h> m: It 1 ,.M* '■p. ."!" LlL.L'.VA'... t-" i' • V>t.i-..r'-,".l<.V;.--';^-' . ifi "-i i" ' ''* * r ir.-3!»..v;.;'.•■ ;' -... '■'""' "a->?<-• . ■ ■■" '■ iW*^-■■■".;■'.■ ; f rn »• * i ■''• • .•'■■, •V ' •vr..^'.::.-."'- k."i7 ./,-'-■■ \ / A TEXT-BOOK OF \ l PRACTICAL MEDICINE, \ WITH PARTICULAR REFERENCE TO PHYSIOLOGY AND PATHOLOGICAL ANATOMY BY / DR. FELIX von KIEMEYER, PROFESSOR OF PATHOLOGY AND THERAPEUTICS, DIBECTOS OF THE MEDICAL CLINIC OF THE UNIVERSITY OF TUBINGEN. TRANSLATED FROM THE SEVENTH GERMAN EDITION, BY SPECIAL PERMISSION OF THE AUTHOR, BY GEORGE H. HUMPHREYS, M. D., ONE OF THE PHYSICIANS TO THE BUREAU OF MEDICAL AND SURGICAL RELIEF AT BELLEVUE HOSPITAL FOR THE OUT-DOOR POOR, FELLOW OF THE NEW-YORK ACADEMY OF MEDICINE, ETC., CHARLES E. HACKLEY, M\D., ONE OF THE PHYSICIANS TO THE NEW-YORK HOSPITAL, ONE OF THE SURGEONS TO THE NEW-YORK EYE AND EAR INFIRMARY, FELLOW OF THE NEW- YORK ACADEMY OF MEDICINE. JETC, VOLUME 1. FOURTH AMERICAN EDIT S.JETC. 1 SURGEON «EWj5rao?F,Cf J NEW YORK D. APPLETON AND COMPANY, 90, 92 & 94 GRAND STREET. 1870. • Entered, according to Act of Congress, in the year 1869, by D. APPLETON & CO., In the Clerk's Office of the District Court of the United States tor the Southern District of New York. TEANSLATOES' PEEFACE. The pleasure and profit derived from the perusal of Dr Niemeyer's Hand-book of Special Pathology and Therapeutics have led the translators to suppose that an English edition of the work might be acceptable to the medical profession in America. It is true that, from the present multiplicity of excellent English treatises upon the practice of medicine, such an under- taking may seem superfluous ; but the translators cannot but hope that the work in question may, in some degree, supply a want which many of the more recent hand-books do not alto- gether satisfy. The sciences of Pathology and Therapeutics have made vast strides within the last ten years; and, for very many important researches and discoveries in both these branches of medicine, we are indebted to Germany. Professor Niemeyer's volumes present a concise and well-digested epitome of the results of ten years of carefully-recorded clinical obser- vation by the most illustrious medical authorities of Europe, together with many valuable and practical deductions regard- ing the causes of disease and the application of remedies, such as we believe have not as yet been assembled in any single work. The rapidity witli which it has passed through seven Ger- ■v \ TRANSLATORS' PREFACE. / mi ns, the last two of triple size, and the fact that it ha y been translated into most of the principal languages of l& Continent, afford ample proof of its appreciation in Em and encourage the translators to hope that, in presenting it ii English form, their labors may not prove wholly useless to tl American professional brethren. New York, May 20, 1869. PREFACE TO THE SEVENTH EDITION Nearly ten years have elapsed since the first appearance of my text-book. Meanwhile, clinical medicine owes a rich acces- sion of knowledge to investigati ns made, not only in her own province, but in the provinces of physiology, pathological anat- omy, and physiological and pathological chemistry. Important questions have been settled; obscure points rendered clear; false theories corrected, and errors recognized. Although, in preparing previous editions, I have taken pains to keep my book well up to the existing state of science, to ren- der account of the most important advances made in the study of medicine and its kindred branches, yet the briefness of the time allowed for this purpose—owing to the rapidity with which editions have been renewed—and the conviction that the true value of many discoveries of supposed importance could be as- certained only by a longer probation, have hitherto deterred me from a full and thorough revision of the entire work. At last, ten years after its first appearance, the proper moment seems to have arrived. The somewhat longer respite now allowed me for my task, is due to the foresiglit of my publisher, who has made the previous edition of triple the usual size. In the present (seventh edition), but few portions of the work remain unaltered; and even those few have nearly all undergone revision on previous occasions. Most parts of it have received valuable emendations, and have been enriched by copious addi- tions. I have everywhere paid particular attention to the im- VI PREFACE TO THE SEVENTH EDITION. portant results obtained in the domain of therapeutics by recent investigations, partly because I wish my book to maintain the honorable confidence which it has won for itself among practical physicians; partly because I regard the happy progress which therapeusis has made, as the most important acquisition of the last ten years. This progress I attribute mainly to the fact that, of late years, medical explorers have recognized the only path by which thera- peutic science can be advanced, and have followed it with bril- liant results. My outspoken assertions of ten years ago have come true. I then denounced the error of postponing all medi- cal treatment of disease, until our knowledge of the action of medicines, and our insight into pathological processes, should be so far advanced, that means of cure would be self-evident. I pronounced this ideal goal to be unattainable, and declared it idle to hope for a time when a medical prescription should be the simple resultant of a computation of known quantities. I lamented that physicians, instead of striving to promote the healing art by their own efforts, should seek aid from the insti- tutes of physiology and pathology, or from the laboratory of the chemist, obtaining now and then an ingenious suggestion, but never gaining an idea serviceable in the relief of an afflicted fel- low-creature. I further showed that experiments made with medicaments upon the lower animals, or upon healthy human beings, with all their scientific value, had as yet been of no direct service to our means of treating disease, and that a continuation of such experiments gave no prospect of such service. I finally declared, without reservation, that even the dazzling progress which pathology had made, had been of but little use to thera- peutics ; that, in spite of new discoveries, our present success at the bedside is scarcely more favorable than that of fifty years ago; nor in the future would pathological investigation promote therapeutic success, unless directed more in accordance with the requirements of general medicine, than has been done hitherto. Thus, after showing that therapeusis must expect no aid PREFACE TO THE SEVENTH EDITION. vii from other incomplete sciences, and that it must be conducted by itself as an independent and peculiar branch of knowl- edge ; after showing, further, that the empirical method of investigation is the only rational and proper one for the study either of therapeutics, or of any other department of natural science, I pointed out more precisely what material we already possessed for the establishment of therapeusis as an independent empirical study; showed what still remained to be done, and how that which is still lacking is to be obtained. I then demonstrated that, before all else, empirical knowledge requires a profound and thorough acquaintance with facts, and that the more accurate the observation, so much the more cor- rect and trustworthy must the deduction be, and that observa- tions in therapeusis, if inaccurate or imperfect, are prolific of false conclusions and of erroneous proceedings, just as in other branches of natural science. I explained that, when ancient therapeutic laws, based sometimes upon the experience of cen- turies, have proved false, the error has been due to inexact and incomplete observation; that the general impression that a remedy has done good or harm, in this or that disease, is utterly worthless in a scientific point of view. I declared that empiri- cal matter, capable of affording trustworthy and useful rules for the ■ treatment of disease, is only to be obtained by the most careful and intelligent investigation of the healing effects of medicaments ; that no sure basis for therapeusis can be estab- lished until this shall occur; until clinical teachers and physicians, particularly those at the head of the science, familiar with all the accessories to diagnosis, shall comprehend that their main task is, most carefully (and, where possible, objectively) to ana- lyze the symptoms of a disease, prior to and subsequent to the administration of a supposed remedy; that such (no doubt very laborious) investigations have hitherto been totally neglected, because no one expected to obtain any results from such a method of study; but that these pessimist views evince an undervalua- tion of the brilliant progress of physical diagnosis, of physiol- viii PREFACE TO THE SEVENTH EDITION. ogy, of pathological anatomy, and pathological chemistry, made in the last ten years. Although direct and immediate advantage to the art of healing is not to be expected of any of these branches of learning, yet every new discovery, in its way, tends to benefit that art, either by improving our knowledge of disease, or by assisting our comprehension of the modus operandi of medicines. My conviction is, that from the present state of knowledge, from our deeper insight into the origin and relation of symptoms from the improved accessories, by means of which we are now enabled to follow the various phases and modifica- tions of disease, the prospect of obtaining sure and authentic therapeutic facts, by dint of accurate comparison of results, is not only by no means unfavorable, but, judging from present experience, is positively certain. Seven years ago, I closed my inaugural address at Tubingen with the following words: " The task is a laborious one; the " difficulties are great; but the knowledge that this is the sole k'path leading to the wished-for goal, the conviction that the wC smallest well-authenticated fact in therapeutics is of profound ■' importance, will inspire the perseverance in research requisite •' to make therapeusis an exact science, a science which may take " equal rank with other branches of physical study." I may now say that my anticipations have been well-nigh surpassed. A band of distinguished teachers have carried out these labori- ous researches with a thoroughness and perseverance which could not fail in its effect. The valuable labors, now under prosecu- tion, in the long-neglected field of treatment of disease, by means of which, already, the value of certain important articles, hitherto ill-appreciated, has been accurately determined, have re- ceived general recognition, and thus a final blow has been given to the dominion of a disheartening therapeutic nihilism. This success, as an example of which I will merely mention the dis- covery of the antipyretic action of quinia in typhus, pneumonia, etc., and the establishment of precise indications for the use of digitalis in disease of the heart, has caused the zeal for therapeu- PREFACE TO THE SEVENTH EDITION. IX tic experimentation to assume a direction destined to lead to great results. Rightly supposing that even the rude experience of the ignorant laity and their belief in the all-healing power of the " cold-water cure " and the " bread cure " have some foun- dation in fact, the effects both of hydropathic treatment and that of the continued limitation of the supply of water to the sys- tem have been subjected to rigid analysis. Such laudable abne- gation of sectarian pride has been richly rewarded. Among other results, we owe to it our more accurate knowledge of the effect produced by active abstraction of heat upon the tempera- ture of the body in acute febrile disease. This alone is a great achievement. By its means, a weapon, powerful for good in time of peril, is taken from the hands of the laity, where it has done much harm, and, under control of educated and experienced men, who know its capacity and how to regulate its effect, it has become the common property of science. It is a favorable sign that the warm recognition and support formerly enjoyed by the so-called " doctrine of Rademacher "—that wonderful offspring of a clear perception of the errors and failings of traditional therapeutic rules, and of blind submission to the obsolete teach- ings of Paracelsus—have become extinct; and still better, that the number of pure and devout homoeopaths, who, implicitly trusting in homoeopathic tenets and doses, make no use of the developments of therapeutic research, has grown small. May these words, and the contents of my book, aid clinical investigation in pursuing more and more the path by which alone its immediate and main object—the establishment of thera- peutic facts—is to be attained! In conclusion, I tender my cordial thanks to my numerous friends and patrons for their favor; especially to my honored friend and colleague Professor Seitz, of Giessen, for the good counsel with which he has assisted me in the preparation of mv new edition. (Signed) Felix von NiemeyePw. Tubingen, October, 1807 TABLE OF CONTENTS OF VOL. I, DISEASES OF THE RESPIRATORY ORGANS. SECTION I. AFFECTIONS OF THE LARYNX. TIG* CaAP, I.— Hyperemia and Catarrh of the Larynx,.......1 II.—Croup, Angina Membranacea,........15 III.—Catarrhal Ulcers of the Larynx,........31 IV.—Typhous and Variolous Ulcers of the Larynx,.....33 V.—Syphilitic Diseases of the Larynx,........35 VI.—Tubercular Ulceration of the Larynx,.......38 VII.—Growths in the Larynx, ..........43 VIII.—(Edema Glottidis, . .........45 IX.—Laryngeal Perichondritis,.........49 NERVOUS DISEASES OF THE LAEYNX. X.—Spasmus Glottidis,...........51 XI.—Paralysis of the Muscles of the Glottis,.......54 SECTION II. DISEASES OF THE TRACHEA AND BRONCHI. Chap. I.—Hyperemia and Catarrh of the Air-passages,......59 II.—Croupous Inflammation of the Trachea and Bronchi, .... 84 III.—Spasm of the Bronchi, Bronchial Asthma,......86 IV.—Spasm of the Eespiratory Muscles,.......91 V.