes suddenly, disappear. haryngosctipic examination shows the mucous membrane of the trachea and visible bronchi reddened. 1'hysical signs: Percussion reveals an increased lung-area, the border of the lungs extending further downward, with a lower position of the liver. The heart-dulness is diminished. lTpon auscultation, sibilant rales are heard, replaced toward the end of the attack by moist rales. A vesicular respiratory murmur is heard over parts of the lungs. Fever is absent, or, if present, would denote complication. In children espe- cially a rise of temperature is often due to catarrh. Expectoratio)i usually occurs only toward the end of the attack. The frothy, grayish-white sputum contains the Charcot-Lcyden crystals and Curschmann spirals (Fig. 31). Spirals have been found also in pneumonia, fibrinous bron- chitis, acute and chronic catarrhal capil- lary bronchitis, diseases which affect the smaller bronchi and bronchioles. The sputum contains eosinophile and granular cells (Mastzellen), and crystalline and amorphous phosphate of lime. During the attack large numbers of eosinophile cells have been observed in the blood by many observers. Other observers have failed to confirm this finding. The more common complications are bronchitis, gout, dis- eases of the skin (herpes, psoriasis, eczema), epilepsy, neu- ralgia, pulmonary emphysema, and bronchiectasis. Tuber- culosis may occur in an asthmatic patient, but is not common. Diagnosis: Asthma is characterized by paroxysmal expira- tory dyspnoea. The sputum usually contains Curschmann spirals, Charcot-Lcyden crystals, and eosinophile cells. Dur- ing the attack there are an acute emphysema and sibilant, later moist, rales. Not all dyspnoeas are asthmas. Prognosis: Where the cause can be discovered and removed Spirals and crystals in sputum of asthma. 272 DISEASES OF THE ORGANS OF RESPIRATION the case may be cured. Frequently treatment is followed only by a cessation of symptoms, which may last even for years, and finally return. Cures are more frequent in early life. Asthma rarely causes death. Asthma—treatment: Treatment of the attack: Any dis- coverable cause should be removed. Attacks may be cut short by the use of opium, morphine, or chloral; but these remedies may not be used continuously. Belladonna, atropine, cannabis Indica, and strychnine ma\ be used. Chloroform, ether, methylene bichloride, and ethyl iodide may be inhaled, but have only a transitory effect. The leaves of stramonium anol belladonna have long been in use, smoked either with or without tobacco. A good combination is the following, given by Trousseau as the composition of the " cigarettes Espic :" B/ Fol. elect, herb, belladonnas, 0.36 ; Fol. elect, herb, hyosoyami, 0.18; Fol. elect, herb, stramonii, 0.18 ; Fol. elect, phellandrii aquat., 0.06 ; Extract opii, 0.008 ; Aquae laurocerasi, q. s. This is made into a cigarette and one or two such cigarettes may be smoked during an attack. In some cases those who are not accustomed to the use of tobacco may gain much benefit from its use. Arsenic and nitre are also used, blotting-paper being soaked in a solution of these substances, then dried, and smoked or burned and the fumes inhaled. The inhalation of ammonia is often of value. Electricity is sometimes used, the induced or faradic current. Cases due to nasal irritation may be relieved by the local application of cocaine. Treatment during the intervals: Often a local cause in the upper respiratory organs or in the genital organs may be dis- closed and treated or removed, when the symptoms will dis- appear. Sometimes several points of irritation may be found. The iodides may be given internally, 1.5-3.0 per day, pre- scribed in peppermint-water and taken largely diluted in milk. The remedy must be given for a long time. Fowler's solution of arsenic is often of value. Numerous remedies CROUPOl\S PNEUMONIA. 273 and contrivances have been recommended. In each case the physician should seek and treat or remove the cause. This sometimes may call for a change of residence. Good hygienic surroundings anol exercise, especially open-air respiratory gymnastics and hydrotherapy, are often of very great value. DISEASES OF THE LUNGS. PNEUMONIA. Definition: An infection of the lung by various micro- organisms, the invasion of which may be favored by exposure to inclement weather, trauma, etc. Varieties : (1) croupous pneumonia, lobar pneumonia, fibrin- ous pneumonia, sometimes referred to as genuine pneumonia; (2) catarrhal pneumonia, lobular pneumonia, broncho-pneu- monia. To these may be added (3) influenza pneumonia, due to the influenza bacillus; (4) tubercular pneumonia, due to the tubercle bacillus, and really a tuberculosis; (5) true typhoid pneumonia, due to invasion of the lung by the typhoid bacil- lus. The term typhoid pneumonia has been abused so much that many suggest that the term should be dropped altogether. (6) Septic pneumonia, set aside by some observers as a special variety, due to the pus-producing microorganisms. Such cases, when possible, may be classified according to the par- ticular variety of micro-organism present, as streptococcus pneumonia, staphylococcus pneumonia, etc. CROUPOUS PNEUMONIA (Lobar Pneumonia; Fibrinous Pneu- monia; Genuine Pneumonia). Definition: An infection of the lung, affecting an entire lobe, characterized by a fibrinous exudate with rusty-colored sputum, high fever, and termination by crisis in five to nine days. Etiology: The infectious agent is the micrococcus pneu- monia1, crouposa- (Sternberg) or the bacillus of Friedlander. These micro-organisms have been found upon the respiratory mucous membrane, especially in the mouth and throat, in 18—P. M, 274 DISEASES OF THE ORGANS OF RESPIRATION. health, and it would seem that exposure to cold and moisture and trauma may play an important role in etiology. In some cases other micro-organisms have been found, such as the in- fluenza bacillus, streptococcus pyogenes, staphylococcus pyo- genes aureus, and the typhoid bacillus; but in such cases the disease does not pursue the typical course of croupous pneu- monia. Croupous pneumonia—symptomatology: Some cases show prodromata for two or three days : malaise, more or less in- flammation of the respiratory mucous membrane, especially of the nose and pharynx, and indigestion. Usually there are no jtrodromata. The disease is announced suddenly with a chill, folloieed by fever, the temperature reaching 104° or 105° F. As a rule, sooner or later there is pain in the side, usually in the region of the nipple, caused by involvement of the pleura. Dyspnoea is prominent, due to pain or to the congestion of the lung. All sorts of'rales may be heard, coarse and fine, moist and drv. This constitutes the stage of en- gorgement, which in a clay or two gives way to consolidation, often with relief* of the pain and dyspiuea. The temperature continues high, vit/i rapid pulse and respiration, anorexia, thirst, headache, constipa- tion. The urine is reduced in quantity anol highly colored. The sputum becomes rusty-colored. Usually the cough is painful. Temperature-curve of croupous rpi , ° i r pneumonia. Inere are restlessness and more or less delirium. As a rule, between the fifth and ninth day resolution is an- nounced by a sudden fall of temperature, crisis, with profuse perspiration (Fig. 32). Occasionally the temperature falls bv lysis, reaching the normal in a few days instead of a few hours. The pulse falls from 110 or 120, sometimes 150 in children, to 50 beats per minute. Croupous pneumonia—physical examination: Inspection re- CROUPOUS PNEUMONIA. 275 veals lessened expansion of the affected side. Palpation may detect increased vocal fremitus anol sometimes a pleuritic fric- tion-sound. Percussion usually shows increased resonance over the affected lobe during the period of congestion, which during the period of hepatization (consolidation) gives way to dulness. After resolution resonance reappears. Auscultation discloses both fine crepitant and coarse rales during the period of congestion. The former disappear during consolidation of the exudate. The breathing then becomes bronchial. There is brotu-hophony, sometimes aegophony, over the affected lobe. With resolution, bronchial breathing and bronchophony give way to the crepitus redux, moist rales which are usually coarser than the fine moist rales heard during the period of conges- tion. In central pneumonia, in which the affection of the lobe does not extend to near the periphery, auscultation may reveal only bronchophony. Especially in severe cases, the heart is called upon to do increased work and the cardiac dulness is found to extend further to the right. Usually there is accentuation of the second pulmonary valve sound. There is often enlargement of the spleen and liver. Croupous pneumonia—examination of the blood: There is a marked leucocytosis, 20,000-32,000 (Ewing). In a very viru- lent case as high as 100,000 has been recorded (Kidd). As a rule, a low number, below 14,000 (Ewing), lends gravity to the prognosis. A very high number is found in severe cases. The number of leucocytes gradually diminishes just before crisis and returns to the normal after resolution. An increase in the leucocytosis would indicate a further invasion of the pulmonary tissue. Complications: Bronchitis and pleurisy occur frequently with croupous pneumonia. Sometimes there is empyema. Pericarditis is found most frequently in pneumonia of the left lung. Occasionally there are endocarditis, meningitis, nephritis; more rarely peripheral neuritis, urethritis, paro- titis, and orchitis. Diagnosis : Usually the symptoms anol physical examination render the diagnosis easy. The disease conies on suddenly, with increaseol respiration, sometimes localized pain in the 276 DISEASES OF THE ORGANS OF RESPIRATION. region of the nipple, with cough, later rusty sputum and physical evidences of consolidation of the lung upon the affected side. Pneumonia of the apex of the lung may resemble tubercu- losis, but does not show the tubercle bacillus in the sputum nor respond to the test with tuberculin. In such cases, as well as in cases of central pneumonia, in which the physical signs may be absent or misleading, an examination of the blood will show leucocytosis. Acute pulmonary oedema may show dyspnoea, cyanosis, rales, and sometimes sputum some- what resembling that of pneumonia. Acute oedema usually depends upon disease of the heart, and is not accompanied by high fever. Pleurisy usually comes on more gradually and does not show rusty sputum. Doubtful cases may call for aspiration. Pluerisy and croupous pneumonia may co-exist, Prognosis: Much depends upon the condition of the heart. The prognosis should be extremely guarded when the heart is enfeebled by age, alcoholism, or disease. The occurrence of complications adds gravity to the case. Pneumonia occurring in pregnancy, especially in the later months, frequently causes miscarriage and a fatal termination. In any case marked and persistent increased frequency of the pulse and respiration, the expectoration of " prune-juice " sputum, persistent tracheal rales, the typhoid state with low delirium, stertor, muscular tremor, and coma, are ominous signs. Croupous pneumonia—treatment: In the way of specific medication most promising are the results that have been ob- tained by the injection of blood-serum from recent convales- cents. Frequently crisis occurs immediately or soon after such injections. The effectiveness of serum-therapy is as- cribed to an antipneumotoxin, which normally accumulates in the body of the patient to cause the crisis on the seventh to the ninth day of the disease. We should not forget, in the application of serum-therapy, that all cases of pneumonia are not due to the same micro-organism. In general the treatment is symptomatic. The sick-room should be well ventilated. Some temperature belongs to the disease and is salutary ; temperature above 103° F. calls for hydrotherapy, best sponging with cold water, and the use of CATARRHAL PNEUMONIA. 277 ice upon the chest. Severe pain may be relieved by mor- phine; cough that is distressing, by Dover's powder/ Ner- vous symptoms —headache, sleeplessness, delirium—may call for sponging with cold water or the application of the ice-bag or cold compresses to the head, or the administration of Dover's powder or trional at bedtime. Most important is the support of the heart. A flagging heart calls for the use of alcohol anol strychnine. Nitro- glycerin or musk may be used to bridge over a threatened collapse. Digitalis or strophantus may be indicated by weak- ness of the heart, Some brilliant results have been reported from the use of large doses of digitalis or digitalin ; but others have failed to secure such results by the use of these remedies in pneumonia. Good results have been reported (Lepine) from the intra- pulmonary injection of bichloride of mercury, 20-26 c.c. of a 1 :4000' solution. CATARRHAL PNEUMONIA (Broncho-pneumonia: Lobular Pneumonia). Definition: An inflammation of the lung, affecting the lobules, finer bronchi, and air-cells, usually following bron- chitis, anol in the great majority of cases due to infection. Etiology: The micro-organisms most frequently found in catarrhal pneumonia are the micrococcus pneumoniae crouposae (Sternberg), Friedlander's bacillus, streptococcus pyogenes, staphylococcus pyogenes aureus, diphtheria bacillus, influenza bacillus, tubercle bacillus, and the typhoid bacillus. Mixed infection is very common. Pneumonia due to the diphtheria bacillus, influenza ba- cillus, tubercle bacillus, and typhoid bacillus is treated of under Diphtheria, Influenza, Tuberculosis, and Typhoid Fever, respectively. Frequently catarrhal pneumonia is due to the extension of a bronchitis. Capillary bronchitis, or bronchiolitis, rarely if ever exists except in the presence of pneumonia. Since many of the micro-organisms found in pneumonia may be present in the respiratory tract, especially in the nose 278 DISEASES OF THE ORGANS OF RESPIRATION. and throat, and probably also in the lungs, in health, an im- portant role in causation is ascribed to exposure to inclement weather, cold, and moisture, the inhalation of dust and anaes- thetics, and trauma, which are believed to favor infection. The so-called aspiration-pneumonia, which occurs most fre- quently after anaesthesia, is due to an invasion of the lung by micro-organisms, which gain access to the lung in abundance at the time of anaesthesia, through, the increased secretion and diminished expectoration. In such cases infection may be favored by the irritation of the lung caused by the anaes- thetic. Symptomatology: The symptoms bear a general resemblance to those of croupous pneumonia, but show wide variations, as might be anticipated from the variety of agents that may enter into the etiology of catarrhal pneumonia, The symp- toms of carbonic-acid poisoning and toxaemia assume impor- tance. The more important symptoms are fever, usually 102° to 103° F. in the evening, sometimes 104° to 105° F.; rapid pulse, 150 or higher, and respiration 20 to 60 or more; dysp- noea, anol cough. The pulse-respiration ratio is altered from the normal 2 : 9 to 1 : 3-2 : 3. Physical signs: Percussion may elicit some dulness, usually near the spine and low down. Auscultation reveals rales of various kinds. Bronchial breathing and bronchophony are the exception. Resolution may take place, but usually appears later than in croupous pneumonia. The duration of the disease is longer in catarrhal pneu- monia than in croupous pneumonia. As a rule the temperature falls by lysis. Often convalescence is protracted. Pericarditis, endocarditis, and meningitis occur only rarely. Catarrhal pneumonia—diagnosis : The disease shows a prefer- ence for the extremes of life. The existence of some etiolog- ical factor, such as bronchitis, is often of value in diagnosis. Important symptoms are the elevation of temperature, in- crease of pulse and respiration, with disproportion of the pulse-respiration ratio, and the presence of rales. Physical examination may show infiltration of parts of a number of lobes, involving usually both lungs. Croupous CATARRHAL PNEUMONIA. 279 pneumonia, on the other hand, shows consolidation of an en- tire lobe, and is usually unilateral. In catarrhal pneumonia the sputum is muco-purulent and may contain blood, but is not of the rusty character found in croupous pneumonia. In some cases the microscopic exami- nation of the sputum will reveal the true nature of the dis- ease. Prognosis : The mortality is much higher than in croupous pneumonia. The outlook is grave in children after measles, whooping-cough, and diphtheria. High temperature, with dyspmea, irregular respiration, especially Cheyne-Stokes respiration, delirium, convulsions, and somnolence are omi- nous, especially late in the course of the disease. Catarrhal pneumonia—treatment: The treatment is sympto- matic. High fever, above 103° F., calls for hydrotherapy, best cold sponging, or a warm or cool bath. In the presence of a strong heart, especially in children, phenacetin or lacto- phenin, best given with whiskey or wine to avoid depression, may give considerable comfort. Such measures also address most pleasantly the nervous distress so often present. Pleu- ritic pain may be relieved by hot or cold applications, a mus- tard plaster, or the administration of opium. The patient should drink plenty of pure water, plain or carbonated, to which lemon-juice or cream of tartar may be added. Emetics are sometimes useful for the removal of the secretion from the trachea. Of more value are the stimulating expectorants, senega, ammonia, camphor, and benzoic acid. A weak heart should be supported with cold sponging, digitalis, alcohol, strophantus, caffeine, carbonate of ammo- nium. Nitroglycerin is of value in cases of arterio-scelerosis. The patient should be kept upon a fever-diet: milk, soup, eggs; later oysters, chicken, and steak. A change of climate may be necessary in chronic cases. In all cases the patient should receive an abundance of pure fresh air (see Treatment of Bronchitis). Influenza-pneumonia (see Influenza): The prognosis is worse than in the other forms of catarrhal pneumonia or in croupous pneumonia. 280 DISEASES OF THE ORGANS OF RESPIRATION. Tubercular pneumonia (see Tuberculosis). Typhoid pneumonia (see Typhoid Fever). A true typhoid pneumonia may be caused by the typhoid bacillus, and occurs especially in the course of typhoid fever, the infection of the lung probably occurring through the blood. In some cases the infection of the lung by the typhoid bacillus has seemed to occur through the respiratory tract (Riehiardiere). The fever, nervous symptoms, and course of the disease resemble those of typhoid fever. Sometimes the term " typhoid pneu- monia" is applied incorrectly to a combination of typhoid fever and croupous or catarrhal pneumonia. EMPHYSEMA (Pulmonary Emphysema). Definition: Vesicular emphysema shows dilatation of the pulmonary alveoli with distention of the alveolar walls, which sometimes atrophy and disappear. In interstitial cmpfiyscma there is inflation of the interstitial lymph-spaces of the lung with air that escapes from the alveoli through rupture. Etiology: The most prominent factor in causation is in- creased intrapulmonary pressure, due to expiratory effort Emphysema is found most frequently in chronic bronchitis, especially in dry bronchitis and in certain occupations, among musicians who play on wind-instruments, glass-blowers, and those who do heavy lifting, in which the glottis is closed and the accessory expiratory muscles are brought into action. Congenital weakness of the pulmonary tissue seems to play a role in some cases. Symptomatology : Vesicular emphysema comes on gradually and pursues a chronic course. With the disappearance of the alveolar walls the aerating surface in the lung is diminished. There is dyspnoea, which is expiratory in character, at first observed only on exercise, later becoming more constant. The dyspnoea is aggravated by bronchitis. Usually there is cough. Because of the lessening of the pulmonary vascular area the heart must do more work. The right ventricle becomes hypertrophied, and later undergoes dilatation. The tricuspid valve becomes relatively insufficient. There are cyanosis and EMPHYSEMA. 281 dropsy, which may become general to constitute a true ana- sarca. The chest conies to occupy the position of inspiration, —becomes " barrel-shaped.," The chest appears as if the indi- vidual were holding his breath at full inspiration. Inspiration is short and expiration prolonged and forced. The heart is pushed downward. The apex-beat may be in the sixth or seventh intercostal space. Epigastric pulsation is common. Physical signs: Percussion reveals drum-like tympanitic resonance; diminution, sometimes obliteration, of the cardiac dulness, due to the heart being covered by the lung. The pulmonary resonance is increased downward, and the liver may be puslwd downward so that it can be readily pal- pated. Auscultation : Expiration is prolonged. In the presence of bronchitis, rales may be heard. Usually there is accentuation of the second pulmonary valve sound. With insufficiency of the tricuspid valve a systolic murmur is heard. The liver and spleen may be enlarged, especially late in the disease. Prognosis: In pronounced cases the prognosis is grave. Those who are able to take proper care of their health, espe- cially with regard to the selection of climate and the treatment or prevention of bronchitis, may live for years in comparative comfort. Where this is not possible the duration of life is shortened. In all cases the disease runs a chronic course. Life often is terminated by some intercurrent malady. Other- wise death comes through failure of the heart. Emphysema—treatment is symptomatic, and should be ad- dressed especially to the prevention or cure of bronchitis and the support of the heart. The patient should reside in a warm climate during the winter. Where this is not possible the individual should remain in the house in winter and during inclement weather. The remedies of most value in the treatment of the bronchitis are iodide of potassium, citrate of potassium, and pilocarpine. Strychnine is an excellent tonic. A failing heart demands rest and the judicious use of digitalis and strophanthus. CEdema may be relieved by calomel or diuretin. 282 DISEASES OF THE ORGANS OF RESPIRATION. ATELECTASIS. Definition : Collapse or incomplete distention of a greater or less number of pulmonary alveoli. Etiology : Complete atelectasis is found normally in the lung of the foetus. In the new-born it is evidence that the child has not breathed. Acquired atelectasis may be due to plugging of a bronchus or compression of the lung. Symptomatology : Partial atelectasis shows increase of respi- ration and absence of fever, except when caused by associated processes. The respiration is superficial. The pulmonary area may be decreased and the cardiac area increased. The lung retracts from over the heart. Percussion may reveal dulness or flatness over the affected portion of the lung. During life, atelectasis may be overshadowed by the symp- toms of the disease or condition which causes it. Treatment should address the cause, in the hope of preven- tion of complete atelectasis, which is incompatible with life. Fro. 33. OZDEMA OF THE LUNG (Pulmonary Oedema). Definition: A collection of fluid in the interstitial tissue of the alveoli and smaller bronchioles. The fluid comes from the blood, through the vessel-walls, and may be clear or tinged with blood. Etiology : Passive congestion of the lung, due to a weak heart, is probably the most common cause. CEdema occurring in nephritis is due to changes in the vessel-walls or in the heart, weakness. (Edema may occur in the neighborhood of in- flammatory processes in the lung. Symptomatology: The onset may be sudden or gradual. There are dyspntra, cyanosis, and increased fre- quency of respiration. Pales occur, at first with resonance, later with dulness or flatness over the more dependent portions of the lung. OEdema mated Desqua- cells con- pulmonum epithelial taining particles of coal-dust (Whittaker). GANGRENE OF THE LUNG. 283 The sputum contains ©edematous cells, known as cells of pulmonary oedema or the cells of heart-failure (Fig. 33). The sputum may contain urea in cases occurring in nephritis. The prognosis is always grave, but depends upon the cause, especially upon the reaction of the heart to stimulation. Pulmonary oedema—treatment: Most cases are due to a weak heart, which should be strengthened by rest and the judicious use of cardiac stimulants and exercise. Grave cases may call for the analeptics, probably best, camphor and oil, 1 : 8, hypo- dermatically. Often considerable comfort is secured by the use of morphine. ABSCESS OF THE LUNG. Abscess of the lung may be single or multiple. Etiology: Among the causes of abscess of the lung are: tuberculosis, pneumonia, empyema, mediastinals, oesophageal carcinoma, abscess of the liver, subdiaphragmatic abscess, em- bolism, and the presence of a foreign body in the lung. The diagnosis is difficult in the absence of expectoration of pus. Sometimes pus may be detected by aspiration. In the differentiation from a bronchiectatic cavity, when pus is ex- pectorated, the finding of portions of the lung or elastic tissue would speak for abscess. Treatment: If possible, the abscess should be treated sur- gically, opened and drained. In other cases the treatment must be expectant, symptomatic. As far as possible the cause should be addressed. GANGRENE OF THE LUNG. Primary gangrene of the lung, due to trauma, is rare. Gan- grene of the lung is most frequently caused by pneumonia, infarction, embolism, abscess, echinococcus, actinomycosis, neoplasms ; rarely by tuberculosis. The disease shows a pref- erence for males, poverty, and the age of twenty to fifty years. Symptomatology: The odor of the breath is very offensive. Expectoration is usually abundant, and the sputum is foul- smelling, and upon standing separates into three layers: the 284 DISEASES OF THE ORGANS OF RESPIRATION. upper muco-purulent, the middle thin and watery, and the lower purulent. Microscopical examination of the sputum reveals pieces of lung-tissue, especially elastic fibres, numer- ous bacteria, mould-fungi, and both fat-crystals and free fat, If the gangrene involve a considerable area, it mav be recog- nized by the presence of dulness and bronchial respiration; or, in the presence of a cavity, by tympanitic resonance, especially the cracked-pot sound, and amphoric respiration. The prognosis depends largely upon the cause and the strength of the patient, but is always grave. Death is usually caused by exhaustion, sometimes by hemorrhage, rarely by abscess of some other organ, especially of the brain! Treatment: Inhalations of creosote lessen the offensive odor of the breath. Rarely surgery may benefit a case by in- cision and drainage. As a rule the treatment is purely symp- tomatic. PNEUMONOKONIOSIS. Definition: Disease due to the inhalation of dust. Varieties: Anthracosis or anthraco-pneumonokoniosis, coal- miners' phthisis, coal-miners' lung, due to the inhalation of coal-dust. Siderosis, knife grinders' phthisis, refers especially to disease caused by the inhalation of particles of metal (steel and iron). Chalicosis is due to the inhalation of mineral dust. Millers' phthisis is due to the inhalation of particles of wheat, especially of the hull of the grain. The symptoms are those of bronchitis, emphysema, intersti- tial pneumonia, or tuberculosis. The diagnosis rests upon the symptoms and occupation of the patient, and the character of the sputum, which contains particles of the dust inhaled. Frequently the irritation caused bv the dust opens the way for invasion by micro-organisms. Many of the patients succumb to tuberculosis. Prognosis : Mild cases recover upon a change of occupation. In advanced cases the prognosis is bad. The invasion by micro-organisms, especially by the tubercle bacillus, adds gravity to the prognosis. Treatment: Something may be done in the way of prophy- PLEURISY. 285 laxis by the use of inhalers, or of apparatus to remove the dust, especially in factories. The treatment of a case calls for a change of occupation. Further treatment is that of bronchitis. Syphilis of the lung (see Syphilis). Echinococcus of the lung (see Echinococcus). Actinomycosis of the lung (see Actinomycosis). DISEASES OF THE PLEURA. PLEURISY. Definition: An inflammation (infection), acute or chronic, of the membrane lining the pleural cavity. Etiology: Tuberculosis is the most frequent cause. Some cases are due to pneumonia, infarctions, rheumatism, syphilis, and infection with the typhoid bacillus. Typhoid infection of the pleura may occur either with or without intestinal lesions. Charrin and Roger (1891) found infection of the pleura with the typhoid bacillus, without infection of the intestine, in a postmortem upon a case in which there were the symptoms of typhoid fever, except those symptoms due to lesion of the intestine. Pleurisy may be caused by trauma or bv Bright's disease. The streptococcus pyogenes is found most frequently in purulent pleurisy (see Empyema). Ex- posure to cold has come to occupy a subordinate place in etiology. Pleurisy—symptomatology: The acute attack comes on sud- denly with chill folloieed by fever, 102° to 103° F., and in- creased, pulse-rate. As a rule the most prominent early svmptom is pain, usually in the side, which is aggravated by pressure, cough, or deep inspiration. At first the patient lies on the well side, to avoid pain, and later on the affected side, to secure greater freedom of respiration. Effusion prob- ably begins soon after the onset of the disease, but usually mav not be readily detected until the second to the fifth day. With the separation of the pleural surfaces by the effusion the 286 DISEASES OF THE ORGANS OF RESPIRATION. pain disappears. Usually the pulse and respiration are in- creased in frequency. As a rule the temperature continues hhdi. Jh/sjnxea may be troublesome. Sometimes the onset of pleurisy is insidious. The patient complains of cough and shortness of breath brought on or increased by exercise. There may be pain in the side. The general health is impaired, the appetite is poor, and there is weakness, frequently pallor. Such cases occur most fre- quently at the extremes of life, usually secondary to other diseases, especially tuberculosis and chronic diseases of the heart and kidneys. In some cases there is no effusion, constituting the so-called dry j)leurisy. Effusion, when present, may last two to five days in rheumatic cases (Xetter); usually four to six weeks in acute cases with small or moderate effusion ; and a number of years in chronic cases, before absorption takes place. Pleurisy—physical signs: At first the most important sign is the pleural friction-rub, heard both upon inspiration and expiration. Later there is the evidence of effusion, appearing first as dulness over the most dependent portion of the pleural cavity. The friction-sound may still be heard above the area of dulness. With increased effusion the dulness becomes more pronounced ; there is absolute flatness. The respiratory movement of the affected side is diminished. Vocal fremitus is absent over the effusion and increased over the compressed lung. large effusion causes distention of the affected side, displacement of organs, and bulging of the intercostal spaces. In marked cases auscultation may detect no sounds upon the affected side. Usually there are bronchial, breathing and bronchophony, occasionally aegophony. After absorption there is a return of the friction-sound, which is found over a larger area than at first. There are numerous crackling rales. The early diagnosis of pleurisy or the detection of mild cases depends largely upon the recognition of the friction- sound. Later, dulness and flatness are characteristic. Atten- tion often is first directed to the chest by the pain in the side. The symptoms may indicate the character of the exudate, which can be determined positively only by puncture. The EMPYEMA. 