—Whooping-cough, Tussis Convulsiva,.......9" SECTIOX III. DISEASES OF THE PARENCHYMA OF THE LUNGS. Chap. I.—Hypertrophy of the Lung,.........104 II.—Atrophy of the Lung, Emphysema Senile,......105 III.—Emphysema of the Lung,..........106 IV.—Collapse of the Lung,..........126 V.—Hyperemia, CEdema of the Lung,........130 VI.—Bronchial Haemorrhage,.........141 VII.—Pulmonary Hemorrhage,..........153 VIII.—Apoplexy of the Lung,..........161 IX.—Croupous Pneumonia,..........162 X.—Catarrhal Pneumonia,..........190 XI.—Induration of the Lung,..........195 XII.—Gangrene of the Lung,..........203 sii TABLE OF CONTENTS OF VOL. I. TUBERCULOSIS OF THE LUNG. PAG1 Chap. XIII.—Pulmonary Consumption,.........208 XIV.—Acute Miliary Tuberculosis,........247 XV.—Cancer of the Lung,..........25) SECTION IV. DISEASES OF THE PLEURA. Chap. I.—Inflammation of the Pleura,.........253 II.—Hydrothorax,............273 III.—Pneumothorax,............276 IV—Tuberculosis of the Pleura,.........283 V.—Cancer of the Pleura,..........281 APPENDIX TO THE DISEASES OF THE RESPIRATORY ORGANS. DISEASES OF THE NASAL CAVITIES. Chap. I.—Catarrh of the Nasal Mucous Membrane,......286 II.—Bleeding at the Nose, Epistaxis.........292 DISEASES OF THE CIRCULATORY ORGANS. SECTION I. DISEASES OF THE HEART. Chap. I.—Hypertrophy of the Heart, . ......297 II.—Dilatation of the Heart,..........316 III.—Atrophy of the Heart,..........325 , IV.—Endocarditis,............328 V.—Myocarditis,............340 VALVULAR DISEASES OF THE IIEART. VI.—Insufficience of Semilunar Valve,........345 VII.—Insufficience of Mitral Valve,........351 VIII.—Insufficience of Semilunar Valve and Contraction of the Mouth of the Pulmonary Artery,..........359 IX.—Insufficience of the Tricuspid,........360 X.—Degeneration of the Substance of the Heart,......361 XI.—Eupture of the Heart,..........364 XII.—Fibrinous Deposits in the Heart,........365 XIII.—Congenital Anomalies of the Heart,.......336 XIV.—Neuroses of the Heart,..........3f0 XV.—Basedow's Disease,..........3^4, SECTION II. DISEASES OF THE PERICARDIUM. Chap. I.—Pericarditis,............373 II.—Adhesion of the Heart and Pericardium,......383 III.—Hydropericardium,...... .... 39] TABLE OF CONTENTS OF VOL. I. xjjj PAGE Chap. IV.—Pneumopericardium,..........393 V.—Tuberculosis of the Pericardium,........395 VI.—Cancer of the Pericardium,.........395 SECTION III. DISEASES OF THE GREAT VESSELS. Chap. I.—Inflammation of the Coats of the Aorta,.......396 II.—Aneurism of the Aorta,..........400 III.—Kupture of the Aorta,..........409 IV.—Stricture and Obliteration of the Aorta,......410 V.—Diseases of the Pulmonary Artery,........411 VI.—Diseases of the Great Venous Trunks,.......412 DISEASES OF THE ORGANS OF DIGESTION. SECTION I. DISEASES OF THE MOUTH. Chap. I.—Catarrh of the Mouth,..........414 II.—Croupous Stomatitis, Aphthae,........420 III.—Diphtheritic Stomatitis, Cancrum Oris,.......422 IV.—Excoriations and Ulcers of the Mouth,.......424 V.—Syphilitic Affections of the Mouth,........427 VI.—Scorbutic Affections of the Mouth,.......428 VII.—Soor, Muguet, Thrush,..........430 VIII.—Glossitis,............432 IX.—Gangrenous Sore Mouth,..........4S4 X.—Parotitis, Mumps,...........436 XI.—Salivation, Ptyalism,...........441 SECTION II. AFFECTIONS OF THE PHARYNX. Chap. I.—Angina Catarrhalis,...........445 II.—Pharyngeal Croup,...........451 III.—Diphtheritic Inflammation of the Pharynx,......452 IV.—Phlegmonous Inflammation of the Pharynx,.....453 V.—Syphilitic Affections of the Pharynx,.......456 VI.—Eetropharyngeal Abscess,.........458 VII.—Angina Ludovici,...........459 SECTION III. AFFECTIONS OF THE OESOPHAGUS. 2hap. I.—Inflammation of the Oesophagus,........461 II.—Strictures of the (Esophagus,..... 463 III.—Dilatation of the Oesophagus,.........466 IV.— Morbid Growths of the (Esophagus,.......467 V.—Perforation and Eupture of the Oesophagus,......469 VI.—Nervous Affections of the (Esophagus,.......47C xiv TABLE OF CONTENTS OF VOL. I. SECTION IV. DISEASES OF THE STOMACH. PArengler) the principal importance has been attributed to the amount of alkaline carbonates contained in these mineral waters, and, depending upon an observation of Vir chow's, ac- cording to which very dilute solutions of alkaHes are capable of exciting the ciliary movements in epitheHum, they assert, in explanation of the beneficial action of the waters in question, that their use reestabHshes the extinguished or repressed cUiary vibrations. Grave objections may be brought against this explanation of the action of the saHne waters, which is not merely palhative, but in many cases absolutely curative, and we must be content with the empirical fact, that the springs of Ems, Obersaltzbrunnen, and Selters, have often aUeviated or cured chronic laryngeal catarrh. The cold sulphur springs, too (such as those of Weilbach, in the dukedom of Nassau, of EUsen, in the principality of Schaumburg-Lippe, of LangenbrUcken, in the grand-dukedom of Ba 12 AFFECTIONS OF THE LARYNX. clen), which we usually make use of, Hke those of Obersaltzbrunnen, and Seltzer, mixed with warm mUk, or whey; the sulphur springs, also, of the Pyrenees, above aU the Eaux-bonnes, are, with good reason, in repute, in the treatment of chronic laryngitis. Our conjectures as to the modus operandi of these waters are as yet vague and untenable—a matter, however, far less to be regretted than the fact that we have no criterion whereby to predetermine the cases in which reHef may be ex- pected, and those in which they do no good. In obstinate and inveterate cases of chronic laryngitis, local treat- ment deserves an extended trial. The attempt to blow medicated powders into the larynx is an ancient practice. For this purpose, a long quill, or a glass tube, eight or ten inches in length, and several lines in diameter, is employed. A few grains of the powder to be inhaled is laid within one end, the other end is introduced as far as possible into the mouth of the patient, who is then to close his lips, and to draw a deep inspiration, or else we may blow into the external end of the tube. If this procedure should excite violent inchnation to cough, we may assume that a part of the medicament, at least, has reached its destination, although, no doubt, the greater part remains dinging to the velum-palati and pharynx. The medicines most frequently used in this practice by Trousseau are arg. nitrat. (gr. j—ij to sacc. alb. 3 j—ij), calomel (gr. x—xx to sacc. 3 j—ij), alumen. ( 3 ss—j tosacc. alb. 3 ij). At present, by aid of the laryngoscope, and of a curved tube, inserted as far as the entrance of the larynx, we can blow into it almost the whole of the powder. Another procedure, which acts with tolerable certainty, consists in expressing the contents of a small sponge, made fast to the end of a httle rod of whalebone, and saturated with solution of arg. nit. (gr. xx to | j) over the entrance of the larynx. The result of this mode of treat- ment is often both instantaneous and brilliant, and finds a striking analogue in the efficient use of solution of nitrate of silver in the treat- ment of catarrhal conjunctivitis. An adept in the use of the laryngoscope enjoys the great advantage of being able to assure himself by direct ocular observation of his suc- cess in passing the sponge behind the epiglottis. The most recent and generaUy-employed method of producing the direct action of medicaments upon the mucous membrane of the larynx consists in causing the patient to inhale them in solution reduced to the condition of a spray or mist. The apparatus hitherto employed for this purpose consequently bear the names of nephogene, pulverization, [nebulizer], inhalations apparatus. Of these there are two kinds. In one, the slender stream of liquid to be inhaled is driven forcibly against a smaU convex disk, and thus reduced to the condition of spray, as in the HYPEREMIA AND CATARRH. 13 machine of Salts- Giron and its modifications by IValdenburg, JOeicin, and Schintzler. In the second sort, smaU quantities of the Hquid for inhalation are "nebulized" by the action of a jet of compressed air. The nephogene of Matthieu is thus formed, as weU as the more simple and cheaper hydroconion of JBergson, which I formerly used at the clinique. By the happy ingenuity of Siegle the apparatus of Bergson has been so modified as to substitute steam for the current of compressed air, which nebuhzes the medicament. This cheap instrument of Siegle, with its various modifications, consisting chiefly in the exchange of the fragile retort of the original for a smaU boiler of tinned brass, for the production of steam, has such advantages over all other inhalation ma- chines, as to have almost universally superseded them. At my clinique, instruments made on Siegle's principle are the only ones in use. The controversy, as to whether the Hquid inhaled actually penetrates into the air passages, has been decided. The fact is beyond all doubt. In recent catarrhs, with scanty and tough secretion, it is best to use a solu- tion of sal-ammoniac or of common salt for inhalation (gr. x—xx. to 3 j). In catarrh of longer standing, in which the secretion is more copious and muco-purulent, a solution of alum (gr. v—x : § j), tannin (gr. ij—x : | j), argent, nitrat. (gr. i—x : 3 j). During inhalation of the latter, in order to avoid staining the patient's face, a mask must be used, or else an appliance such as accompanies the apparatus which we employ. I am unable to state, from my own experience, whether the inhalations of narcotic solutions (morphias acet. gr. -£ — \ : 3 j), (tr. opii gr. ij—iv : § j), (ext. hyoscyami gr. ss—j : 3 j) are of any mate- rial service in aUaying the impulse to cough. By exaggerated praise of the treatment by inhalation, a discovery of real value has been retarded rather than advanced, and indeed has been often brought into positive discredit in the estimation of discreet and thoughtful men, who have fafled in Aerifying the brilliant success claimed for it in treatment of the various diseases of the air-passages. However, " in emptying the bath, one need not spill the baby." The in- troduction of the inhalation apparatus does not mark a new era in thera- peutics; nevertheless, obstinate, inveterate pharyngeal and laryngeal catarrhs, which hitherto have resisted all modes of treatment, are now frequently cured, after persevering inhalation of a solution of alum or of nitrate of silver. Spray-baths and inhalation-rooms have been established of late in manv well-known watering-places, particularly at the "brine-baths" ISoolbadem). The most simple baths of brine-spray are the prome- nades and galleries along the salt-works of Kreutznach, Koesen, Elmen, and Reichenhall. The atmosphere there is heavily charged with a Aveak solution of chloride of sodium. At Kreutznach and ReichenhaU the 14 AFFECTIONS OF THE LARYNX. brine is also nebuhzed in appropriate closets, after the method of Sails- Giron. In Rehme (Oeynhausen), a sahVspring, there is an excellent spray-bath. At Kreutznach, ReichenhaU, and Ischl, besides the spray, the warm steam generated by the boiHng brine is also inhaled. This contains less salt than the spray of the salt-works, and inhalation hall. Whether, and how, inhalation of the brine-spray acts as a remedy for laryngeal catarrh, is stiU a question. Many patients, especially those in the closets, complain of pain in the eyes, and contract a conjunctivitis by the same process, whereby they hope to be reheved of laryngeal or bron- chial disease, a fact Avhich has many analogues, should further experience pronounce in favor of inhalation of brine in chronic laryngitis. In pro- posing the inhalation of brine in this disease, the fact tfyat it contains iodine and bromine has also been borne in mind. The momentary relief, obtained by the patient during, and for a short time after, inhaling, is attributable simply to the Hquefaction of the mucus in air-passages by the nebuhzed liquid, Avhereby, in the narroAvest sense of the word, the cough is rendered " looser." At Ems the thermal gases, and at the sul- phur springs, the vapor of the richly sulphureted waters, have recently been similarly inhaled. With regard to the latter, it may be remem- bered that even Galen recommended an abode near Vesuvius to the " phthisical," that they might respire the moist sulphureted vapor as it rose. The diet for chronic catarrh of the larynx must be similar to that for the acute; salted articles, indeed, particularly the roe of a herring taken fasting, are in especially good repute. Besides allaying the cough, the symptomatic indication calls for a means of promptly reheving the nocturnal paroxysms of dyspnoea above described. To apply leeches to the throat, though often done, is useless. The repeated apphcation of a sponge dipped in hot Avater to the throat, until the skin groAvs red, the exhibition of copious draughts of hot liquid, and, above all, the administration of an emetic, are often indicated and frequently are of surprising efficacy. As an emetic, ipecacuanha, or tartar emetic, is to be preferred in these cases to sulphate of copper, and should be gi\ren in efficient doses (best according to Hufeland, pulv. rad. ipec. 3j, ant. et pot. tart. gr. j, sciUse. oxymel 3 iij, aqua 3 j ss; shake AveU, a teaspoonful eA^ery ten minutes). Should the paroxysm recur, the emetic is to be repeated. It is a good rule not to let the child sleep too profoundly, but, from time to time, to waken it and let it drink. This Avill often cause it to expector- ate, and Ave thus prevent the accumulation and drying up of the secre- tions in the rima glottidis. CROUP. 15 CHAPTER II. CROUP.—ANGINA MEMBRANACEA.—LARYNGITIS CRUPOSA.—MEM- BRANOUS CROUP. Etiology.—Croupous inflammations are inflammatory disorders in which a fibrinous exudation which rapidly coagulates is thrown out upon the free surface of a mucous membrane, but Avhich involves the epithehum only. If the croup-membrane thus formed be detached, the epithehum is quickly reproduced. No loss of substance occurs in the mucous membrane itself, and no scar remains. The diphtheritic process is also characterized by the production of a fibrinous rapidly-coagulable exudation, but differs from croup, the exudation forming, not merely upon the surface of the mucous membrane, but also within its sub- stance. The pressure upon the blood-vessels exerted by this interstitial exudation, as AveU as by the SAVoUen elements of the tissue, results in sloughing of a portion of the inflamed mucous membrane, and in the formation of a so-caUed diphtheritic eschar, Avhich, upon separating, oc- casions a loss of substance and consequent cicatrix. Of these two forms of inflammation (the essential duahty of AA'hich has of late been much in dispute), it is almost exclusively the croupous form AAThich ap- pears in the mucous membranes of the respiratory passages; and it is only in rare and soHtary instances of secondary croup, Avhen that malady forms part of some general acute infectious disorder, as measles, small- pox, typhus, scarlatina, or epidemic diphtheria, that a transition from croupous to diphtheritic inflammation is observable. Even here, too, though the pharynx may be the seat of a most exquisite diphtheria, it is far more common, and it is, in fact, the rule, for the laryngeal inflamma- tion to retain the characteristics of true croup. (See chap. " Diphtheria.") Croup is of far rarer occurrence upon other mucous membranes than upon those of the air-passages, and, during childhood, is almost ex- clusively a disease of the trachea and larynx, rarely affecting the ah-eoH of the lungs. On the other hand, croupous pneumonia, a true croup of the air-ceUs, is one of the most common diseases of adults, in Avhom primary croup of the trachea and larynx scarcely ever occurs. Although pecuharly a disease of chUdhood, still the disposition to it is less during the period of suckling. After the second dentition, too, the disease is more rare; so that the period of greatest predisposition for croup Hes betAveen the second and the seventh year of Hfe. Boys are more subject to it than girls ; but it is an error to suppose that vig- orous, full-blooded, blooming children are especially Hable. On the contrary, tender, delicate, ill-nourished offspring of tuberculous parent- age, with pale skin and conspicuous A'eins (an ominous sign even for the 16 AFFECTIONS OF THE LARYNX. laity), children Avith a tendency to moist eruptions, to enlarged lymphat- ics, or to acute hydrocephalus, suffer from croup with equal or even greater frequence than those who are more robust. It is our daUy experience that, in the great mortahty Avhich desolates certain families, a portion of the members die of croup, and another of hydrocephalus, while, in the survivors, pulmonary tuberculosis develops later in Hfe (see "Pulm. Tuberculosis"). It Avould appear that the croup not unfre- quently begins very soon after the disappearance of a moist eruption on the head or face. The croup is more common in northerly, Avindy, damp places, bor- \ dering on the Avater, than in southerly, warmer, and more protected regions. Not unfrequently Ave observe its epidemic appearance. At such times many children are attacked even in one smaU place, and often several children of the same family in quick succession, and by the most intense and pernicious form of the disease. It is this epidemic croup of the larynx which seems most commonly to be combined with croup of the pharynx. In some croup-epidemics facts have been observed which make it somewhat probable that the disease may spread by contagion. It is questionable, however, whether there may not have been confusion AA'ith that highly-contagious malady, epidemic diphtheria, in these cases, as Ave shall hereafter demonstrate the fact that secondary croup of the larynx often accompanies diphtheria of the fauces. The exciting causes of croupous laryngitis are in most cases not to be explained. Sometimes the irritated condition of the mucous mem- branes, knoAvn as " a cold," occasions the disease. A sharp northerly or northeasterly Avind stands in especially evil repute in this respect. We shall treat hereafter of the relation of secondary croup to the infec- tious diseases. Anatomical Appearances.—The affected mucous membrane shoAvs a varying degree of reddening, partially through ecchymosis, and in part through injection. It has been maintained that the redness dimin- ishes when the exudation increases; nay, formerly the opinion pre- vailed, based upon the absence of inflammatory reddening in croup, that it constituted a peculiar form of inflammation wherein there Avas no hyperaemia. We have already shoAvn that the pallor, after death, of the mucous membrane, which during Hfe had been hyperaemic, is principally due to the abundance of elastic fibres in its tissues. The mucous membrane is deprived of its epithehum, and, together Avith the submucous tissue, is swollen and relaxed. Even the muscles of the larynx seem moist, pale, and softer. Very often too, but not always, the mucous membrane of the cadaver is stiU covered with exu- dation. The frequent absence of the croup-membrane, in the bodies of CROUP. IT persons avIio have died Avith all the symptoms of croup, has given rise to an artificial division into true and false croup, and even to-day there are many physicians who maintain that, in the subjects in Avhich, upon autopsy, no membrane has been found in the larynx, the cause of death has not been true croup. In croup, too, a fluid plasma first exudes, and it, of course, does not coagulate until after exudation. If ejected from the body, either in the coagulated or Hquid form, on section we find the larynx to be free ; but Ave havre to do Avith exactly the same disease as that in A\hich a coagu- lated coating is found upon the mucous membrane. Croupous exuda- tion sometimes has the consistence of a thick cream ; sometimes it forms a compact, tough membrane; sometimes it entirely fines the interior surface of the larynx as a continuous sheet, and is prolonged into the trachea and even into the bronchi, forming tubular and ramifying clots ; sometimes it only presents isolated flakes and patches, Avhich chng here and there to the mucous membrane. • The softer and thinner pseudo-membranes may generally be de- tached from the mucous surface with ease; the tougher and more co- herent ones chng more firmly. Upon the external surface of this firm, strong substance, Avhich is often more than a line in thickness, Ave fre- quently may notice numerous red streaks, and points of adherent blood, Avhich correspond to smaU bleeding spots of the mucous membrane upon Avhose areolar layer the exudation is situated. After persisting for a longer or shorter time, the pseudo-membranes gradually become loosened by a serous exudation Avhich proceeds from the mucous surface, and are expelled either in the form of continuous tubes and sheets, or in smaU flakes and patches. Under favorable circumstances, the epithelium is soon reproduced, and the laryngeal mucous membrane returns to its normal condition. In other cases, a fresh membrane succeeds upon the fall of the first one, and thus the process may be many times repeated, until the disease ex- hausts itself, or until the patient succumbs. The membrane of croup consists microscopically of amorphous or fi\ ly-fibriUated fibrin, in which numerous young cells have been en- tangled during the process of its excretion. The frequent association of pharyngeal croup Avith croup of the larynx has a very important bearing, not only upon the diagnosis of the disease, but also upon the physiological elucidation of its symptoms. The French do not acknowledge any case as true croup, Avhere this com- phcation is absent; caUing aU others false croup. Since attention has been called to the subject in Germany, it has been found that the co- existence of both forms of the malady, although extremely frequent, is by no means constant. o 18 AFFECTIONS OF THE LARYNX. In the bodies of croupous children Ave may almost ahvays find intense hyperaemia of the lungs and bronchial mucous membrane, bronchial ca tarrh with copious secretion, oedema of the lungs, and not uncommonly croup of the bronchi, spots of pneumonia, atelectasis, Avith both vesicular and interstitial emphysema. It AviU be shoAvn, hereafter, that such con- ditions are in a great measure the necessary consequences of laryngeal croup. Symptoms and Course.—In many instances prodromata give Avarn- ing of the attack. The child is cross and feverish; is hoarse, and coughs with suspicious tone. Such symptoms alone, however, may be of Httle moment, being quite as indicative of the approach of an insignificant laryngeal catarrh, as of the onset of one of the most fatal disorders of childhood. Even thus early, hoAvever, an observant physician may dis- tinguish between the two. In all cases examine the fauces forthwith, although the child do not complain of difficulty in SAvalloAving. Should Ave find them SAvofren, and spotted here and there with small, firm, white patches, we have before us the signs of incipient'croup, Avhile the same symptom, accompanied by persistent sneezing, and by a profuse flow from the nose, is equally characteristic of laryngeal catarrh. A further diagnostic point is found in the predisposition of the individual. If a child habitually grows hoarse and coughs Avith a bark upon taking cold, but never exhibits other sign of croup; if his brothers and sisters show no tendency toward the disease, Ave may feel less concern for him, than for one who already has suffered an attack, or who has lost a brother or sister by this malady. These prodromata may precede the attack itself by one or tAvo days. They are absent, however, in very many cases, the disease setting in suddenly and unexpectedly in aU its terrors. Late in the evening, generally, or in the middle of the night, the child is roused from his sleep with a harsh, hoarse, inaudible voice, the deep, soft note of which breaks into shrill, piercing discord, as the SAvollen vocal chords, aHeady frequently coated by exudation, come for an instant into contact. The cough, Avhich Avas short and sharp in the beginning, soon becomes harsh, hoarse, and is no longer barking, except Avhen, upon a violent expiratory effort, the air in its exit stretches the chords, and causes them to bulge. At last the cough loses all sound. We see the child cough and speak; we hear nothing. Besides these symptoms, Avhich are, and indeed must be, entirely dentical Avith those of catarrh of the larynx, and which OAve their origin to the thickening and relaxation of the vocal chords, from incipient palsy of the muscles, by which they are stretched, and to the exudation Avhich coats them, there is dyspnoea, a persistent, perilous dyspnoea, char- acteristic of croup, and rarely seen in catarrh of the larynx, and only then as a transitory symptom. This dyspnoea, AAThich proceeds from nar- CROUP. 19 roAving of the glottis, and the occurrence of Avhich, Avhere there is no false membrane, requires further explanation, is peculiar, and not easily confounded Avith any other form of impeded respiration. In the firsl place, it is tremendously laborious. The efforts made by the chUd, in order to draw breath, are very evident. Every muscle, which can aid in expanding the chest, is called into vehement action. He sits up, extends his spinal column, so as more effectuaUy to dilate the thorax by upheaval of the ribs. In spite, however, of every effort, the air can pass but sl6wly through the contracted rima glottidis. The breathing is re- markably protracted and tedious, and hence, of course, much less fre- quent than in dyspnoea from other causes (pneumonia, for instance, Avhere the muscles of respiration have no abnormal obstacle to OA~er- come). It also giA^es rise to an exceedingly characteristic Avheezing or sawing sound, which, if once heard, AviU ahvays be recognized in future. During these laborious efforts at inspiration, the levatores alaa nasi contract, dilating the nostrils (for, without this instinctive muscular ac- tion, the nostrils would tend to close, from the rapid rarefaction of the air Avithin the nose). This "Avorking of "the nostrils," hoAvever, is not pecuhar to the dyspnoea of croup. Besides this, however, there is another and characteristic sign of croup, Avhich is knoAvn even to the laity, and which depends upon the rare- faction of the air, within the thorax, Avhen dilated during stricture of the glottis. We see, namely, that Avith every inspiration the epigastrium, instead of projecting, is strongly and deeply depressed. When the air within the chest becomes rarefied, the pressure upon the thoracic surface of the diaphragm becoming far lighter than that upon its abdominal surface, it yields, and is forcibly pushed upAvard, the xyphoid and costal cartilages being HkeAvise drawn in by the inspiration. This, too, is easy of comprehension, if Ave only bear in mind the mechanism of normal respiration. If the air can enter the air-passages Avith freedom, the dia- phragm, upon contracting, causes its pars tendinea to descend, but pro- duces no incurvation of the ribs; for their resisting poAver is far greater than that encountered by the diaphragm in the elasticity of the lung, or in the feeble pressure of the abdominal viscera. If, hoAve\rer, the tendinous centre be draAvn up by the rarefaction of the air in the lungs, or if it be only fixed and hindered from moA'ing doAvmvard, the inspiratory contractions of the muscles of the diaphragm must then, of necessity, cause the arch of the ribs to curve imvard. The desire to draw breath, the efforts to do so, and the desperation Avhich its fruitless exertions produce, are evinced in the entire being of the chUd. Noav it begs to be taken out of bed into the arms of its nurse, and from its nurse to be put to bed again. The greatest terror is depicted in its manner; it beats about, throAvs itself hither and thither, 20 AFFECTIONS OF THE LARYNX. clutches at its throat, pulls at its tongue, as if to remove the obstacle to its breathing. The face is distorted and bedewed with sweat. The look of a