287 examination of the exudate, microscopically and by inocula- tion and culture, may reveal the micro-organisms present in a given case. The prognosis depends largely upon the cause. So-called rheumatic pleurisy almost invariably pursues a short and favorable course. Many cases of pleurisy seem to recover from the attack', and succumb later to tuberculosis. But even tubercular pleurisy may recover. Chronic pleurisy mav cause permanent deformity of the chest. Pleurisy—treatment: The patient should remain in bed. Pain may be relieved by hot applications and poultices, and by strapping the side to prevent the movements of respira- tion. Severe pain calls for opium, best in the form of Dover's powder in broken doses; or morphine hypodermatically. The bowels must be kept open. Irever is relieved best bv cold sponging. Pleurisy due to tuberculosis, rheumatism, or syphilis should be treated with remedies addressed to these diseases—tuberculin, the salicylates, and iodides, respectively. An exudation that threatens life or is very slowly absorbed must be removed by aspiration or incision. Symptoms de- manding aspiration are asphyxia, weakness of the heart, rising of the fluid to or above the third interspace with the patient in the erect position, and delayed absorption. The puncture is best made in the fourth interspace on the left side, or the fifth interspace on the right side. Not all the fluid should be removed. EMPYEMA (Purulent or Suppurative Pleurisy). Etiology: The most frequent causes are the streptococcus pyogenes and the micrococcus pneumoniae crouposae. The tubercle bacillus opens the way for invasion of the pleura by other micro-organisms. The staphylococcus i< usually found associated with the tubercle bacillus or the micrococcus pneu- monia* crouposae. The bacillus of Friedlander, the typhoid bacillus, and saprophytic micro-organisms are sometimes present. Infection of the pleura may come from the lung, from pneu- monia, tuberculosis, abscess, gangrene, infarction, bronchiec- 288 DISEASES OF THE ORGANS OF RESPIRATION. tasis, and cancer; from the chest-wall, from inflammations of the skin, lymphatic glands, or breast, especially (•ancer of the breast and' peripleuritis; from the mediastinum, from medias- tinal abscess, pericarditis, and cancer of the oesophagus ; from the abdomen, from peritonitis, and hepatic, subdiaphragmatic, and peritvphlitie abscess; and from certain infectious diseases, especially septicaemia (puerperal fever), erysipelas, influenza, scarlet fever, and diphtheria. Infection may occur through trauma (wounds). Symptomatology: Aside from the symptoms of pleurisy, in empyema there is evidence of the presence of pus in the pleural cavitv. The onset of empyema may be sudden or insidious, and the course of the disease may be acute or chronic. Usually sooner or later the temperature shows the curve character- istic of septiciemia. At the same time there are emaciation and loss of strength. The dyspiura becomes greater than may be accounted for by the amount of fluid present in the pleural cavity. The symptoms vary somewhat with the cause. In empyema due to the streptococcus pyogenes the streptococcus (hectic) temperature-curve is usually present from the beginning. To this class belong, as a rule, the fulminant cases. CFdema of the chest-wall is frequent, Often there is enlargement of the axillary glands. Exceptionally metastatic abscesses occur, most frequently in the brain. Kmpvema due to the micrococcus pneumonia', crouposte is usually, if not always, secondary to pneumonia, which may pass unrecognized. Frequently the course resembles that of pneumonia, with sudden onset, pain in the side, cough, and marked improvement in seven to nine davs. Cases occurring after the crisis of pneumonia show a less characteristic course. CEdema of the chest-wall is rare. Spontaneous evacuation, oftenest through the lungs, less frequently through the inter- costal spaces, occurs in at least one-fourth of the cases. Encapsulation of the exudate occurs more frequently than in other varieties of empyema. The pus is dense and viscid, usually of a grayish-yellow color. This form of empyema terminates, as a rule, in recovery, which may account for the usually favorable course of empyema in children. HYDROTHORAX. 289 Cases of empyema in which the tubercle bacillus is present are usually insidious in onset and pursue a chronic course. Etrtid or putrid empyema is caused by the presence of sapro- phytic micro-organisms. Frequently gangrene of the lung is the source of the infection. The cases usually present marked symptoms of sepsis. Often the expectoration is offensive, even in the absence of discharge of the empyema. ( uses of empyema due to the typhoid bacillus usually termi- nate favorably. As a rule, the fever resembles that of typhoid fever. In many cases there is mixed infection. Diagnosis: The symptoms of pleurisy in combination with the evidence of septicaemia may lead to the suspicion of em- pyema. (Edema of the chest-wall occurring in pleurisy would indicate empyema. A positive diagnosis may be made by the withdrawal of pus, through aspiration or incision. Prognosis is good, provided early evacuation of the pus is obtained. Many cases undergo resolution without operation. Empyema is, however, a serious disease. Much depends upon the cause. Treatment : The pus may be absorbed, especially in chil- dren. As long as the general condition of the patient remains good, in the absence of marked evidence of septicaemia, the treatment may be expectant. Impairment of the health of the individual, especially changes in the pulse and respiration, calls for surgical inter- ference, incision, and drainage. Sometimes it is necessary to resect part of a rib to secure thorough drainage of the empyema. HYDROTHORAX. Definition: An ©edematous transudation of fluid into the pleural cavity. Etiology: The causes are those which may produce oedema elsewhere : obstruction to the circulation, due to disease of the heart or of the lung (emphysema); hydraemia, due to kidney disease or cachexia. Symptomatology: There is dyspnoea, which may be aggra- 19—P. M. 290 DISEASES OF THE ORGANS OF RESPIRATION. vated by the conditions that produce the hydrothorax. Ily- drothorax docs not cause pain or fever. Physical examination reveals fiuid in the pleural cavity, the character of which may be determined by aspiration. Hydro- thorax is almost always bilateral. Diagnosis : The occurrence of bilateral transudation of fluid into the pleural cavity, in the presence of general (edema, is characteristic. Doubtful cases may be cleared up by aspira- tion. The prognosis depends upon the cause. Treatment should address the cause. In bad cases the fluid may be withdrawn by aspiration. In the presence of general dropsy, relief may be obtained by increasing the action of the heart, kidneys, and bowels; or fluid may be withdrawn from the legs by the introduction of silver canulae into the subcutaneous tissue. PNEUMOTHORAX. Definition: Air in the pleural cavity. A combination of pneumothorax and hydrothorax constitutes pneumo-hydro- thorax. The presence of air and pus in the thorax is known as pneumo-pyo-thorax. Etiology : Air may gain access to the pleural cavity through perforation. Cases may rarely be due to the presence of anaerobic gas-forming micro-organisms^ Such organisms were found by Levy in a case of pneumothorax following pleurisy. But perforation is the more common cause. The perforation may be caused by trauma, as by a broken rib or rupture of the lung. Aside from trauma, the majority of cases are due to tuberculosis. Other causes are empyema, emphysema, pneumonia, gangrene of the lung, abscess of the lung or liver, carcinoma, and the emptying of a bronchieetatic cavity into the pleural cavity. Pneumothorax—symptomatology: Usually the onset, is sud-' den, with pain, dy.spmra, and cyanosis. There may be cough. Prostration is marked. The jnifse and respiration arc increased, the temperature subnormal. The patient may pass into col- lapse and die within a few hours or days; or death may occur PNEUMOTHORAX. 291 later from exhaustion. In other cases the symptoms improve and recovery follows with absorption of the air or gas. Physical examination shows enlargement of the affected side, with displacement of the organs,—heart, liver, and spleen,—as in pleurisy. Vocal fremitus is diminished or absent over the affected area and increased over the collapsed lung. The percussion-note may be tympanitic, but is usually only loud with a low pitch. At any rate, the percussion-note over the affected area differs from that over the normal lung. Auscul- tation over the affected area reveals diminution of the respira- tory murmur. The sounds of respiration and the voice are distinctly amphoric (metallic tinkle, which may also originate in the stomach). The presence of fluid or pus (pneumo-hydro-thorax, pneumo- pvo-thorax) mav give rise to suecussion. This should not be mistaken for suecussion occurring in the stomach. Suecussion may also occur in a large cavity in the lung. Soon the symptoms of fluid in the pleural cavity appear (see Pleurisy). The fluid changes its level with changes in the position of the body more readily than when the hydrothorax is not accom- panied by the presence of air or gas. Usually the air or gas is soon absorbed after the appearance of fluid. Diagnosis: The sudden onset, dyspiuea, and the physical signs, especially the increased resonance, with feeble or amphoric respiration oyer the affected area, and the displace- ment of organs, especially of the heart anol diaphragm (liver and spleen), arc characteristic. The respiratory sounds may be entirely absent. Light cases are sometimes difficult to diagnosticate. Differential diagnosis has to do chiefly with emphysema, pulmonary cavities, hernia of the diaphragm, and pyopneumo- thorax subphrenicus. Prognosis : In the absence of infection the prognosis is good. Tubercular cases have a worse outlook. The occurrence of pus (pneumo-pyo-thorax) adds gravity to the prognosis. The prognosis is unfavorable in double pneumothorax. Pneumothorax—treatment: Pain should be relieved with hot applications, poultices, or opium, preferably in the form of morphine hypodermatically. Prostration and collapse 292 DISEASES OF THE ORGANS OF RESPIRATION. should be met with the analeptics, alcohol, sodium benzoate, of caffeine, camphor, ether, digitalis, strychnine. Asphyxia may necessitate puncture with a hypodermatic needle or fine trocar, best made in the fourth to sixth interspace in front. Later, effusion may call for the intervention of surgery, aspiration, or incision and drainage. Echinococcus of the pleura (see Echinococcus). Malignant diseases of the pleura: Sarcoma rarely invades the pleura. Carcinoma of the pleura is almost always secondary to carcinoma elsewhere. Primary carcinoma of the pleura has been reported in a few cases. CHAPTER IV. DISEASES OF THE ORGANS OF CIRCULATION. DISEASES OF THE PERICARDIUM. PERICARDITIS. Definition: An acute or chronic inflammation of the peri- cardium. Etiology : Primary pericarditis may be clue to trauma or causes apparently not connected with other disease, such as "taking cold." More important, because much more frequent, are the cases of secondary pericarditis, which may be caused by the infec- tions or by extension of inflammation from contiguous organs, clue to bacterial invasion or the action of toxins. Pericarditis is most freopiently found in rheumatism, especially in acute articular rheumatism, chorea, tuberculosis, pleurisy, endocar- ditis and myocarditis, pneumonia, influenza, scarlatina, septi- caemia, variola, scorbutus, nephritis, gout, cholera, dysentery, erysipelas, diphtheria, cerebro-spinal meningitis, haemophilia, hemorrhagic diathesis, purpura, morbus maculosus, leukaemia, diabetes, cirrhosis of the liver, carcinoma, sarcoma, and syphilis ; typhus, typhoid fever, intermittent fever, relapsing fever, gonorrhoea, phlebitis, and osteomalacia. Aneurism is a rare cause. Symptomatology: The symptoms of pericarditis may be slight, overshadowed by associated disease, or entirely absent; again, they are pronounced. Sometimes the onset is sudden, with chill and rigor, a rise of temperature, malaise, anorexia, headache, and dizziness. There may be palpitation of the heart, In other cases the onset is insidious and these symptoms are not present, Some- 293 294 DISEASES OF THE ORGANS OF CIRCULATION. times, especially in the aged, the temperature may be sub- normal. Frequently pericarditis first manifests itself by pain, which sometimes extends to the left shoulder and down the arm. There may be tenderness over the region of the heart and in the epigastrium. Sometimes the pain is increased by inspira- tion. Later, upon the appearance of effusion, the pain disap- pears or at least is diminished. The effusion interferes with the action of the heart. The pulse becomes weak and irregu- lar. Exertion or excitement may be followed by syncope. Frequently there is dyspnoea, which may amount to orthopnea, with cyanosis. Interference with the heart's action may lead to oedema, especially of the extremities, in some cases assuming the proportions of an anasarca. There may be distention of the cervical veins, with venous pulsation, dysphagia, and cough, sometimes aphonia, from pressure on the recurrent laryngeal nerve. Usually the patient lies upon the back, in a semirecumbent posture. The urine is high colored, and may contain albumin and blood, rarely casts. Pericarditis—physical signs: Inspection may reveal distention of the ribs, especially in children, and the presence of consider- able effusion. There may be more or less restriction of the respiratory movements. Sometimes a large effusion produces only widening and bulging of the intercostal spaces, because of the inelasticity of the ribs. The apex-beat may be dis- placed to the left and upward. With absorption of the effusion all these signs disappear. Palpation may or may not detect tenderness over the heart or in the epigastrium. A. friction-fremitus may be felt. There is dislocation of the apex-beat, which may change with the position of the body. EJffusion, causing great distention, may be recognized by palpation. After absorption of the effusion the friction-fremitus may again become perceptible, and the apex-beat resumes its normal position. The friction-sound may disappear from effusion, adhesion, or resolution. Percussion shows enlargement of the heart-dulness, when there is any considerable amount of effusion. Dulness in the fifth intercostal space to the right of the sternum occurs early PERICARDITIS. 295 in pericardial effusion. In extreme cases the dulness may extend from the second rib, sometimes as high as the clavicle, down to the ensitbrm appendix, and from nipple to nipple. Auscultation is of most value in early oliagnosis. Peri- cardial jriction-sounds, varying in character, occur synchronous with the heart-sound, sometimes with respiration. The fric- tion-sounds are heard best during full inspiration with the body inclined forward, and are increased by pressure over the heart. The friction-sounds become less distinct, and finally disappear with the occurrence of effusion. The fieart-sounds become muffed. Upon absorption of the effusion a friction- sound may again be heard, and the heart-sounds again become normal. The friction-sounds finally entirely disappear with absorption of the fibrin or adhesion of the pericardial sur- faces. Diagnosis : The symptoms may be suggestive, but a diag- nosis can be made only upon physical examination. The pericardial friction-sound and the evidence of effusion, espe- cially dulness in the fifth intercostal space on the right of the sternum, the precordial dulness later assuming the shape of the pericadial sac, with the base of the triangle above, are characteristic. Aspiration may be necessary to detect effu- sion, anol at the same time will reveal the character of the effusion. Sometimes aspiration may not detect fluid in the pericardium even when present, Differentiation concerns especially endocarditis, pleurisy, hypertrophy of the heart, mediastinal tumors, and irritation or inflammation of the stomach. The prognosis varies with the cause, extent, and character of the inflammation and the general condition of the patient, especially the strength of the heart-muscle. The mortality is high at the extremes of life. The outlook is bad in tubercu- lar or purulent pericarditis. In all cases the prognosis should be guarded. Usually the cases due to rheumatism are lighter than those due to Bright's disease, pyaemia, or scurvy. Pericarditis—treatment: The first requisite is absolute rest in bed. Cold applications—an ice-bag or Leber's coil—may be used early. Sometimes these are not tolerated, when they mav be substituted by hot applications. It is better to keep 296 DISEASES OF THE ORGANS OF CIRCULATION. the patient on a fever-diet; milk and eggs form the best food. Opium, best in the form of Dover's powder, or morphine, may be given to relieve pain and quiet the heart's action. Violent action of the heart is best relieved by rest and the application of cold. Temperature that is excessive may be controlled by sponging with cold water. In the treatment of pericarditis due to rheumatism the sali- cylates are advised. DaCosta believes them useless, and that they may do harm by depressing the heart, Weak and irregular action of the heart may be met with digitalis. Large effusions may demand paracentesis, best in the fifth interspace about two inches to the left of the median line. Potassium salts, especially the iodide, acetate, and citrate, best in combination with digitalis, have been recommended to promote absorption of the effusion. In the presence of fever and irregular pulse quinine may be administered, gr. iij-v every four hours. Purulent cases should be treated surgically, by incision and drainage. PERICARDIAL EFFUSIONS. Effusions into the pericardial cavity, according to their char- acter, are known as tiydropericardium, or hydrops pericardii, clear fluid in the pericardium ; hiemopericardium, blood in the pericardium ; pyopericardium, pus in the pericardium; and pneumopericardium, when there is air in the pericardium. DISEASES OF THE HEART. It is now believed that both contraction and dilatation of the arteries and heart are active processes. In embryonic life an aggregation of cells takes place in the middle germinal layer, which forms a network in the area pellucida. Within these cells, cavities develop, the primary capillaries, from which there are offshoots, the secondary vessels, which trav- erse the body as bloodvessels. The heart, which has been aptly described as a quadruplication of the bloodvessels, is de- veloped later. HYPERTROPHY AND DILATATION OF THE HEART. 297 ATROPHY OF THE HEART. Atrophy of the heart may be partial, involving only a part of the heart; or complete, involving the whole heart. Etiology: Sometimes the condition is congenital. A partial atrophy may be due to chronic endopericarditis. Usually acquired atrophy of the heart is general, associated with gen- eral wasting of the body. Thus we find atrophy of the heart in the marasmus of phthisis, cancer, diabetes, amyloid degen- eration of the kidneys, etc. The walls of the heart may show atrophy from arteriosclerosis. Atrophy—symptomatology: The heart's action becomes weakened, the pulse feeble, the impulse of the heart dimin- ished. Usually other evidences of marasmus are present. The area of heart-dulness is diminished. With weakness of the heart muscle the first sound becomes muffled and may not be heard ; the second sound may be accentuated. Diagnosis: Is made by the marasmus, atrophy of other organs, weak heart-action, and diminution of the area of heart-dulness. The prognosis takes color with the cause. The immediate outlook depends upon the condition of the heart. Atrophy—treatment: This should address the cause. A flagging heart calls for the judicious use of heart-stimulants. Probably one of the best is strychnine. Above all, the indi- vidual should live a pleasant life in an abundance of fresh air and sunshine. HYPERTROPHY AND DILATATION OF THE HEART. Cases of hypertrophy of the heart may be divided into (1) hypertrophy caused by some obstruction within the heart, especially valvular disease; and (2) so-called "idiopathic" hypertrophies, the cause of which may be : (a) disease of the heart-muscle, especially infection, over-strain and degenera- tion ; (b) some obstruction in the vascular system outside of the heart, especially arteriosclerosis ; and (c) affections of the nervous system. In some cases the cause may not be found, when the condi- 298 DISEASES OF THE ORGANS OF CIRCULATION. tion may be properly classed as a eryptogenetic hypertrophy. Hypertrophy is caused by some obstruction to the circula- tion, and is compensatory so long as it overcomes the ob- stacle. Diseases of the heart-muscle which may cause hypertrophy and dilatation of the heart are: (1) fatty degeneration; (2) myocarditis; (3) tumors of the heart (myomata, cysts, malig- nant growths); and (4) parasites (cysticerci, echinococci). Resistance within the vascular system, which may cause hypertrophy and dilatation of the heart, may be due to : (1) Fig. 34. Superficial cardiac dulness (approximate) (Flint). congenital contraction of the vessels; (2) arteriosclerosis; (3) muscular effort (hard work, strain); (4) plethora (excess in eating and drinking); (5) pregnancy ; (6) disease of the kid- HYPERTROPHY AND DILATATION OF THE HEART. 299 ney (Bright's disease); (7) diseases and deformities of the chest (emphysema, kyphosis). Among the affections of the nervous system that may cause hypertrophy and dilatation of the heart are: (1) mechanical irritation of the vagus nerve (tumors, enlarged lymphatic glands, Basedow's disease); (2) chemical irritation of the vagus (alcohol, tobacco, coffee, tea); (3) psychic irritation (domestic troubles, business worries); (4) excess in venery. Symptomatology : Hypertrophy of the heart is indicated by increased pulse-tension, dislocation of the apex-beat to the left, increase of the impact of the /wart and dulness, accentuation of the second aortic valve sound. The increased blood-supply may cause headache, epistaxis, and polyuria. Dilatation of the heart is indicated by the signs of a failing heart, frequent and small pulse, dyspnoea, bronchitis, asthma, headache (caused by anaemia of the brain), and (edema, first of the ankles and eyelids, sometimes of the lungs, which may finally amount to anasarca. Dilatation may cause a valve to become insufficient in the absence of any disease of the valve itself. Such relative in- sufficiency or incompetency is most frequently found in the tricuspid valves, due to dilatation of the right ventricular orifice, most frequently the result of mitral regurgitation. In such eases a bruit may be heard over the ensiform cartilage. Diagnosis: The symptoms of most value in the diagnosis of hypertrophy of the heart are : (1) the dislocation of the apex to the left; (2) accentuation of the second aortic valve sound ; (3) increased cardiac impact and dulness; (4) the full pulse; and (5) evidence of increased blood-pressure in various organs (headache, epistaxis, polyuria). Dilatation of the heart is recognized by the weakened heart's action, frequency of the pulse, tachycardia, palpitation, dysp- mea upon slight exertion, reduction in the quantity of urine, with usually enlargement of the liver, later oedema. Soon the urine assumes the character of the urine of stasis—high colored, containing hyaline casts. Most important is the discovery of the cause : syphilis, alcohol, Bright's disease, tobacco, coffee, tea, valvular dis- ease, etc. 300 DISEASES OF THE ORGANS OF CIRCULATION. The differential diagnosis concerns especially (1) pericardi- tis, in which the area of dulness takes the form of the peri- cardial sac, with the base upward ; the impact of the heart and the apex-beat are weak and sometimes may not be felt upon palpation ; and there are the characteristic friction-sound, fever, pain, etc.; and (2) aneurism of the aorta, in which there is the aneurismal bruit or thrill. The heart may be hyper- trophied in cases of aneurism of the aorta. The prognosis depends upon (1) the condition of the heart. In compensatory hypertrophy the prognosis is good. The out- look becomes bad when the hypertrophy gives way to dila- tation. (2) The prognosis depends largely upon the cause. The prognosis is good in the hypertrophy of pregnancy ; but preg- nancy may make the prognosis worse when it occurs in the course of disease of the heart. The outlook is not bad in hypertrophy clue to excess in venery, or the abuse of tobacco, tea, or coffee, if such excess or abuse be discontinued. The prognosis is more grave in arterio-sclerosis and Bright's disease. (3) The prognosis takes color with the occurrence of cer- tain symptoms : uraemia, cyanosis, and tachycardia are grave signs. (4) The outlook is bad when the heart no longer responds to digitalis or other heart-stimulants. Prophylaxis: Care should be exercised not to break clown an hypertrophy that is compensatory. This calls for control of the emotions, especially worry, anger, and fear; and avoid- ance of excesses, strains, and exposures. Treatment: Tumultuous action of the heart may be con- trolled by rest and cold applications (cold compresses, ice-bag) over the heart, and the administration of the bromides, sodium bromide, gr. xx-xl in a glass of water, or Selters water. The symptoms of dilatation call for rest, best in bed in the recumbent posture, whereby the greatest relief is obtained from dyspnoea, palpitation, and heart-failure. Upon recovery of the tone of the heart, marked bv im- provement in the pulse and an increased secretion of urine, judicious exercise of the heart-muscle may be recommended. MYOCARDITIS. 301 Such exercise is secured by very gradual increasing gymnastic exercise, best in the open air, but never continued to the point of fatigue. Contraindications to such exercise are acute myo- carditis and acute dilatation of the heart. The diet should be light and nutritious, and may consist largely of milk. Compensatory hypertrophy should not be interfered with by the administration of heart-stimulants. With the breaking of compensation heart-stimulants become useful. Digitalis stands first. In mild cases the tincture of digitalis, gtt. v-x, may be given every three or four hours ; in more severe cases the infusion of digitalis, teaspoonful to a tablespoonful at the same intervals. Digitalis is probably more effective in the form of the powder, a grain ever}- two to six hours. Sooner or later digitalis disturbs the stomach, when it may be substituted by the tincture of strophanthus, gtt. v-x every three or four hours, or the sulphate of sparteine, in the same dose as the sulphate of morphine. The heart may be sup- ported for a long time by strychnine, in the form of the tinct- ure of mix vomica, gtt. x-xx, or of the sulphate or nitrate of strychnine, gtt. x of a grain-to-the-ounce solution three times a clay. The sodium benzoate of caffeine, gr. iij-v, especially when injected subcutaneously, acts more readily. Nitroglycerin is especially valuable in the cases due to kidney disease (see Treatment of Heart-failure). Further treatment is symptomatic. MYOCARDITIS. Inflammation of the myocardium, heart-muscle, may be acute or chronic ; circumscribed or diffused ; parenchymatous, in- volving chiefly the muscular fibres; or interstitial, involving chiefly the interstitial tissue. Etiology: Circumscribed myocarditis may be caused by em- bolism in the coronary artery or its branches, or by septicaemia. The disease is often associated with ulcerative endocarditis, puerperal fever, malignant pustule, acute articular rheumatism, diphtheria, or typhoid fever, and with purulent or gangrenous affection of the lungs. 302 DISEASES OF THE ORGANS OF CIRCULATION. Acute diffuse myocarditis, whether parenchymatous or inter- stitial, usually is caused by the infections, especially sep- ticaemia, typhoiol fever, diphtheria, pneumonia, and gonor- rhoea. Chronic myocarditis also may depend upon the infections, especially acute articular rheumatism, malaria, syphilis, gout, diabetes, Bright's disease. Many cases are caused by alcohol, tobacco, and lead. Probably most cases are ascribed to cold, trauma, or strain. Myocarditis is frequently due to the ex- tension of inflammation from the endocardium or pericardium. Symptomatology : Symptoms of myocarditis may be absent or overshadowed by endocarditis or pericarditis. As a rule, the heart is not able to do its work so well. Slight exertion causes palpitation and shortness of breath. There may be pain in the region of the heart, extending to the right arm or epi- gastric region. The apex-beat, impact of the heart, and the heart-sounds are weakened, indicating a weak heart. The pulse becomes weak and irregular. Frequently the respi- ratory passages show catarrh. Digestion is impaired. All the organs suffer from the poor blood-supply. The individual is cyanotic. The veins of the neck are distended. The diagnosis rests chief!}' on the evidence of a weak heart and the history of some disease that may play a role in etiology. The prognosis is always grave, but recovery is the rule. The outlook is better in typhoid fever than in scarlet fever or diphtheria. The occurrence of pericarditis or endocarditis adds to the gravity of a case. The prognosis is bad in Bright's disease. Failure of digitalis is a bad sign. Prophylaxis: The patient should take very carefully gradu- ated exercise during convalescence from the infections—diph- theria, typhoid fever, etc. Excesses in gymnastics, vencry, drinking (especially alcohol), and eating should be avoided. As far as possible the infections and obesity should be pre- vented. The proper treatment of the infections will do much to lessen the number of cases of myocarditis. Treatment: The patient with acute myocarditis should ob- serve absolute rest in bed, and not arise from the recumbent posture under any pretext. This implies the use of the bed- ENDOCARDITIS. 