child sick of croup is, above all things, sad and piteous. The circumstance, that children often die of croup, Avho, during life, evinced signs of the greatest dyspnoea, but in Avhom, after death, neithei pseudo-membrane nor considerable swelling, either of mucous membrane or of the submucous tissue, could be discovered, has given rise to the impression that, in these cases, spasmodic contraction of the laryngeal muscles has constricted the glottis. This vieAV is contradictory to patho- logical and physiological fact. In all severe inflammation of mucous or serous membranes, Ave find not only the submucous, and subserous cellular tissues, but also the muscles covered by the inflamed membrane, infiltrated with serum, sod- den, and pale. Even a priori, it is not to be supposed that muscles in this condition should be capable of a spasmodic contraction, and Ro- kitansky declares his'opinion, from a pathological point of vieAV, that " the infiltrated, pale, relaxed muscular tissue, in croupous inflammation, is stricken with palsy." That muscles in this condition reaUy do lose their contractile power, is shown by the paralytic bulging of the inter- costal muscles in pleurisy, and in the loss of peristaltic action of the in- testine in peritonitis, or dysentery, from palsy of the intestinal muscles, covered by the inflamed mucous or serous membrane. These, and many other analogous observations, render it highly improbable that the laryngeal muscles should be spasmodically contracted, instead of palsied, where their mucous covering is inflamed. Section of the par-vagum nerve, in young animals (an operation originaUy practised for an entirely different purpose), furnishes absolute proof, that paralysis of the muscles of the larynx produces dyspnoea; nay, the dyspnoea arising in consequence of this experiment bears so strong a resemblance to croupous dyspnoea, is attended by such simUar long-drawn AvhistHng inspiratory efforts, and other signs, that the similarity of the two con- ditions must strike the most indifferent beholder. But the study of the anatomy of the larynx of a child makes it certain, that a forced effort at inspiration wiU contract or close the glottis, unless it be held open by muscular action. In childhood, Ave do not find that triangular space, bounded by the base of the arytenoid cartilage, stretching for- Avard, and inward, to the processus vocales, knoAvn as the pars respira- toria of Zonget. In chUdren, the base of the arytenoid cartilage has no extension, the glottis forming a smaU cleft, running antero-posteriorly, and bounded by the membranous expansion of the vocal chords. These membranes lying obliquely opposed, one to the other, unless the glottis be held open by muscular action, the effect of an energetic inhalation must be to contract, and close the cleft, by rarefying the air Avithin the trachea. CROUP. 21 In any juvenile larynx Avhich Ave may cut out ci the body, the glottis is capable of being completely closed by the apphcation of powerful suction to the trachea. As it is of the utmost importance, in the treat- ment of croup, for us to know Avhether false membranes occlude the glottis, or Avhether palsy of the laryngeal muscles, by cedematous infil- tration, be the main cause of the dyspnoea, we must carefully note AAdiether inspiration and expiration are in equal degree obstructed, or Avhether inspiration alone be laborious, and expiration free. In the former, and most common case, false membranes clog the rima glottidis, impeding both exit and entrance of the air; in the latter, crippfing of the muscles is the cliief cause of the dyspnoea. Upon rarefaction of the air Avithin the trachea during inspiration, the inflowing current, through the nose and mouth, forces the folds of the glottis together; but expira- tion foUoAvs freely, as the air, Avhen expired, drives the vocal chords apart, without any need of muscular aid. Let us bear in mind, too, that the posterior crico-ary tenoid muscles, which open the rima glottidis, are more easily paralzyed when the mucous membrane of the pharynx, which covers them, takes part in the inflammation. Thus, it is easUy seen Avhy those cases of croup, which the French alone admit to be true croup, cases in Avhich croup-membrane can be seen upon the pharynx, must be by far the most dangerous. The Avide gaping of the glottis during inspiration, when the laryn- geal muscles are acting normaUy, of Avhich I have been able to convince myself as often as I have looked in the laryngoscope, has materially strengthened my conviction of the correctness of my theory, that palsy of the muscles of the glottis forms an important element in the dyspnoea of croup. It is difficult to say Avhether any real pain in the larynx forms a sj-mptom of croup. The clutching of the chUd at its throat may depend upon the desire to remove the impediment to its breathing, which it in- stinctively perceives. In the beginning of the disease, the expectora- tion, which is usuaUy scanty, rarely contains masses of shreds, or of cohe- rent false membrane. The pulse, at first, is generally full, hard, and of moderately increased frequence; the face is flushed, and the tempera- ture of the body elevated. Croup, in a groat many cases, exhibits decided remissions in the morning, and through the course of the day, Avhich might almost seem Intermissions. (Hence the homoeopathists promise that their medicines wiU not evince their Avonderful effect until after a lapse of several hours.) ToAvard morning the respiration becomes more free. The voice returns. The cough is less frequent; it is hoarse, but not Avithout sound. The fever abates; the general condition appears almost undisturbed; and only the thin piping, or the still suspicious tone of the cough, remains, 22 AFFECTIONS OF THE LARYNX. to recaU to mind the scene of terror of the previous night. But be- Avare of building too great hopes upon these remissions. The coming night may bring Avith it a repetition of the same symptoms, and the greatest danger to the Hfe of the chUd. .The continuance of fever, even if only moderate, and, above aU, the presence of pseudo-membrane in the pharynx, should excite the greatest sohcitude. Sometimes the croup exhibits this rhythmical type throughout its en- tire duration, bad nights following upon tolerable days; in fatal cases, the remissions becoming more and more incomplete, and the nocturnal exacerbations growing more and more formidable. In other instances, which are far more dangerous, the symptoms of croup run a continuous course from the beginning. The remission expected in the morning fails to appear, and death may ensue in the course of two or three days. When, instead of abating, the malady tends to terminate unfavor- ably (an event but too common in croup), the scene changes. The flushed face of the child grows palhd, the lips lose their color, the eye, Avhich hitherto has been gazing anxiously about it, assumes a droAvsy expression. Quite frequently spontaneous vomiting sets in, Avhile the emetics which Ave administer remain Avithout effect, and the child grows insensible to sinapisms and other cutaneous stimulants. The respira- tion becomes diminished, and now the whistling sound of inspiration often ceases ; the child lies exhausted in a half-slumber; the symptoms of croup seem gone. It seems to have no more dyspnoea, until, upon aAvakening from sleep, or after coughing, it involuntarily attempts to draw a long breath. Then the glottis closes; the chUd, once more in danger of suffocation, springs up, props itself up with its hands, looks desperately around it, anew makes violent efforts to draw breath, and finally sinks back again exhausted, and faUs into a state of semi-somno- lence. (In young animals in which the par \Tagum nerves have been cut, we observe precisely these phenomena. Respiration almost free as long as they breathe quickly; respiration impeded in the highest degree the moment they attempt to draw a deep breath—a condition easily un- derstood after the above explanation.) These changes in the child's condition are a result of gradual blood- poisoning by carbonic acid, overcharge of the blood Avith this gas form- ing one of the main sources of danger from this disease. The above-described train of symptoms is by no means due to en- gorgement of the brain and its meninges (as has been generaUy assumed), nor is a chUd Avith croup ever cyanotic from impeded respiration alone, excepting Avhen, in the act of coughing, the flow of blood within the jugulars is arrested by compression of the contents of the thorax. A child with croup cannot be otherwise than pale at this stage of the dis CROUP. order, and the pallor continues until, as palsy of the heart sets in, the contents of the arteries grow less and less, the veins fuller and fuller, and thus a Hvid tinge is imparted to the paUid Hps. As the blood of the veins Avithin the thorax is subjected to a pressure less than that upon the veins Avithout, the tendency of the elastic lung being to contract, and thus to cause the vessels which border upon it to expand; as with each deep inspiratory effort the poAver of suction of the lung grows stronger (since the draught increases as the lung expands), this suction must reach its highest pitch of intensity; blood wiU be drawn AA-ith greatest poAver from the external ATeins into those A\ithin the thorax, Avhen any one Avith constricted glottis rarefies the air within his lungs b}' trying to draAA' a long breath. Cyanosis and obstructed evacuation of the cerebral Aeins can neA^er take place in this Avay. The process must always haAre an opposite effect. When inspiration and expiration meet Avith equal obstruction, the circulation is someAAThat differently affected. As the glottis becomes so much occluded by false membrane, that very little air can enter into, or escape from, the lungs, inspiration and expiration can only be carried on by means of all the auxiharies at command. Noav, as Ave are able to expel our breath Avith greater force than Ave can inhale it, the influ- ence of the forced expiration over the discharge of blood from the thorax outweighs that of the forced inspiration, and then, indeed, cyano- sis takes place. Since the interchange of gases in the lungs depends principally upon the renewal of air contained in the air-vesicles, and as the blood does not give out carbonic acid, and absorb oxygen, unless the air within the A'esicles contain less of carbonic acid and more of oxygen than the blood in the plexus of capiUaries about it, the necessary conse- quence of the incomplete respiration in croup, and of the imperfect ren- ovation of the air in the vesicles is, that the carbonic acid Avhich inces- santly forms in the blood cannot escape from it into the air of the A'esicles which is already OA^ercharged with it. The symptoms described are exactly the same as those produced by the inhalation of carbonic acid. In croup, the carbonic acid created Avithin the body itself poisons the patient, Avhile in the other case the poison is breathed Avith the atmosphere. In fatal cases, death almost always takes place AATith the symptoms described, through the gradual estabfishment of general paralysis, in consequence of carbonic-acid poisoning. In rare instances, the access of air to the lungs may be suddenly and absolutely cut off by the fall: of a piece of loosened membrane before the glottis, and rapid death by suffocation may ensue. If the croup take a turn for the better, the improvement may take 24 AFFECTIONS OF THE LARYNX. place gradually Avith occasional expectoration of quantities of tough sputum, containing a more or less profuse admixture of flakes of coagu- lum—the cough becoming easier, the A-oice louder, the symptoms of narcotism disappearing, as the embarrassment of respiration subsides. In other instances, however, Avhich are far less numerous than is generally supposed, large masses of pseudo-membrane, and often tubular casts of the substance, are throAvn out after violent coughing, retelling, and vomiting, so that the breathing, tiU now extremely oppressed, sud- denly becomes much more free. The chUd is safe from immediate danger, if a reproduction of the exudation do not once more occlude the glottis, or a hcav exacerbation of the inflammation again produce oedema of the laryngeal muscles. After subsidence of the croupous process in the larynx, Avhen its dura- tion has been somewhat protracted, many children perish from hypersemia and oedema of the lungs, and of bronchial catarrh. The comparatively ill success of tracheotomy, after protracted croup, is entirely due to these compHcations, the frequence of which we can easUy show to be a neces- sary result of the previous disease. When the thorax is expanded, and the alveoH are made to dUate Avithout aUoAving the atmosphere to pene- trate into them, the air already contained in the bronchi and air vesicles must be expanded and rarefied. The bronchial mucous membrane and inner waU of the air-vesicles during croup are thus placed in a condition similar to that of a portion of external skin under a cupping-glass. Hyperaemia and increased secretion are the necessary result of the sus- pension or diminution of the pressure to Avhich the capiUaries are habitu- ally subjected. The circumstance recently urged by Bohn and Gerhardt in their two valuable works upon croup, that bronchial catarrh invariably and promptly associates itself Avith croupous laryngitis with constricted glottis, seems to me to argue in favor of the genetic connection of the two processes. With regard to the croupous pneumonia and bronchitis, hoAvever, which compHcate laryngeal croup in many cases, it is quite otherwise. As I have stated in the opening words of this text-book, it is catarrhal inflammation only which arises in consequence of vascular engorgement of a mucous membrane.* I shaU repeatedly recur to the impropriety of regarding other forms of inflammation as an exaggeration or a consequence of simple hyperemia. " That the danger from croupous laryngitis is considerably heightened by the addition to it of bronchial catarrh" is perfectly admissible; that, however, in real croup, " death always proceeds from bronchitis or broncho-pneumonia " (JBohn) is cer- tainly an exaggeration. The symptoms of the secondary croup which * I have no objections to make against the opinions of authors who do not consider catarrh as an inflammation, but rather as derangement of secretion, characterized bi swelling and succulence. CROUP. 25 comphcates measles, small-pox, scarlatina, epidemic cbphtheria, and other infectious disorders, Avill be described hereafter Avhen treating of the diseases themselves. Diagnosis.—We haA'e already draAvn attention to the points of resemblance between croup and laryngeal catarrh, and have also shoAvn in what respects the two diseases differ. We have merely to add that the pharyngeal patches of croup membrane are of nearly as great diag- nostic value as the masses of membranous exudation discharged by coughing or vomiting; that dyspnoea is rare in laryngeal catarrh, and is never persistent, nor is there often much fever, AA'hUe in croup, fever never fails. Prognosis.—ChUdren who have passed their seventh year may survive attacks of croupous laryngitis of the utmost intensity, but during the earlier years of life croup is one of the most formidable of aU dis- eases. We haAre already remarked that the dazzhng reports of cures of which many practitioners boast are to be accepted Avith caution, most of them being based upon an error in diagnosis. The epidemic appearance of croup undoubtedly renders the bad prognosis of the disease stiU Avorse, and though it would be going too far to pronounce croupous laryngitis, compHcated by croup of the pharynx, absolutely mortal, yet it is not to be denied that this complication renders our prognosis still more grave. Among the symptqms, the terror, the restlessness, the fuU pulse, the flushed face, the hoarseness or aphonia, are of far less prognostic impor- tance than the first indications of commencing blocd poisoning. If the face groAV pale, the lips colorless, the child drowsy, the sensorium be- numbed ; if an emetic remain AA'ithout action; or if, on the other hand, vomiting spontaneously set in, AAre are rarely justified in expecting a favorable termination of the malady. Treatment.—Prophylaxis against croupous laryngitis requires the measures already recommended for protection against laryngeal catarrh. Never shut up a child permanently in its chamber because it has once had an attack of croup, nor accustom it to too much clothing. Mean- Avhile, however, teach the mother not to let herself be deceived by bright sunshine alone, nor to send the cluld out AA'ithout paying attention to the direction of the Avind. When there is decided predisposition to croup, watch the Aveather-cock, and keep the child from exposure to a rude northerly or northeasterly Avind. It is also advisable to keep the chUd Avithin doors after sunset. Finally, cold washing of the throat and breast, proAided that the skin be afterward carefully dried, is a capital prophy- lactic where there is predisposition to croup. As the real causes of croup are obscure, the causal indications cannot, in most instances, be met. Among the laity it is considered a settled 26 AFFECTIONS OF THE LARYNX. fact that the croup is the result of " taking cold." With true fanaticism, the moment that a child becomes hoarse, an incredible quantity of hot sweet milk (AA'hich is here preferred to elder-tea) is poured doAvn his throat. Not until the child begins to SAveat do they believe him safe, and the foe (often an imaginary one) driven from the field. The teachers of the hydropathic school claim similar results from envelopment of the body in Avet cloths, by means of AA'hich, " in a great number of cases, they attain the most briUiant success," by thus restoring the re- pressed action of the skin. Granting, hoAvever, that many cases of croup arise from chilhng of the surface, the disease is not so simple a one, the nutritiA'e disorder of the mucous membrane is of far too grave a nature to admit of restora- tion by the mere production of diaphoresis. In catarrh it may be other- wise. Where hyperaemia alone has sufficed to sweU the mucous membrane, active sohcitation of the blood to the surface may produce a depletion from the same and cure the complaint. As, however, it is almost impossible for the laity to distinguish be- tAveen the two maladies, and as even the physician is often obfiged to reserve his decision Avhen first caUed to see a child suffering from hoarseness, a barking cough, and sudden nocturnal dyspnoea, it is AveU, in such emergencies, while awaiting the doctor, to give the child hot drinks, to cover him warmly, and to apply a succession of hot, moist sponges to the throat. It has been stated that in many instances, espe- cially of epidemic croup, the inflammation seems to be propagated from the pharyngeal surface into the larynx. If, then, croupous patches be visible upon the fauces, the utmost energy is demanded on the part of the physician. He must not content himself Avith the application of a few leeches over the throat, as such practice is of very doubtful efficacy. Let him rather remove the false membrane from the tonsils, and thoroughly cauterize the affected part. This treatment is much more to be refied on, and (perhaps from the astringent action of the caustic) is one of the surest of antiphlogistics. With regard to the management of the disease itself, many phy- sicians, especially country ones, are in the habit of caUing for leeches, and emetics, and of fortHwith applying one or both articles, if the smallest trace of pseudo-membrane be discoverable. The leeches are to moderate the inflammation; the emetic to remove the exudation. Hardly any one has eA'er had the courage to treat croup expectantly, and to wait until special incidents in the disease shaU call for special measures. It is chiefly to the homoeopaths that Ave owe the discovery, that even a child Avith the croup may get well Avithout leeches or emetics. Leeches (of which Ave apply one or two upon the manubrium sterni, or throat of a child under a year old, increasing them in number CROUP. 27 according to the age) are, moreoA'er, of exceedingly doubtful assistance in croup. In far the greater number of instances they are directly hurtful. Their recommendation is, in great measure, supported upon the erroneous vieAV that hyperemia and inflammation are identical, hence abstraction of blood Avill aUay inflammation. A reaUy inflammatory pro- cess is not interrupted by blood-letting, although it may moderate the collateral hyperasmia in the A-icinity of the inflamed spot; however, if a stasis of the blood take place in the mucous membrane of the larynx, i if its circulation be interrupted, the blood Aoavs with greater force into the Aressels of the neighboring tissues, and produces in them transuda tion, SAvelling, and oedema. We have shown that a part of the danger in croup proceeds from such SAvelfing and infiltration; hence, when Ave have to deal with a vigor ous, blooming chUd (but only in such a case), we may apply a feAv leeches to the manubrium sterni. They must never be apphed over the larynx, as at that point the bleeding is hard to stanch. In aU cases Ave should apply the leeches ourselves, or employ an expert to do it, who can check haemorrhage. Among puny, badly-nourished children, leeches are contraindicated. It is most dangerous to exhaust the strength of a child, which he will require at a later stage of the disease to enable him to expectorate Avith vigor. Blood-letting has no poAA'er Avhatever to prevent the formation of the exudation. With regard to the employment of emetics, the revulsive action through AAThich they are supposed to exert an influence upon croup is altogether problematic. Still less may Ave promise ourselves help from their diaphoretic effect. They are only indicated where obstructing croup-membranes play a part in producing the dyspnoea, and when the child's efforts at coughing are insufficient to expel them. We haA'e stated, in describing the symptoms, that impeded expiration sJioidd cause us to infer that the glottis is becoming choked by false membrane. We, therefore, would lay great stress upon this symptom as an indication for emetics. As the formation of pseudo-membrane may take place at a very early period, an emetic, if indicated, may be given early in the disease. In treating croup, preference is given to sulphate of copper over tartar-emetic or ipecacuanha, and, as it seems to me, with reason. Beware, hoAvever, of givnng this remedy in doses too small, for it may then act Avith uncertainty, and is much more apt to operate as a poison than Avhen used in fuU doses. We prescribe ten or fifteen grains of sulphate of copper dissolved in tAVO ounces of Avater, and let the child take a large teaspoonful of it every five minutes until A'omiting sets in. The more complete the remission after the vomiting, the more the membrane thrown out, so much the more reason have Ave for repeating the emetic, should the peculiar dyspnoea above described I 28 AFFECTIONS OF THE LARYNX. rcur& If there should be no remission, should no croup membrane be expelled, or if the expiratory act be free from impediment, the repe- tition of the emetic is contraindicated. This rule is often broken. How often do Ave see children incessantly dosed with different salts of copper, even when they have ceased to vomit, and they can do no more service! They He bathed to the armpits in the bluish fluid Avhich, mixed AA'ith curdled irdlk, Aoavs from their bowels, and in A'ain turn aAvay their head and push away the spoon containing the repulsive medicine which gives them so much griping and distress. The apphcation of cold deserves a fuU trial, in the shape of cold compresses, quickly changed, laid upon the throat of the child, as soon as the signs of croupous laryngitis appear. In famiHes Avhere they are not afraid to use this treatment, we shaU have a far more happy result than in houses in which the prejudice against it is not to be overcome. The employment of cold to the skin in inflammation of internal organs, as first recommended by ICiwisch in puerperal peritonitis, seems indeed to act as a direct antiphlogistic; and difficult as it may be to compre- hend what effect it can have upon an organ separated from it by skin and muscle, experience has here more right to respect than physiological abstract reasoning. (See treatment of pneumonia.) The fanaticism of the hydropaths in this matter, who, while applying cold to an inflamed part, are loath to refrain from other hydropathic measures, has done more harm than good. We have already recommended touching of the pharyngeal mucous membrane with nitrate of sUver as a direct antiphlogistic, and now, after personal experience, cannot sufficiently urge the apphcation of a solution of the lunar caustic to the inflamed mucous membrane of the larynx, as has been much practised in France, and but too Httle resorted to among ourselves. Bretonneau, with whom this local treatment of croup originated, uses a curved rod of Avhalebone, Avith a small sponge made fast to its loAver end. This is dipped in a concentrated solution of nitrate of silver ( 3 ss to 3 ij). We press doAvn the tongue of the child, and endeavor to reach the entrance of the glottis with the sponge. There the sponge is immediately compressed by the muscular contrac- tion which takes place, whereby certainly a portion of the Hquid, if only a smaU one, arrives in the larynx. It is doubtful if calomel have indeed an antiphlogistic, or even a specific effect upon croup, although I cannot deny that very high authority is incHned to credit the beneficial effect of this agent in its treatment; nor that I myself make use of from a quarter to half a grain of calomel every two hours, in most cases of this disease, while my ex- perience leads me to shun the too customary employment of small doses of tartar-emetic and sulphate of copper (tart. stib. gr. i; aquae CROUP. 29 3 i—S. 3 i. 2 h.). (Cupri. sulp. gr. i; aquae, \ i; s. 3 i. 2 h.) Sulphuret of potassium (IS, potas. sulp. 3ss.