303 pan, and not permitting the patient to sit up when being ex- amined. The best single article of diet is milk, to which may he added fruit, fish, and the white meat of fowl. The supper should always be light, consisting only of a glass of warm water or weak tea. In chronic myocarditis the patient should take carefully graded exercise, best in the open air. Such exercise delays or stops degeneration of the muscular fibres of the heart. Some times a change of climate is advisable. Bad cases may prefer the seashore, especially during the summer. It may be better to go to a warmer climate during the cold months. With improvement or with the beginning of treatment in light cases the heart may be given additional exercise by altitude, which at first should not be too high. ('ases of emphysema, asthma, and chronic bronchitis should lead neither a too active nor a too indolent life. The effect of toxins upon the heart is met by quinine, gr. iij every three or four hours. The heart should be supported by strychnine, best hypodermatically. Further support of the heart calls for digitalis and the treatment given under Heart-failure. The sulphate of sparteine, gr. -1 may be given hypodermatically several times a day; or camphor dissolved in oil or ether, hypodermatically ; or the sodium benzoate of caffeine, internally or hypodermatically. Friction of the skin, especially of the extremities, hot applications, and mustard-plasters address the heart. The hot bath may be \\iradion, even in the absence of exercise, as in rest and sleep. Thrombosis may occur, most frequently in the femoral vein. The plugging of a cerebral sinus may cause death. The diagnosis is easy in the presence of typical changes in the blood. Before such changes occur the diagnosis is diffi- cult, In all cases an attempt shoulol be made to rule out per- nicious anaemia and the secondary anaemias. The prognosis is usually favorable. Chlorosis—treatment: Bad cases should be confined to bed. Persistent cases may require a change of climate. Usually the disease responds readily to iron. A good form of iron is the improved Bland pill. Arsenic may also be given, prob- ably best as Fowler's solution or Roncegno water. Constipa- tion is relieved by cascara or the pill of aloes and iron. Symp- toms on the part of the stomach may be met with lavage and the administration of dilute hydrochloric acid, gtt, x-xx in a wineglassful of water before meals. Sometimes it is advan- tageous to use some bitters, the infusion of condurango, calumbo, absinthe, or the aromatic tincture of rhubarb. Bad habits and bad hygiene should be corrected. Nux vomica or gentian with bicarbonate of sodium often give good results. PERNICIOUS ANEMIA. The etiology is obscure. Upon the discovery of a cause, most observers no longer classify cases as pernicious anaemia. Thus, many cases, which formerly would have been classified as pernicious anaemia, are now known to be infections by animal or vegetable parasites—c. g., helminthiasis, malaria, tuberculosis, syphilis, etc. Pernicious anaemia is most frequent in middle life, thirty 22— P. M. ■ASS DISEASES OF THE BLOOD. to Mxty years, although cases have been reported in infancy and old age. Pernicious anaemia—symptomatology: The disease comes on gradually with pallor, sometimes with a light icterus. The patient complains of weakness and dyspmra. (Edema appears first about the ankles and eyelids; later there, is effusion into the serous cavities. Notwithstanding the anaemia and degra- dation in strength, the nutrition of the body siffers no or only slight impairment. There may even be some fat apparent. Emaciation is the exception. As a rule, there is more or less irregular continuous fever. There is usually anorexia and an offensive breath, and frequently there are periods of nausea and vomiting. Occasionally patients complain of a voracious appetite. There may be constipation or diarrhoea. Physical examination may show enlargement of the liver and spleen. the most frequent symptom on the part of the nervous sys- tem is headache ; there may be neuralgias, paraesthesiae, pareses, apoplectiform attacks and delirium, numbness, tingling, lanci- nating pains, spasms, and delusions and hallucinations of sight and hearing. Hemorrhage occurs often, especially from the nose and gums. Retinal hemorrhage is not infrequent. Palpi- tation, vertigo, and faintness are common. Svstolic ancemic murmurs may be heard over the base of the heart. Some cases show the Corrigan pulse. Examination of the chest may reveal the moist rales of passive congestion, and some- times the presence of hydrothorax. Most important are the symptoms on the part of the blood. The blood is pale and thin. The number of red blood-cor- puscles varies from 1,000,000 to 500,000 or less per cubic millimetre. The reduction of red blood-corpuscles does not bear a direct ratio to the apparent, health of the individual. The haemoglobin usually shows a relative increase. The num- ber of white blood-corpuscles may be increased or diminished. The blood-plates are decreased in number. Poikilocytosis fre- quently occurs, but is not pathognomonic of pernicious anaemia. Xummulation is imperfect or absent. The red blood-corpuscles are increased in size. Shattuck and Cabot, found a red blood- corpuscle measuring 17 by 19.6 p.. The normal is about i.5 u. The nucleated red blood-corpuscles are characteristic THE SECONDARY ANJEMIAS. 339 in the predominance, of megaloblasts, and atypical corpuscles, and the diminution of normoblasts. The number of nucleated red blood-corpuscles may vary widely in the same case from time to time. Polychromatophi/ic, nucleated red blood-cor- puscles, the protoplasm of which shows an affinity for Ehrlich's tri-color mixture, are found in pernicious anaemia more frequently than in other anaemias. The leukocytes are diminished in number, but there is a relative increase in the number of the small mononuclear leukocytes. There is a small number of myelocytes, which occur in large numbers in splenic myelogenous leukaemia, and are occasionally found in chlorosis and the secondary anaemias. The diagnosis is made by an examination of the blood. Secondary anaemias should be excluded. Every effort should be made to find the cause. The prognosis is grave, but not necessarily fatal. The dura- tion of life is usually about one or two years, rarely three or four years. Hope lies largely in the discovery of the cause, when the case becomes one of secondary anaemia rather than of pernicious anaemia. Pernicious anaemia—treatment is largely symptomatic. Fow- ler's solution of arsenic, beginning with gtt. ij doses and in- creasing to tolerance, deserves a trial. THE SECONDARY ANEMIAS. Secondary anaemia is found especially in cases of gastric ulcer, menorrhagia and metrorrhagia, hemorrhoids, haemophilia, and traumatism; poisoning by lead and arsenic; malaria, syphilis, tuberculosis, leprosy, typhoid fever, septicaemia, Bright's disease, cirrhosis of the liver, and malignant disease. Symptomatology: The individual is pale and suffers from muscular weakness, dyspnoea, vertigo, syncope, anorexia, vom- iting, and emaciation. The diagnosis has to do chiefly with the discovery of the cause, upon which the prognosis depends. The treatment, aside from address to the cause, consists largely in the administration of iron and arsenic, and an abundance of nutritious food. Persistent cases may be bene- fited by a change of residence to a higher altitude. 340 DISEASES OF THE BLOOD. LEUKOCYTOSIS. In leukocytosis there is an increase in the number of leuko- cytes in the peripheral blood. The average number of white blood-corpuscles to the cubic millimetre of blood varies nor- mally from 5000 to 10,000 ; in leukocytosis the number may reach 70,000 or more. The proportion of white to red blood- corpuscles, which normally varies from 1 : 400 to 1 :1000, may reach in leukocytosis 1 : 50, or even 1 :5 (Litten) in the death agony. Leukocytosis occurs normally, or physiologically, in the new-born ; after the digestion of proteids ; during increased blood-pressure after exercise, massage, electricity and cold baths; especially during the later months of pregnancy; during the puerperium, gradually decreasing after the first day ; and in the moribund state, and just before death. Leukocytosis occurs abnormally, or pathologically, after hemorrhage, corresponding in degree with the anaemia pro- duced rather than with the amount of blood lost ; and in the infectious diseases. Perhaps the most marked leukocytosis has been found in the bubonic plague, in which 200,000 has been observed (Aoyoma). Leukocytosis occurs in some cases of diabetes; in the so- called uric-acid diathesis ; in cases of poisoning by illuminat- ing-gas ; after injections of ergotin and tuberculin or of the normal saline solution ; during and after ether-narcosis ; after the internal use of the salicylates; and in cases of malignant disease, especially when of rapid growth. Malignant disease may interfere with the ingestion of food, and thereby cause a decrease in the number of leukocytes. The following diseases are marked by an absence of leukocy- tosis : Pure infections by the typhoiol bacillus or tubercle bacillus, although typhoid fever and tuberculosis frequently show leukocytosis, due to the secondary septicaemia in these diseases ; malaria, measles, leprosy, and intestinal obstruction, when not of a malignant character, and probably in influenza and cystitis. Treatment should address the underlying disease. LEUKjEMIA. 341 LEUKEMIA (Leukocythemia). Leukaemia is distinguished by a reduction of both red and white blood-corpuscles, a relative increase of the white blood- corpuscles, and the general signs of anaemia. The disease may be conveniently divided into: (1) Splenic- myelogenous leuhemia, in which there is an increased number of myelocytes, corpuscles which are believed to originate in the bone-marrow, with little alteration in the size of the spleen or lymphatic glands; and (2) Dymphatic leukwmia, in which the lymphatic glands show enlargement, with an in- crease in the number of leukocytes and a relative increase of the small mononuclear leukocytes as compared with the other white blood-corpuscles. Mixed forms are common. The etiology is obscure. Most cases occur in men in mid- dle life. Leukcemi'a is believed by many to be an infectious disease. Such an opinion is supported by the observation of Obrastow. An attendant who had charge of a case of lymph- atic leukaemia and came into intimate contact with the case began to show the symptoms of the disease forty days later. The case in the attendant ran a course similar to that in the first patient, Both cases were fatal. Transitions from leukaemia to pernicious anaemia, and vice versa, and from Hodgkin's disease to leukaemia, have been reported. Among the conditions to which leukaemia has been attrib- uted are malaria, syphilis, pregnancy, parturition, the climac- teric, mental strain, traumatism, and heredity. Leukaemia is probably not caused directly by any of these conditions. Leukaemia—symptomatology : There are the usual symptoms of ancemia. The skin and mucous membranes are pale, the patient complains of palpitation of the heart, early fatigue, shortness of breath on slight effort, and hemorrhage, especially epistaxis. Hemorrhage in the brain may be fatal; bleeding may also occur in the subcutaneous tissue, in the stomach, or in the bladder. Hemorrhage is most common in acute lym- phatic leukaemia, occurring most frequently from the gums. Frequently there is diarrhoea, which is obstinate to treatment. The disease affects especially the spleen, or the lymphatic 342 DISEASES OF THE BLOOD. glands, or the bone-marrow. The spleen may push the heart upward and interfere with its action. The liver is often en- larged. Dropsy is not uncommon. There is often fever, ap- parently without cause. The blood is normal in color or somewhat pale, but in not so fluid as normal blood. There is usually a diminution of the hemoglobin. Splenie-myelogenous leukwmia shows an enor- mous' increase in the number of leukocytes, averaging about 350,000 ; and also a large number of myelocytes. Myelocytes may be present in pernicious anaemia, but are much more numerous in leukaemia, averaging 37 per cent,, or 80,000 per cubic millimetre. The polymorphonuclear cells show a rela- tive decrease, but absolute increase in number. Lymphocytes anol large mononuclear cells are present in small numbers. There may be a slight increase in the eosinophile cells. In lymphatic leukwmia about nine-tenths of the white blood-corpuscles are small lymphocytes. A few myelocytes are usually present. Diagnosis: Affection of the lymphatics, spleen, or marrow of the bones, in a patient with the appearance and symp- toms of anaemia points strongly to leukaemia. An absolute diagnosis can be made by an examination of the blood, whereby the different varieties of the disease may also be recognized. The prognosis is bad. Most cases die within two years, and only very rarely does life extend beyond four years. As in pernicious anaemia, about the only hope is that the cause may be found. Leukaemia—treatment is symptomatic. The use of large doses of quinine or of Fowler's solution sometimes is bene- ficial A diet made up chiefly of carbohydrates, and contain- ing little of the proteids, has been recommended, since it has been proven that the proteids are poorly assimilated. PSEUDOLEUKEMIA (Hodgkin's Disease). Pseudoleukaemia bears a strong resemblance to leukemia. Transition-cases have been reported. Pseudoleukaemia is marked by enlargement of the spleen or lymphatic glands or THE HEMORRHAGIC DIATHESIS. 343 both ; sometimes with enlargement of the lymphatics in various parts of the body. The etiology is obscure. Many observers believe the dis- ease to be due to an infection. Pseudoleukaemia occurs most frequently in men under forty. Symptomatology: Aside from the symptoms of anaemia pseudoleukaemia is distinguished by the presence of pressure- symj>toms, clue to enlargements of the lymphatics or lymphatic glands. Examination of the blood reveals as a rule no increase of the white blood-corpuscles. Of course, an increase of the white blood-corpuscles may appear as a coincidence, and not infrequently is present in cases of suppuration of an en- larged gland ; but the leukocytosis is never marked ; nor is there much degradation of the red blood-corpuscles, except toward the end of the disease, when they may number only 2,000,000. The reduction of the amount of haemoglobin goes along with the reduction in the number of the red blood- corpuscles. There may be an increase of the lymphocytes or of the large mononuclear leukocytes. Myelocytes are some- times present in small numbers, and occasionally normoblasts may be found. The diagnosis depends upon the symptoms of anaemia, the pressure-symptoms, examination of the blood, and the exclu- sion of tubercular adenitis and syphilis. When the spleen alone is affected, malaria, leukaemia, rickets, and amyloid dis- ease must be excluded. The prognosis is grave. Acute cases may run their course in a few weeks. As a rule the course is not so rapid as in leukaemia. Usually the disease lasts for a number of years. Hope lies largely in finding the cause. Occasionally cases recover. Treatment: The best single remedy is arsenic, which should be given both internally and hypodermatically. Further treatment is symptomatic. THE HEMORRHAGIC DIATHESIS. Definition: A disposition to hemorrhage upon slight injury is sometimes inherited. More frequently the condition is ac- 344 DISEASES OF THE BLOOD. quired as a sequel to some infection, especially typhoid fever or smallpox; less frequently yellow fever, septicaemia, or diphtheria. The hemorrhage may come from the capillaries, per diapedesin, or from the larger vessels, per rhexin.^ Bleed- ing occurs most frequently from the nose and intestine ; less frequently from the mouth, lungs, bladder, uterus, etc. Triv- ial insult may cause hemorrhage from any surface or into serous membranes and internal organs (brain). Prognosis: Crave. Treatment: Epistaxis may be arrested by plugging the nares. In general, hemorrhage may be controlled by rest, ice, tampons, and the internal use of opium, atropine, acetate of lead, digitalis, and the subcutaneous use of ergotin and sclerotinic acid. Further treatment is the same as for anaemia. Haematidrosis (sweating of blood): A rare condition in which blood-corpuscles escape through the ducts of the sweat- glands in the presence of an unbroken skin. PURPURA. Definition: A class of affections characterized by the ex- travasation of blood into the skin. Symptomatic purpura may be caused by the infections, sep- ticaemia, and especially malignant endocarditis. Typhus fever, measles, scarlet fever, and smallpox are characterized by a purpuric rash. Toxic causes of purpura are snake-bites and occasionally certain drugs: copaiba, quinine, belladonna, mercury, ergot, and the iodides. Sometimes purpura appears in cancer, tuberculosis, Hodgkin's disease, Bright's disease, scurvy, and in old age. So-called myelopathic purpura may appear in locomotor ataxia. Purpura may also be found in acute myelitis, trans- verse myelitis, occasionally in neuralgia, and the stigmata of hysteria. Sometimes purpura occurs in cases of venous stasis, such as may occur in the paroxysms of whooping-cough and in epi- lepsy. Arthritic purpura is characterized by the affection of joints. In purpura simplex the process is limited to a portion of the HAEMOPHILIA. 345 body, usually the lower extremities, either with or without involvement of the joints. There is often an associate diar- rhoea. Purpura rheumatica, Schonlein's disease, is characterized by the affection of a number of joints and an eruption. Purpura urticans is a combination of wheals and purpura. In pemphi- goid purpura there is an associated vesication. Sometimes there is oedema, constituting the condition known as febrile purpuric oedema. Schonlein's disease is characterized by mul- tiple arthritis, purpura, and urticaria. Henoch's purpura usually occurs in children and is charac- terized by numerous relapses and recurrences, cutaneous lesions, affection of joints, hemorrhages into the mucous mem- branes, and gastro-intestinal crises : pain, vomiting, and diar- rhoea. Not all these symptoms are necessarily present in every case. Purpura hemorrhagica includes the cases of very severe pur- pura with hemorrhages from the mucous membranes. Some- times cases prove fatal within a day, purjjura fulminans. Death may occur before there is hemorrhage. Favorable cases of purpura haemorrhagica recover in ten days to two weeks. The diagnosis calls for the exclusion of scurvy, and the recognition of smallpox and measles. Treatment: Any apparent cause, such as may usually be found in symptomatic purpura, should be properly treated. For further treatment see the Treatment of the Hemorrhagic Diathesis. HAEMOPHILIA (An Hereditary Hemorrhagic Diathesis). Etiology: The disease is usually transmitted through a mother who is not herself affected, but is the daughter of a bleeder. The great majority of cases occur in males, as a rule within the first two years of life. The skin is usually fine and soft, and the individuals appear perfectly healthy. The cause of the condition is unknown. Symptomatology: Slight lesions are followed by excessive bleeding. Usually the condition is first recognized as an epis- taxis ; sometimes by hemorrhage from the mouth, stomach, 346 DISEASES OF THE BLOOD. bowels, urethra, lungs ; more rarely from the skin of the head, tongue, finger-tips, tear-papilla, eyelids, external ear, vulva, navel, or scrotum. Even so slight an operation as the extrac- tion of a tooth may prove fatal. Traumatisms that do not cause lesion of the skin or mucous membrane may be followed bv the formation of petechiae or even large lucmatonmta. There is often arthritis, involving especially the large joints. Prognosis : The outlook is grave, although individuals usu- ally do not die from the first hemorrhage. The disease may be persistent even for years, so that the individual exception- ally may reach an advanced age. Treatment: As prophylactic measures, individuals known to be bleeders or from suspicious stock, should be guarded from injury anol not subjected to operations. The daughters in bleeder families, even though apparently unaffected, may transmit the disease to their descendents, without themselves showing any evidence of haemophilia. When bleeding occurs the usual remedies for the control of hemorrhage should be tried. As styptics, a solution of fibrin-ferment and sodium chloride, the application of fresh blood, and the use of a 5 per cent, solution of gelatin, have been recommended. Further treatment is addressed to the general condition of the patient, with exercise in the open air, nutritious food, and the use of tonics, especially iron and cod-liver oil. SCURVY (Scorbutus). Definition: A disease characterized by hemorrhage, spongy gums, cachexia, anol marasmus. Etiology: The disease seems to depend upon an imper- fect food-supply, especially the absence of those elements of food supplied by fresh vegetables. Many observers be- lieve the true cause to be some micro-organism. Others would attribute the disease to a decreased alkalinity of the blood. Probably both views are correct, Symptomatology: The onset is insidious. There are pro- gressive loss of st re ngtfi and weight, and the anaemia and de- pression of spirits characteristic of cachexia. Ttie gums are ADDISON'S DISEASE. 347 swollen and bleed easily, become spongy, ulcerated, necrosed, and covered with foetid debris. The affection of the gums is confined to the region of the teeth. The breath is offensive. Epistaxis is frequent. Soon there is the picture of a general he m orrfi agio diathesis. Diagnosis: The recognition of scurvy is easy in the pres- ence of an epidemic. Isolated cases may be recognized by knowledge of the character of the food used by the indi- vidual, in the presence of characteristic symptoms, and the im- provement of the symptoms following the use of proper food. Prognosis : Much depends upon the strength of the patient, the stage of the disease, and the ability to secure proper food. Prophylaxis: The disease may be prevented by the use of fresh food, especially vegetables. Scurvy—treatment: At first the juio:e of lemons or oranges may be given ; later, apples, lettuce, potatoes, cabbage, water- cress, sauer-kraut, spinach, onions, dandelions, and other fruits, vegetables, and greens may be added. The mouth should be cleaned and kept clean. Various antiseptic and astringent washes are recommended : peroxide of hydrogen, solutions of creolin, permanganate of potassium, and dilute carbolic acid. The gums may be treated with a solution of nitrate of silver. Constipation is best relieved by enemata. ADDISON'S DISEASE (Morbus Addisonii; Bronze-skin Disease). Definition: An affection of the suprarenal capsules, charac- terized by pigmentation of the skin, progressive anaemia, cachexia, gastro-intestinal catarrh, depressed circulation, and marasmus. Etiology: The disease is rare in this country. ^ Males are most frequently attacked. The most common lesion is tuber- culosis of the suprarenal capsules. The disease depends upon a loss of function of these bodies. Carcinoma of the supra- renal capsules is rare. Traumatism seems to play a role in some cases. Addison's disease—symptomatology: Usually the onset is insidious, with anaemia and general debility. The action of the heart is feeble. There are symptoms of gastro-intestinal 348 DISEASES OF THE BLOOD. catarrh, nausea, and vomiting, later pain and retraction of the abdomen, sometimes severe anorexia, and at times diar- rhoea. The most characteristic lesion is the bronze pigmenta- tion of the skin, which may vary in color from light yellow to brown or even black. The pigmentation occurs first where there is normally a deposit of pigment, around the nipples and genitals ; or where there is some irritation of the skin, as about the waist-band. The mucous membranes of the mouth, conjunctivae, and vagina show pigmentation. There may be patches of pigment in the serous membranes. Usually the bronze color is first observed on the face and hands. The pigmentation may be diffuse. There is degeneration of the suprarenal bodies. Diagnosis: The recognition of the disease depends upon the presence of the characteristic pigmentation, progressive cachexia, anol marasmus. Differential diagnosis has to do chiefly with the separation from abdominal tumors, pregnancy, disease of the liver, pedic- ulosis, argyria ; more rarely exophthalmic goitre, melanotic cancer, scleroderma, ulcer or dilatation of the stomach, and a free eruption of small black comedones. Prognosis: Unfavorable. Rapid cases may reach a fatal termination in a few weeks. Protracted cases may last a number of years, sometimes with periods of improvement lasting for months, rarely with complete recovery. The out- look is usually best in the cases with most marked pigmentation. Addison's disease—treatment: The suprarenal capsule may be administered raw, partially cooked, or in the form of the glycerin extract or^ the dried extract. In a collection of 48 cases treated in this manner, 22 were improved and 6 were reported cured (Kinnicutt). Further treatment is symp- tomatic (see Anaemia). LITH.EMIA (Uric-acidemia; Uricaemia; Lithuria; Lithic-acid Diathesis; Uric-acid Diathesis; American Gout). Definition : An excess of lithic (uric) acid in the blood with the production of symptoms, especially on the part of the nervous and digestive systems. GOUT. 349 Etiology: Lithaemia occurs chiefly in individuals who are subjected to mental strain, worry, and anxiety, who eat too much, drink too little, and suffer from lack of exercise. To- bacco and alcohol often seem to play a role in causation. Other factors are heredity, cold climate, and neurotic temper- ament. Lithaemia—symptomatology: The more common nervous symj)toms are neuralgia, headache, vertigo, hebetude, insom- nia, restlessness, and hypochondriasis. On the part of the digestive system then1 are coated tongue, lost or capricious ap- petite, pyrosis, weight and oppression in the epigastrium, sometimes nausea, vomiting, and gastralgia. There are flatu- lence, constipation, offensive stools, hemorrhoids, sometimes hepatic tenderness. The skin may show pruritus, eczema, ur- ticaria, and lichen. Genito-urinary symptoms are urethritis, cystitis, orchitis, epididymitis, vaginitis, and endometritis (Anders): inflammations that are caused by slight insult in the presence of lithaemia. The diagnosis is made by the presence of a number of the above symptoms. True gout gives a family history of the disease, and presents tophi and distorted joints. Prognosis: Usually good under proper treatment. Lithaemia—treatment: The individual must change his habits of life and subject himself to less worry and excite- ment. He must eat less, especially of meats and rich food, anol drink an abundance of pure water. The cause must be removed. Outdoor life and bathing are beneficial. In the wav of medicines, sodium phosphate and salicylic acid are of value for their action respectively upon the liver and excre- tion of urea. Further treatment is symptomatic. GOUT (Podagra). Definition: A disease characterized by an excessive forma- tion of uric acid ; and the deposition of urate of sodium in the joints; marked by paroxysmal pain anol deformity of the joints, with affection of the heart and kidneys, and marasmus. Etiology: There is a disturbance in metabolism, with ex- 350 DISEASES OF THE BLOOD. cessive formation of uric acid. Cases have been observed in infancy ; but, as a rule, the disease occurs late in life. Hered- ity seems to plav a role in more than half the cases. Gout shows a preference for males. Rich food, the ingestion of alcohol, especially beer and ale, are the most prominent factors in etiology. The disease often occurs in cases of chronic plumbism. Gout—symptomatology: The onset of the disease is usually sudden. The attack comes on often late in the night, with pain of greater or less severity, amounting at first sometimes only to a feeling of uneasiness, localized in a joint, usually the joint of the big toe. The pain becomes excruciating. The attack ceases in the course of an hour or two. The individ- ual resumes his sleep ; and in the morning the joint is found to be red, swollen, tender, and the movements limited. Such at- tacks come on in the midst of apparent health, more often following dyspepsia. The attack maybe repeated the follow- ing night, or after a much longer interval, a month or year, depending upon the habits of the individual, especially with regard to the diet. Chronic cases show characteristic deformities of the joints, due to the deposit of the urate of sodium. There are chronic gastric catarrh, arterio-sclerosis, a.nd affection of the heart arid kidneys. The enlarged joints may show ulceration, with the discharge of a substance composed largely of urate of sodium. The enlargements at first show fluctuation, later pre- sent a doughy sensation, and still later become hard tophi. Gout—diagnosis: Usually there are dyspepsia and other evidence of over-indulgence in rich food and alcohol, espe- cially the malt preparations, beer and ale. The polyarthritis usually, but not invariably, begins in the joint of the big toe. The inflammation remains fixed in the joints affected, which, together with the overlying tendons, become characteristically deformed through the deposit of urate of sodium in tophi (Fig. 37). Gout prefers the small joints. Males are most frequently affected. Examination of the urine shows the elimination of little or no uric acid during the paroxysm ; during the interval the excretion of uric acid is greatly in- creased as a rule. Sometimes gout finds expression in con- GOUT. 351 Fig. 37. junctivitis, iritis, corneal ulcer; or the deposit of tophi in the ear, nose, eyelids, and larynx. Gout should be differentiated from rheumatism, especially from arthritis deformans, in which the disease usually begins in the hands and more fre- quently involves the larger joints. There is usually little or no fever in gout, Prognosis : Good in acute gout. Chronic gout may take life through disease of the kidneys, heart, or brain. Gout — treatment: Most important is the regulation of the life of the individual, especially as to diet and ex- ercise. The use of artificial alkaline mineral water, or better a sojourn at the springs, may sometimes suf- fice even without the use of drugs. The waters usually recommended are Vichy, Carlsbad, and the lithiated waters. The most popular springs are those of Carls- bad, Homberg, Wildbad, in Germany ; Oontrexeville and Aix-les-Bains, France; Bath anol Buxton, in Eng- land ; and Saratoga, Bed- ford, and the White Sulphur Springs in this country. In the way of drugs, most may be accomplished with the wine of colchicum, piperazin, and the salicylates. The limb shoulol be wrapped in cotton-wool. The local application of hot air may be tried. The bowels should be kept open. Cal- omel is often of value early in the disease. Occasionally cases may be benefited by the iodides. Further treatment is symptomatic. Tophi in joints and tendons. 352 DISEASES OF THE BLOOD. ARTHRITIS DEFORMANS (Nodular Rheumatism). Definition: A chronic disease of obscure etiology, charac- terized by progressive, symmetrical deformity of the joints. Etiology : Many observers believe the disease to be a chronic infection ; others "that it is of nervous origin. Most cases are found between thirty and fifty years. The great majority of cases occur in women. Heredity sometimes seems to play a role. There is a history of gout oftener than of true rheu- matism. Exposure to cold, wet, damp, errors in diet, de- pressing mental emotions, prolonged sorrow, grief or dejection, are prominent factors in causation. Arthritis deformans—symptomatology: Usually the onset is insidious. Affected joints first become stiff, especially in the morning, and tender, and later show characteristic deformity. The joints of the hands and fingers are usually first attacked. The fingers are flexed upon the hand anol point toward the ulna; the thumb is not affected. When the disease attacks the foot, the big toe is first involved. The joints become locked, so that in cases of extensive involvement of the joints the patient mav become immovably fixed in the position usually occupied. The disease is marked by great deformity. With exacerba- tions and abatements the disease is progressive. There are im- pairment of the appetite and digestion anol constigmtion, largely due to lack of exercise. The patients become irritable and hypochondriacal. Tfie muscles undergo atrophy. Diagnosis: The only difficulty is offered early in the course of the disease. The disease prefers the female sex, and is comparatively rare under twenty. Permanent deformities are produced in the joints affected. Fever is usually absent. The disease is polyarticular and shows preference for the small joints. The hands and fingers, but not the thumbs, are usually first involved. Prognosis: The disease docs not seem to shorten life. It is chronic, and may be relieved, but not cured. Arthritis deformans—treatment: The pain mav be relieved by hydrotherapy and massage, which also assist the nutrition of the muscles. Electricity is sometimes of value. Arsenic probably does good as a tonic. Iron may be indicated by RICKETS. 353 an.emia. Iodine, best in the tincture, gtt. x, or the iodide of potassium or sodium, given in milk, is recommended. Sali- pyrin, salol, and the salicylates, and phenacetin may be ad- vantageously used during the acute exacerbations. Massage and the local application of hot air sometimes produce good results. Blisters arc of value, especially in chronic cases. Often a change of climate is advisable. RICKETS (Rachitis). Definition: A disease of infancy and childhood, character- ized by gastro-intestinal disturbances, bronchial catarrh, im- paired nutrition, and changes in the bones. Etiology: Some observers attribute the disease to a chronic infection. An essential factor seems to be a faulty diet, espe- cially one deficient in animal fat and proteid (Cheadle). The disease is most frequent from seven months to seven years, rare under six months, and in exceptional cases appears as late as the ninth to the twelfth year. Rickets—symptomatology: There is early gastro-intestinal disturbance, marked by anorexia, and diarrluea or constipation. There are bronchial catarrh and cough. The child becomes restless at night. Sweating occurs, often without apparent cause. There is general soreness, especially sensitiveness of the body. Sometimes cases are announced suddenly by a spasm, especially by laryngo-spasm. There is slight fever. The bones show characteristic deformities. Xodules may be observed at the junction of the ribs and costal cartilages, forming the rickety rosary. The sternum projects, to form the pigeon- or chicken-breast. The upper part of the head is large, compared with the face anol body of the child. Often softened, spots may be made out over the bones of the skull, especially the occipital bone. The fontanclles do not close early. The top of tfie head is more flat than normally. The frontal eminences are prominent. The teeth appear late and often are ill formed. The child grows slowly ; usually the stature is below the normal. The bones are soft ; hence, the frequency of bow-legs. The abdomen is usually large and distended. The bones easily suffer fracture, especially the green-stick fracture. 