— 3j; aquas; syrup simphc. aa §i TH, s. 3 i. every 2 hours), in spite of the Avarm eulogium of distinguished authorities, such as Mill let and Barthez, has never come much into use, and now is almost obsolete. The proposal of bicarbonate of soda in large doses is obviously based rather upon theoretical grounds than upon actual experience ; hence deserves Httle reliance. The drug has been administered in the hope of loosening the false membrane, and preA'enting further coagulation of the exudation, or else of improving the state of the blood. Chlorate of potash, Avhich is a faA'orite remedy in treatment of diph- theria of the fauces, and of the secondary croup of the larynx, which accompanies it, is also recommended in true primary croup, by those who make no distinction between the latter and the pseudo-membranous laryngitis of acute infectious disorders. I have no personal experience of the action of this article in treating primary laryngeal croup. "When called to the bedside of a child, recently attacked, the physi- cian should not be misled by the idea that, Avithout his immediate and active interference, the chfld must soon die. Leeches should never be applied, save under the exceptional conditions above stated, and the after-bleeding from the bites should be kept Avithin bounds. It is bet- ter, in most cases, to confine one's self to the use of cold, and do not hesitate to put on the first compresses Avith your own hand, until the parents perceiA'e the relief Avhich they afford. Besides this, if the boAvels be confined, administer a clyster, so that the diaphragm may have free room to act. The best is a cold one, of three parts water, and one of Aanegar. If the dyspnoea increase, if the respiration be impeded, give an active emetic, Avithout suspending the cold apphcations. The emetic is to be repeated, under the conditions stated above; if, hoAvever, under this treatment, there be no remission, apply a solution of nitrate of sUver, at intervals of several hours, to the entrance of the glottis. Do not forget, during the night, that, AAath the early morning hours, there often comes a remission, nor during the next day, that, in spite of the improvement, the coming night may again bring Avith it the greatest danger. HoAvever AveU the child may seem to be, it must not quit its bed. The temperature of the room must be kept uniform, and the air rendered moist by means of open A-essels of Avater. Give half a grain of calomel every tAvo hours; aud noAV change the compresses less often, and cover them Avith a Avoollen cloth. Continue meanAA'HUe, but at longer intervals, to use the solution of nitrate of silver. The next night, if the croup grOAV Avorse, the same measures are required. Should this treatment remain Avithout effect, should there be no improvement in the course of ten or tAvelve hours, do not lose time 30 AFFECTIONS OF THE LARYNX. in giving ScbwefeUeber, or the "liver of sulphur," so long prized as a specific, carbonate of soda, chlorate of potash, or senega, or other expectorant; but proceed at once to tracheotomy. The earlier we undertake this, so much the more hope may Ave have that pulmonary hyperaemia, oedema, and bronchial catarrh will not injure our prognosis. Were the results, however, as bad again, it should never be neglected Avhen other means have faUed. Even death itself, after performance of the operation, is far less painful, both to patient and relatives, than where it has been omitted. Besides treating the dyspnoea upon the principles given above, Ave have also to refieve the paralytic symptoms due to blood-poisoning by carbonic acid. For this purpose, the powerful stimulus obtained by pouring cold water upon the child, while in a warm bath, is of great service. This is also a favorite remedy in treatment of asphyxia by charcoal vapor. Lose no time in making use of it, the moment the child begins to groAV drowsy, the skin to cool, the sensorium to be benumbed, or as soon as emetics fail to act; for, at this period, their operation is often of the utmost importance. A few gallons of cold water, poured from a moderate height, over the head, nape, and back of the child, almost always cause it to reATve for a Avhile, and to cough vigorously. Thus, sometimes after the bath, masses of exudation are expelled. Other stimulants, such as camphor or musk, are much less effective, and ought not to be employed save when insuperable objections are opposed to the cold effusion. They should be given in large doses, immediately prior to the emetic. (IJ. camphor gr. x. Ether acet. 3 nj. m. S. gtt. x— xv. every quarter of an hour. IJ. moschi. gr. iv. Sacch. alb. 3 i. m. div. in. ch. Ad. s., a powder, every hour or half hour.) The apphcation of sinapisms to the calves of the legs and soles of feet, repeated bathing of the hands and forearms in Avater as hot as the child can bear, the use of "flying bhsters" to the neck and chest, are recommended, partly to corroborate the action of the stimulants ad- ministered internally, and partly as a derivative from the larynx to the skin. Although Ave do not rate cutaneous irritants very high among the remedies against croup, yet, for Avant of better or more promising means, we make use of them where the disease is protracted, sometimes improving, and again groAving Avorse; and where Ave are dissatisfied Avith the effects of the treatment already described, and yet hesitate to proceed to tracheotomy. In order to accelerate the action of the flying blister, Bretonneau advises that the plaster be smeared Avith a solution of cantharidin in oil, and covered Avith blotting-paper before appli- cation. CATARRHAL ULCERS OF THE LARYNX. 31 CHAPTER III. CATARRHAL ulcers of the larynx. Etiology.—When the ceU-formation, which takes place upon the surface of the mucous membrane in acute and chronic catarrh, en- croaches upon the tissue of the mucous membrane itself, producing in it a solution of continuity, a superficial loss of substance occurs, con- stituting the simple catarrhal ulcer or catarrhal erosion. The pathogeny of this ulcer is easily understood, if we compare it with a very similai process upon the skin. Where a plaster of cantharides has raised the epidermis in a blister, the contents of the blister, in a few days, become turbid from admixture of young cells. These are formed upon the sur- face of the cutis, through the prohferation of the more deeply-situated epidermic ceUs. The substance of the cutis is intact. If, however, after opening the blister, we anoint the exposed cutaneous surface with an irritating salve, the ceU-formation extends to the substance of the skin, causing its destruction, and forming a superficial sore completely analogous Avith the catarrhal ulcer of the mucous membrane. In other cases, the numerous mucous glands Avhich exist in the larynx become the seat of a vast multiplication of cells. They enlarge consider- ably ; their covering is finally perforated, their contents are discharged, and, in place of the gland, there remains a round, crater-formed loss of substance—the second form of catarrhal ulceration, the follicular sore. Ulcers are rare in acute laryngeal catarrh. In the chronic form, hoAV ever, especiaUy in the follicular variety, affecting the fauces and larynx of preachers, singers, inveterate smokers, and immoderate drinkers of spirits, there is a decided tendency to ulceration. This is stiU greater in the chronic laryngeal catarrh Avhich almost ahvays accompanies pulmonary consumption, independently of tubercu- lous disease of the larynx. Finally, Tilr/c has repeatedly noticed catar- rhal ulcers of the larynx, in the vicinity of which scarcely any trace of catarrhal disease could be discovered. Special exciting causes render certain portions of the laryngeal mucous membrane particularly liable to catarrhal ulceration, namely, the posterior Avail of the larjmx, the aryepiglottic ligament, the anterior and posterior ends of the vocal chords and the epiglottis, at the point corresponding to the processus-vocahs of the arytenoid cartilage. The places first named are particularly rich in mucous glands, and the tissue of the mucous membrane is loose, as it here contains a lesser quantity of elastic fibre. At the latter-named spots the cause of ulceration seems to be mechanical. In all loud talking the vocal chords are forced toward one another, so that their edges almost touch. When their 32 AFFECTIONS OF THE LARYNX. mucous integument is SAVoUen by catarrh, a constant friction takes place during speaking, which results in excoriation and ulceration. (Zewin.) Anatomical Appearances.—In the beginning catarrhal erosions have either a rounded or an elongated shape, according to the arrange- ment of the elastic fibres; but they afterAvard coalesce, forming an ex- tensive loss of substance of irregular contour. The follicular ulcers, hoAV- ever, retain their circular form, even Avhen of long standing, and shoAV less tendency to increase in Avidth than in depth. They readUy lead to disease of the cartilage, and, exceptionally, several of them run to- gether, and produce extensive destruction of the mucous membrane, the " catarrhal consumption of the larynx." The ulcers originating at the anterior and posterior ends of the vocal chords spread lengthways over the greater part of one, or stiU oftener of both chords. In many cases the loss of substance is so shallow that the chords appear as if they had been only superficiaUy shaved off; in other cases the destruction is more considerable. Lewin describes ca- tarrhal ulcers upon the lower surface of the vocal chords, of Avhich, during life, we can only make out the outer border, as a minute fold of mucous membrane, Avhich seems to be inserted under the level of their upper membrane. In phthisical patients this author has so often found catarrhal ulcera- tion in that portion of the laryngeal mucous membrane where the vocal processes cover the arytenoid cartilages that he describes this laryngo- scopy appearance, which hardly ever is met with in persons Avith healthy lungs, as almost pathognomonic of pulmonary consumption. Symptoms and Course.—The general symptoms of a chronic laryn- geal catarrh are not materiaUy modified when accompanied by ulceration. True, Ave may suspect the existence of an ulcer AA'hen a patient with a harsh, barking cough, of long standing, and chronic hoarseness, running from time to time into aphonia, complains of a sensation of burning, or soreness upon speaking or coughing; but these symptoms (although sometimes so distressing that the sufferer, in order to avoid pain, speaks Avithout moving the vocal chords, that is to say, in a Avhisper) are often entirely absent, even Avhen very extensive ulceration exists. The addi- tion of painful and difficult deglutition to the other symptoms renders the presence of an ulcer stiU more probable; and Avhen the epiglottis, the aryepiglottic Hgament, or the arytenoid cartilage is involved, this symptom is rarely absent. But as painful deglutition also occurs in a severe case of simple catarrh at this point, no positive inference can be drawn from this symptom alone. Next to the objective signs of ulcera- tion, the admixture of smaU streaks of blood in the sputa furnishes the most reliable token of its existence. Among objective signs, the condition of the fauces and guUet is of TYPHOUS AND VARIOLOUS ULCERS OF THE LARYNX. great diagnostic importance. Experience teaches that follicular ulcers of the larvnx are often combined Avith follicular pharyngeal ulceration. If, then, in patients Avith long-standing hoarseness and other symptoms of chronic laryngeal catarrh, Ave find a reddening of the mucous mem- brane of the soft palate, and see the posterior pharyngeal AvaU studded Avith smaU round, yelloAvish sores, it is to be presumed that the disease has also invaded the larynx. The majority of laryngeal ulcers may be brought into A'ieAV by means of the laryngoscope, especiaUy Avhen situated upon the epiglottis, upon the arytenoid cartilages, on the aryepiglottic folds, and upon the true and false vocal chords. Treatment.—The treatment of catarrhal ulceration of the larynx is almost identical Avith that of the simple laryngeal catarrh; and, as in catarrh of other mucous membranes, we do not materially modify our treatment Avhere ulceration supervenes upon simple inflammation. It cannot, hoAvever, be denied that the cure of catarrhal ulcers of the larynx takes place somewhat more rapidly Avhen the medicaments are applied directly and solely to the sore itself, instead of over the Avhole mucous surface. Whoever has obtained sufficient laryngoscopic dexterity to enable him to touch the ulcers Avith lunar caustic in substance, or with a concentrated solution of nitrate of silver, will do AveU to adopt such local treatment, instead of that recommended in the last chapter, espe- cially instead of inhalation of alum or nitrate of sih'cr in solution. While practising local treatment, hoAvever, Avhether by cautery or inhalation, the dietetic and other internal treatment already described is not to be neglected. The partiality to AA'hich specialists are so often prone is not only hurtful to the patient, but injures the credit of neAV therapeutic measures. When a chronic ulcer of the larynx, Avhich has long resisted a regular course of caustic at the hands of a speciahst, recoArers under the use of Ems-Avater and careful nursing of the mucous membrane, perhaps after Aveeks of absolute enforced silence, it aa-UI generally be found that the patient had relied solely upon the local treatment for a cure, and had liA'ed imprudently or absurdly. CHAPTER IV. TYPHOUS AND A'ARIOLOUS ULCERS OF THE LARYNX. Etiology.—From the teaching of Mo/citansA-y, the belief has long ^prevailed that typhous ulceration of the larynx proceeded from " me- dullary infiltration of the mucous glands of the larynx AA-ith subsequent slouching," and AA'as therefore quite analogous to the intestinal ulcers of tA-phus, Avhich are formed by the action of a similar morbid process upon the solitary glands and the glands of Peyer. 34 AFFECTIONS OF THE LARYNX. This mode of origin, HoAvever, if it occur at all, is certainly not the sole, nor even the most frequent, source of typhous laryngeal ulceration. RoHtanshy himself,, in his last edition of his pathological anatomy, attributes typhous ulcer of the larynx to diphtheritic infiltration of the mucous membrane; and, indeed, it is entirely in harmony with this vieAV of the matter that typhous ulcers appear upon the most dependent por- tions of the larynx, in which hyperaemia from gravitation is easUy de- veloped, after long-standing disease; and, as is also the case in the loAver parts of the lungs, and of the integument of the back and loins, at points most exposed to pressure or mechanical irritation. The most striking observation, however, is that of RiXhle, according to whom, even in exanthematic typhus (a disease entirely foreign to abdominal typhus, which runs its course without medullary infiltration of the in- testinal glands), besides the products of catarrhal, croupous, and the diphtheritic processes, we find ulcers of the larynx exactly similar to those of abdominal typhus. WhUe the infection of measles is followed by catarrhal, or, in rare cases, by croupous laryngitis, and Avhile the poison of scarlatina does not localize itself in the larynx, excepting by propagation of diphtheritic inflammation from the fauces, the virus of small-pox, in a majority of cases, causes pustular inflammation of the mucous membranes of this organ. The variolous ulcer has its origin in the propagation of the exan- thema from the skin, and from the mucous membrane of the mouth and pharynx. We thus have to do Avith an eruption of smaU-pox in the larynx, Avhich, however, as a rule, is compHcated by a diffuse croupous inflammation—a secondary croup. Anatomical Appearances.—The typhous ulcer presents a loss of substance of the mucous membrane, bounded -by relaxed discolored edges. Its most common seat is the posterior wall of the larynx above the transverse muscle, and on the lateral edges of the epiglottis. As a rule, it only has a circumference of a feAV lines. In some cases, however, it extends so as to inA'olve the entire free edge of the epiglottis. In others it is more disposed to penetrate deeply, and thus may lead to laryngeal perichondritis, and to exposure and consequent necrosis of the cartilage. The variolous ulcer commences by the formation of a soft, flattened, non-umbihcated pustule, Avhich soon bursts, forming a shaUoAAr, rounded sore, which readily heals. The croupous exudation which accompanies the small-pox eruption, and which, according to RiXhle, is often found"1 there when the pustules are wanting, consists of a someAA-hat thin film, spreading over the swoUen mucous membrane. The latter is at first someAvhat reddened, but aftenvard grows paler. After the fall of the false membrane, Avhich usually extends as far as the bifurcation of the SYPHILITIC DISEASE OF THE LARYNX. 35 trachea, the condition of the mucous membrane is normal, with the ex- ception of a feAV trifling abrasions. Svmptoms and Course.—Owing to the position Avhich it usually occupies, the typhous ulcer of the larynx does not cause alteration of the voice, unless there be a coexisting SAvelling, and relaxation of the vocal chords. Pain, or other sensation, is either shght or entirely absent. At all events, the sick, as they He half slumbering, do not usually com- plain of it. Hence, we see that, during Hfe, the typhous ulcer is not recognized, nay, cannot be recognized, and is often only discovered by accident upon the dissecting-table. Never neglect, therefore, in typhus subjects, to examine the larynx post mortem, even though during Hfe no symptoms of disease of the larynx existed. In other cases the relax- ation and swelling of the vocal chords are so great, that the voice becomes rough and hoarse, and in cases Avhere the stupor is not very great, there may even be Adolent fits of coughing, or of harsh, hoarse, inaudible " hacks." Although these symptoms are not so much signs of typhous ulcer of the larynx as of disease of the mucous membrane causing the ulcers, yet, from the fact of their appearance in the second or third Aveek of the fever, Ave may diagnosticate the so-called laryngo-typhus from them. Although almost Avithout importance of itself, this laryngeal typhous ulcer may occasion danger from oedema glottidis and laryngeal perichondritis. Variolous ulcers necessarily give rise to symptoms identical Avith those of severe laryngeal catarrh. The tAVO diseases Avould not be dis- tinguishable, did not the eruption upon the skin and the pustules in the mouth and throat furnish a distinct criterion. The secondary (variolous) croup, Hke the genuine, causes hoarseness and aphonia. The cough is generaUy moderate or entirely Avanting. Either because the false membranes are not thick enough materiaUy to occlude the passage of the glottis, or because oedema and palsy of the muscles of the glottis (to Avhich Ave ascribe a part of the dyspnoea of croup) do not occur here, it is only on rare occasions that dyspnoea, Hke that of genuine primary croup, is met Avith in this form of laryngitis. Treatment.—Typhous and variolous ulcers usually heal, with subsi- dence of the primary disease, and need no particular treatment if uncom- plicated by oedema glottidis, or by perichondritis laryngea. CHAPTER V. syphilitic disease of the larynx. Etiology.—Our knowledge of syphilitic disease of the larynx has been greatly extended and modified by means of laryngoscopy. Ger- hardt and Roth have shoAvn that this class of disorders is much more 36 AFFECTIONS OF THE LARYNX. common than had hitherto been supposed. By means of laryngoscopic examination, they have discovered laryngeal disease in a large number of syphilitic patients Avho eA'inced no outAvard signs of it, and have shown that, besides the grave and destructive disorders already known as tertiary syphilis, the so-caUed secondary forms—the catarrh, condylo- mata, and simple ulcer—also occur in the larynx AA'ith unexpected fre- quence. I prefer to base my description of this class of syphilitic affec- tions upon the Avork of these observers, AA'ho state that some of the patients dated their laryngeal affection from a " cold;" and hence think J it probable that the localization of syphihs in this organ is, in some degree, determined by fortuitous catarrhal inflammation. Anatomical Appearances.—The anatomical lesions, arising from syphihtic laryngitis, are often merely those of catarrh, and are quite analogous AArith those of simple syphilitic angina. Although syphihtic laryngeal catarrh is not distinguishable from other laryngeal catarrhs by any palpable anatomical peculiarity, yet the time of its occurrence, after a primary syphilitic ulcer, its duration, its disappearance upon mercurial treatment, testify as to its specific nature, and to its dependence upon syphihtic infection. Condylomata and plaques muqueuse are much more frequently ob- served. They form flattened, reddish projections, and some of them sHoav upon their surface the Avhitish thickening and loosening of the epithehum, Avhich we see in the condylomata of the pharynx and mouth. The most common situation of condylomata is on the vocal chords, although they also occur at other points, particularly the pos- terior AA'all of the larynx, and on the arytenoid cartilages and on the aryepiglottic fold. Simple (secondary) syphilitic ulcers are, on the whole, rare. No ulcers, accompanying the condylomata in the larynx, existed in any of the cases reported by Gerhardt and Roth. These authors declare the diagnosis of this form of ulcer to be altogether uncertain, as both the yellow coating upon their base and the luxuriant condition of the neighboring parts are found in other forms of ulcers. Simple syphilitic ulcers occur in most varied positions in the larynx, upon the epiglottis, the true and false chords, or in the loAver part of the organ. They are not al\Arays, nor even frequently, complicated Avith ulceration of the fauces. Finally, there are the Aveil-knoAvn extensive and profound tertiary ulcers, Avhich coexist with syphilitic lupus of the skin, and, like the lat- ter, are probably due to the breaking doAvn of syphihtic tubercle. Such ulcers almost always begin upon the epiglottis, Avhich they destroy, more or less completely, not unfrequently spreading thence throughout the entire larynx. As a rule, these ulcers have a dentated, ragged shape, SYPHILITIC DISEASE OF TnE LARYNX 3; and a smooth base, covered Avith a yellow coating. They shoAV a ten- dency to cicatrize at the point first attacked, AvhUe the destruction ad- vances at other places. The A'ery voluminous papUlary and bulbous groAvths, Avhich surround the sore, and its deeply-retracted scars, are especially characteristic. Symptoms and Course.—The simple catarrh and the condylomata of the larynx are among the earliest manifestations of constitutional syphilis Avhich appear. If, then, a person, Avho, some months preAiously, has contracted a primary syphihtic ulcer, should begin to complain, Avithout assignable exciting cause, of a feeling of tickling in the throat, should his voice become deep and hoarse, should he acquire a harsh, barking cough, and should these symptoms persist in spite of the most careful management, or should the hoarseness graduaUy increase to complete ajihonia, Ave may suspect that the symptoms are not dependent upon a simple laryngeal catarrh, but upon syphilitic catarrh, or upon the devel- opment of condylomata in the larynx. Thus, it appears, from Avhat Ave haATe stated in the previous chapters, about the origin of hoarseness, apho- nia, and harsh, barking cough, that both syphilitic and simple catarrhs, condylomata, as well as mucous accumulations upon the chords, are ca- pable of modifying the tone of the voice and of the cough, and of pre- venting the occurrence of sonorous vibrations of the vocal chords. The fact, therefore, that condylomata, so situated as not to disturb the vibrations of the chords, do not give rise to hoarseness, needs no further explanation. As, in almost all the cases reported by Gerhardt and Roth, condylomata of the larynx haA'e been accompanied by con- dylomata upon other parts, especially upon the mouth and throat, the existence of such groAvth should aAvaken our suspicions as to their pres- ence in the larynx, Avhile their non-existence permits us to regard the case as probably one of simple catarrh. Simple (secondar}'-) syphUitic ulceration seems to belong to a some- what later period, as its appearance does not coincide Avith that of sim- ple syphihtic ulceration of the fauces. Its presence should be suspected Avhen, in an individual Avho, one or tAvo years before, has had primary syphUis, and avIio has since had secondary symptoms, there arises a dis- ease of the larynx, Avhich neither encroaches upon the cavity of the organ nor exhibits characteristics of other forms of laryngeal disease. Here, too, laryngoscopy affords the surest means of diagnosis. The extensive and profound (tertiary) ulcerations are the easiest to recognize. They form one of the later Hnks in the chain of syphihtic disorders, and almost exclusively attack patients avIio have for a series of years suffered first from one form of it, then from another, and have resorted to the various methods of treatment by mercury. The sufferers are here not simply hoarse and A'oiceless, Avith harsh cough, AA'ith pro- 38 AFFECTIONS OF THE LARYNX. fuse and not unfrequently bloody expectoration, but these symptoim are always combined Avith a more or less intense dyspnoea. We mark the laborious, long-drawn breathing, so characteristic of stricture of the larynx, with its stridor audible even at a distance. This narrowing of the larynx may graduaUy become so extreme, from contraction of cicatrices and development of exuberant growths in their vicinity, that respiration becomes insufficient, and poisoning by carbonic acid sets in. In other cases, the dyspnoea suddenly rises to an alarming pitch from the occurrence of oedema of the glottis. The fact that the ulceration spreads graduaUy into the larynx from the root of the tongue and fauces, and there begins its ravages upon the epiglottis, makes it a duty carefuUy to examine the region of the larynx of aU patients suffering from laryngeal stricture, and to press with the finger upon the epiglot- tis, in order to ascertain if it have suffered any loss of substance. In fact, the positive or negative result of this examination gives almost certain ground for diagnosis for or against the malady, although a closer insight as to the extent of the process is only to be obtained by means of laryngoscopic examination. In condylomata and simple catarrh the prognosis is good. It is not so good in the simple ulceration, from which sometimes the grave forms last described seem to develop. In the latter, the prognosis is a very unfavorable one. Most patients die, sooner or later, Avith symptoms of increasing marasmus, even although the respiration remain sufficient, or be made so by tracheotomy. However, in some cases, a partial improve- ment at least takes place. Thus, in one far-advanced instance, in which the relatives of the patient were confidently awaiting her speedy disso- lution, I have seen an almost complete recovery. In this patient, now a blooming female, there is nothing, save a shght stridor and a deficience in the soft palate, to recaU to mind the once terrible malady under which for weeks she lay utterly emaciated, without voice, with racking cough, Avith profuse and often bloody sputum, and bereft of aU hope of im- provement. Treatment.—For the treatment of syphilitic disease of the larynx, the same rules apply Avhich are laid doAvn for the general management of syphilis. In extreme contraction of the orifice, tracheotomy is inch- oated. CHAPTER VI. tubercular ulceration of the larynx. Etiology.—Laryngeal ulcers, AA'hich, until recently, Avere regarded aa depending upon tuberculosis of the larynx, are found in nearly half uf all cases of advanced tubercle of the lung. Latterly, we have hesi- TUBERCULAR ULCERATION OF THE LARYNX. 39 tated to admit any ulcers as tubercular, in Avhich the disease, instead of springing from isolated nodules, develops from diffuse degeneration of the mucous membrane. We doubt the identity of that diffuse interstitial ceU-formation, and consecutive necrosis of tissue (infiltrated tubercle), Avith that discrete neoplastic generation of aggregate masses of con- glomerate cells and nuclei (miliary tubercle). We cannot deny, hoAV- ever, that both forms so often occur side by side, that a relationship between the two is highly probable. Until a new nomenclature comes into general use, Ave shaU continue to speak of the one as " tubercular infiltration," the other as "miliary tuberculosis." (See section on " Pulmonary Tuberculosis.") The circumstance that the affection in question never occurs Avhen the lungs are not the seat of tuberculosis confutes the opinion that it is the consequence of injury which the mucous membrane of the larynx suffers through cough, or through the accumulation of acrid secretion at the affected spot. The cough which generaUy accompanies bronchial dilatation is often much more violent than the cough of tuber- culosis ; the secretion of dilated bronchi, or of gangrenous vomica, is more foul, acrid, and corrosive, than that from the cavities formed by tubercle; and yet the ulcers in question never form in cases of bron- chial dilatation, or of gangrene of the lungs. We befieATe it to be be- yond doubt, that miliary tubercle of the larynx, as avcII as the diffuse form, takes root upon the same soil as that from Avhich tuberculosis of the lung is developed. Anatomical Appearances.