354 DISEASES OF THE BLOOD. Most dwarfs are rickety. Deformity of the pelvis is often caused by rickets. . . Diagnosis: The disease is recognized by the characteristic changes in the bones. Prognosis: Good. Fatalities depend upon complications. Rickets—treatment: Malnutrition may be avoided by atten- tion to the diet of the child. In cases of rickets the diet should include some fruit, such as lemon- or orange-juice. The child should be placed under good hygienic surroundings, receive plenty of*pure, fresh air and sunshine, and a daily warm bath. 'When the bones are soft the child should not be permitted to remain in one position too long. Of drugs, phosphorus has the best reputation. The remedy is o-iven in cod-liver oil, 1 : 16, a teaspoonful after meals, three times a day. The syrup of the iodide of iron may be added. Further treatment is symptomatic. OSTEOMALACIA. The disease is characterized by softening and consequent deformity of the bones. Etiology: Numerous micro-organisms have been found in osteomalacia. The bones contain an excess of lactic acid; but this is sometimes found in the absence of osteomalacia. Some observers believe the condition due to a disturbance of the centres that preside over nutrition. Symptomatology : The bones become tender, and pain is often first noticed in the pelvis, spine, and thighs, especially during the latter part of gestation. The muscles of the thighs and pelvis may suffer weakness, pain, and spasm. The affected bones become soft and show deformity. The stature of the individual is diminished (Strumpell). Increased knee- jerk and ankle-clonus are prominent symptoms. The disease is confined almost exclusively to the female sex. The affected women are usually above the average in fertility (Eisenhart). Abortion is frequent. The blood shows diminished alkales- cence (von Jaksch), and contains myelocytes and an increased number of eosinophilic cells (Musser). Diagnosis : The disease may be suspected in the presence of OBESITY. 355 pain in the pelvis, spine, and thighs, in women, especially when the pain recurs in succeeding pregnancies. Usually the height is diminished. The softening and deformity of the affected bones are characteristic. Differential diagnosis has to do chiefly with rheumatism, spinal disease, peripheral neuritis, and diffuse infiltration of bones with malignant growths. Prognosis : The disease is usually progressive ; but may fre- quently be brought under control by proper treatment. Osteomalacia—treatment: The use of phosphorus (Stern- berg) and cod-liver oil (Trousseau) has given good results. In the way of surgery, ovariotomy and Porro's operation have both been followed by recovery in a large number of instances. OBESITY (Polysarcia; Corpulence). Definition: An excessive general deposit of fat. Etiology : Obesity occurs especially after forty. Sometimes the condition appears in young persons. The chief causes are excessive eating and sleeping and lack of exercise. Women are most frequently affected. Symptomatology: The development of fat may be termed obesity only when it accumulates to such a degree as to inter- fere with the comfort and health of the individual. Treatment: The individual should eat less, take more exer- cise, best in the open air, and less sleep. The ingestion of fluids should be limited. Probably the best dietaries are those given by Banting, Ebstcin, anol Oertel. Banting reduces the amount of food and drink, and excludes the fats and carbo- hydrates. Ebstcin permits the use of fats and excludes the carbohydrates. Oertel limits the fat, and permits the use of albumin anol starch, anol advises systematic exercise for the purpose of increasing the strength of the heart. Skimmed milk and massage are recommended by Weir Mitchell. Warm baths are of value. Sometimes good results may be secured by the use of the thyroid extract. 356 DISEASES OF THE BLOOD. DIABETES MELLITUS. Definition: A disease characterized by polyuria, glycosuria, and progressive impairment of health and strength. History: Celsus recognized the polyuria and emaciation. Glycosuria was suspected, from the sweet taste of the urine, bv'the Arabian physician Susruta, in the seventh century, and became generally * known when re-discovered by Thomas Willis (1674). The sweet taste was proven to depend upon suo-ar by Matthew Dobson (1775). Cowley (1778) separated the sugar by evaporation. Rollo (1798) introduced the meat- diet and the use of opium in the treatment of diabetes. Chevreuil (1815) observed that the sugar of diabetic urine is the same as grape-sugar. Tiedemann and Gmelin discovered the formati.Mi of sugar from starch during digestion. Am- brosiani (1835) found sugar in the blood of diabetic patients. This Mialhe believed to be due to diminished alkalescence, caused bv suppression of the secretion of the skin. Stosh (1828) observed diabetic coma. Bernard (1856) produced glycosuria by puncture of the floor of the fourth ventricle. Marchel (1852) recognized diabetic gangrene. Frerichs and Von Recklinghausen (1866) observed disease of the pancreas frequently in diabetes; and later Mering and Minkowsky found diabetes to follow extirpation of the pancreas. Etiology : The disease is found more frequently in some places than others. Certain races, for instance, the Israelites, are frequently affected ; while others, especially the negro, seldom show the disease. Most cases occur in the male sex, and at from twenty to fifty years of age, especially between thirty and forty. Only about one-fourth of the cases are found in the female sex. Age anol infancy are not exempt. Sometimes heredity seems to play a role. Diabetics often show disease of the kidneys, blood, nervous system, and pan- creas ; but diabetes may occur in the absence of disease of these organs. Anxiety, luxury, alcohol, and obesity are prominent etio- logical factors. Most cases show arterio-sclerosis. Syphilis probably plays a minor role. Diabetes sometimes appears after trauma, in the course of or after nervous diseases, emo- DIABETES MELL1TUS. 357 tional disturbances, and the infectious diseases. The belief has been advanced that diabetes is contagious. Diabetes follows total extirpation of the pancreas ; but if more than one-tenth of the organ be left, diabetes does not result. It has been demonstrated experimentally that removal of the pancreas is not followed by diabetes if at the same time the medulla or spinal cord be divided in the region of the upper cervical vertebra. Also, experimental removal of the pancreas is not followed by diabetes if the liver be removed at the same time. Diabetes mellitus—symptomatology: The onset is insidious, with anorexia, nausea, headache, and insomnia, symptoms usually ascribed to dyspepsia or neurasthenia. There are thirst and polyuria, the urine discharged in the twenty-four hours amounting to more than three pints, usually four to eight pints, sometimes more. The urine is light colored and foams readily. The reaction is acid ; the specific gravity high, 1030-1040, rarely lower than 1020, nor higher than 1050. Trousseau reported as high as 1074. There is glycosuria, the amount of sugar varying from 2 per cent, or less in mild cases, to as high as 10 per cent. Rarely there is pneumaturia, gas discharged with the urine. Other abnormal ingredients found in dia- betic urine are acetone, acetic aciol, ammonia, anol oxv- butyric acid. The proportion of cases showing albuminuria has been variously given by different observers. Frerichs found albuminuria in 5 per cent, of cases ; Rokitanskv, in 65 per cent. There is not often oedema. Sometimes there is cystitis. The urine may contain short hyaline casts. The appetite is sometimes voracious and insatiable. Never- theless there is progressive impairment of health and strength. As a rule there is constipation. Often there is impotence. The knee-jerk mav be diminished or lost. The increased secretion of urine is in marked contrast with the lessened secre- tion of the skin. Often there is pruritus, especially pruritus vulvae and furuneutosis, sometimes phlegmonous inflamma- tions and gangrene. Cataract is not infrequent. Among the nervous symptoms are headache, neuralgia, par- acsthesia, and coma. Tuberculosis is a frequent complication. 358 DISEASES OF THE BLOOD. Diabetes mellitus—diagnosis : 1, impairment of health ; 2, increased quantity of urine ; and 3, the presence of sugar in the urine. Glycosuria may be detected by the following Tests for Sugar: Bremer's test: The specific gravity of the urine must not be less than 1015. To 10 c.c. of urine, at a temperature of 14° or 15° C, in a test-tube, add gr. -^""To °f niethyl-violet or ethylene-blue. Normal urine does not dissolve methyl- violet; diabetic urine dissolves the dye and assumes a deep violet or bluish-violet tint. When ethylene-blue is used, normal urine gives a green color, and diabetic urine a blue. The test gives a positive reaction when normal urine is diluted with water. Thus the Bremer test might be of value in life- insurance examinations, in the detection of fraud, when indi- viduals are suspected of diluting the urine in order to give a lower specific gravity. Moore's test: To a test-tube one-third full of urine an equal quantity of concentrated KHO is added anol heat ap- plied. Sugar is indicated by a brownish color. Trommer's test: To equal quantities of urine and concen- trated KHO add 1 p r cent, solution of copper sulphate, drop by drop, under gentle heat, as long as the copper sulphate will dissolve. Sugar gives a yellowish or reddish precipitate before the boiling-point is reached. Hain'stest: Hain's fluid: copper sulphate, gr. xxx ; glyc- erin, ?ss ; aquae, sss; liquor potass;e (U. S. P.), Jvv. Heat the test-fluid and add four or five drops of urine. Sugar gives a yellow or red, salmon-colored precipitate. Bottger's test: To equal quantities of urine and KHO add bismuth subnitrate and apply heat. Sugar gives a black color. The test is useless in the presence of albumin. A better bis- muth test is : Nylander's test: Nylander's reagent: Rochellc salt, 4.0; 8 per cent, solution of NaHO, 106.0; add bismuth sub- nitrate to saturation. Method: To ten parts of urine add one part of the reagent and boil two minutes. A black color indicates sugar. DIABETES MELLITUS. 359 Phenyl-hydrazin test: To 6-8 c.c. of urine add phenyl- hydrazin hydrochlorate (twice as much as will go on the point of a penknife) and pulverized acetate of sodium (three point- of-a-penknifefuls). Heat. If the reagent does not dissolve, add hot water. Cool. If sugar is present, there will be formed a yellow precipitate, which may appear amorphous to the naked eye, but under the microscope will be seen to consist of fine needles of phenyl-glucosazon arranged in stars (Fig. 38). Fig. 38. Crystals of phonyl-glucosazon (von Jaksch). Fermentation-test: To 10 c.c. of urine add 1 gramme of commercial compressed yeast (y1^ Fleischmann cake). Shake until the yeast is dissolved. Place in a saceharometer and leave at the room-temperature for twenty-four hours. In the presence of sugar alcoholic fermentation causes the formation of carbonic acid gas, which gathers at the top of the saceha- rometer and causes the fluid to change its level. The percent- 360 DISEASES OF THE BLOOD. age of sugar may be read off the scale. When the specific gravity is above 1022 the urine should be diluted from two to ten times, depending upon the height of the specific gravity, and the reading of the saceharometer should then be multi- plied accordingly. Roberts has observed that urine after fermentation is of lighter specific gravity than before, and that the difference in specific gravity is such that every degree lost is approxi- mately equivalent to one grain of sugar (glucose). The test may conveniently be made by dissolving a cake of Fleischmann yeast in four ounces of urine, taken from the total quantity passed in the twenty-four hours, and placing in a pint bottle in a warm place for twenty-four hours. The bottle should be loosely corked, to permit the escape of the carbonic aciol gas. Four ounces of the urine, tightly corked, are used as a con- trol-specimen. At the end of twenty-four hours the specific gravity of the two specimens is taken ; the difference repre- sents the amount of sugar in grains, and this multiplied by 0.23 will give the approximate percentage of sugar. Prognosis: Asa rule, which is not invariable, the outlook depends upon the amount of sugar in the urine. Most cases are not curable, but usually the disease may be brought under such control that the patient may live to an advanced age. In general, the patients hold their fate in their own hands, for the outlook depends largely on the diet. Severe nervous symptoms, especially coma, are ominous. Cases of acute diabetes, diabetes acuta and acutissima, may terminate in a few weeks or months. As a rule diabetes is chronic, lasting for a number of years or for life. Diabetes mellitus—treatment: Most important is the did. The following diet-list is given by Van Noorden : 8 o'clock, first breakfast. 10.30 o'clock, second breakfast j 3 ounces of ham. < 1 cup of tea. ( 1 glass of cognac. < 2 eggs, fried in 1 ounce of butter. DIABETES MELLITUS. 361 12.30 o'clock, luncheon. 5 o'clock, tea. 7.30 o'clock, dinner. 10.30 o'clock, nightcap. 5 ounces of cold roast meat. Mayonnaise, made with the yolk of 1 egg and 1 spoonful of oil. Raw cucumber, with l ounce of vinegar, 1 spoonful of oil, salt and pepper. ^ ounce of Gorgonzola cheese. l bottle of Moselle. 1 cup of coffee with tablespoonful of cream. 1 cup of tea. 1 boiled egg. 1 glass of cognac. 1 cup of bouillon, with ^ ounce of mar- row. 21 ounces of boiled salmon. itoi pound of asparagus, with | ounce of butter. 1 ounce of smoked ox tongue. 3 ounces of capon. Salad, with |- ounce of vinegar and 1 spoonful of oil. \ bottle of Burgundy. 1 glass of cognac, with Seltzer water. Of drugs, opium is one of the most valuable remedies, but may be used only a short time. Codein has much of the virtue of opium with fewer evils. Some cases respond well to benzosol, the benzoate of guaiacol, in five-grain capsules, one every four hours. Often good results may be obtained with Jambul, the Java plum, or in the form of the fluid ex- tract, TH x, in powders of five to ten grains, gradually increased to gr. 75-150. Relief is sometimes afforded by salicylate of sodium, 5-10 grammes, or benzoic acid, 3-5 grammes. Coma may demand infusion of the normal salt solution (0.6 per cent, of chloride of sodium) into the rectum, under the skin, or in bad eases into the veins. Often good results follow lavage. Gangrene calls for the intervention of surgery. 362 DISEASES OF THE BLOOD. DIABETES INSIPIDUS. Definition: A disease characterized by increased secretion of urine, polyuria, without glycosuria. The condition differs from a simple polyuria, such as may follow the ingestion of large quantities of fluid, chiefly in that there is impairment of the general health. Etiology: The disease shows a preference for youth and for the male sex. Cases have been observed after traumatism, sunstroke, violent emotion, sometimes excessive drinking of cold water, or after a protracted spree, or during convalescence from the acute infections. Many believe the condition to be of nervous origin. Sometimes lesions of the medulla, tumors of the brain, meningitis, have been found in cases of diabetes insipidus. The disease is sometimes congenital. Weil reports twenty-three cases in four generations in a family of ninety- one members, which would seem to indicate a rote played by heredity. Symptomatology: Tfie urine is increased in tpiautity to twenty, forty, or more pints in the twenty-four hours, and is of low specific gravity, 1001-1005, light in color, and con- tains little sediment. With the discharge of so much fluid there is thirst. There may be no impairment of the gen- eral health. Diagnosis depends upon the discharge of a large quantity of urine of low specific gravity, without the presence of sugar. The polyuria of hysteria may be eliminated by the absence of other evidence of hysteria. Furthermore, hys- terical polyuria is more transitory. Bright's disease may sometimes give a large quantity of light urine, but there is always some albuminuria, which is rare in diabetes in- sipidus. Prognosis: The disease usually runs a chronic course. Medication seems to have little effect as a rule. Sometimes spontaneous recovery takes place. Cases have been known to persist as long as fifty years. Usually death results from some intercurrent malady. Diabetes insipidus—treatment: Opium will diminish the amount of urine, but is of doubtful value because of the re- DIABETES INSIPIDUS. 363 mote evils attending its use. Thirst should be relieved by frequent rather than copious libations. Among the remedies recommended are valerian, the valerianate and lactate of zinc, ergot, ergotin, antipyrin, antifebrin, the salicylates, arsenic, strychnine, turpentine, and the bromides. Open-air exercise and the use of electricity are often of value. CHAPTER VI. DISEASES OF THE GENITOURINARY ORGANS. ALBUMINURIA. The presence of albumin in the urine, abuminuria, is caused almost entirely by the transudation of blood, especially serum- albumin, from the bloodvessels into the tubules of the kidney. The exfoliation of a large number of epithelial cells may give rise to a trace of albumin in the urine. Etiology: Albuminuria does not always depend upon dis- ease of the kidneys. Small quantities of albumin may some- times be found in the urine in pregnancy, after severe and prolonged exertion, and after the ingestion of large quantities of food, especially albuminous food, eggs, cheese, pastry, par- ticularly when not properly digested, and when the individual indulges in exercise immediately after eating. Albuminuria may result from some change in the composi- tion of the blood, as in anaemia and some cases of puerperal eclampsia, without inflammation of the kidney. In some puerperal cases, and in chronic congestion of the kidney, al- bumin appears in the urine as the result of changes in the blood-pressure. Some cases of albuminuria are due to changes in the walls of the capillaries not of an inflammatory char- acter. More important and numerous are the cases of albuminuria due to disease of the kidney, inflammation of the walls of the capillaries, which thus more readily permit transudation. To this category belong the cases of acute nephritis, the severe forms of acute degeneration, acute congestion, anol some cases of chronic nephritis with exudation. Accidental albuminuria may be caused, outside of the kiol- ney>. ty pyuria, haematuria, the escape into the urine of seminal or prostatic fluid, more rarely chyluria, and not infre- 364 ALBUMINURIA. 365 quently by hemorrhage or transudation of serum from some part of the urinary tract below the kidneys. Albuminuria from the exfoliation of epithelial cells has been mentioned. Tests for Albumin. Heller's test: Cloudy urine should be filtered. Boil the urine and add concentrated nitric acid. Albumin gives a white precipitate. A similar precipitate may be obtained when patients are taking balsam, which, however, may be dissolved by alcohol. Phosphates are precipitated by heat and redissolved by the aciol. Urates are dissolved by the heat, Potassium-ferrocyanide test: Acidify the urine with acetic acid, and add 10 per cent, solution of potassium ferrocyanide. Albumin is precipitated. Spiegler's test: Spiegler's test-fluid : corrosive sublimate, 40; tartaric acid, 20; white sugar, 100; anol distilled water, 1000. Method: A layer of urine is allowed to flow gently upon some of the test-fluid in a test-tube. Albumin is indicated by a white precipitate formed at the junction of the urine and the test-fluid. Heller's test precipitates serum-albumin (and albumose when cold). The potassium-ferrocyanide test precipitates serum- albumin and albumose. Spiegler's test precipitates serum-albu- min, albumose, and peptones. Peptonuria indicates suppuration somewhere in the body. Its determination may be of value sometimes when we can exclude scurvy, intestinal ulceration, anol the puerperium. In obscure cases its absence indicates the absence of suppurative processes in the body. Thus it is a means of differentiation between suppurative and tubercular meningitis. Casts. (1) Epithelial casts are composed partly or wholly of epithelial cells from the tubules of the kidney, and are in- dicative of a parenchymatous nephritis. 366 DISEASES OF THE GENITO-URINARY ORGANS. Fig. 39. Hyaline casts from a case of acute nephritis. 1, plain hyaline cast; 2, granular de- posit of hyaline casts; 3, cellular deposit (blood and epithelium). Fig. 40. Fatty casts from a case of chronic parenchymatous nephritis. (2) Blood-casts, composed of more or less perfect blood- ALBUMINURIA. 367 Fig. 42. Cylindroids from the urine in con- gested kidneys (von Jaksch). corpuscles, indicate hemorrhage from the kidney : (a) acute con- gestion of the 'kidney, (6) acute inflammation of the kidnev, (c) infarction of the kidnev. (3) The constant presence of pus-casts, which are rare, may be due to multiple abscess of the kidnev. (4) Casts composed of micro- Fig. 41. Different forms of waxy casts (von Jaksch). cocci may be discharged in cases of renal sepsis (embolism), suppurative nephritis, and pyelonephritis. (5) Granular casts are found in the presence of degenera- tion of the renal epithelium. 368 DISEASES OF THE GENITO-URINARY ORGANS. (6) Fatty casts indicate fatty degeneration, such as may be present in the large white kidney, or in cases of poisoning by phosphorus, antimony, or iodoform. (7) Hyaline casts point strongly to chronic interstitial nephritis. (8) '' Waxy" casts (broad hyaline casts) are found in amy- loid degeneration of the kidney. (9) Cylindroids, or streamers, which are not true casts, indi- cate irritation of the kidney. They are often present in lithaemia and oxaluria. DROPSY. Dropsy depends upon an increased transudation of blood- serum from the capillaries and diminished absorption by the lymphatics. Inflammatory exudation and passive dropsy may he causeol by increased blood-pressure or some change in the blood, especially the injury caused by poisons (toxins) circu- lating in the blood. Dropsy due to disease of the kidneys is expressed first as oedema of the lower eyelids and ankles; later, of the legs anol serous cavities; and finally of the entire body—anasarca. A fatal termination may be caused by oedema of the glottis, lungs, or bronchi. UREMIA. Uraemia is probably a misnomer, since the so-called uraemic symptoms do not always follow the injection of urea into the blood, nor is there always an increased amount of urea in uraemia. The condition is caused by the circulation in the blood of some poison, possibly a toxin, that normally is excreted through the kidneys. Uraemia—symptoms: 1, headache, hebetude, somnolence or insomnia, and anxiety, which may occur in cases of nephritis, either acute or chronic, and in cases of puerperal eclampsia, with or without nephritis; 2, hemiplegia and aphasia, sepa- rately or together in chronic nephritis or eclampsia, ascribed by some to an endarteritis; 3, blindness, amaurosis, which PYURIA. 369 comes on suddenly in puerperal eclampsia and sometimes in chronic nephritis; 4, general epileptiform convulsions, in puer- peral eclampsia and in acute or chronic nephritis. Other symptoms arc : muscular contractions, delirium, coma, vomit- ing, diarrhoea, fever, dyspnoea, and increased arterial tension, due to hypertrophy of the left ventricle. PYURIA. Pus in the urine, pyuria, may be recognized readily by microscopic examination of the urine. Sometimes pus is present in such quantities as to be obtrusive. Etiology: A heavy deposit of pus in acid urine usually comes from pyelitis or chronic pyelonephritis. The constant discharge of muco-purulent urine is usually found in con- junction with bladder-symptoms. Such urine, in the absence of vesical symptoms, especially when accompanied by the discharge of blood, may come from pyelitis due to the presence of a calculus. The intermittent discharge of puru- lent urine usually indicates pyelitis. Sometimes pus comes from outside the urinary tract. Fever will then accompany the accumulation of pus, to disappear upon its discharge. The origin of the suppuration mav be recognized in some cases by the presence of pain and other symptoms. Flakes or threads of pus usually come from the urethra, but may come from other parts of the urinary tract, as in cases of pyelitis, nephrolithiasis, tuberculosis of the bladder and prostate, and perivesical abscess. Often the presence of epithelial cells, recognized upon microscopic examination of the urine, in cases of pyuria, will aid materially in determining the origin of the pus. A careful examination, especially by palpation, should be made of the entire urinary tract. The use of the cystoscope is often of value. As a rule the source of the pus will be found in the pelvis of the kidney, the bladder, or the urethra. As stated, pus may come from without the urinary system— e. g., perivesical abscess and hip-joint disease. 24—p. 1\[. 370 DISEASES OF THE GENITO-URINARY ORGANS. CHYLURIA. The presence of chyle gives to the urine a milky appear- ance. Sometimes the urine is more or less colored by the admixture of blood. The amount of fat varies from 0.2 to 2 per cent., and may be dissolved by the addition of ether, whereupon the urine loses its milky appearance. Microscopic examination of the urine reveals the presence of fat. The filaria sanguinis hominis, which is a common cause of chyluria, is found in the urine secreted during the day, as a rule, and in blood withdrawn during the night (see Filaria Sanguinis Hominis). The chyle and filaria probably gain entrance to the bladder through some communication between the dilated lacteal channels and the urinary tract. HEMATURIA. Etiology: Hemorrhage may take place from any part of the urinary tract. Aside from traumatism, nephritis, and gonorrhoeal prostatitis, haematuria is causeol most frequently by stone in the bladder, tumors of the bladder, stone in the kidnev, tuberculosis of the bladder, tuberculosis of the pros- tate, carcinoma of the kidney, cystitis, and enlarged prostate. Some cases are due to the distoma haematobium. An effort should be made to determine the cause of the haematuria. Some knowledge may be gained by observing the color of the urine, the presence anol shape of clots of blood, the time at which the blood is discharged in the stream of urine voided, the intimacy with which the blood is mixed with the urine, anol the microscopic examination of the sediment, A careful physical examination shoulol be made of all accessible parts of the urinary tract, the kidneys, ureters, bladder, prostate, and testicle by palpation, and if necessary by the use of the endoscope anol cystoscope. Haematuria may occur in some of the infectious diseases, especially in measles, smallpox, typhus fever, septicaemia ; cholera, malaria, scurvy, and in the hemorrhagic diathesis. Certain drugs, especially cantharides and turpentine, may cause haematuria. PYELITIS. 371 PYELITIS. Pyelitis is an inflammation of the pelvis of the kidney. Pyelonephritis is a conjoint inflammation of the substance and pelvis of the kidney. When suppuration extends to cause destruction of the kidney-substance and form a large abscess-cavity the condition is known as j>yoneptiro- sis. The involvement of surrounding tissues leads to peri- nephritis, paranephritis, and sometimes to the formation of abscess. Inflammation of the pelvis of the kidney, pyelitis, may be primary, caused by the discharge of some irritating sub- Fig. 43. Cellular elements from the urine. 1,squamous epithelium; 2, red blood-corpuscles; 3, polynuciear leukocytes : 4,transitional cells; 5, epithelium from the kidneys; 6, epithelium from the pelvis of the kidney and the bladder; 7, micrococcus urese; 8, yeast-fungi. stance through the kidney; or secondary, caused by infection travelling from below upward along the urinary passages. Thus, the cause may come from above, as in tuberculosis of the kidney; or the passage of micro-organisms, more especially the toxins, toxalbumins, of the infectious dis- 372 DISEASES OF THE GENITO-URINARY ORGANS. eases—tvphus, typhoid fever, septicaemia, influenza, small- pox, scarlet fever, diphtheria, tuberculosis, or cholera ; or the elimination of certain drugs—cantharides, turpentine, or copaiba. The most frequent local cause of pyelitis is kidney-stone. Some cases depend upon traumatism. The cause may come from below, from a cystitis, gonorrhoea, or the use of unclean instruments. Pyelitis—symptomatology: There is dull pain, radiating from the kidney along the ureters to the bladder. More often there is a feeling of tension and weight in the region of the kidney. The urine contains pus, sometimes blood and albumin, and the tailed epithelial cells normally found in the pelvis of the kidney. The urine is aciol in reaction, or becomes alkaline only when there is retention. Diagnosis : There is pyuria, sometimes haematuria and albu- minuria, and the discharge of characteristic epithelial cells. The presence of hebetude, the typhoid state, with chills and fever, would indicate pyelonephrosis. The prognosis is serious, but depends largely upon the cause. Cases dependent upon cystitis or kidney-stone usually disappear upon the relief of these conditions. When due to the infections, much depends upon the nature of the infectious agent. The outlook is better after typhoid fever than after septicaemia. Pyelitis—treatment: In the way of prevention, only clean instruments (catheters) should be used ; kidney-stones should be removed : gonorrhoea properly treated. The kidney may be flushed by the free use of water, which is best adminis- tered in the form of alkaline mineral water. The patient shoulol observe absolute rest in bed. The bladder mav be washed with dilute solutions of creolin. The salicylates and methylene-blue may be given to limit or prevent bacterial activity. Other remedies highly recommended are quinine, dilute hydrochloric acid, creosote, turpentine, and the oils of copaiba and sandalwood. Sometimes resort must be made to nephrotomy or nephrectomy. NEPIIR OLITHIASIS. 373 FLOATING KIDNEY (Wandering Kidney; Movable Kidney; Ren Mobile). Undue mobility of the kidney is caused by the presence of a mcsonephron, undue laxity of the abdominal walls, more often by compression by belts, corsets, and still more fre- quently, probably, by traumatism, violent concussions of the body. Floating kidney—symptomatology : There may be no symp- toms. The patient sometimes complains of the symptoms of dyspepsia, which are not relieved by the usual treatment of dyspepsia. There may be pain, colic, abdominal dragging, sensations of displacement, sometimes icterus, and symptoms of the most varied character. A movable tumor may be felt upon palpation ; but the failure to find such a tumor does not necessarily exclude floating kidney. The kidney is usually sensitive. Prognosis as to life is good. As a rule permanent relief may be secured only by appeal to surgery. Treatment: Should satisfactory relief not be afforded by the use of an abdominal supporter, nephrorrhaphy (fixation of the kidney by suture) should be resorted to. Nephrectomy (removal of the kidney) may be necessary when the organ is diseased. NEPHROLITHIASIS; KIDNEY-STONE (Renal Calculus; Gravel; Sand). Over 99 per cent, of all urinary calculi originate in the kidneys. Kidney-stones may consist of uric acid or urates, oxalate of lime, less frequently of cystin, carbonate of lime, xanthin, or indigo ; sometimes two or more of these sub- stances in combination ; and in the presence of suppuration, and decomposition of urine, there may be deposits of phos- phate of lime and triple phosphate. Kidney-stones occur in all varieties of shape, anol in size from so-called sand to over a thousand grammes in weight; and from one to over a thousand in number. Etiology: The great majority of cases occur in males, most frequently from two to twelve years old. Association of 374 DISEASES OF THE GENITO-URINARY ORGANS. kidney-stone with gout has been frequently noted. Cases are often ascribed to an excess of uric acid in the blood, or a diminution of the Diphosphate of sodium, a salt that holds the uric acid in solution. Phosphates are precipitated in an alkaline urine, the result of decomposition. Nepfiroldhiasis may occur at any age; calculi have been found in the kidneys of the new-born. Some observers believe a prominent role in etiology is played bv the mucus and possibly some colloid material se- creted by the kidney. Symptomatology : There may be no symptoms. But usually the presence, especially the passage, of kidney-stones gives rise to distinct symptoms/ The most common symptom is pain, radiating from the kidney to the bladder, aggravated by move- ment of the body, and usually increased by pressure over the kidnev. The pain is irregular, occurs in paroxysms, and may be relieved only by large doses of opium or morphine or the use of aiKesthesia. There is usually tuematuria, often pyuria, and sometimes albuminuria even independently of the presence of blood. The pain, especially during the passage of a cal- culus through the ureter, is intense. With the paroxysm there are often rigor, vomiting, cramp, and profuse perspira- tion. Pain is often reflected to the groin, testicle, gluteal region, and inner side of the thigh and leg. Often there is retraction of the testicle. With the passage of the stone into the bladder the paroxysm suddenly ceases, possibly to leave the patient narcotized if much opium or morphine has been administered. The urine often contains mucus during the re- tention of a stone in the kidney. Diagnosis: Sometimes the patient comes with the diagnosis already made by the passage of a stone, more often of the small particles known as sand, or with the history of having passed a calculus. Such specimens should be examined to determine the character of the stone. The most common urinary calculi are the uric acid and phos- phatic stones. When there is no history of the passage of a calculus the characteristic pain, the presence of blood and mucus, sometimes of pus in the urine, should lead to a micro- scopic examination of the urine, whereby crystals may be NEPHROLITHIASIS. 375 found, to reveal the presence and character of the stone. The condition should not be mistaken for the passage of uric acid Fig. 44. Various forms of uric-acid crystals (Finlayson). Fig. 45. Various forms of triple phosphate i,Finlayson). in gout, or of the debris from tubercular or cystic kidneys or hydatids of the kidney. Prognosis should be guarded. Recovery is the rule. The 376 DISEASES OF THE GENITO-URINARY ORGANS. chief clanger is rupture of the ureter and consequent peri- tonitis ; or the formation of abscesses, with sinuses and fis- tulae, and consequent marasmus; and amyloid degeneration in the various organs. Kidney-stone—treatment: During the attack the pain should be relieved by moderate doses of morphine combined with atropine, round doses of chloral, the application of moist heat, and if necessary the use of an anaesthetic. Curative treatment consists in thorough flushing of the kidneys by free libations of fluids, the mineral waters—Sara- toga, Bethesda, Carlsbad, Contrexeville, Ems—and the lith- iated waters, barley-water, or pure water. Piperazin, gr. v-xv, may be given in soda or Seltzer water three to five times a day. Gentle massage is sometimes of value. Upon failure of these means an appeal must be made to surgery. Nephrolitfiotomy or, in the presence of extensive disease of the kidney, nep/ircctomy may be indicated. HYDRONEPHROSIS. Etiology: When the escape of urine is prevented, through occlusion of the pelvis of the kidney or ureter, the pelvis and calyces of the kidney undergo dilatation to form a retention- cyst. The cyst may vary from the size of a pea to an extreme size, in which the kidney-substance suffers destruction from pressure and the cyst conies to occupy the entire capsule. The smaller cysts are caused by dilatation of the urinary tubules. The larger cysts, to which the name hydronephrosis is given, are due to occlusion of the pelvis of the kidney or ureter by calculi, strictures, cicatrices, and pressure from without, as from tumors of the uterus and ovaries, enlarged prostate, etc. Other causes are cancer, cystitis, and vesical calculus. ('(im- pression of the ureter of a movable kidney may be caused by the gravid uterus. Rarely cases are caused by traumatism. Some eases are due to congenital deformity. The retained fluid is usually composed of dilute urine, more or less albuminous ; occasionally colloid material; sometimes blood and broken-down cells. The cysts may attain immense size. As much as thirty gallons have been removed (Glass). HYPEREMIA OF THE KIDNEY. 377 The loss of one kidney may be compensated for by the oppo- site organ. Implication of both kidneys is always dan- gerous. Treatment should address the cause. Sometimes appeal must be made to surgery : aspiration, nephrotomy, and drain- age ; possibly nephrectomy. HYPEREMIA OF THE KIDNEY. Hyperaemia may be acute or chronic, depending upon tem- porary or more or less permanent congestion of the blood- vessels of the kidney. Acute hypertonia of the kidney may be caused by : certain poisons—for instance, cantfuirides, either when ingested or sometimes when used as blisters or ointments ; the extirpation of the opposite kidney; severe traumatism; surgical opera- tions, especially upon the bladder or urethra; and over- exertion, forced marches, severe physical contests, and violent exercise. The most common causes of chronic hyperaemia of the kid- ney are chronic inflammations involving the aortic and mitral valves, dilatation of the heart, aneurism of the arch of the aorta, pulmonary emphysema, and large accumulations of fluid in the pleural cavities that are not properly treated by re- moval. In acute hypoxemia the urine is diminished in quantity, sometimes to constitute anuria; the specific gravity remains about normal; blood, albumin, and casts are present, In chronic hyperaemia there is some diminution in the quantity of urine, and the specific gravity may be a little higher than normal; there is little albumin, and there are but few or no hyaline casts; there is often dropsy, usually with some symp- toms of affection of the heart. The treatment will depend upon the cause. Usually of most value is rest of the kidney, which implies rest of the body, best in bed, and address to the skin and alimentary canal. Anaemia of the kidney: In general anaemia the kidneys 378 DISEASES OF THE GENITO-URINARY ORGANS. mav suffer a reduction in size. The quantity of urine excreted is less than normal. Chronic anaemia of the kidney is ob- served in arterio-sclerosis. AMYLOID DEGENERATION. Amyloid degeneration is most frequently recognized when the process involves the kidneys. Amyloid follows protracted suppuration in some part of the body, as a rule. Tubercu- losis and syphilis are frequent causes. Symptomatology and diagnosis: The patient voids an in- creased quantity of clear urine, as a rule of low specific gravity, containing various amounts of albumin, with some casts and white corpuscles. Hardy there may be dropsy, especially in the lower extremities, often associated with ascites, due to obstruc- tion of the portal vein from affection of the liver. Vomiting and diarrluea are sometimes persistent, Amyloid matter may be found in the stools, from involvement of the intestine. There may also be symptoms on the part of other organs liable to amyloid degeneration, especially the spleen and liver. Nervous symptoms are usually absent, Evidence of amyloid degeneration may be found on the part of other organs, especially the spleen, liver, and alimentary canal. A chronic suppuration may be recognized. Prognosis: Bad. Most may be accomplished by proper treatment of the cause of the amyloid degeneration, especially septicaemia, syphilis, tuberculosis, malaria. Treatment: Any chronic suppuration should receive proper attention. Pus should be evacuated. Of drugs, iodine has the best reputation, probably because of the etiological rela- tionship of syphilis. Gtt, x of the tincture, or of the ounce- to-the-ounce solution of the iodides, may be given in a wine- glassful of milk three times a day. Should digestion be impaired by iodine, the remedy may be substituted by hydro- chloric acid, nux vomica, condurango, or the aromatic tincture of rhubarb. Tuberculosis of the kidney : See Tuberculosis. Syphilis of the kidney: See Syphilis. NEPHRITIS. 379 NEPHRITIS; BRIGHT'S DISEASE. Etiology : Not clear. Some investigators believe the disease to be due to micro-organisms ; others attribute it to toxins or chemical poisons. Probably both views are correct. Some cases are caused by ptomaines, toxalbumins, acetone (von Jaksch); and cases may be caused by uric aciol, creatin, xan- thin, and also by cantharides and other poisons. Interstitial nephritis has been produced experimentally, in the dog, by the subcutaneous injection of oxalic aciol and oxamide (Ebstein anol Nicolaier). Most cases of nephritis are attributed to the infections, in- cluding " colds." Pregnancy often plays a prominent role. Classification of nephritis: After Pel, of Amsterdam, as given by Whittaker: 1-Acute Nephritis 2-Clironic Nephritis 3-Renal Cirrhosis General degenerative /arteriosclerosis (frequent) Chronic hemorrhagic Nephritis) (not frequent) Spotted or smooth small white or secondary shrunken kidney (very frequent) Genuine (inflammatory) Interstitial nephritis (most frequent) Three varieties of Bright's disease are generally accepted: acute nephritis, chronic nephritis, and renal cirrhosis. Be- sides these there are transition-forms, as indicated in the above table. Acute Parenchymatous Nephritis. Etiology: Acute parenchymatous nephritis is caused by the excretion of some poison through the kidneys. Typical acute inflammation of the kidney may be produced by cantharides. Acute parenchymatous nephritis is most frequently caused by toxins, toxalbumins, in the course of or following the infec- 380 DISEASES OF THE GENITO-URINARV ORGANS. tious diseases, especially scarlet fever and diphtheria; loss frequently measles, rotheln, smallpox, pneumonia; rarely typhoid fever anol the other infections. Some cases are ascribed to "cold" and pregnancy. "Colds" are usually infectious. Symptomatology: The onset may be sudden or insidious. Usually micturition is increased in frequency, but the quantity of urine voided in twenty-four hours is less t/ian normal. There mav even be anuria. With the reduction in quantity there is an increased specific gravity, 1025-1030. There may be haematuria with consequent change in color of the urine. More characteristic is the presence of albumin, usually with epithelial and blood-casts. Asa rule there is dropsy, observed first as a puffiness about the eyelids, sometimes extending to become general over the body, possibly to take life through oedema of the lungs or glottis. Prominent nervous symptoms are headache and neuralgia, vertigo, nausea and vomiting. Some cases are announced by sudden blindness or early con- vulsions. There may be sopor, stupor, and coma. Chronic Parenchymatous Nephritis. Etiology: Chronic parenchymatous nephritis is caused, for the most part, by the long-continued elimination of a poison, usually a toxin. Some cases result from acute parenchyma- tous nephritis, especially when due to septicaemia, syphilis, or tuberculosis; sometimes when due to scarlatina, pregnancy, or "cold." Symptomatology: The onset is usually insidious, with loss of ambition, fatigue on slight exertion, sometimes with nervous symptoms, especially hebetude, headache, and neuralgia. There are anorexia, loss of weight, pallor, droivsiness or insomnia, palpitation, shortness of breath ; and dropsy, appearing first as oedema of the face, especially the eyelids ; and about the ankles, becoming later extensive aiul'marked. There may be retinitis albumin mica. ^ The urine is reduced in quantity, from two pints to a half pint or less in twenty-four hours, and is high in specific gravity, 1025-1040, and cloudy. Albumin is present in large quantity, NEPHRITIS. 381 and casts may be found in large numbers and great variety. Broad, waxy, and granular casts are characteristic. Vomiting and diarrhtra may become troublesome and per- sistent. The poison of the disease seems sometimes to become localized in an inflammation of some serous membrane, as a pleuritis, peritonitis, or pericarditis. Nervous symptoms may be present in all grades of severity. Renal Cirrhosis. Renal cirrhosis is the most frequent form of Bright's dis- ease, constituting more than one-half of all cases. The onset is insidious, so that the condition may be unrecognized for a number of years. Renal cirrhosis is characterized by the secretion of a large amount of urine, of light specific gravity ; the presence of nervous symptoms, and the absence of dropsy. Symptomatology : The onset of renal cirrhosis is insidious, with depression of spirits anol impairment of health. The color is bad. Xervous symptoms predominate. There are often headache, neuralgia, vertigo, dyspnoea (renal asthma), palpita- tion of the heart, and sometimes blindness or other disturbance of vision. The first suspicion of the disease may be aroused by the occurrence of apoplexy or hemorrhage, especially from the nose, stomach, or bowels. The patient voids a large quantity of clear urine, with light specific gravity, 1010 or less. The urine contains little sediment. Upon examining a speci- men from the total quantity passed in twenty-four hours a trace of albumin will be found (sec Spiegler's test). Casts are few and difficult to find. Usually there is no dropsy. En- largement of the heart is caused by hypertrophy of the left ventricle, which becomes necessary to overcome the obstruction offered to the circulation through the kidneys. The strong heart continues for a long time to force a large quantity of fluid through the kidneys, and as long as this continues dropsy is absent, The urine, though passed in large quantities, eon- tains little solid matter, so that symptoms of uraemia are not infrequent. 382 DISEASES OF THE GENITO-URINARY ORGANS. Diagnosis of Bright's Disease. Acute parenchymatous nephritis may come on suddenly or insidiously. There is a reduction in the quantity of urine, which is high in specific gravity and contains albumin anol casts, especially "epithelial and blood-casts. CEdema appears first about the eyelids. There may be headache, neuralgia, vertigo, convulsions, nausea anol vomiting, sometimes sudden blindness. In the presence of the large viiite kidney there are marked pallor and obstinate dropsy, 'in the absence of hypertrophy of the heart. The urine is small in quantity, of high specific gravity, and contains casts, especially fatty and granular casts. Nervous symptoms are usually not pronounced. Chronic parenchymatous nephritis is usually insidious in onset, with general degradation of the health, spirits, and strength. Some cases show nervous symptoms. There is odema, first of the face and ankles. A retinitis albuminuria may be observed. The urine is reduced in quantity, of high specific gravity, anol contains albumin and casts, especially broad and waxy casts. There may be inflammation of the serosa1. Often there are vomiting and diarrluea. Nervous symptoms vary in severity. In hemorrhagic nephritis there is persistent bleeding. The course is longer than in acute nephritis, and the nervous symptoms are not so marked. Cases of the .small white kidney show enlargement of the heart, and reduced quantity of urine containing casts of all kinds. Transition from the large white kidney, or chronic hemorrhagic nephritis, to the small white kidnev is marked by an increase in the quantity of urine and diminution in the number of casts, with hypertrophy of the heart. Renal cirrhosis, the most frequent form of Bright's disease, begins insidiously. Nervous symptoms are marked. Qui em a is slight or absent. A large quantity of urine is voided, of light specific gravity, containing a trace of albumin and pos- sibly a few hyaline casts. There are hypertrophy of the heart and the symptoms of arterio-sclerosis. Blindness may be caused by retinitis albuminurica. The patients are usually in middle or advanced life. NEPHRITIS. 383 Prognosis of Bright's Disease. Acute nephritis may result in recovery. Anuria, haema- turia, and severe nervous symptoms, especially convulsions and coma, are ominous signs. Much depends upon the time when proper treatment is instituted. Cases of chronic nephritis or renal cirrhosis probably never recover, but the patients may live for a long time under proper treatment and hygiene. Treatment of Bright's Disease. The best single article of diet is milk, which may be used exclusively in severe cases. Later, vegetables anol fruit may be added. The patient should drink an abundance of pure water; but an undue amount of fluid must not be given in the presence of a weak heart. Meat may be given, but not to excess: The patient may receive stewed sweetbreads, stewed chicken, calf-brains, pig's feet, or broiled fish once a day. Bathing: A hot bath, 100°-110° R, may be given at bed- time, and in severe cases oftcner. Duration of bath, five to twenty minutes. A hot drink should be given before and after the bath. While in the bath the patient's head should be enveloped in a cloth wrung out of cold water. Sometimes it is necessary to substitute the hot bath by the hot pack. Palpitation and a fluttering heart are contraindications to the hot bath. In such cases pilocarpine may be used, gr. yj-^, subcutaneously. Drugs: Pilocarpine has been recommended externally, in the form of an ointment, 0.05-0.1 to 10.0 of vaseline (Mol- liere). The use of pilocarpine is contraindicated by uraemia. Cardiac diuretics, usually contraindicated in acute paren- chymatous nephritis, are often of service in chronic nephritis and renal cirrhosis. The best diuretic is digitalis, which at times mav be substituted by strophanthus, sodium-benzoate of caffeine, diuretin, or nitroglycerin, which is the best agent with which to secure immediate results in the presence of cirrhosis. 384 DISEASES OF THE GENITO-URINARY ORGANS. Dropsy that causes dyspnoea or other great discomfort, or that threatens rupture of the skin, may be relieved by the free use of calomel or a dose or two of elaterin; or by the intro- duction of silver canuhe into the feet or legs, or by minute punctures of the skin. Often a change of residence to a warm, dry climate is advisable. The patient should wear warm clothing and remain indoors during inclement weather. Further treatment is addressed to the relief of symptoms. CYSTITIS. Etiology : Cystitis is caused most frequently by extension of disease froni the urethra, especially gonorrhoea. Next most frequently, the cause of cystitis comes from above, especially from pyelitis and calculus. Tuberculosis and cancer may be conveyed to the bladder through the blood or lymph-vessels, or by extension from contiguous structures, especially from the uterus and rectum. Infection of the bladder may occur as a local expression of septicaemia. Paralysis of the bladder, by permitting reten- tion, may favor infection of the bladder. Sometimes trauma, especially the introduction of foreign material into the blad- der, plays an important part in the etiology of cystitis. In operations upon the bladder, the use of the catheter and the introduction of the cystoscope or instruments for crushing and removing stones, strict asepsis should be observed. Stricture of the urethra, or any cause of retention of urine, is a prominent cause of cystitis. Cystitis—symptomatology : There are pain in the region of the bladder, tenderness, vesical and rectal tenesmus, freqncnt and painful micturition. The urine contains )>us, mucus, fre- quently blood, and usually large numbers of the characteristic flat epithelial cells found normally in the bladder. The pain is often reflected to the penis, testicles, and rectum. In tuber- culosis of the bladder there is often polyuria. When cystitis is due to the presence of a calculus in the bladder, there is often hemorrhage, and pain is increased by movement of the body. ENURESIS. 385 Prophylaxis : Only clean instruments should be introduced into the bladder. This applies equally to the use of the catheter, cystoscope, and instruments for crushing stones. Urethritis, especially gonorrhoea, should receive early and continuous treatment until completely cured. Strictures should be dilated and stones removed." Cystitis—treatment: Rest in bed is important. The diet shoulol be light. The bowels must be kept open. The bladder may be flushed by the free use of hot drinks, milk, mucilaginous drinks. Harrison recommends a combination of the ulmus fulva, or slippery elm, anol succus hyoscyami in decoction. ttyoscyamin may be given, gtt, iij-v of the grain- to-the-ounce solution, every three or four hours. Atropine is administered in the same dosage. Great relief is often afforded by the warm bath, and the rectal injection of hot water. More severe pain calls for opium in suppositories or by rectal injection. Strangury may be relieved by the subcutaneous use of morphine, preferably suprapubic, in the region of the bladder. Cystitis due to gonorrhoea is benefited by the internal use of copaiba, the oil of yellow sandalwood, safol, the salicylate of sodium, and methylene-blue. Chronic cases of cystitis are best treated by irrigation of the bladder. For this purpose use may be made of solutions of nitrate of silver ; protargol; creolin ; boric acid ; bichloride of mercury (1:20,000); permanganate of potassium ; tannin; sulphate of zinc; alum ; alumnol, or the neutral sulphate of quinine (gr. j to *j). ENURESIS (Incontinence of Urine). The involuntary discharge of urine occurs normally in in- fancy. Sometimes delayed development of the sphincter, especially of its nerve-supply, causes persistence of enuresis. Thus the condition is seen frequently from three to ten years of age, especially during sleep. As a neurosis, enuresis occurs in the presence of a normal bladder and normal urine. At times the condition appears at puberty, often with other neuroses, sometimes onanism. 25.—P. M. 386 DISEASES OF THE GENITO-URINARY ORGANS. Inability to retain the urine—incontinence of urine—oc- curs most frequently in the young and old ; in women more often than in men. In women the urethra may suffer dilata- tion and the action of the sphincter be imperfect, especially after parturition, so that urine may be discharged with no, or but slight strain, such as coughing, sneezing, laughing. Enuresis mav be caused by masturbation. Men, especially in old age, suffer incontinence of urine through affection of the prostate. Incontinence of urine is caused by over distention of the bladder, or by defective closure of the sphincter. Thus, the condition may be caused by either paresis of the detrusor or of the sphincter. Sometimes incontinence of urine results from organic disease. Treatment: An overdistended bladder should be relieved with a clean catheter. Urethral polypi and calculi should be removed. Often much may be accomplished with electricity, particularly when the current is brought into contact with the sphincter by introducing the electrode into the rectum. The best drug is atropine, gtt. iij of the grain-to-the-ounce solution at bedtime, increaseol gradually up to tolerance. In the way of general treatment, cold baths, outdoor exer- cise, and the use of iron, quinine, and cod-liver oil are of value. SPERMATORRHEA. The involuntary discharge of semen may occur physiologi- cally once or twice a month. The condition is pathological, only when the discharge is followed by exhaustion. Biit not every discharge of fluid, even when followed by exhaustion, is a spermatorrhoea. The fluid may not be semen. Thus the condition may be a prostatorrhoea. Etiology: The most frequent causes of spermatorrhoea are masturbation, sexual excess ; urethritis, especially gonorrhoea ; an elongated prepuce, phimosis ; ascarides, constipation, hem- orrhoids, eczematous eruptions, and abnormal conditions of the rectum and anus. Symptomatology : Sometimes the patient is not aware of the loss of semen, which is discharged with the urine, possibly to IMPOTENCE. 387 be recognized as a cloudiness of the urine and the discovery of spermatozoa upon microscopic examination. But sperma- tozoids are not always present in semen ; they may be absent in impotence. Following^ pathological discharge of semen there are ex- haustion, a feeling of weakness, languor, and depression, and various nervous disturbances, partcst'/wsite, flashes of heat, head- ache, and vertigo. Later there are palpitation, dyspntea, and dyspepsia. Depending usually upon sexual abuse, there is as a rule more or less hypochondriasis and melancholia. Diagnosis: In the presence of an exhausting discharge, the clinician should determine whether or not the discharge is semen. A simple prostatorrhoea will not contain spermato- zoids. Sometimes the discharge of semen takes place with urination, when the spermatozoids may be found in the urine. Treatment: Sexual abuse should be stopped. The sexual function had better be given a rest anol the mind occupied with healthy thought and the body with healthful exercise. The cold bath or cold douche invigorates the body. Elec- tricity is sometimes of value : short sessions of feeble gal- vanic or faradic currents. Posterior urethritis should he properly treated. Matrimony may be advisable, when other treatment, as a rule, becomes unnecessary. The discharge of semen, which usually occurs at night, may be prevented by potassium bromide, gr. xx-xl, largely diluted, at bedtime. IMPOTENCE. Incapacity for natural coitus may result from lack of sexual desire, absent or imperfect erection, premature discharge and alterations, especially reduction or absence, of the seminal fluid, and the absence of living spermatozoids. Impotence is caused most frequently by excess in venerv, onanism, and gonorrhoea. The condition occurs early in dia- betes, diphtheria, and locomotor ataxia. Aversion, dislike, and the fear of loss of the sexual power are prominent physi- cal causes. Toxic causes are alcohol, the bromides, iodides, opium, camphor, salicylic acid, and lupulin. The condition 388 DISEASES OF THE GENITOURINARY ORGANS. may be caused by physical malformations and defects, atrophy, and tumors. Fndeseendod testicles cause impotence only when atrophied. The prognosis depends upon the cause, and is usually most favorable in the toxic and psychical cases. Treatment: The cause must be removed. Pest and ab- stention are important. The best remedies, as a rule, are strychnine and electricity. INDEX. A. Abscess of the liver, 238 of the lungs, 2S3 Achylia gastrica, 202 Actinomyces, 132 Actinomycosis, 132 diagnosis, 133 etiology, 132 symptoms, 132 treatment, 133 Acute infectious icterus, 125 Addison's disease, 347 symptoms, 347 treatment, 348 Ague, 134 Akoria, 204 Albumin, tests for, 365 Heller's, 365 potassium-ferrocyanide, 365 Spiegler's, 365 Albuminuria, 364 accidental, 364 etiology, 364 Amoebi coli, 142 Amphistoma, 156 Amygdalitis, 176-178 Amyloid degeneration, 378 liver, 2ir> Anaemia, 336 pernicious, 337 primary, 336 secondary, 336. 339 blood in, 33rt symptoms, 338 treatment, 339 Aneurism, 329 varieties (see also Bloodvessels, eases of), 329, 330 Angina, 176 Ankylostomiasis, 161 Anorexia, 204 Anthracosis, 284 Anthrax, 115 bacillus, 115 Anthrax, external, 116 forms, 116 anthrax cedema, 116 external anthrax, 116 internal anthrax, 116 malignant pustule, 116 internal, 116 intestinal, 117 cedema, li6 pulmonary, 116 symptomatology, 116 treatment, 117 caustics, 117 cautery, 117 serum, 117 Antitoxin in diphtheria, 67 Aortitis, 326 Aphtha, 171 Bednar's, 172 Appendicitis, 217 chronic, 218 diagnosis, 218 etiology, 217 prognosis, 218 symptoms, 217 ' dulness, 217 pain, 217 treatment, 219 diet, 219 operation, 219 rest. 219 Arterio-sclerosis, 327 Arthritis deformans, 352 etiology, 352 symptoms, 352 treatment, 352 Ascaris lumbricoides, 157 (lis- ' other varieties, 159 Asthma, 269 etiology, 269 symptoms, 270 spirals, 271 treatment, 272 of the attack, 272 cigarettes, 272 389 390 INDEX. Asthma, treatment during intervals, 272 arsenic, 272 iodides, 272 Atelectasis, 2S2 symptoms, 282 treatment, 2S2 Atheroma, 306, 328 aorta, 328 coronary arteries, 328 Atrophy of the heart, 297 liver, 243 acute, 243 simple, 243 yellow, 243 Autumnal catarrh, 130 B. Break-bone fever, 123 Bright's disease (see also Nephritis), 379 Bronchi, dilatation, 268 diseases of, 261-273 Bronchiectasis, 268 etiology, 268 symptoms, 268 treatment, 269 Bronchitis, 262 acute, 262 etiology, 262 symptoms, 263 treatment, 263 capillary, 264 chronic, 264 etiology, 264 symptoms, 265 treatment, 265 fibrinous, 267 plastic, 267 etiology, 267 symptoms, 267 treatment, 268 Bronze-skin disease, 347 Buboes, 89 c. (Aecitis, 215 Calculus, renal, 373 Cancer of the stomach, 196 Cancrum oris, 172 Carbuncle, 115 Carcinoma of the intestine, 225 of the larynx, 259 of the peritoneum, 230 Cardiospasmus, 205 Casts, 365-368 blood, 366 epithelial, 365 fatty, 368 granular, 367 hyaline, 368 micrococci, 367 pus, 367 waxy, 368 Cerebro-spinal meningitis, 26 complications, 27 diagnosis, 28 etiology, 26 forms, 27 abortive, 27 apoplectic, 27 chronic, 27 foudroyant, 27 Bacillus anthracis, 115 coli communis, I 42 icteroides, 107 pestis, 124 prodigiosus, 171 of tetanus, 118 tuberculosis,carbol-fuchsin solution, 74 examination, 73 tuberculin test, 74 typhosus. 93, 98 Beri-beri, 128 etiology, 12S symptoms, 128 treatment, 129 Big-jaw, 132 Biliary lithiasis, 233 Blood, diseases of, 335-355 parasitic, 335 blood-corpuscles, 335 red, 335 white, 335 Bloodvessels, diseases of, 326-334 aneurism, 329 dissecting, 330 external, 329 internal, 330 miliary, 330 aortitis, 326 arteritis, 326 arterio-sclerosis, 327 embolism, 332 phlebitis, 333 thrombosis, 331 varices, 334 Bothriocephalus latus, 153 other species, 153 IND Cerebro-spinal meningitis, forms, ful- minant, 27 intermittent, 27 malignant, 27 history, 26 morbid anatomy, 27 prognosis, 28 symptomatology, 26 blood, 27 eruptions, 27 incubation, 26 treatment, 28 diet, 28 hot bottles, 29 ice-bags, 29 laminectomy, 29 lumbar puncture, 29 opium, 28 Cestodes, 145 Chalicosis, 284 Chancroid, 86 Chickenpox (see also Varicella), 63 Chills and fever, 134 Chlorosis, 336 Egyptian, 161 tropical, 161 Cholelithiasis, 233 Cholera, 110 Asiatic, 110 definition, 110 diagnosis, 111 bacteriological examination, 111 blood-test, 112 etiology, 110 spirillum cholerse, 110 history, 110 prognosis, 112 prophylaxis, 112 quarantine, 112 symptomatology, 111 incubation, 111 onset, 111 stools, 111 treatment, 112 anticholerin, 112 antitoxin, 112 infusion, 113 intestinal irrigation, 113 opium, 113 warm bath, 113 gravis, 111 infantum, 113 morbus, 113 nostras, 113 true, 110 Cholerine, 111 391 Chyluria, 370 Cirrhosis of the liver, 240 hypertrophic, 242 renal (see also Renal cirrhosis), 381 Clap, 86 Colitis, 208 Corpulence (see also Obesity), 355 Cowpox, 61 Croup, 69 false, 69 true, 69 Cylindroids, 368 Cysticercus acanthotrias, 151 cellulosae, 151 Cystitis, 384 etiology, 384 prophylaxis, 385 symptoms, 384 treatment, 385 D. Degeneration, amyloid, 378 Dengue, 123 diagnosis, 123 etiology, 123 symptoms, 123 treatment, 124 Diabetes, acute, 360 insipidus, 362 symptoms, 362 treatment, 362 mellitus, 356 etiology, 356 history, 356 symptoms, 357 treatment, 360 diet-list, 360, 361 drugs, 361 Diarrhoea, choleraic, 111 Diathesis, hemorrhagic, 343 uric-acid, 348 Dilatation of heart, 297 of stomach, 199 Diphtheria, 64 complications, 65 diagnosis, 65 bacteriological examination, 65, 66 media, 66 pseudo-diphtheria bacillus, 65 false membrane, 65 etiology, 64 bacillus diphtherias, 64 history, 64 membrane in, 64 prophylaxis, 67 392 INDEX. Diphtheria, prophylaxis, antitoxin, 67 isolation, 67 symptomatology, 64 laryngeal diphtheria, 65 nasal diphtheria, 65 pharyngeal diphtheria, 64 treatment, 67 antitoxin, 67 local applications, 68 steam, iiS Distoma, 154 haematobium, 156 hepaticum, 154 other varieties, 155-157 Distomiasis, 154-156 Downward displacemeut of the stom- ach, 200 Dracontiasis, 163 Dropsv, 368 Dysentery, 142 etiology, 1 12 prophylaxis, 144 drinking-water, 144 sequelae, 143 symptoms, 143 treatment, 144 castor-oil, 114 diet, 145 irrigation of colon, 144 Dyspepsia, nervous, 207 E. Elephantiasis graecorum (see also Lep- rosy), 78 Embolism, 332 Emphysema, 280 interstitial, 280 pulmonary, 280 symptoms, 280 treatment, 281 vesicular, 280 Empyema (see also Pleurisy), 287 Endocarditis, 303 acute, 303 etiology, 303 physical signs, 305 symptoms, 304 treatment, 306 chronic, 306 etiology, 306 symptoms, 307 remote, 307 treatment, 308 sclerotic, 306 septic, 303 Enteric fever, 92 Enteritis, 208 Entero-colitis, 208 acute, 208 chronic, 209 diagnosis, 210 burns of skin, 210 indican in urine, 210 symptoms, 209 treatment, 211 autisepsis, 211 boiled water, 212 diet, 211 drugs, 211 irrigation, 211 Enteroptosis, 223 Enterorrhagia, 213 collapse, 214 diagnosis, 214 etiology, 213 haematemesis, 214 symptoms, 214 Enuresis, 385 treatment, 386 Eructation, 206 Erysipelas, 22 complications, 24 mixed infection, 24 diagnosis, 21 etiology, 22 history, 22 prognosis, 25 symptomatology, 23 eruption, 23 incubation, 23 cedema, 24 treatment, 25 local, 25 serum-therapy, 26 varieties, 23 erratic, 23 erysipelas migrans, 23 multiple, 23 F. Farcy, 89, 90 Fatty liver, 244 degeneration, 244 infiltration, 244 Filaria sanguinis hominis, 370 Filariasis, 164 Flukes, 154 Flux, 142 Fomites, 23 Foot-and-mouth disease, 91 INDEX. 393 Foot-and-mouth disease, symptomatol- ogy, 91 treatment, 92 G. Gall-stones, 233 constituents, 233 bile-pigment, 233 cholesteriu, 233 salts, 233 etiology, 234 gout, 234 rheumatism, 234 symptoms, 234 treatment, 235 glycerin, 235 morphine, 235 olive-oil, 235 surgery, 235 Gastralgia, 204 Gastrectasia, 199 Gastric catarrh, 187 acute, 187 etiology, 187 symptoms, 187 toxic cases, 187 treatment, 188 chronic, 189 diagnosis, 190 etiology, 189 symptoms, 190 treatment, 191 diet, 191 drugs, 192 electricity, 191 enemata, 192 mineral waters, 191 carcinoma, 196 diagnosis, 198 absence of HC1, 198 cachexia, 198 pain, 198 presence of lactic acid, 198 tumor, 198 etiology, 196 sporozoa, 196 symptoms, 197 treatment, 199 chloral, 199 iodides, 199 opium, 199 resection of pylorus, 199 washing the stomach, 199 varieties, 197 colloid, 197 Gastric carcinoma, varieties, epithe- lial, 197 medullary, 197 melanotic, 197 scirrhous, 197 hyperaesthesia, 204 ulcer, 193 etiology, 193 infarct, 193 injuries, 193 vegetable diet, 193 symptoms, 194 hyperchlorhydria, 194 nausea, 194 vomiting, 194 treatment, 195 milk, 195 rectal alimentation, 195 rest, 195 Gastroptosis, 200 Gastrosuccorrhoea, 202 Glanders, 89 chronic, 90 symptomatology, 90 treatment, 90 Glandular fever, 129 diagnosis, 130 symptoms, 129 Glossitis, 175 acute, 175 chronic, 175 Glycosuria, 356 Gonococcus, 87, 88 examination, 88 Gonorrhoea, 86 complications, 87 diagnosis, 87 etiology, 86 gonococcus, 87 symptomatology, 87 treatment, 88 bowels, 88 copaiba, 88 diet, 88 local, 89 lead acetate, 89 protargol, 89 silver nitrate, 89 posterior urethritis, 89 priapism, 88 rest, 88 sandalwood, 89 Gout, 349 American, 348 symptoms. 350 tophi, 350 394 INDEX. Gout, symptoms, uric acid, 350 treatment, 351 alkaline mineral waters, 351 colchicum, 351 diet, 351 Gravel, 373 Grip (see also Influenza), 34 H. Haematidrosis, 344 Haematuria, 370 etiology, 370 diseases of bladder, 370 kidney,370 prostate, 370 ureter, 370 urethra, :»70 distoma haematobium, 370 drugs, 370 infectious diseases, 370 Haeinocytozoon. 131 Haemophilia, 315 etiology, 345 through mother, 345 symptoms, 345 treatment, 346 Hay-asthma, 130 -fever, 130 etiology, 130 occurrence, 130 symptoms, 130 treatment, 131 Heart atrophy, 297 dilatation, 297 symptoms, 299 treatment, 300 diseases of, 296 hypertrophy, 297 etiology, 298 treatment, 301 inflammations, 301-320 neuroses, .'120-326 allorrhythmia, 321 angina pectoris, 324 etiology, 324 symptoms, 324 treatment, 325 arrhythmia. 321 bradycardia, 324 permanent, 324 temporary, 324 delirium cordis, 321 palpitation, 322 pseudo-angina, 325 Heart neuroses, pseudo-angina, etiol- ogy, 325 symptoms, 326 treatment, 326 pulsus alterans, 321 bigeminus, 321 paradoxus, 321 trigeminus, 321 tachycardia, 323 etiology, 323 tremor cordis, 321 valvular disease (see also Valvular disease), 306, 308 Hemorrhagic diathesis, 343 Hemorrhoids, 224 Hepatitis, 238-241 chronic interstitial, 240 suppurative, 238 Hodgkin's disease, 342 Hydatid cysts, 149 booklets, 150 of the peritoneum, 230 Hydronephrosis, 376 fluid in, :>76 Hydrophobia, 121 diagnosis, 122 prophylaxis, 122 Past cur treatment, 122 symptoms, 121 incubation, 121 stages, 121 excitement, 121 paralytic, 121 premonitory, 121 treatment, 122 Hydrothorax, 2s9 symptoms, 2s9 treatment, 290 Hyperaemia of liver, 236-237 active, 236 passive, 237 tropical, 237 Hyperanakinesis, 206 Hyperchlorhydria, 201 Hyperorexia, 203 Hypertrophy of the heart, 297 Hyponakinesis, 206 I. Icterus, 231 acute febrile, 125 iufectious, 125 diagnosis, 232 Gmelin's test, 232 Marechal's test, 232 INDEX. 395 Icterus, diagnosis, Pettenkofer's 232 gravis, 243 ■ treatment, 233 Ileus, 219 Impotence, 387 Infection, 17 secondary, 18 Influenza, 34 bacillus, 35 definition, 34 diagnosis, 36 etiology, 35 history, 31 prophylaxis, 36 symptomatology, 35 treatment, 36 Insufficiency, 308-314 aortic, 31 i mitral, 308 pulmonary, 314 tricuspid, 313 Intermittent fever, 134 Intestinal catarrh, 208 hemorrhage, 213 neoplasms, 225 adenomata, 226 angiomata, 226 carcinoma, 225 fibromata, 226 lipomata, 226 lymphosarcoma, 226 myomata, 226 myxomata, 226 papillomata, 226 polypi, 226 sarcoma, 226 obstruction, 219 diagnosis, 222 rectal examination, 222 etiology, 219 constipation, 220 intussusception, 220 strangulation, 220 stricture, 220 tumors, 220 volvulus, 220 symptoms, 221 constipation, 221 meteorism, 221 pain, 221 vomiting, 221 treatment, 222 air into bowel, 223 colotomy, 223 enterostomy, 223 , Intestinal obstruction, treatment, irri- gation, 223 lavage, 223 purgatives, 223 Intestines, diseases of, 208-226 hemorrhage, 213 ulcer, 212 tubercular, 212 typhoid, 212 J. Jaundice, 231 K. Kidney, amyloid degeneration, 378 anaemia, 377 floating, 373 symptoms, 373 treatment, 373 hyperaemia, 377 acute, 377 chronic, 377 movable, 373 nephritis (see also Nephritis), 379 stone in, 373 syphilis of, 378 tuberculosis of, 378 white, 379 large, 379, 382 small, 379, 382 Kidney-stone, 373 phosphatio, 375 symptoms, 374 treatment, 376 uric-acid, 375 varieties, 373 L. Laryngitis, 251-256 catarrhal, 254-256 acute, 254 chronic, 255 Larynx, diseases of, 254-261 benign tumors, 261 carcinoma, 259 neuroses, 261 cedema, 256 perichondritis, 257 sarcoma, 260 syphilis, 258 tuberculosis, 258 Leprosy, 78 definition, 78 39b' INDEX. Leprosy, diagnosis, 80 etiology, 79 bacillus leprae, 79 history, 78 prognosis, 80 symptomatology, 79 ana-sthesia, 79 eruptions, 79 nodules, 79 treatment, 80 chaulmoogra oil, 80 gurguu oil, 80 serum, 80 Leukaemia, 341 blood in, 342 lymphatic, 341 spleuic-myelogenous, 341 symptoms, 341 treatment, 342 Leukocythaemia(seealsoLeitfc«mia),; Leukocytosis, 340 absence of, 340 occurrence, 340 abnormal, 340 normal, 340 Lichen tubercle, 71 Lingua geographica, 175 Lithaemia, 348 definition, 348 etiology, 349 symptoms, 349 treatment, 349 Liver, abscess of, 238 chronic, 239 subacute, 239 symptoms, 238 treatment, 239 amyloid, 245 atrophy, 243 acute, 243 simple, 243 cirrhosis of, 240 etiology, 240 hypertrophic, 242 symptoms, 240 ascites, 240 caput Medusae, 241 treatment, 242 diseases of, 231-247 fatty, 244 degeneration, 244 infiltration, 244 hyperaemia, 236 active, 236 symptoms, 236 treatment, 237 Liver, hypencmia, passive, 237 causes, 237 symptoms, 237 treatment, 238 tropical, 236 neoplasms, 246 varieties, 246, 247 tropical abscess of, 238 Lockjaw, 118 Lues (see also Syphilis), 81 Lungs, diseases of, 273-285 abscess, 283 actinomycosis, 285 echinococcus, 285 gangrene, 283 inflammation (see Pneumonia). cedema, 282 syphilis, 285 M. Macroglossia, 175 Malaria, 134 etiology, 134 parasite, 134 history, 134 mosquito in, 137 pernicious, i40 prognosis, 140 prophylaxis, 140 symptoms, 137 quartan, 137 tertian, 137 temperature-curve, 136 treatment, 141 arsenic, 142 quinine, 141 Malignant pustule, 115, 116 Mallein, 90 Malta fever, 126 Marsh fever, 134 Measles, 44 definition, 44 diagnosis, 47 Koplik's spots, 47 long prodroma, 47 photophobia, 47 etiology, 44 protozoa, 44 forms, 46 rubeola afebrilis, 46 nigra, 46 siderans, 46 sine catarrho, 46 eruptione, 46 INDEX. 397 Measles, French (see also Rubella), 49 German (see also Rubella), 49 prognosis, 47 prophylaxis, 47 symptoms, 45 desquamation, 46 eruption, 45, 46 exanthem, 45 incubatiou, 45 invasion, 45 treatment, 48 serum, 48 Mediastinum, diseases of, 334 Mediterranean fever, 126 Meningitis, cerebro-spinal (see also Cerebrospinal meningitis), epi- demic, 26 Miasmatic fever, 134 Micrococcus pneumoniae crouposae, 273 Miliary fever, 127 Morbilli (see also Measles), 44 Mouth, diseases of, 168-174 dry, 180 parasites, 174 Mumps, 41 definition, 41 diagnosis, 43 etiology, 42 Steno's duct, 42 history, 42 prophylaxis, 43 symptomatology, 42 breast, 43 incubation, 42 parotid gland, 42 testicle, 43 treatment, 43 Myalgia, 33 Myocarditis, 301 acute, 302 chronic, 302 etiology, 301 symptoms, 302 treatment, 302 N. Neapolitan fever, 126 Nematodes, 157 Neoplasms of the liver, 246, 247 Nephritis, 379-383 acute parenchymatous, 379 diagnosis, 382 prognosis, 383 chronic parenchymatous, 380 Nephritis, chronic parenchymatous, diagnosis, 382 prognosis, 383 classification, 379 hemorrhagic, 379, 382 interstitial, 379, 381 treatment, 383 bathing, 383 change of residence, 384 diet, 383 of dropsy, 384 drugs, 383 Nephrolithiasis, 373 Nervous dyspepsia, 207 Neuroses of heart, 320-326 Noma, 172 Nose, diseases of, 250-254 acute catarrh, 250 chronic catarrh, 252 new growths, 253 adenoids, 254 polypi, 253 syphilitic catarrh, 253 o. Obesity, 355 treatment, 355 dietaries, 355 Banting, 355 Ebstein, 355 (Edema of the larynx, 256 of the lungs, 282 (Esophagism, 186 Oesophagitis, 185 (JEsophagoscope, 182 OIEsophagus, dilatation of, 183 diseases of, 181-187 diverticulum, 183 hemorrhage, 184 inflammations, 185 obstruction, 182 congenital stenosis, 182 external compression, 182 foreign bodies, 182 strictures, 182 tumors, 182 perforation, 184 Rontgen ray, 182 rupture, 184 spasm, 186 tuberculosis, 185 tumors, 186 carcinoma, 186 Oi'dium albicans, 173 Osteomalacia, 354 Oxyuris vermicularis, 159 398 INDEX. P. Pancreas, calculi, 249 cvsts, 248 diseases of, 247-249 hemorrhage, 247 symptoms, 218 treatment, 218 tumors, 218 Paratyphlitis, 215, 216 Parorexia, 203 Parotitis, 41, ISO secondary, ISO Peptonuria, 365 Pericardial effusions, 296 Pericarditis, 293 acute, 293 chronic, 293 etiology, 293 physical signs, 294 primary, 293 purulent, 2!)0 treatment, 296 secondary, 293 symptoms, 293 treatment, 295 Pericardium, 296 diseases of, 21)3-296 effusions, 296 hseino-, 296 hydro-, 296 pneumo-, 296 pyo-, 296 inflammation (see Pericarditis). Peritoneal neoplasm, 230 carcinoma, 230 hydatid cysts, 230 other varieties, 231 Peritonitis, 227 acute, 227 complications, 228 etiology, 227 symptoms, 227 treatment, 228 laparotomy, 228 opium, 228 chronic, 230 etiology, 230 symptoms, 230 treatment, 230 tubercular, 229 diagnosis, 229 etiology, 229 tubercle bacillus, 229 symptoms, 229 treatment, 229 Peritoneum, diseases of, 227 231 Perityphlitis, 215, 216 Pertussis (see also Whooping-cough), 37 Pest, 124 Pharyngitis, 178 acute, 178 chronic. 17ft Pharynx, diseases of, 178, 179 Phlebitis, 333 Piles, 224 Plague, 124 etiology, 121 bacillus pestis, 124 history, 124 symptoms, 124 treatment, 125 Plasmodium malariae, 134, 135, 136 Plethora, 335 Pleura, diseases of, 285-292 carcinoma, 292 echinococcus, 292 Pleurisy, 285-289 acute, 285 chronic, 286 definition, 285 dry, 286 etiology, 285 physical signs, 2*6 suppurative, 287 etiology, 287 treatment, 289 resect ion of rib, 289 symptoms, 285 treatment, 287 Pneumatosis, 206 Pneumo-hydro-thorax, 290 Pneumonia, 273-279 broncho-, 277 catarrhal, 277 etiology, 277 bacteria, 277 symptoms, 278 treatment, 279 croupous, 273 etiology, 273 micrococcus crouposae, 273 symptoms, 274 blood. 275 treatment. 276 fibrinous, 273 genuine, 273 influenza, 279 lobar, 273 lobular, 277 tubercular, 280 INDEX. 399 Pneumonia, typhoid, 280 Pneumonokoniosis, 284 Pneumo-pyo-thorax, 290 Pneumothorax, 290 etiology, 290 gas-forming micro-organisms, 290 symptoms, 290 treatment, 291 Podagra, 34.9 Polyphagia, 203 Polysareia, 355 Polyuria, 356, 361 Pox (see also Syphilis), 81 Prostatorrhoea, 386 Pseudoleukaemia, 342 Purpura, 344 arthritic, 344 fulminans, 345 hemorrhagica, 345 Henoch's, 345 myelopathic, 344 pemphigoid, 315 rheumatica, 345 symptomatic, 344 urticans, 345 venous stasis, 344 Pvaemia, 17 Pyelitis, 371 primary, 371 secondary, 371 symptoms, 372 pyuria, 372 treatment, 372 Pyelonephritis, 371 Pyloric incontinence, 206 Pylorospasmus, 206 Pyonephrosis, 371 Pyuria, 369 etiology, 369 Q. Quinsy, 69 definition, 69 symptomatology, 69 treatment, 70 R. Rabies, 121 Rachitis (see also Rickets), 353 Ray-fungus, 132 Recurrent fever, 104 Relapsing fever, 104 Relapsing fever, diagnosis, 106 etiology, 104 symptomatology, 104 eruption, 105 incubation, 104 invasion, 104 relapse, 105 treatment, 106 serum, 106 symptomatic, 106 Renal cirrhosis, 381 diagnosis, 382 prognosis, 383 Retropharyngeal abscess, 179 etiology, 179 symptoms, 1>0 treatment, 180 Rheumatism, 29 acute articular, 30 diagnosis, 31 etiology, 30 symptomatology, 30 treatment, 31 blisters, 32 cold bath, 32 diet, 31 salicylates, 32 chronic articular, 32 diagnosis, 32 symptoms, 32 treatment, 33 climato-therapy, 33 heat, 33 potassium iodide, 33 gonorrhoeal, 33 cause, 33 occurrence, 33 treatment, 33 muscular, 33 causes, 33 diagnosis, 34 symptomatology, 33 treatment, 34 varieties, 34 cephalodynia, 34 lumbago, 34 occipitofrontal, 34 pleurodynia, 34 torticollis, 34 nodular (see also Arthritis defor- mans), 352 Rhinitis, 250-252 acute, 250 symptoms, 250 treatment, 252 chronic, 252 400 INDEX. Rhinitis, chronic, symptoms, 253 treatment, 253 hyperaesthetica, 130 syphilitic, 253 Rickets, 353 symptoms, 353 fontanelles, 353 rosary, 353 treatment, 354 Rock fever, 126 Rotheln (see also Rubella), 49 Rubella, 49 definition, 49 diagnosis, 50 etiology, 49 morbillosa, 50 scarlatinosa, 50 desquamation, 50 symptoms, 49 enanthem, 49 eruption, 50 incubation, 49 treatment, 50 Rubeola (see also Measles), 44 S. Saint Anthony's fire, 22 Salivary glands, diseases of, 180 Sand, 3*73 Scarlatina (see also Scarlet fever), 50 Scarlet fever, 50 complications, 53 albuminuria, 53 nephritis, 53 diagnosis, 53 etiology, 50 forms, 53 abortive, 53 fulminant, 53 localized, 53 malignant, 53 immunity, 51 in pigs, 51 prognosis, 54 prophylaxis, 54 isolation, 54 sodium sulphocarbolate, 55 symptomatology, 51 convulsions, 51 enanthem, 52 exanthem, 52 desquamation, 53 incubation, 51 invasion, 51 strawberry tongue, 53 Scarlet fever, symptomatology, tem- perature, 52 treatment, 55 bath, 55 diet, 55 serum, 55 turpentine, 55 Schonlein's disease, 345 Scorbutus, 346 Scurvy, 346 symptoms, 346 treatment, 347 Sepsis, 17 cryptogenetic, 18 Septicaemia, 17 diagnosis, 19 differential diagnosis, 19 cerebro-spinal meningitis, 20 endocarditis, 20 joints, 20 malaria, 20 miliary tuberculosis, 20 typhoid fever, 19 uraemia, 20 examination of the blood, 18 metastatic affection, 19 micro-organisms, 17 prognosis, 21 symptomatology, 18 treatment, 21 antiseptics, 21 serum-therapy, 21 Septico-pyaemia, 17 Serums (foot-note), 76 Siderosis, 284 Simon's triangles, 57 Simple continued fever, 130 Smallpox, 56 complications, 59 ears, 59 eyes, 59 heart, 59 diagnosis, 59 umbilicated vesicles, 60 etiology, 56 forms, 60 confluent, 60 hemorrhagic, 60 history, 56 prognosis, 60 prophylaxis, 60 vaccination, 60 symptoms, 56 desiccation, 59 eruption, 57 measles, 57 INDEX. Smallpox, symptoms, eruption on mu cous membranes, 58 papules, 58 pustules, 58 vesicles, 58 incubation, 56 invasion, 56 Simon's triangles, 57 temperature, 58 secondary fever, 58 treatment, 61 of pitting, 61 serum-injection, 61 vaccination, 61 Soft chancre, 86 Spermatorrhoea, 386 Spirillum cholerse, 110 Spirochaete, 104, 106, 170 Splenic fever, 115 Spotted fever, 26 Stenosis, 309-315 aortic, 312 mitral, 309 pulmonary, 315 tricuspid, 314 Stomach, atony, 207 diseases of, i87-20S Stomatitis aphthosa, 171 acute, 169" catarrhalis, 169 erythematous, 169 symptoms, 170 treatment, 170 gangraenosa, 172 etiology, 172 symptoms, 173 treatment, 173 herpetica, 172 symptoms, 171 treatment, 171 mycotica, 173 simple, 169 ulcerosa, 170 Streptococcus erysipelatis, 22 treatment of sarcoma, 23 Sugar in urine, 358 tests, 358 Bremer's, 358 fermentation, 359 phenyl-hvdrazin, 359 Roberts', 360 Tromruer's, 358 Suppurative hepatitis, 238 Swamp fever, 134 Sweating fever, 127 Syphilis, 81 26—P. M, Syphilis, congenital, 83 signs, 83 diagnosis, 83 eruption, 83 falling of the hair, 83 etiology, 81 hereditary, 81 of the larynx, 258 prognosis, 84 prophylaxis, 84 symptomatology, 82 chancre, 82 incubation, 82 primary sore, 82 second stage, 82 third stage, 82 treatment, 84 excision of chancre, 84 second stage, 84 mercury, 84 fumigation, 85 inhalation, 85 injection, 85 internally, 85 inunction, 84 third stage, 85 potassium iodide, 85 T. Taenia armata, 150 cucumerina, 152 diminuta, 153 echinococcus, 148 lata, 153 nana (von Beneden), 148 (v. Siebold), 153 saginata, 152 solium, 150 Taeniae, 145 Tapeworms, 145 beef, 152 broad, 153 dog, 148 etiology, 145 pork, 150 prophylaxis, 146 treatment, 147 calomel, 147 male fern, 148 unarmed, 152 Tetanus, 118 bacillus of, 118 diagnosis, 119 strychnine-poisoning, 119 idiopathic, 118 402 INDEX. Tetanus, prognosis, 119 prophylaxis, 119 symptomatology, 118 spasms, 119 treatment, 120 antitoxin, 120 toxin, 120 Thrombosis, 231 Thrush,173 Tongue, diseases of, 174-176 geographical, 175 mapped, 175 Tonsillitis, 176-178 acute catarrhal, 176 chronic, 178 croupous, 176 epidemic (see also Quinsy), 69 lacunar, 176 parenchymatous (see also Quinsy), 69 suppurative (see also Quinsy), 69,178 Tonsils, diseases of, 176-178 hypertrophy of, 17s Trachea, diphtheria of, 261 diseases of, 261 tumors, 201 Trematodes, 151 Trichina spiralis, 165 Trichinosis, 165 Tricocephaliasis, 160 Trismus. 118 Tuberculin, 74, 76 modifications (foot-note), 76 new, 76 old, 74 test, 74 Tuberculosis, 70 diagnosis, 73 sputum, 73 tubercle bacillus, 73 etiology, 70 bacillus tuberculosis, 70 environment, 71 secondary infection, 71 wounds, 71 history, 70 of the larynx, 258 physical signs, 73 prognosis, 75 prophylaxis, 75 milk inspection, 76 symptomatology, 72 expectoration, 72 haemoptysis, 72 hectic, 72 night-sweats, 72 treatment, 76 Tuberculosis, treatment, drugs, 77 nebulization of essential oils, 78 new tuberculin, 76 method of administration, 76 solutions, 76, 77 open air, 77 sanitaria, 77 Tumors of the intestines (see also In- testinal neoplasms), 225 of the liver, 246, 247 of the peritoneum (see Peritoneal neoplasms). Typhlitis, 215 causes, 216 symptoms, 216 treatment, 216 Typhoid fever, 92 blood-test, 97 Diazo reaction, 98 Widal test, 97 complications, 97 heart-failure, 97 perforation, 97 septicaemia, 97 etiology, 93 history, 92 prognosis, 99 prophylaxis, 99 food, 99 excreta, 99 symptomatology, 93 eruption, 93 incubation, 93 onset, 93 spleen, 93 stools, 93. temperature, 93, 94 tongue, 93 treatment, 99, 101 bathing, 100 diet, 99 drugs, 100 hygienic surroundings, 100 injections, 100 laparotomy for perforation, 101 nursing, 99 sponging, 101 stupes, 101 Typhus abdominalis, 92 exanthemicas, 101 fever, 101 diagnosis, 103 etiology. 102 history, 102 prognosis, 104 symptomatology, 102 INDEX. 403 Typhus fever, symptomatology, erup- tion, 102 incubation, 102 incursion, 102 temperature, 103 treatment, 104 u. Ulcer of the duodenum, 212 symptoms, 213 treatment, 213 of the intestine, 212 of the stomach, 193 Uraemia, 368 toxin, 368 Urethritis specifica, 86 Urine, albumin (see also Albuminuria), 364 blood (see also Hematuria), 370 chyle (see also Chyluria), 370 incontinence, 385 pus (see also Pyuria), 369 sugar (see also Sugar in urine), 358 V. Vaccination, 60 etiology, 62 history, 62 method, 62 Vaccinia, 61 Valve-lesions (see also Valvular Dis- ease), 317 physical signs, 317 insufficiency, 317 aortic, 317 mitral, 317 pulmonary, 318 tricuspid, 318 stenosis, 318 aortic, 318 mitral, 317 pulmonary, 318 tricuspid, 318 treatment, 319 bath, 320 bromides, 320 climate, 320 exercise, 320 nitroglycerin, 320 plasters, 320 rest, 319 stimulants, 319 Valves of the heart (see Valvular dis- ease). Valvular disease, 308-320 combined lesions, 316 insufficiency, 308, 311, 313, 314 aortic, 311 mitral, 308 pulmonary, 314 tricuspid, 313 stenosis, 309, 312, 314, 315 aortic, 312 mitral, 309 pulmonary, 315 tricuspid, 315 Varicella, 63 symptomatology, 63 treatment, 63 Varices, 334 Variola (see also Smallpox), 56 Varioloid, 61 W. Waterpox (see also Varicella), 63 Weil's disease, 125, 244 Whooping-cough, 37 complications, 39 contagion, 38 definition, 37 diagnosis, 39 lingual ulcer, 39 with measles, 39 etiology, 37 history, 37 immunity, 38 prophylaxis, 39 symptomatology, 38 chart in, 38, 39 whoop, 38 treatment, 40 benzine vapor, 41 drugs, 40 grasping hyoid bone, 40 local application, 40, 41 naphthalin vapor, 40 sulphur fumes, 41 tqssol, 40 Wool-sorters' disease, 115 Worm, Guinea, 163 Worms, filiform, 157 pin-, 159 round-, 157 whip-, 160 X. Xerostomia, 180 404 INDEX. Y. Yellow fever, 107 diagnosis, 109 blood-test, 108 icterus, 108 etiology, 107 amaril poison, 107 bacillus icteroides, 107 bacillus X, 107 prognosis, 108 prophylaxis, 109 Yellow fever, symptomatology, 107 black vomit, 108 incubation, 107 jaundice, 108 onset, 107 stages, 108 treatment, 109 cathartic, 109 drugs, 109 enemata, 109 serum, 109 CATALOGUE OF PUBLICATIONS OF LEA BROTHERS & COMPANY, 706, 708 & 710 Sansom St., Philadelphia. Ill Fifth Ave. (Cor. 18th St.), New York. The books in the annexed list will be sent by mail, post-paid, to any Post-Office in the United States, on receipt of the printed prices. INDEX. ANATOMY. Gray, p. 11 ; Treves, 30 ; Gerrish, 11; Brockway, 4. DICTIONARIES. Dunglison, p. 8; Dnane, 8 ; National, 4. PHYSICS. Draper, p. 8 ; Eobertson, 24 ; Martin & Rockwell, 20. PHYSIOLOGY. Foster, p. 10; Chapman, 5; Schofield, 25; Collins & Rockwell, 6. [Luff, 19 ; Renisen, 24. CHEMISTRY. Simon, p. 26 ; Attfield, 3 ; Martin & Rockwell, 20; PHARMACY. Caspari, p. 5. [Bruce, 4 : Schleif, 25. MATERIA MEDICA. Culbretb, p. 6 ; Maisch, 19 ; Farquharson, 9 ; DISPENSATORY. National, p. 21. THERAPEUTICS. Hare, p. 13 ; Fothergill, 10 ; Whitla, 31 ; Hay em & Hare, 14 ; Bruce, 4 ; Schleif, 25 ; Cushny, 6. PRACTICE. Flint, p. 9 ; Loomis & Thompson, 19 ; Malsbary, 20. DIAGNOSIS. Musser, p. 21; Hare, 12; Simon, 25; Herrick, 15; Hutchi- son & Rainey, 16 ; Collins, 6. CLIMATOLOGY. Solly, p. 26 ; Hayem & Hare, 14. NERVOUS DISEASES. Dercum, p. 7 ; Gray, 11; Potts, 23. MENTAL DISEASES. Clouston, p. 5 ; Savage, 24 ; Folsorn, 10. BACTERIOLOGY. Abbott, p. 2; Vanghan & Novy, 30 ; Senn's (Surgical), 25. Park, 22 ; Coates, 6. [Vale, 21. HISTOLOGY. Klein, p. 17 ; Schafer's, 25 ; Dunham, 8 ; Nichols & PATHOLOGY. Green, p. 12; Gibbes, 10; Coats, 6; Nichols & Vale, 21 SURGERY. Park, p. 22; Dennis, 7; Roberts, 24; Ashhurst, 3; Treves, 29; Cheyne & Burghard, 5 ; Gallaudet, 10. SURGERY—OPERATIVE. Stimson, p. 27 ; Smith, 26 ; Treves, 29. SURGERY—ORTHOPEDIC. Young, p. 31; Gibney, 10. SURGERY—MINOR. Wharton, p. 30. TBallenger & FRACTURES and DISLOCATIONS. Stimson, p. 27. [Wippern, 3. OPHTHALMOLOGY. Norris & Oliver, p. 21; Nettleship, 21; Juler,17; OTOLOGY. Politzer, p. 23; Burnett, 5; Field, 9; Bacon, 4. LARYNGOLOGY and RHINOLOGY. Coakley, p. 6 ; DENTISTRY. Essig (Prosthetic), p. 9 ; Kirk (Operative), 17 ; Ameri- can System, 2 ; Coleman, 6; Burchard 4. URINARY DISEASES. Roberts, p. 24 ; Black, 4 ; Morris, 20. VENEREAL DISEASES. Taylor, p. 28 ; Hayden, 14 ; Cornil, 6 ; Likes, 19. SEXUAL DISORDERS. Fuller, p. 10 ; Taylor, 29. DERMATOLOGY. Hyde, p. 16 ; Jackson, 16 ; Pye-Smith, 24 ; Mor- ris, 20 ; Jamieson, 16 ; Hardaway, 12 ; Grindon, 12. GYNECOLOGY. American System, p. 3 ; Thomas & Mund6, 29 Emmet, 9 ; Davenport, 7 ; May, 20 ; Dudley, 8 ; Crockett, 6. OBSTETRICS. American System, p. 3 ; Davis, 7 ; Parvin, 22 ; Play- fair. 23 ; King, 17 ; Jewett, 17 ; Evans, 9. PEDIATRICS. Smith, p. 26 ; Thomson, 29 ; Williams, 31 ; Tuttle, 30. HYGIENE. 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R.). MATERIA MEDICA AND PHAR- MACOLOGY. In one handsome octavo volume of 812 pages, with 445 illustrations. Cloth, $4.75. A thorough, authoritative and systematic exposition of its most important domain. — The Canada Lancet. This work ought to be at once adopted as the text-book in all col- leges of pharmacy and medicine. It is one of the most valuable works that have been issued.—The Ohio Medical Journal. CUSHNY (ARTHUR R.). TEXT-BOOK OF PHARMACOLOGY. Handsome 8vo., 728 pages, with 47 illus. Just ready. Cloth, $3.75, net. Lea Brothers & Co., Philadelphia and New York. 7 DALTON (JOHN C). A TREATISE ON HUMAN PHYSIOLOGY. Seventh edition. Octavo, 722 pages, with 252 engravings. Cloth, $5; leather, $6. — DOCTRINES OF THE CIRCULATION OF THE BLOOD. one handsome 12mo. volume of 293 pages. Cloth, $2. In DAVENPORT (F. H.). DISEASES OF WOMEN. A Manual of Gynecology. For the use of Students and Practitioners. New (3d) edition. In one handsome 12mo. volume of 387 pages, with 150 illustrations. Cloth, $1.75, net. Just ready. DAVIS (EDWARD P.). A TREATISE ON OBSTETRICS. FOR STUDENTS AND PRACTITIONERS. In one very handsome octavo volume of 546 pages, with 217 engravings and 30 full-page plates in colors and monochrome. Cloth, $5; leather, $6. This work must become the prac- titioner's text-book as well as the student's. It is up to date in every respect.— Va. Med. Semi-Monthly. A work unequalled in excellence. — The Chicago Clinical Review. Decidedlv one of the best text- books on the subject. It is exception- ally useful from every standpoint.— Nashville Jour, of Med. and Surgery. From a practical standpoint the work is all that could be desired. A thoroughly scientific and brilliant treatise on obstetrics. —Med. News. DAVIS (F. H.). LECTURES ON CLINICAL MEDICINE. Second edition. In one 12mo. volume of 287 pages. Cloth, $1.75. DE LA BECHE'S GEOLOGICAL OBSERVER. In one large octavo volume of 700 pages, with 300 engravings. Cloth, $4. DENNIS (FREDERIC S.) AND BILLINGS (JOHN S.). A SYS- TEM OF SURGERY. In contributions by American Authors. Complete work in four very handsome octavo volumes, containing 3652 pages, with 1585 engravings and 45 full-page plates in colors and monochrome. Per volume, cloth, $6.00; leather, $7.00; half Morocco, gilt back and top, $8.50. For sale by subscription only. Full prospectus free on application to the publishers. It is worthy of the position which surgery has attained in the great Republic whence it comes. — The London Lancet. It may be fairly said to represent the most advanced condition of American surgery and is thoroughly practical.—Annals of Surgery. No work in English can be con- sidered as the rival of this.— The American Journal of the Medical Sciences. DERCUM (FRANCIS X., EDITOR). A TEXT-BOOK ON NERVOUS DISEASES. By American Authors. In one handsome octavo volume of 1054 pages, with 341 engravings and 7 colored plates. Cloth, $6.00; leather, $7.00. Net. Representing the actual status of our knowledge of its subjects, and the latest and most fully up-to-date of any of its class.—Jour, of Amer- ican Med. Association. The most thoroughly up-to-date treatise that we have on this subject. —American Journal of Insanity. The work is representative of the best methods of teaching, as devel- oped in the leading medical colleges of this country.—Alienist and Neu- rologist. The best text-book in any lan- guage.—The Medical Fortnightly. DE SCHWEINITZ (GEORGE E.). THE TOXIC AMBLYOPIAS. Their Classification, History, Symptoms, Pathology and Treatment. Very handsome octavo, 240 pages, 46 engravings, and 9 full-page plates, in colors. Limited edition, de luxe binding, $4. Net. Lea Brothers & Co., Philadelphia and New York. convenience and thoroughness. —■ Medical Record. The best student's dictionary.— Canada Lancet. nRAPER(JOHNC). MEDICAL PHYSICS. A Text-book for Stu- DRd^Sfni Practitioners of Medicine. In one handsome octavo volume of 734 pages, with 376 engravings. Cloth, $4. nRUITT (ROBERT). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. A new American, from the twelfth London edition, edited by Stanley Boyd,F.R.C.S In one large octavo volume of 965 pages, with 373 engravings. Cloth, $4; leather, $5. DUANE (ALEXANDER). THE STUDENT'S DICTIONARY OF MEDICINE AND THE ALLIED SCIENCES. New edition. Com- prising the Pronunciation, Derivation and Full Explanation of Medi- cal Terms, with much Collateral Descriptive Matter. Numerous Tables, etc. Square octavo of 658 pages. Cloth, $3.00; half leather, $3.25; full sheep, $3.75. Thumb-letter Index, 50 cents extra. Far superior to any dictionary for the medical student that we know of. — Western Med. and Surg. Reporter. The book is brought accurately to date. It is a model of conciseness, DUDLEY (E. C). THE PRINCIPLES AND PRACTICE OF GYNECOLOGY. Handsome octavo of 652 pages, with 422 illustra- tions in black and colors. Cloth, $5.00, net; leather, S6.00, net. Just ready. The book can be safely recom-1 tice of modern gynecology.—Inter- mended as a complete and reliable national Medical Magazine. exposition of the principles and prac- | DUNCAN (J. MATTHEWS). CLINICAL LECTURES ON THE DISEASES OF WOMEN. Delivered in St. Bartholomew's Hospital. In one octavo volume of 175 pages. Cloth, $1.50. DUNGLISON (ROBLEY). A DICTIONARY OF MEDICAL SCI- ENCE. Containing a full explanation of the various subjects and terms of Anatomy, Physiology, Medical Chemistry, Pharmacy, Phar- macology, Therapeutics, Medicine, Hygiene, Dietetics, Pathology, Sur- gery, Ophthalmology, Otology, Laryngology, Dermatology, Gynecol- ogy, Obstetrics, Pediatrics, Medical Jurisprudence, Dentistry, etc., etc. By Robley Dunglison, M. D., LL. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. Edited by Richard J. Dunglison, A. M., M. D. Twenty-first edition, thor- oughly revised and greatly enlarged and improved, with the Pronuncia- tion, Accentuation and Derivation of the Terms. With Appendix. In one magnificent imperial octavo volume of 1225 pages. Cloth, $7; leather, $8. Thumb-letter Index for quick use, 75 cents extra. The most satisfactory and authori- tative guide to the derivation, defini- tion and pronunciation of medical terms.—The CharlotteMed. Journal. scarcely be measured.—Med. Record. Pronunciation is indicated by the phonetic system. The definitions are unusually clear and concise. The book is wholly satisfactory.— Uni- versity Medical Magazine. Covering the entire field of medi- cine, surgery and the collateral sciences, its range of usefulness can DUNHAM (EDWARD K.). MORBID AND NORMAL HIS- TOLOGY. Octavo, 450 pages.with 363 illustrations. Cloth, $3.25, net. Just ready. The best one-volume text or refer-1 of published in America.— Virginia ence book on histology that we know I Medical Semi-Monthly. EDES (ROBERT T.). TEXT-BOOK OF THERAPEUTICS AND MATERIA MEDICA. In one 8vo. volume of 544 pages. Cloth, $3.50; leather, $4.50. EDIS (ARTHUR W.). DISEASES OF WOMEN. A Manual for Students and Practitioners. In one handsome 8vo. volume of 576 pages, with 148 engravings. Cloth, $3; leather, $4. Lea Brothers & Co., Philadelphia and New Yore:. 9 EGBERT (SENECA). A MANUAL OF HYGIENE AND SANI- TATION. In one 12mo. volume of 359 pages, with 63 illustrations. Just ready. Cloth, Net, $2.25. It is written in plain language, ligence. The writer has adapted it and, while primarily designed for to American conditions, and his physicians, it can be studied with suggestions are, above all, practical. profit by any one of ordinary intel- —The New York Medical Journal. ELLIS (GEORGE VTNER). DEMONSTRATIONS IN ANATOMY. Eighth edition. Octavo, 716 pages, with 249 engravings. Cloth, $4.25; leather, $5.25. EMMET (THOMAS ADDIS). THE PRINCIPLES AND PRAC- TICE OF GYNAECOLOGY. Third edition. Octavo, 880 pages, with 150 original engravings. Cloth, $5; leather, $6. ERICHSEN (JOHN E.). THE SCIENCE AND ART OF SUR- GERY. Eighth edition. In two large octavo volumes containing 2316 pages, with 984 engravings. Cloth, $9 ; leather, $11. ESSIG (CHARLES J.). PROSTHETIC DENTISTRY. See American Text-Books of Dentistry, page 2. EVANS (DAVID J.). A POCKET TEXT-BOOK OF OHSTETRICS. In one handsome 12mo. volume of about 300 pages, with many illustra- tions. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. FARQUHARSON (ROBERT). A GUIDE TO THERAPEUTICS. Fourth American from fourth English edition, revised by Frank Woodbury, M. D. In one 12mo. volume of 581 pages. Cloth, $2.50. FEELD (GEORGE P.). A MANUAL OF DISEASES OF THE EAR. Fourth edition. In one octavo volume of 391 pages, with 73 engravings and 21 colored plates. Cloth, $3.75. To those who desire a concise It is just such a work as is needed work on diseases of the ear, clear by every general practitioner. — and practical, this manual com- American Practitioner and News. mends itself in the highest degree. FLINT (AUSTIN). A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE. Seventh edition, thoroughly revised by Frederick P. Henry, M.D. In one large 8vo. volume of 1143 pages, with engravings. Cloth, $5.00; leather, $6.00. The work has well earned its lead- medicine in the medical schools.— ing place in medical literature.— Northwestern Lancet. Medical Record. The best of American text-books ml_ , .. , , , , -, on Practice.—Amer.Medico-Surqical The leading text-book on general nune*in ----A MANUAL OF AUSCULTATION AND PERCUSSION; of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. Fifth edition, revised by James C. Wilson, M. D. In one handsome 12mo. volume of 274 pages, with 12 engravings. ----A PRACTICAL TREATISE ON THE DIAGNOSIS AND TREATMENT OF DISEASES OF THE HEART. Second edition enlarged. In one octavo volume of 550 pages. Cloth, $4. ----A PRACTICAL TREATISE ON THE PHYSICAL EXPLO- RATION OF THE CHEST, AND THE DIAGNOSIS OF DIS- EASES AFFECTING THE RESPIRATORY ORGANS. Second and revised edition. In one octavo volume of 591 pages. Cloth, $4.50. -----MEDICAL ESSAYS. In one 12mo. vol. of 210 pages. Cloth, $1.38. ----ON PHTHISIS : ITS MORBID ANATOMY ETIOLOGY, ETC. A Series of Clinical Lectures. In one 8vo. volume of 442 pages. Cloth, $3.50. 10 Lea Brothers & Co., Philadelphia and New York. FOLSOM (C. P.). AN ABSTRACT OF STATUTES OF U. S. ON CUSTODY OF THE INSANE. In one 8vo. vol. of 108 pages. Cloth, $1.50. With Clouston on Mental Diseases (new edition, see page 6) $5.00, net, for the two works. FORMULARY, POCKET, see page 32. FOSTER (MICHAEL). A TEXT-BOOK OF PHYSIOLOGY. New (6th) and revised American from the sixth English edition. In one large octavo volume of 923 pages, with 257 illustrations. Cloth, $4.50; leather, $5.50. Unquestionably the best book that This single volume contains all can be placed in the student's hands, and as a work of reference for the busy physician it can scarcely be excelled.—ThePhila. Polyclinic. that will be necessary in a college course, and all that the physician will need as well.—Dominion Med. Monthly. FOTHERGILL (J. MILNER). THE PRACTITIONER'S HAND- BOOK OF TREATMENT. Third edition. In one handsome octavo volume of 664 pages. Cloth, $3.75; leather, $4.75. To have a description of the clearly stated, cannot fail to prove normal physiological processes of an organ and of the methods of treat- ment of its morbid conditions brought together in a single chapter, and the relations between the two a great convenience to many thought- ful but busy physicians. The prac- tical value of the volume is greatly increased by the introduction of many prescriptions—New York Med. Jour. FOWNES (GEORGE). A MANUAL OF ELEMENTARY CHEM- ISTRY (INORGANIC AND ORGANIC). Twelfth edition. Em- bodying Watts' Physical and Inorganic Chemistry. In one royal 12mo. volume of 1061 pages, with 168 engravings, and 1 colored plate. Cloth, $2.75; leather, $3.25. FRANKLAND (E.) AND JAPP (F.R.). INORGANIC CHEMISTRY. In one handsome octavo volume of 677 pages, with 51 engravings and 2 plates. Cloth, $3.75; leather, $4.75. FULLER (EUGENE). DISORDERS OF THE SEXUAL OR- GANS IN THE MALE. In one very handsome octavo volume of 238 pages, with 25 engravings and 8 full-page plates. Cloth, $2. It is an interesting work, and one which, in view of the large and profitable amount of work done in this field of late years, is timely and well needed.—Medical Fortnightly. The book is valuable and instruc- tive and brings views of sound pathology and rational treatment to many cases of sexual disturbance whose treatment has been too often fruitless for good. — Annals of Surgery. FULLER (HENRY). ON DISEASES OF THE LUNGS AND AIR PASSAGES. Their Pathology, Physical Diagnosis, Symptoms and Treatment. From second English edition. In one 8vo. volume of 475 pages. Cloth, $3.50. GALLAUDET (BERN B.). A POCKET TEXT-BOOK ON SUR- GERY. In one handsome 12mo. volumeof about 400 pages, with many illustrations. Cloth, si.50, net. Shortly. Lea's Series of Pocket Text- books, edited by Bern B. Gallaudet, M. D. See page 18. GANT (FREDERICK JAMES). THE STUDENT'S SURGERY. A Multum in Parvo. In one square octavo volume of 845 pages, with 159 engravings. Cloth, $3.75. GD3BES (HENEAGE). PRACTICAL PATHOLOGY AND MORBID HISTOLOGY. Octavo, 314 pages, with 60 illustrations. Cloth, $2.75. GIBNEY (V. P.). ORTHOPEDIC SURGERY. For the use of Practi- tioners and Students. In one 8vo. vol. profusely illus. Preparing. Lea Brothers & Co., Philadelphia and New York. 11 GERRISH (FREDERIC H.). A TEXT-BOOK OF ANATOMY. By American Authors. Edited by Frederic H. Gerrish, M. D. In one imp. octavo volume of 915 pages, with 950 illustrations in black and colors. Just ready. Clth,$6.50; flexible waterproof, $7; leath.,$7.50,«^. In this, the first representative treatise on Anatomy produced in America, no effort or expense has been spared to unite an authoritative text with the most successful anatomical pictures which have yet appeared in the world. The editor has secured the co-operation of the professors of anatomy in leading medical colleges, and with them has prepared a text conspicuous for its simplicity, unity and judicious selection of such anatomical facts as bear on physiology, surgery and internal medicine in the most compre- hensive sense of those terms. The authors have endeavored to make a book which shall stand in the place of a living teacher to the student, and which shall be of actual service to the practitioner in his clinical work, emphasizing the most important subjects, clarifying obscurities, helping most in the parts most difficult to learn, and illustrating everything by all available methods. GOULD (A. PEARCE). SURGICAL DIAGNOSIS. In one 12mo. vol. of 589 pages. Cloth, $2. See Student's Series of Manuals, p. 27. GRAY (HENRY). ANATOMY, DESCRIPTIVE AND SURGICAL. New and thoroughly revised American edition, much enlarged in text, and in engravings in black and colors. In one imperial octavo volume of 1239 pages, with 772 large and elaborate engravings on wood. Price of edition with illustrations in colors : cloth, $7 ; leather, $8. Price of edition with illustrations in black: cloth, $6; leather, $7. This is the best single volume upon Anatomy in the English language.— University Medical Mag- azine. Gray's Anatomy affords the student more satisfaction than any other treatise with which we are familiar. —Buffalo Med. Journal. The most largely used anatomical text-book published in the English language.—Annals of Surgery. Particular stress is laid upon the practical side of anatomical teach- GRAY (LANDON CARTER). A TREATISE ON NERVOUS AND MENTAL DISEASES. For Students and Practitioners of Medicine. New (2d) edition. In one handsome octavo volume of 728 pages, with 172 engravings and 3 colored plates. Cloth, $4.75; leather, $5.75. An up-to-date text-book upon measures which are often the physi- ing, and especially the Surgical Anatomy.— Chicago Med. Recorder. Holds first place in the esteem of both teachers and students.— The Brooklyn Medical Journal. The foremost of all medical text- books.—Medical Fortnightly. Gray's Anatomy should be the first work which a medical student should purchase, nor should he be without a copy throughout his pro- fessional career.—Pittsburg Medical Review. nervous and mental diseases com bined. A well-written, terse, ex- plicit, and authoritative volume treating of both subjects is a step in the direction of popular demand.— The Chicago Clinical Review. "The word treatment," says the author, " has been construed in the broadest sense to include not only medicinal and non-medicinal agents, but also those hygienic and dietetic cian's best reliance."—The Journal of the American Medical Association. The descriptions of the various diseases are accurate and the symp- toms and differential diagnosis are set before the student in such a way as to be readily comprehended. The author's long experience renders his views on therapeutics of great value. —The Journal of Nervous and Men- tal Disease. 12 Lea Brothers & Co., Philadelphia and New York. GREEN (T. HENRY). AN INTRODUCTION TO PATHOLOGY AND MORBID ANATOMY. New (8th) American from the eighth London edition. In one handsome octavo volume of 582 pages, with 216 engravings and a colored plate. Cloth, $2.50, net. Just ready. A work that is the text-book of probably four-fifths of all the stu- dents of pathology in the United States and Great Britain stands in no need of commendation. The work precisely meets the needs and wishes of the general practitioner.—The American Practitioner and News. Green's Pathology is the text-book of the day—as much so almost as Gray's Anatomy. It is fully up-to- date in the record of fact, and so pro- fusely illustrated as to give to each detail of text sufficient explanation. The work is an essential to the prac- titioner—whether as surgeon or phys- ician. It is the best of up-to date text-books.— Virginia Med. Monthly. GREENE (WILLIAM H.). A MANUAL OF MEDICAL CHEM- ISTRY. For the Use of Students. Based upon Bowman's Medical Chemistry. In one 12mo. vol. of 310 pages, with 74 illus. Cloth, $1.75. GROSS (SAMUEL D.). A PRACTICAL TREATISE ON THE DIS- EASES, INJURIES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROSTATE GLAND AND THE URETHRA. Third edition. Octavo, 574 pages, with 170 illustrations Cloth, $4.50. GRINDON (JOSEPH). A POCKET TEXT-BOOK OF SKIN DISEASES. In one handsome 12mo. volume of 3">0 pages, with many illustrations. Shortly. Cloth, $1.50, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. HABERSHON (S. O.). ON THE DISEASES OF THE ABDOMEN Second American from the third English edition. In one octavo vol- ume of 554 pages, with 11 engravings. Cloth, $3.50. HALL (WINFIELD S.) TEXT-BOOK OF PHYSIOLOGY. Octavo about 500 pages, richly illustrated. In press. HAMILTON (AULAN MCLANE). NERVOUS DISEASES, THEIR DESCRIPTION AND TREATMENT. Second and revised edition. In one octavo volume of 598 pages, Avith 72 engravings. Cloth, $4. HARD AW AY (W. A.). MANUAL OF SKIN DISEASES. New (2d) edition. In one 12mo. volume of 560 pages, with 40 illustrations and 2 plates. Cloth, $2.25, net. Just ready. The best of all the small books to recommend to students and practi- tioners. Probably no one of our dermatologists has had a wider every- day clinical experience. His great strength is in diagnosis, descriptions of lesions and especially in treat- ment.-—Indiana Medical Journal. HARE (HOBART AMORY). PRACTICAL DIAGNOSIS. THE USE OF SYMPTOMS IN THE DIAGNOSIS OF DISEASE. New (4th) edition. In one octavo volume of 623 pages, with 205 engravings and 14 full-page colored plates. Cloth, $5.00, net. Just ready. It is unique in many respects, and the author has introduced radical changes which will be welcomed by all. Anyone who reads this book will become a more acute observer, will pay more attention to the simple yet indicative signs of disease, and he will become a better diagnosti- cian. This is a companion to Prac- tical Therapeutics, by the same author, and it is difficult to conceive of any two works of greater practical utility.—Medical Review. Lea Brothers & Co., Philadelphia and New York. 13 HARE (HOBART AMORY). A TEXT-BOOK OF PRACTICAL THERAPEUTICS, with Special Reference to the Application of Reme- dial Measures to Disease and their Employment upon a Rational Basis. With articles on various subjects by well-known specialists. New (7th) and revised edition. In one octavo volume of 776 pages. Cloth, $3.75, net; leather, $4.50, net. Its classifications are inimitable, and the readiness with which any- thing can be found is the most won- derful achievement of the art of in- dexing. This edition takes in all the latest discovered remedies.— The St. Louis Clinique. The great value of the work lies in the fact that precise indications for administration are given. A complete index of diseases and remedies makes it an easy reference work. It has been arranged so that it can be readily used in connection with Hare's Practical Diagnosis. For the needs of the student and general practitioner it has no equal. —Medical Sentinel. The best planned therapeutic work of the century.—American Prac- titioner and News. It is a book precisely adapted to the needs of the busy practitioner, who can rely upon finding exactly what he needs.— The National Med- ical Review. HARE (HOBART AMORY) ON THE MEDICAL COM PLICA TIONS AND SEQUEL.E OF TYPHOID FEVER. Octavo, 276 pages, 21 engravings and two full-page plates. Just ready. Cloth, $2.40, net. A very valuable production. One , read with great profit.- of the very best products of Dr. Journal of Medicine. Hare and one that every man can | -Cleveland HARE (HOBART AMORY, EDITOR). A SYSTEM OF PRAC- TICAL THERAPEUTICS. In a series of contributions by eminent practitioners. In four large octavo volumes comprising about 4500 pages,with about 550 engravings. Vol. IV., just ready. For sale by sub- scription only. Full prospectus free on application to the Publishers. Regular price, Vol. IV., cloth, $6; leather, $7; half Russia, $8. Price Vol. IV. to former or new subscribers to complete work, cloth, $5 ; leather, $6; half Russia, $7. Complete work, cloth, $20; leather, $24 ; half Russia, $28. The great value of Hare's System of Practical Therapeutics has led to a widespread demand for a new volume to represent advances in treatment made since the publication of the first three. More than fulfilling this request the Editor has secured contributions from practically a new corps of equally eminent authors, so that entirely fresh and original matter is ensured. The plan of the work, which proved so successful, has been fol- lowed in this new volume, which will be found to present the latest devel- opments and applications of this most practical branch of the medical art. The entire System is an unrivalled encyclopaedia on the practical parts of medicine, and merits the great success it has won for that reason. 14 Lea Brothers & Co., Philadelphia and New York. HARTSHORNE (HENRY). ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDICINE. Fifth edition. In one 12mo. volume, 669 pages, with 144 engravings. Cloth, $2.75. ----A HANDBOOK OF ANATOMY AND PHYSIOLOGY. In one 12mo. volume of 310 pages, with 220 engravings. Cloth, $1.75. -----A CONSPECTUS OF THE MEDICAL SCIENCES. Comprising Manuals of Anatomy, Physiology, Chemistry, Materia Medica, Prac- tice of Medicine, Surgery and Obstetrics. Second edition. In one royal 12mo. vol. of 1028 pages, with 477 illus. Cloth, $4.25; leather, $5. HAYDEN (JAMES R.). A MANUAL OF VENEREAL DISEASES. New (2d) edition. In one 12mo. volume of 304 pages, with 54 en- gravings. Cloth, $1.50, net. Just ready. It is practical, concise, definite and of sufficient fulness to be satis- factory.—Chicago Clinical Review. This work gives all of the prac- tically essential information about the three venereal diseases, gon- orrhoea, the chancroid and syphilis. In diagnosis and treatment it is par- ticularly thorough, and may be relied upon as a guide in the man- agement of this class of diseases.— Northwestern Lancet. It is well written, up to date, and will be found very useful.—Inter- national Medical Magazine. HAYEM (GEORGES) AND HARE (H. A.). PHYSICAL AND NATURAL THERAPEUTICS. The Remedial Use of Heat, Elec- tricity, Modifications of Atmospheric Pressure, Climates and Mineral Waters. Edited by Prof. H. A. Hare, M. D. In one octavo volume of 414 pages,with 113 engravings. Cloth, $3. This well-timed up-to-date volume is particularly adapted to the re- quirements of the general practi- tioner. The section on mineral waters is most scientific and prac- tical. Some 200 pages are given up to electricity and evidently embody the latest scientific information on the subject. Altogether this work is the clearest and most practical aid to the study of nature's therapeutics that has yet come under our obser- vation.—The Medical Fortnightly. For many diseases the most potent remedies lie outside of the materia medica, a fact yearly receiving wider recognition. Within this large range of applicability, physical agencies when compared with drugs are more direct and simple in their results. Medical literature has long been rich in treatises upon medical agents, but an authoritative work upon the other great branch of therapeutics has until now been a desideratum. The section on climate, rewritten by Prof. Hare, will, for the first time, place the abundant resources of our country at the in- telligent command of American practitioners.— The Kansas City Medical Index. HERMAN (G. ERNEST). FIRST LINES IN MIDWIFERY. In one 12mo. vol. of 198 pages, with 80 engravings. Cloth, $1.25. See Student's Series of Manuals, page 27. HERMANN (L.). EXPERIMENTAL PHARMACOLOGY. A Hand- book of the Methods for Determining the Physiological Actions of Drugs. Translated by Robert Meade Smith, M. D. In one 12mo. volume of 199 pages, with 32 engravings. Cloth, $1.50. Lea Brothers & Co., Philadelphia and New York. 15 HERRICK (JAMES B.). A HANDBOOK OF DIAGNOSIS. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. Excellently arranged, practical, concise, up-to-date, and eminently well fitted for the use of the prac- titioner as well as of the student.— Chicago Med. Recorder. This volume accomplishes its ob- jects more thoroughly and com- pletely than any similar work yet published. Each section devoted to diseases of special systems is pre- ceded with an exposition of the methods of physical, chemical and microscopical examination to be em- ployed in each class. The technique of blood examination,including color analysis, is very clearly stated. Uranalysis receives adequate space and care.—New York Med. Journal. We commend the book not only to the undergraduate, but also to the physician who desires a ready means of refreshing his knowledge of diag- nosis in the exigencies of professional life.—Memphis Medical Monthly. HILL (BERKELEY). SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo. volume of 479 pages. Cloth, $3.25. HDL.LIER (THOMAS). A HANDBOOK OF SKIN DISEASES. Second edition. In one royal 12mo. volume of 353 pages, with two plates. Cloth, $2.25. HIRST (BARTON C.) AND PLERSOL (GEORGE A.). HUMAN MONSTROSITIES. Magnificent folio, containing 220 pages of text and illustrated with 123 engravings and 39 large photographic plates from nature. In four parts, price each, $5. Limited edition. For sale by subscription only. HOBLYN (RICHARD D.). A DICTIONARY OF THE TERMS USED IN MEDICINE AND THE COLLATERAL SCIENCES. In one 12mo. volume of 520 double-columned pages. Cloth, $1.50; leather, $2. HODGE (HUGH L.). ON DISEASES PECULIAR TO WOMEN, INCLUDING DISPLACEMENTS OF THE UTERUS. Second and revised edition. In one 8vo. vol. of 519 pp., with illus. Cloth, $4.50. HOFFMANN (FREDERICK) AND POWER (FREDERICK B.). A MANUAL OF CHEMICAL ANALYSIS, as Applied to the Examination of Medicinal Chemicals and their Preparations. Third edition, entirely rewritten and much enlarged. In one handsome octavo volume of 621 pages, with 179 engravings. Cloth, $4.25. HOLMES (TIMOTHY). A TREATISE ON SURGERY. Its Prin- ciples and Practice. A new American from the fifth English edition. Edited by T. Pickering Pick, F.R.C.S. In one handsome octavo vol- ume of 1008.pages, with 428 engravings. Cloth, $6; leather, $7. — A SYSTEM OF SURGERY. With notes and additions by various American authors. Edited by John H. Packard, M. D. In three very handsome 8vo. volumes containing 3137 double-columned pages, with 979 engravings and 13 lithographic plates. Per volume, cloth, $6; leather, $7; half Russia, $7.50. For talc by subscription only. 16 Lea Brothers & Co., Philadelphia and New York. HORNER (WILLIAM E.). SPECIAL ANATOMY AND HIS- TOLOGY. Eighth edition, revised and modified. In two large 8vo. volumes of 1007 pages, containing 320 engravings. Cloth, $6. HUDSON (A.). LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. HUTCHISON (ROBERT) AND RAINY (HARRY). CLINICAL METHODS. A GUIDE TO THE PRACTICAL STUDY OF MEDICINE. In one 12mo. volume of 562 pages, with 137 engrav- ings and 8 colored plates. Cloth, $3.00. A comprehensive, clear and re- markably up-to-date guide to clinical diagnosis. The illustrations are plentiful and excellent. As exam- ples of the more recent additions to medical knowledge which receive recognition, we mention Widal's test for typhoid and the Neuron theory of the nervous system.— Montreal Medical Journal. HUTCHINSON (JONATHAN). SYPHILIS. In one pocket-size 12mo. volume of 542 pages, with 8 chromo-lithographic plates. Cloth, $2.25. See Series of Clinical Manuals, p. 25. HYDE (JAMES NEVTNS). A PRACTICAL TREATISE ON DIS- EASES OF THE SKIN. New (4th) edition, thoroughly revised In one octavo volume of 815 pages, with 110 engravings and 12 full- page plates, 4 of which are colored. Cloth, $5.25; leather, $6.25 This edition has been carefully re- vised, and every real advance has been recognized. The work answers the needs of the general practitioner, the specialist, and the student.—The Ohio Med. Jour. A treatise of exceptional merit characterized by conscientious care and scientific accuracy. —Buffalo Med. Journal. A complete exposition of our knowledge of cutaneous medicine as it exists to-day. The teaching in- culcated throughout is sound as well as practical.—The American Jour- nal of the Medical Sciences. It is the best one-volume work that we know. The student who gets this book will find it a useful investment, as it will well serve him when he goes into practice.— Vir- ginia Medical Semi-Monthly. A full and thoroughly modern text-book on dermatology. — The Pittsburg Medical Review. It is the most practical hand- book on dermatology with which we are acquainted.—The Chicago Med- ical Recorder. JACKSON (GEORGE THOMAS). THE READY-REFERENPF HANDBOOK OF DISEASES OF THE SKINL New(Id) eSon In one 12mo. volume of 637 pages, with 75 illustrations and a colored plate. Just ready. Cloth, $2.50, net. As a student's manual, it may be considered beyond criticism. The book is singularly full.—St. Louis Medical and Surgical Journal. Without doubt forms one of the best guides for the beginner in der- matology that is to be found in the English language.—Medicine. JAMJESON (W. AJLLAN). DISEASES OF THE SKIN Third edition. In one octavo volume of 656 pages, with 1 engraving and 9 double-page chromo-lithographic plates. Cloth, $6. S Lea Brothers & Co., Philadelphia and New York. 17 JEWETT (CHARLES). ESSENTIALS OF OBSTETRICS. In one 12mo. volume of 356 pages, with 80 engravings and 3 colored plates. Cloth, $2.25. Just ready. An exceedingly useful manual for student and practitioner. The au- thor has succeeded unusually well in condensing the text and in arrang- ing it in attractive and easily tangi- ble form. The book is well illus- trated throughout.—Nashville Jour. of Medicine and Surgery. ----- THE PRACTICE OF OBSTETRICS. By American Authors. One large octavo volume of 763 pages, with 441 engravings in black and colors, and 22 full-page colored plates. Just ready. Cloth, $5.00, net; leather, $6.00, net. A clear and practical treatise upon the book abounds. The work is obstetrics by well-known teachers of sure to be popular with medical the subject. A special feature of students, as well as being of extreme this work would seem to be the value to the practitioner. — The excellent illustrations with which Medical Age. JONES (C. HANDF1ELD). CLINICAL OBSERVATIONS ON FUNCTIONAL NERVOUS DISORDERS. Second American edi- tion. In one octavo volume of 340 pages. Cloth, $3.25. JULER (HENRY). A HANDBOOK OF OPHTHALMIC SCIENCE AND PRACTICE. Second edition. In one octavo volume of 549 pages, with 201 engravings, 17 chromo-lithographic plates, test-types of Jaeger and Snellen, and Holmgren's Color-Blindness Test. Cloth, $5.50; leather, $6.50. The volume is particularly rich in | color blindness, etc. The sections matter of practical value, such as devoted to treatment are singularly directions for diagnosing, use of full and concise.—Medical Age. instruments, testing for glasses, for | KING (A. F. A.). A MANUAL OF OBSTETRICS. Seventh edition. In one 12mo. volume of 573 pages, with 223 illustrations. Cloth, $2.50. From first to finish it is thoroughly practical, concise in expression, well illustrated, and includes a statement of nearly every fact of importance discussed in obstetric treatises or cyclopedias. The well-arranged index renders the book useful to the practitioner who is in haste to refresh his memory. — Virginia Medical Semi-Monthly. KIRK (EDWARD C). OPERATIVE DENTISTRY. Handsome octavo of 700 pages, with 751 illustrations. Just ready. See American Text-Books of Dentistry, page 2. We have only the highest praise for this valuable work. It is replete in every particular, and surpasses anything of the kind heretofore at- tempted. We can heartily recom- mend it to the profession.— The Ohio Dental Journal. KLEIN (E.). ELEMENTS OF HISTOLOGY. New (5th) edition. In one 12mo. volume of 506 pages, with 296 engravings. Just ready. Cloth, $2.00, net. See Student's Series of Manuals, page 27. It is the most complete and con- cise work of the kind that has yet emanated from the press.— The Med- ical Age. This work deservedly occupies a first place as a text-book on his- tology.— Canadian Practitioner. 18 Lea Brothers & Co., Philadelphia and New York. LANDIS (HENRY G.). THE MANAGEMENT OF LABOR. In one handsome 12mo. volume of 329 pages, with 28 illus. Cloth, $1.75. LA ROCHE (R.). YELLOW FEVER. In two 8vo. volumes of 1468 pages. Cloth, $7. LAURENCE (J. Z.) AND MOON (ROBERT C). A HANDY- BOOK OF OPHTHALMIC SURGERY. Second edition. In one octavo volume of 227 pages, with 66 engravings. Cloth, $2.75. LEA'S SERIES OF POCKET TEXT-BOOKS, edited by Bern B. Gallaudet, M. D. Covering the entire field of Medicine in a series of 16 very handsome cloth-bound 12mo. volumes of 350-450 pages each, profusely illustrated. Compendious, clear, trustworthy and modern, and issued at the very moderate price of $1.50, net, per volume. The following volumes constitute the series. Coates'Bacteriology and Hygiene. Brockway's Anatomy. Collins and Rockwell's Physiology. Martin and Rockwell's Chemistry and Physics. Nichols and Vale's Histology and Pathology. Schleif's Materia Medica, Therapeutics, Medical Latin, etc. Mals- bary's Practice of Medicine. Collins' Diagnosis. Potts' Nervous and Mental Diseases. Gallaudet's Surgery. Likes' Genito- urinary and Venereal Diseases. Grindon's Dermatology. Ballen- GER and Wippern's Diseases of the Eye, Ear, Throat and Nose. Evans' Obstetrics. Crockett's Gynecology. Tuttle's Diseases of Children. For separate notices see under various authors' names. LEA (HENRY C). A HISTORY OF AURICULAR CONFESSION AND INDULGENCES IN THE LATIN CHURCH. In three octavo volumes of about 500 pages each. Per volume, cloth, $3.00. ----CHAPTERS FROM THE RELIGIOUS HISTORY OF SPAIN; CENSORSHIP OF THE PRESS; MYSTICS AND ILLUMINATI- THE ENDEMONIADAS; EL SANTO NINO DE LA GUARDIA; BRIANDA DE BARDAXI. 12mo., 522 pages. Cloth, $2.50. ----FORMULARY OF THE PAPAL PENITENTIARY. In one octavo volume of 221 pages, with frontispiece. Cloth, $2.50. — SUPERSTITION AND FORCE; ESSAYS ON THE WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL AND TORTURE. Fourth edition, thoroughly revised. In one hand- some royal 12mo. volume of 629 pages. Cloth, $2.75. — STUDIES IN CHURCH HISTORY. The Rise of the Temporal Power—Benefit of Clergy—Excommunication. New edition. In one handsome 12mo. volume of 605 pages. Cloth, $2.50. ----AN HISTORICAL SKETCH OF SACERDOTAL CELIBACY IN THE CHRISTIAN CHURCH. Second edition. In one hand- some octavo volume of 685 pages. Cloth, $4.50. LEHMANN (C. G.). A MANUAL OF CHEMICAL PHYSIOLOGY. In one 8vo. volume of 327 pages, with 41 engravings. Cloth, $2.25. Lea Brothers & Co., Philadelphia and New York. 19 LIKES (SYLVAN H.). A POCKET TEXT-BOOK OF GENITO- URINARY AND VENEREAL DISEASES. In one handsome 12mo. volume of about 350 pages, with many illustrations. Shortly. Cloth, S1.50, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. LOOMIS (ALFRED L.) AND THOMPSON (W. GILMAN, EDITORS). A SYSTEM OF PRACTICAL MEDICINE. In Contributions by Various American Authors. In four very hand- some octavo volumes of about 900 pages each, fully illustrated in in black and colors. Complete work now ready. Per volume, cloth, $5; leather, $6; half Morocco, $7. For sale by subscription only. Full prospectus free on application to the Publishers. See American System of Practical Medicine, page 2. LUFF (ARTHUR P.). MANUAL OF CHEMISTRY, for the use of Students of Medicine. In one 12mo. volume of 522 pages, with 36 engravings. Cloth, $2. See Student's Series of Manuals, page 27. LYMAN (HENRY M.). THE PRACTICE OF MEDICINE. In one very handsome octavo volume of 925 pages, with 170 engravings. Cloth, $4.75; leather, $5.75. Complete, concise, fully abreast of Practical, systematic, complete and the times and needed by all students well balanced.—Chicago Med. Re- and practitioners.— Univ. Med. Mag. \ corder. An exceedingly valuable text-book. ' LYONS (ROBERT D.). A TREATISE ON FEVER. In one octavo volume of 362 pages. Cloth, $2.25. MACKENZIE (JOHN NOLAND). ON THE NOSE AND THROAT. Handsome octavo, about 600 pages, richly illustrated. Preparing. MAISCH (JOHN M.). A MANUAL OF ORGANIC MATERIA MEDICA. New (7th) edition, thoroughly revised by H. C. C. Maisch, Ph. G., Ph. D. In one very handsome 12mo. volume of 512 pages, with 285 engravings. Just ready. Cloth, $2.50, net. Used as text-book in every college of pharmacy in the United States and recommended in medical col- leges.—American Therapist. Noted on both sides of the Atlantic and esteemed as much in Germany as in America. The work has no equal. —Dominion Med. Monthly. The best handbook upon phar- macognosy of any published in this country.—Boston Med. & Sur. Jonr. 20 Lea Brothers & Co., Philadelphia and jnew * MVLSBAKY (GEORGE E.). A POCKET TENT-BOOK OF THEORY AND PRACTICE OF MEDICINE. In one handsome i 'mo volume of about 350 pages. Cloth, S1.50 net Shortly. Da's Series of Pocket Text-books, edited by Bkrn B. Gallaudet, M. D. See page 18. MANUALS. See Student's Quiz Series, page 27, Student's Series of Manuals, page 27, and Series of Clinical Manuals, page 25. MARSH (HOWARD). DISEASES OF THE JOINTS. In one 12mo. volume of 468 pages, with 64 engravings and a colored plate. Cloth, $2. See Series of Clinical Manuals, page 25. MARTIN (EDWARD). A MANUAL OF SURGICAL DIAGNOSIS. In one 12mo. volume of about 400 pp., fully illustrated. Preparing. MARTIN (WALTON) AND ROCKWELL (WM. H). A POCKET TEXT-BOOK OF CHEMISTRY AND PHYSICS. In one hand- solne 12mo. volume of about 350 pages, with many illustrations. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. MAY (C. H.). MANUAL OF THE DISEASES OF WOMEN. For the use of Students and Practitioners. Second edition, revised by L. S. Rau, M. D. In one 12mo. volume of 360 pages, with 31 engrav- ings. Cloth, $1.75. MEDICAL NEWS POCKET FORMULARY, see page 32. MITCHELL (S. WEIR). CLINICAL LESSONS ON NERVOUS DISEASES. In one 12mo. volume of 299 pages, with 19 engravings and 2 colored plates. Cloth, $2.50. Of the hundred numbered copies with the Author's signed title page a few remain; these are offered in green cloth, gilt top, at $3.50, net. contractions, rotary movements in the feeble minded, etc. Few can speak with more authority than the author.— The Journal of the Ameri- can Medical Association. The book treats of hysteria, recur- rent melancholia, disorders of sleep, choreic movements, false sensations of cold, ataxia, hemiplegic pain, treatment of sciatica, erythromelal- gia, reflex ocularneurosis, hysteric MITCHELL (JOHN K.). REMOTE CONSEQUENCES OF IN- JURIES OF NERVES AND THEIR TREATMENT. In one handsome 12mo. volume of 239 pages,with 12 illustrations. Cloth, $1.75. Injuries of the nerves are of fre- quent occurrence in private practice, and often the cause of intractable and painful conditions, conse- quently this volume is of especial interest. Doctor Mitchell has had access to hospital records for the last thirty years, as well as to the government documents, and has skilfully utilized his opportunities. —The Med. Age. MORRIS (MALCOLM). DISEASES OF THE SKIN. New (2d) edition. In one 12mo. volume of 601 pages, with 10 chromo-litho- graphic plates and 26 engravings. Cloth, $3.25, net. Just ready. MULLER (J.). PRINCIPLES OF PHYSICS AND METEOROL- OGY. In one large 8vo. vol. of 623 pages, with 538 cuts. Cloth, $4.50. Lea Brothers & Co., Philadelphia and New York. 21 MUSSER (JOHN H.). A PRACTICAL TREATISE ON MEDICAL DIAGNOSIS, for Students and Physicians. New (3d) edition, thor- oughly revised. In one octavo volume of about 1000 pages, with about 220 engravings and 48 full-page colored plates. In press. Notices of previous edition are appended. We have no work of equal value in English. — University Medical Magazine. His descriptions of the diagnostic manifestations of diseases are accu- rate. This work will meet all the requirements of student and physi- cian.—The Medical News. From its pages may be made the diagnosis of every malady that afflicts the human body, including those which in general are dealt with only by the specialist.—North- western Lancet. It so thoroughly meets the precise demands incident to modern research that it has been adopted as a leading text-book by the medical colleges of this country.—North American Practitioner. Occupies the foremost place as a thorough, systematic treatise.— Ohio Medical Journal. The best of its kind, invaluable to the student, general practitioner and teacher.—Montreal Medical Journal. NATIONAL DISPENSATORY. See Stilli, Maisch & Caspari, p. 27. NATIONAL FORMULARY. See Stille, Maisch & Caspari's National Dispensatory, page 27. NATIONAL! MEDICAL DICTIONARY. See Billings, page 4. NETTLESHD? (E.). DISEASES OF THE EYE. New (5th) American from sixth English edition, thoroughly revised. In one 12mo. volume of 521 pages, with 161 engravings, and 2 colored plates, test-types, formulae and color-blindness test. Cloth, $2.25. Just ready. English language. — Journal of Medicine and Science. The present edition is the result of revision both in England and America, and therefore contains the latest and best ophthalmological ideas of both continents.— The Phy- sician and Surgeon. By far the best student's text-book on the subject of ophthalmology and is conveniently and concisely ar- ranged.— The Clinical Review. It has been conceded by ophthal- mologists generally that this work for compactness, practicality and clearness has no superior in the NICHOLS (JOHN B.) AND YALE (F. P.). A POCKET TEXT- BOOK OF HISTOLOGY AND PATHOLOGY. In one handsome 12mo. volume of about 350 pages, with many illustrations. In ])ress. Cloth, $1.50, net. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. NORRIS (WM. F.) AND OLIVER (CHAS. A.). TEXT-BOOK OF OPHTHALMOLOGY. In one octavo volume of 641 pages, with 357 engravings and 5 colored plates. Cloth, $5; leather, $6. A safe and admirable guide, well j best, the safest and the most conipre qualified to furnish a working knowledge of ophthalmology. — Johns Hopkins Hospital Bulletin. It is practical in its teachings. We unreservedly endorse it as the hensive volume upon the subject that has ever been offered to the Amer- ican medical public— Annals of Ophthalmology and Otology. 22 Lea Brothers & Co., Philadelphia and New York. OWEN (EDMUND). SURGICAL DISEASES OF CHILDREN. In one 12mo. volume of 525 pages, with 85 engravings and 4 colored plates. Cloth, $2. See Series of Clinical Manuals, page 25. PARK (ROSWELL). A TREATISE ON SURGERY BY AMERI- CAN AUTHORS. New and condensed edition. In press. In one royal octavo volume of about 1250 pages, with about 1000 engravings and many full-page plates. ^©"This work is also published in a larger edition, comprising two volumes. Volume I., General Surgery, 799 pages, with 356 engravings and 21 full-page plates, in colors and monochrome. Volume II., Special Surgery, 800 pages, with 430 engra- vings and 17 full-page plates, in colors and monochrome. Per volume, cloth, $4.50; leather, $5.50. Net. The work is fresh, clear and practi- cal, covering the ground thoroughly yet briefly, and well arranged for rapid reference, so that it will be of special value to the student and busy practitioner. The pathology is broad, clear and scientific, while the suggestions upon treatment are clear-cut, thoroughly modern and admirably resourceful.—Johns Hop- kins Hospital Bulletin. The latest and best work written upon the science and art of surgery. Columbus Medical Journal. The illustrations are almost en- tirely new and executed in such a way that they add great force to the text.—The Chicago Medical Re- corder. The various writers have em- bodied the teachings accepted at the present hour.—The North Amer- ican Practitioner. Both for the student and practi- tioner it is most valuable. It is thoroughly practical and yet thor- oughly scientific.—Medical News. A truly modern surgery, not only in pathology, but also in sound surgical therapeutics. — New Or- leans Med. and Surgical Journal. PARK (WILLIAM H.). BACTERIOLOGY IN MEDICINE AND SURGERY. 12mo., about 550 pages, fully illustrated. In press. PARRY (JOHN S.). EXTRA-UTERINE PREGNANCY, ITS CLINICAL HISTORY, DIAGNOSIS, PROGNOSIS AND TREAT- MENT. In one octavo volume of 272 pages. Cloth, $2.50. PARVIN (THEOPHULUS). THE SCIENCE AND ART OF OB- STETRICS. Third edition. In one handsome octavo volume of 677 pages, with 267 engravings and 2 colored plates. Cloth, $4.25; leather, $5.25. In the foremost rank among the most practical and scientific medical works of the day.—Medical News. It ranks second to none in the English language.—Annals of Gyne- cology and Pediatry. The book is complete in every de- partment, and contains all the neces- sary detail required by the modern practising obstetrician. — Interna- tional Medical Magazine. Parvin's work is practical, con- cise and comprehensive. We com- mend it as first of its class in the English language.—Medical Fort- nightly. It is an admirable text-book in every sense of the word.—Nashville Journal of Medicine and Surgery. Lea Brothers & Co., Philadelphia and New York. 23 PEPPER'S SYSTEM OF MEDICINE. See page 3. PEPPER (A. J.). FORENSIC MEDICINE. In press. See Student's Series of Manuals, page 27. SURGICAL PATHOLOGY. In one 12mo. volume of 511 pages, with 81 engravings. Cloth, $2. See Student's Series of Manuals, p. 27. PICK (T. PICKERING). FRACTURES AND DISLOCATIONS. In one 12mo. volume of 530 pages, with 93 engravings. Cloth, $2. See Series of Clinical Manuals, page 25. PLAYFAIR (W. S.). A TREATISE ON THE SCIENCE AND PRACTICE OF MIDWIFERY. Seventh American from the ninth English edition. In one octavo volume of 700 pages, with 207 engravings and 7 plates. Cloth, $3.75 net; leather, $4.75, net. Just ready. In the numerous editions which have appeared it has been kept con- stantly in the foremofct rank. It is a work which can be conscientiously recommended to the profession.— The Albany Medical Annals. This work must occupy a fore- most place in obstetric medicine as a safe guide to both student and obstetrician. It holds a place among the ablest English-speaking authori- ties on the obstetric art.—Buffalo Medical and Surgical Journal. An epitome of the science and practice of midwifery, which em- bodies all recent advances. — The Medical Fortnightly. ---- THE SYSTEMATIC TREATMENT OF NERVE PROSTRA- TION AND HYSTERIA. In one 12mo. volume of 97 pages. Cloth, $1. POCKET FORMULARY, see page 32. POCKET TEXT-BOOKS, see page 18. POLITZER (ADAM). A TEXT-BOOK OF THE DISEASES OF THE EAR AND ADJACENT ORGANS. Second American from the third German edition. Translated by Oscar Dodd, M. D., and edited by Sir William Dalby, F. R. C. S. In one octavo volume of 748 pages, with 330 original engravings. Cloth, $5.50. The anatomy and physiology of ment are clear and reliable. We each part of the organ of hearing are carefully considered, and then follows an enumeration of the dis- eases to which that special part of the auditory apparatus is especially liable. The indications for treat- can confidently recommend it, for it contains all that is known upon the subject.—London Lancet. A safe and elaborate guide into every part of otology.—American Journal of the Medical Sciences. POTTS (CHARLES S.). A POCKET TEXT-BOOK OF NERVOUS AND MENTAL DISEASES. In one handsome 12mo. volume of about 450 pages. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See page 18. PROGRESSIVE MEDICINE, see page 32. PURDY (CHARLES W.). BRIGHT'S DISEASE AND ALLIED AFFECTIONS OF THE KIDNEY. In one octavo volume of 288 pages, with 18 engravings. Cloth, $2. 24 Lea Brothers & Co., Philadelphia and New York. PYE-SMITH (PHHJJP H.). DISEASES OF THE SKIN In one 12mo. vol. of 407 pp., with 28 illus., 18 of which are colored. Cloth, $2. QUIZ SERD3S. See Student's Quiz Series, page 27. RALFE (CHARLES H.). CLINICAL CHEMISTRY. In one 12mo. volume of 314 pages, with 16 engravings. Cloth, $1.50. See Student's Series of Manuals, page 27. RAMSBOTHAM (FRANCIS H.). THE PRINCIPLES AND PRAC- TICE OF OBSTETRIC MEDICINE AND SURGERY. In one imperial octavo volume of 640 pages, with 64 plates and numerous engravings in the text. Strongly bound in leather, $7. REICHERT (EDWARD T.). A TEXT-BOOK ON PHYSIOLOGY. In one handsome octavo volume of about 800 pages, richly illustrated. Preparing. REMSEN (IRA). THE PRINCIPLES OF THEORETICAL CHEM- ISTRY. New (5th) edition, thoroughlv revised. In one 12mo. vol- ume of 326 pages. Cloth, $2. A clear and concise explanation of a difficult subject. We cordially recommend it.— The London Lancet. The book is equally adapted to the student of chemistry or the practi- tioner who desires to broaden his theoretical knowledge of chemistry. —New Orleans Med. and Surg. Jour. The appearance of a fifth edition of this treatise is in itself a guarantee that the work has met with general favor. This is further established by the fact that it has been trans- lated into German and Italian. The treatise is especially adapted to the laboratory student. It ranks unusu- ally high among the works of this class. This edition has been brought fully up to the times.—American 3Iedico-Surgical Bulletin. RICHARDSON (BENJAMIN WARD). PREVENTIVE MEDI- CINE. In one octavo volume of 729 pages. Cloth, $4; leather, $5. ROBERTS (JOHN B.). THE PRINCIPLES AND PRACTICE OF MODERN SURGERY. New (2d) edition. In one octavo volume of about 800 pages, with about 500 engravings. Shortly. ---- THE COMPEND OF ANATOMY. For use in the Dissecting Room and in preparing for Examinations. In one 16mo. volume of 196 pages. Limp cloth, 75 cents. ROBERTS (SIR WILLIAM). A PRACTICAL TREATISE ON URINARY AND RENAL DISEASES, INCLUDING URINARY DEPOSITS. Fourth American from the fourth London edition. In one very handsome 8vo. vol. of 609 pp., with 81 illus. Cloth, $3.50. ROBERTSON (J. MCGREGOR). PHYSIOLOGICAL PHYSICS. In one 12mo. volume of 537 pages, with 219 engravings. Cloth, $2. See Student's Series of Manuals, page 27. ROSS (JAMES). A HANDBOOK OF THE DISEASES OF THE NERVOUS SYSTEM. In one handsome octavo volume of 726 pages, with 184 engravings. Cloth, $4.50; leather, $5.50. SAVAGE (GEORGE H.). INSANITY AND ALLIED NEUROSES, PRACTICAL AND CLINICAL. In one 12mo. volume of 551 pages, with 18 typical engravings. Cloth, $2. See Series of Clinical Man- uals, page 25. Lea Brothers & Co., Philadelphia and New York. 25 SCHAFER (EDWARD A.). THE ESSENTIALS OF HISTOL- OGY. DESCRIPTIVE AND PRACTICAL. For the use of Students. New (5th) edition. In one handsome octavo volume of 359 pages, with 392 illustrations. Cloth, $3.00, net. Just ready. Nowhere else will the same very The most satisfactory elementary moderate outlay secure as thoroughly text-book of histology in the Eng- useful and interesting an atlas of lish language.—The Boston Med. and structural anatomy.—The American Sur. Jour. Journal of the Medical Sciences. -----A COURSE OF PRACTICAL HISTOLOGY. New (2d) edition. In one 12mo. volume of 307 pages, with 59 engravings. Cloth, $2.25. The book very nearly approaches overpraised. It bears eloquent tes- perfection. Methods are given with timony to the wide knowledge and an accuracy of detail and prevision untiring industry of its author.— of difficulties which can hardly be The Scottish Med. and Surg. Jour. SCHLEIF (WILLIAM). MATERIA MEDICA, THERAPEUTICS, PRESCRIPTION WRITING, MEDICAL LATIN, ETC. 12mo., 352 pages. Cloth, $1.50, net. Just ready. Lea's Series of Pocket Text-books. Edited by Bern B. Gallaudet, M. D. See page 18. SCHMITZ AND ZUMPT'S CLASSICAL SERIES. Advanced Latin Exercises. Cloth, 60 cts. Schmidt's Elementary Latin Exer- cises. Cloth, 50 cents. Sallust. Cloth, 60 cents. Nepos. Cloth, 60 cents. Virgil. Cloth, 85 cents. Curtius. Cloth, 80 cents. SCHOFIELD (AX-FRED T.). ELEMENTARY PHYSIOLOGY FOR STUDENTS. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates. Cloth, $2. SCHRED3ER (JOSEPH). A MANUAL OF TREATMENT BY MASSAGE AND METHODICAL MUSCLE EXERCISE. Octavo volume of 274 pages, with 117 engravings. SENN (NICHOLAS). SURGICAL BACTERIOLOGY. Second edi- tion. In one octavo volume of 268 pages, with 13 plates, 10 of which are colored, and 9 engravings. Cloth, $2. SERDES OF CLINICAIj MANUAJLS. A Series of Authoritative Monographs on Important Clinical Subjects, in 12mo. volumes of about 550 pages, well illustrated. The following volumes are now ready: Yeo on Food in Health and Disease, new (2d) edition, $2.50; Carter and Frost's Ophthalmic Surgery, $2.25; Hutchinson on Syphilis, $2.25; Marsh on Diseases of the Joints, $2; Owen on SurgicalDis- eases of Children, $2; Pick on Fractures and Dislocations, $2; Savage on Insanity and Allied Neuroses, $2. For separate* notices, see under various authors' names. SERIES OF STUDENT'S MANUAJLS. See page 27. SIMON (CHARLES E.). CLINICAL DIAGNOSIS, BY MICRO- SCOPICAL AND CHEMICAL METHODS. New (2d) edition. In one very handsome octavo volume of 530 pages, with 135 engravings and 14 full-page colored plates. Cloth, $3.50. Just ready. This book thoroughly deserves its j In all respects entirely up to date. success. It is a very complete, authen-1 —Medical Record. tic and useful manual of the micro-1 The chapter on examination of scopical and chemical methods the urine is the most complete and which are employed in diagnosis. | advanced that we know of in the Very excellent colored plates illus- j English language.— Canadian Prac- trate this work.—New York Medical titioner. Journal. I 26 Lea Brothers & Co., Philadelphia and New York. SIMON (W.). MANUAL OF CHEMISTRY. A Guide to Lectures and Laboratory Work for Beginners in Chemistry. A Text-book specially adapted for Students of Pharmacy and Medicine. New (6th) edition. In one 8vo. volume of 536 pages, with 46 engravings and 8 plates showing colors of 64 tests. Cloth, $3.00, net. Just ready. It is difficult to see how a better the covers of this book.— The North- book could be constructed. No man western Lancet. who devotes himself to the practice Its statements are all clear and its of medicine need know more about teachings are practical.— Virginia chemistry than is contained between | Med. Monthly. SLADE (D. D.). DIPHTHERIA; ITS NATURE AND TREAT- MENT. Second edition. In one royal 12mo. vol., 158 pp. Cloth, $1.25. SMITH (EDWARD) DIABLE STAGES. CONSUMPTION; ITS EARLY AND REME- In one 8vo. volume of 253 pp. Cloth, $2.25. SMITH (J. LEWIS). A TREATISE ON THE DISEASES OF IN- FANCY AND CHILDHOOD. Eighth edition, thoroughly revised and rewritten and much enlarged. In one large 8vo. volume of 983 {•ages, with 273 engravings and 4 full-page plates. Cloth, $4.50; eather, $5.50. The most complete and satisfac- tory text-book with which we are acquainted.—American Gynecologi- cal and Obstetrical Journal. It truly is the most evenly bal- anced, clear in description and thorough in detail of any of the books published in this country on this subject.—3Iedical Fortnightly. A treatise which in every respect SMITH (STEPHEN). OPERATIVE SURGERY. Second and thor- oughly revised edition. In one octavo volume of 892 pages, with 1005 engravings. Cloth, $4 ; leather, $5. can more than hold its own against any other wrork treating of the same subject.—American Medico-Surgical Bulletin. A safe guide for students and phy- sicians.—The Am. Jour, of Obstetrics. For years the leading text-book on children's diseases in America.— Chicago Medical Recorder. dium for the modern surgeon.—Bos- ton Medical and Surgical Journal. One of the most satisfactory works on modern operative surgery yet published. The book is a compen- SOLLY (S. EDWIN). A HANDBOOK OF MEDICAL CLIMA- TOLOGY. In one handsome octavo volume of 462 pages, with en- gravings and 11 full-page plates, 5 of which are in colors. Cloth, $4.00. Just ready. A clear and lucid summary of • an accurate observer and practical what is known of climate in relation to its influence upon human beings. — The Therapeutic Gazette. The book is admirably planned, clearly written,and the author speaks from an experience of thirty years as therapeutist.—Maryland Med. Jour. Every practitioner of medicine should possess himself of a copy and study it, and we are sure he will never regret it.—St. Louis Medical and Surgical Journal. STILLE (ALFRED). CHOLERA; ITS ORIGIN, HISTORY, CAUS- ATION, SYMPTOMS, LESIONS, PREVENTION AND TREAT- MENT. In one 12mo. volume of 163 pages, with a chart showing routes of previous epidemics. Cloth, $1.25. -----THERAPEUTICS AND MATERIA MEDICA. Fourth and revised edition. In two octavo volumes, containing 1936 pages. Cloth, $10; leather, $12. Lea Brothers & Co., Philadelphia and New York. 27 STILLE (ALFRED), MAISCH (JOHN M.) AND CASPARI (CHAS. JR.). THE NATIONAL DISPENSATORY: Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medicines, including those recognized in the latest Pharmacopoeias of the United States, Great Britain and Germany, with numerous refer- ences to the French Codex. Fifth edition, revised and enlarged, including the new U. S. Pharmacopoeia, Seventh Decennial Revision. With Supplement containing the new edition of the National Formu- lary. In one magnificent imperial octavo volume of about 2025 pages. with 320 engravings. Cloth, $7.25; leather, $8. With ready reference Thumb-letter Index. Cloth, $7.75 ; leather, $8.50. Recommended most highly for the amount of information contained in physician, and invaluable to the druggist.—Therapeutic Gazette. It is the official guide for the Med- ical and Pharmaceutical professions. —Buffalo Med. and Sur. Jour. The readiness with which the vast this work is made available is indi- cated by the twenty-five thousand references in the two indexes.—Bos- ton Medical and Surgical Journal. Should be recognized as a national standard.—North Am. Practitioner. STIMSON (LEWIS A.). A MANUAL OF OPERATIVE SURGERY. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 engravings. Cloth, $3.75. A useful and practical guide for all students and practitioners.—Am. Journal of the Medical Sciences. The book is worth the price for the illustrations alone.— Ohio 3Iedical Journal. STIMSON (LEWIS A.). A TREATISE ON FRACTURES AND DISLOCATIONS. In one handsome octavo volume of 831 pages, with 326 engravings and 20 plates. Just ready. Cloth, $5.00, net; leather, $6.00, net. Preeminently the authoritative | Taken as a whole, the work is the text-book upon the subject. The best one in English to-day.—St. Louis Jfedieal and Surgical Journal. Pointed, practical, comprehensive, exhaustive, authoritative, well writ- ten and well arranged.—Denver Medical Times. vast experience of the author gives to his conclusions an unimpeachable value. The work is profusely il- lustrated. It will be found indis- pensable to the student and the prac- titioner alike.— The 3Iedical Age. STUDENT'S QUIZ SERIES. Thirteen volumes, convenient, author- itative, well illustrated, handsomely bound in cloth. 1. Anatomy (double number); 2. Physiology; 3. Chemistry and Physics; 4. Histol- ogy, Pathology, and Bacteriology; 5. Materia Medica and Thera- peutics ; 6. Practice of Medicine; 7. Surgery (double number); 8. Genito- urinary and Venereal Diseases; 9. Diseases of the Skin; 10. Diseases of the Eye, Ear, Throat and Nose; 11. Obstetrics; 12. Gynecology; 13. Diseases of Children. Price, $1 each, except Nos. 1 and 7, Anatomy and Surgery, which being double numbers are priced at $1.75 each. Full specimen circular on application to publishers. 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In one 12mo. volume of 513 pages, with 119 engravings and 5 colored plates. Cloth, $3. TAIT (LAWSON). DISEASES OF WOMEN AND ABDOMINAL SURGERY. In two handsome octavo volumes. Vol. I. contains 546 pages and 3 plates. Cloth, $3. TANNER (THOMAS HAWKES) ON THE SIGNS AND DIS- EASES OF PREGNANCY. From the second English edition. In one octavo volume of 490 pages, with 4 colored plates and 16 engrav- ings. Cloth, $4.25. TAYLOR (ALFRED S.). MEDICAL JURISPRUDENCE. New American from the twelfth English edition, specially revised by Clark Bell, Esq., of the N. Y. Bar. In one 8vo. vol. of 831 pages, with 54 engrs. and 8 full-page plates. Cloth, $4.50; leather, $5.50 Just ready. To the student, as to the physician, we would say, get Taylor first, and then add as means and inclination enable you.—American Practitioner and News. It is the authority accepted as final by the courts of all English- speaking countries. This is the im- portant consideration for medical men, since in the event of their being summoned as experts or wit- nesses, it strongly behooves them to be prepared according to the princi- ples and practice everywhere ac- cepted. The work will be found to be thorough, authoritative and modern.—Albany Law Journal. Probably the best work on the subject written in the English lan- guage. The work has been thor- oughly revised and is up to date.— Pacific 3Iedical Journal. — ON POISONS IN RELATION TO MEDICINE AND MEDI- CAL JURISPRUDENCE. Third American from the third London edition. In one octavo volume of 788 pages, with 104 illustrations. Cloth, $5.50; leather, $6.50. TAYLOR (ROBERT W.). THE PATHOLOGY AND TREAT- MENT OF VENEREAL DISEASES. New (2d) edition. In one very handsome octavo volume of about 700 pages, with about 200 en- gravings and 6 colored plates. In press. Notices of previous edition are appended. By long odds the best work on venereal diseases.—Louisville 3Iedi- cal 3Ionthly. In the observation and treatment of venereal diseases his experience has been greater probably than that of any other practitioner of this con- tinent.—New York Medical Journal. The clearest, most unbiased and ably presented treatise as yet pub- lished on this vast subject.—The 3Iedical News. Decidedly the most important and authoritative treatise on venereal diseases that has in recent years ap- peared in English.—American Jour- nal of the Jledical Sciences. It is a veritable storehouse of our knowledge of the venereal diseases. It is commended as a conservative, practical, full exposition of the greatest value. — Chicago Clinical Review. The best work on venereal dis- eases in the English language. It is certainly above everything of the kind.—The St. Louis 3Iedical and Surgical Journal. Lea Brothers & Co., Philadelphia and New York. 29 TAYLOR (ROBERT W.). A PRACTICAL TREATISE ON SEX- UAL DISORDERS IN THE MALE AND FEMALE. In one 8vo. vol. of 448 pp., with 73 engravings and 8 colored plates. Cloth, $3. Net. ss v It is a timely boon to the medical profession that an observer of Dr. Taylor's skill and experience has written a work on this hitherto neglected and little understood class of diseases which places them on a scientific basis and renders them so clear that the physician who reads its pages can treat this class of patients intelligently. Sterility in the female is presented in an exhaus- tive manner, all of the causes pro- ducing it being described. The author has presented to the profes- sion the ablest and most scientific work as yet published on sexual disorders, and one which, if carefully followed, will be of unlimited value to both physician and patient.— Medical News. —A CLINICAL ATLAS OF VENEREAL AND SKIN DISEASES. Including Diagnosis, Prognosis and Treatment. In eight large folio parts, measuring 14 x 18 inches, and comprising 213 beautiful figures on 58 full-page chromo-lithographic plates, 85 fine engravings and 425 pages of text. Complete work now ready. Price per part, sewed in heavy embossed paper, $2.50. Bound in one volume, half Russia, $27; half Turkey Morocco, $28. For sale by subscription only. Address the publishers. Specimen plates by mail on receipt of ten cents. TAYLOR (SEYMOUR). INDEX OF MEDICINE. A Manual for the use of Senior Students and others. In one large 12mo. volume of 802 pages. Cloth, $3.75. THOMAS (T. GAILLARD) AND MUNDE (PAUL F.). A PRAC TICAL TREATISE ON THE DISEASES OF WOMEN. Sixth edition, thoroughly revised by Paul F. Munde, M. D. In one large and handsome octavo volume of 824 pages, with 347 engravings. Cloth, $5 ; leather, $6. The best practical treatise on the subject in the English language. It will be of especial value to the general practitioner as well as to the specialist. The illustrations are very satisfactory. Many of them are new and are particularly clear and attrac- tive.—Boston Med. and Sur. Jour. This work, which has already gone through five large editions, and has been translated into French, Ger- man, Spanish and Italian, is the most practical and at the same time the most complete treatise upon the subject.—The Archives of Gynecol- ogy, Obstetrics and Pediatrics. THOMPSON (SLR HENRY). CLINICAL LECTURES ON DIS- EASES OF THE URINARY ORGANS. Second and revised edi- tion. In one octavo vol. of 203 pp., with 25 engravings. Cloth, $2.25. ----- THE PATHOLOGY AND TREATMENT OF STRICTURE OF THE URETHRA AND URINARY FISTULA. From the third English edition. In one octavo volume of 359 pages, with 47 engravings and 3 lithographic plates. Cloth, $3.50. THOMSON (JOHN). DISEASES OF CHILDREN. In one crown octavo volume of 350 pages, with 52 illus. Cloth, $1.75, net. Just ready. TODD (ROBERT BENTLEY). CLINICAL LECTURES ON CER- TAIN ACUTE DISEASES. In one 8vo. vol. of 320 pp., cloth, $2.50. TREVES (FREDERICK). OPERATIVE SURGERY. In two 8vo. vols, containing 1550 pp., with 422 illus. Cloth, $9; leath., $11. ------A SYSTEM OF SURGERY. In Contributions by Twenty-five English Surgeons. In two large octavo volumes. Vol. I., 1178 pages, with 463 engravings and 2 colored plates. Vol. II., 1120 pages, with 487 engravings and 2 colored plates. Complete work, cloth, $16.00. 30 Lea Brothers & Co., Philadelphia and New York. TREVES (FREDERICK). SURGICAL APPLIED ANATOMY. In one 12mo. volume of 540 pages, with 61 engravings. Cloth, $2. See Student's Series of Manuals, page 27. TUTTLE (GEORGE M.). A POCKET TEXT-BOOK OF DISEASES OF CHILDREN. In one handsome 12mo. volume of about 300 pages, with many illustrations. Cloth, $1.50, net. Shortly. Lea's Series of Pocket Text-books, edited by Bern B. Gallaudet, M. D. See p 18. VAUGHAN (VICTOR C.) AND NOVY (FREDERICK G.). PTOMAINS, LEUCOMAINS, TOXINS AND ANTITOXINS, or the Chemical Factors in the Causation of Disease. New (3d) edition. In one 12mo. volume of 603 pages. Cloth, $3. The work has been brought down to date, and will be found entirely satisfactory.—Journal of the Ameri- can Medical Association. The most exhaustive and most re- cent presentation of the subject.— American Jour, of the 3Ied. Sciences. The present edition has been not only thoroughly revised throughout but also greatly enlarged, ample consideration being given to the new subjects of toxins and antitoxins.— Tri-State Medical Journal. VISITING LIST. THE MEDICAL NEWS VISITING LIST for 1899. Four styles: Weekly (dated for 30 patients); Monthly (undated for 120 patients per month); Perpetual (undated for 30 patients each week); and Perpetual (undated for 60 patients each week). The 60- patient book consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data, thoroughly revised, and 160 pages of assorted blanks. Each in one volume, price, $1.25. With thumb-letter index for quick use, 25 cents extra. Special rates to advance-paying subscribers to The Medical News or The American Journal of the Medical Sciences, or both. See p. 32. WATSON (THOMAS). LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. A new American from the fifth and enlarged English edition, with additions by H. HARTSHORNE, M. D. In two large 8vo. vols, of 1840 pp., with 190 cuts. Cloth, $9; leather, $11. WEST (CHARLES). LECTURES ON THE DISEASES PECULIAR TO WOMEN. Third American from the third English edition. In one octavo volume of 543 pages. Cloth, $3.75; leather, $4.75. ____ON SOME DISORDERS OF THE NERVOUS SYSTEM IN CHILDHOOD. In one small 12mo. volume of 127 pages. Cloth, $1. WHARTON (HENRY R.). MINOR SURGERY AND BANDAG- ING. New (4th) edition. In one 12mo. vol. of about 600 pages, with about 500 engravings, many of which are photographic. Shortly. Notices of previous edition are appended. We know of no book which more thoroughly or more satisfactorily covers the ground of Minor Surgery and Bandaging.— Brooklyn 3fedical Well written, conveniently ar- ranged and amply illustrated. It covers the field so fully as to render it a valuable text-book, as well as a work of ready reference for sur- geons.— North Amer. Practitioner. The part devoted to bandaging is perhaps the best exposition of the subject in the English language. It can be highly commended to the student, the practitioner and the specialist.—The Chicago Medical Recorder. Lea Brothers & Co., Philadelphia and New York. 31 WHITLA (WTLLIAM). DICTIONARY OF TREATMENT, OR THERAPEUTIC INDEX. Including Medical and Surgical Thera- peutics. In one square octavo volume of 917 pages. Cloth, $4. WILLIAMS (DAWSON). THE MEDICAL DISEASES OF CHIL- DREN. In one 12mo. volume of 629 pages, with 18 illustrations. Just ready. Cloth, $2.50, net. The descriptions of symptoms are full, and the treatment recommended will meet general approval. Under each disease are given the symptoms, We doubt whether any book on dietetics has been of greater or more widespread usefulness than has this much-quoted and much-consulted In studying the different chapters, one is impressed with the thorough- ness of the work. The illustrations are numerous—the book thoroughly practical—Medical News. It is a thorough, a very compre- hensive work upon this legitimate diagnoses, prognosis, complications, and treatment. The work is up to date in every sense.—The Charlotte Medica.1 Journal. work of Dr. Yeo's. The value of the work is not to be overestimated. —New York 3Iedical Journal. surgical specialty and every page abounds with evidences of prac- ticality. It is the clearest and most modern work upon this growing de- partment of surgery.—The Chicago Clinical Review, WILSON (ERASMUS). A SYSTEM OF HUMAN ANATOMY. A new and revised American from the last English edition. Illustrated with 397 engravings. In one octavo volume of 616 pages. Cloth, $4; leather, $5. ----THE STUDENT'S BOOK OF CUTANEOUS MEDICINE. In one 12mo. volume. Cloth, $3.50. WTNCKEL ON PATHOLOGY AND TREATMENT OF CHILDBED. Translated by James R. Chadwick, A. M., M. D. With additions by the Author. In one octavo volume of 484 pages. Cloth, $4. WOHLER'S OUTLINES OF ORGANIC CHEMISTRY. Translated from the eighth German edition, by Ira Remsen, M. D. In one 12mo. volume of 550 pages. Cloth, $3. YEAR-BOOK OF TREATMENT FOR 1892, 1893, 1896,1897 and 1898. Critical Reviews for Practitioners of Medicine and Surgery. In con- tributions by 25 well-known medical writers. 12mos., about 500 pages each. Cloth, $1.50. In combination with The Medical News and The American Journal of the Medical Sciences, 75 cents. YEO (I. BURNEY). FOOD IN HEALTH AND DISEASE. New (2d) edition. In one 12mo. volume of 592 pages, with 4 engravings. Cloth, $2.50. See Series of Clinical 3Ianuats, page 26. ----A MANUAL OF MEDICAL TREATMENT, OR CLINICAL THERAPEUTICS. Two volumes containing 1275 pages. Cloth, $5.50. YOUNG (JAMES K.). ORTHOPEDIC SURGERY. In one 8vo. volume of 475 pages, with 286 illustrations. Cloth, $4; leather, $5. PERIODICALS. PROGRESSIVE MEDICINK. A Quarterly Digest of New Methods, Discoveries, and Improvements in the Medical and Surgical Sciences by Eminent Authorities. Edited by Dr. Hobart Amory Hare. In four abundantly illustrated, cloth bound, octavo volumes, of 400-500 pages each, issued quarterly, commencing March 1st, 1899. Per annum (4 volumes), $10.00 delivered. THE MEDICAL NEWS. Weekly, #1.00 per Annum. Each number contains 32 quarto pages, abundantly illustrated. 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