—The seat of tuberculosis of the larynx is, in by far the majority of cases, that portion of the mucous mem- brane which covers the transverse muscles ; not unfrequently, hoAvever, tuberculous ulcers are found in other places, above all, upon the pos- terior surface of the epiglottis. Here, but only in rare cases, Ave may observe gray round nodules of the size of a miUet-seed, AA'hich aftenA-ard become yelloAV, soften, disintegrate, and leave in their stead round ulcers of the size of a millet or hemp seed (RoJcitanslnfs primary tubercular ulcers). Through a fresh deposit of nodules in the vicinity, and through the confluence of several ulcers, an irregularly-shaped loss of substance is finally established, Avith serrated ragged edges (Rokitansky's second- ary tubercular ulcers). Much more frequently AA'e notice first a yelloAA'- ish discoloration of the mucous membrane, Avhich, under the microscope, is found to arise from the infiltration of its tissue Avith innumerable small cells. The tissues of the mucous membranes gradually become relaxed. First, a shalloAV, then often a very profound loss of substance, takes place in their tissues. The destruction frequently adATances from the posterior Avail to the vocal chords, so that their posterior insertions, or even laro-e portions of the chords themselves, are sometimes destroyed. 40 AFFECTIONS OF THE LARYNX. The epiglottis is not often perforated by tuberculous ulceration of the posterior Avail; when it does happen, the contour of the part is still preserA-ed, thus forming a contrast to Avhat occurs in syphUitic ul- ceration. Tuberculosis of the larynx is very often combined Avith ossification of its cartilages. If ulceration reach the cartilages, they become carious and necrosed, so that portions of ossified cartilages are often discharged, In rare instances, the ulceration has perforated the AA'all of the larynx, producing laryngeal fistulae and emphysema of the skin. Symptoms and Course.—When hoarseness supervenes upon symp- toms of tuberculosis of the lungs of long standing, Ave may confidently infer the coexistence of tubercle of the larynx. (There are cases in which the hoarseness of tuberculous patients depends not upon an alter- ation of texture of the mucous membrane, but upon a paralysis of the muscles of the glottis. To this we shall recur hereafter.) Here, too, hoarseness, at least in most instances, is not the immediate result of a tuberculous ulcer, the latter, as we have seen, being, in the great ma- jority of cases, situated upon the posterior laryngeal AA'all, and upon the epiglottis. The hoarseness is occasioned by the relaxation and thickening of the vocal chords, and by the secretion AAThich lies upon them. We can thus understand Avhy the hoarseness come3 and goes, wliile the ulcers are ahvays growing and persistent. The mucous mem- brane of a diseased larynx is more vulnerable than that of a healthy one, and far slighter irritants suffice to produce in it a catarrhal affection. Nay, just as, without any assignable cause, the parts about every chronic ulcer of the skin become more sensitive, congested, and swollen at one time than at another, so, too, the laryngeal mucous membrane Avhen the seat of ulceration seems ahvays in a state of alternate swelling and detumescence. The nearer the destruction approaches to the vocal chords, so much the more persistent and obstinate does the hoarseness become. If, finaUy, the ulceration destroys their posterior attachment, it is no longer possible to tighten them, nor to throAV them into sonorous vibration. The voice is totally extinguished; speech becomes AAduspering and inaudible. In other cases, in Avhich the disease runs a more acute course, symp- toms of hyperaesthesia of the mucous membrane are more prominent. It is characterized by great irritability and A'iolent reflex phenomena. The most distressing fits of coughing, brought on by the most insignifi- cant and often inappreciable causes, paroxysms of choking, which not unfrequently end in retching and vomiting, besides hoarseness or in- audible voice; aU these very striking and painful symptoms forcing themselves so prominently into notice that the phenomena of tubercle TUBERCULAR ULCERATION OF THE LARYNX. 41 of the lung, if not very far advanced, are thrown into the background. The sufferer declares " that he has nothing the matter Avith his chest," ridicules the percussion and auscultation, and protests that the only evU with which he believes himself to be afflicted, or Avhich he fears, is the " consumption of the larynx." It is rare for patients to complain of burning or smarting in the larynx, and usually, too, they are but slightly sensitive to pressure there, even though we push the organ back against the spine. The feeling of crepitation perceptible upon this manipulation is also felt in pressing upon this organ in a healthy person, and is of no diagnostic significance. The expectoration is useless as a means of diagnosis (unless, indeed, pieces of cartilage be ejected), since but a smaU portion of it springs from the larynx. The shortness of breath, the hectic fever, the night-SAveats, the emaciation proceed equally from the coexisting tuberculosis of the lungs. In one case only of pulmonary tubercle, besides the symptoms just described, I have seen intense and gradually- increasing stricture of the larynx. The patient died in a feAV Aveeks, after having been materially relieved by tracheotomy. At the autopsy there Avcre found in the larynx the thickening and induration of the submucous tissue (previously described as a cause of chronic stricture), together with tuberculous ulceration. Examination of the pharynx almost always sIioavs that chronic catarrh exists there also. We find its blood-vessels varicose, and see smaU vesi- cles, phlydxeme, or small, shaUoAV, rounded erosions. The sufferer haAvks, a great deal; deglutition is difficult. At last it is often impossible for him to enjoy Hquid food AA'ithout choking himself, AA'hile solid food passes doAvn more easily. In these cases the closure of the glottis is incom- plete. All of these symptoms, hoAvever, Avill not Avarrant a diagnosis of tubercle of the larynx unless Ave are able to shoAV that the lungs, too, are affected. They are all capable of being produced by other kinds of laryngeal degeneration. It is avcU, therefore, in every chronic affection of this organ, at once to institute an accurate physical examination of the chest, and not to pronounce an opinion until Ave may have been able to a\rail ourselves of the revelations of percussion and auscultation. The subjective manifestations often fail us, being frequently obscured by those of the larynx. Hectic fever and emaciation are the only signs capable of rendering the diagnosis almost certain AA'ithout the aid of physical investigation. By means of the laryngoscope Ave can easUy brino- the ulcers on the epiglottis and arytenoid cartilages into vieAV. Of the posterior AvaU of the larynx aboA'e the transverse muscle, we, as a rule, can see at least the upper edge, in form of a fringe, Avith a feAV pointed jags of a dirty-whitish color {Turk). £2 AFFECTIONS OF THE LARYNX. The praises of specific remedies in cases of pretended cure of tubercle of the larynx are founded chiefly upon error of diagnosis. On the other hand, a number, although a small one, of actual cures of this malady can be authenticated beyond doubt. Death takes place, in most cases, from exhaustion, or Avith the symptoms of consumption, Avhich Ave shall treat upon more fully in discussion of the subject of tubercle of the lungs. In some very rare cases, oedema glottidis is suddenly set up, under Avhich the patient rapidly succumbs. Treatment.—In the treatment of laryngeal tuberculosis, Ave are not in condition to meet either the indication as to cause or the indication from the disease. The symptomatic indications are, first of all, to combat the burdensome cough and attacks of choking, which not unfrequently rob the sufferer of his rest. The treatment in the main must be the same as that recommended for chronic laryngeal catarrh, smaU as the result to be looked for may be. The Obersaltzbrunnen and the Emser Krahnchen Avaters, mixed with equal parts of hot milk, and drunk fasting in the morning, seem, in some degree, to moderate the cough. Do not make any objection to the roe of a herring, to be swalloAved fasting, nor to the hope which the patient attaches to this prescription. If the pharynx be reddened; if its blood-vessels be varicose; if phlyctaenae and ulcers be visible in it, swab it with a concentrated solution of nitrate of silver, and let the patient gargle assiduously Avith alum. In this Avay Ave can best guard against the too frequent " haAvking," which is in itself a source of annoying cough. The insufflation of lunar caustic, the squeezing of a sponge saturated with a solution of nitrate of sUver over the entrance to the glottis, by moderating the cough, sometimes haAre a palliative effect, if repeatedly applied; and, in the few rare in- stances in which also pulmonary phthisis recedes, this treatment may even have a radical effect. Here, too, we must concede a certain prefer- ence to the direct and exclusive apphcation of nitrate of silver in solu- tion, or substance, to the surface of the ulcer itself, AA^hen accomplished \>y skilful and practised hands. The most important medicaments in the treatment of tubercle of the larynx are the narcotics. Little as they contribute to the heahng of the ulcers, their palliative action upon the burdensome symptoms of the dis- ease is indispensable. It has been customary to prefer the use of hy- oscyamus and beUadonna to that of opium; nevertheless the preparations of the former remedies are seldom as uniform, and their effects, conse- quently, seldom are as trustworthy as those of opium. As a matter of course, the patient whose larynx suffers from ex- cessive irritabihty from tuberculous ulceration must remain in a uni- formly heated and, if possible, in a somewhat moist atmosphere. We forbid him aU loud speaking; nay, in especially bad cases, compel abso- GROWTHS IN THE LARYNX. 43 lute silence of Aveeks' duration. When we reflect that, Avith every act of speech, the vocal chords are subjected to friction from the air AA'hich is driven past them, this direction must seem as rational as in practice it Avill be found to be sendceable. CHAPTER VII. GROWTHS IN THE LARYNX. Some of the groAvths which form in the larynx are of the papillary kind, Avarty caulifloAver-hke excrescences, produced principaUy by luxu- riant development of the epithehum. Some are true mucous polypi, partial hypertrophies of the mucous membrane rendered prominent by their serous or colloid fluid contents. The mucous polypi are sometimes attached by a pedicle; sometimes they rest upon a base more or less broad; and they vary in size from that of a pin's head to that of a hazel- nut. More rarely fibrous tumors are found, and these, AA'hen provided with a pedicle, are called fibrous polypi. Scirrhus and medullary cancers of the larynx are found almost exclusively in instances Avhere the malady, Inning originated in the oesophagus, or areolar tissue of the throat, has spread into it from without. EpitheHal cancer appears more frequently in the form of soft, Avhitish-red excrescences, uniformly covering the mucous membrane, frequently penetrating deeply and destroying the cartilage. In other cases they assume the form of sofitary tumors and encroach considerably upon the cavity of the organ. Among the great number of cases of laryngeal tumor which Lewin has collected from the literature, tAventy-tvro had their seat upon the epiglottis, nine on the aryepiglottic ligament, tAventy-one on the ventriculus morgani; thirty-two on the true, five on the false vocal chords; three on the aryt- enoid cartilages; eight on the anterior Avail of the larynx; Avhile in only tAVO instances Avere pathological groAvths observed upon its hinder Avail, the most frequent seat of ulceration. Lewin seeks to explain this remarkable circumstance by the fact that the latter point is subjected to alternate folding and extension during the motions of the glottis. Such a position Avould therefore be the more prone to ulceration, Avhile commencing groAvths AATould soon break doAvn; so that, instead of tumors, ulcers Avould form. It is a puzzhng fact that tumors of the larynx, and particularly polypi, which, a few years ago, passed for pathological rarities, have lately been observed and described in tolerably large num- bers. From the care and thoroughness Avith which autopsies are con- ducted at the present day, not only by pathological anatomists and clinical prosectors, but also by the better class of private physicians, it is hardly to be supposed that hitherto most polypi of the larynx have been 44 AFFECTIONS OF THE LARYNX. overlooked in the cadaA-er. On the other hand, the numerous observa- tions of polypous groAvths of the larynx come, in great part, from such trustworthy investigators, that Ave cannot believe that insignificant groAvths or folds of mucous membrane can have been mistaken for and reported as polypi. Until the introduction of the laryngoscope, a positive diagnosis Avas impossible, save in rare instances. It is true, that sometimes Ave could surmise, AA'ith a certain degree of confidence, that a tumor Avas groAving in the larynx, AA'hen the symptoms of laryngeal stricture began to supervene on those of laryngeal catarrh, and the dyspnoea underAvent fluctuations as the varying engorgement or deple- tion of the growth made it vary in size. The probability became greater, when, in the course of the disease, repeated attacks of suffo- cation took place, Avhich Ave could only attribute to contraction or closure of the glottis caused by the sudden change of. position of the tumor. However, even the periodical return of such choking-fits, Avhich used to be considered pathognomonic of growths Avithin the larynx, by no means made the diagnosis sure. Certainty Avas possible in those cases only in Avhich the groAvth protruded, so as to become accessible to palpation or to inspection, or Avhere the patients coughed up fragments of the tumor. To-day, the recognition of a tumor in the larynx presents no diffi- culties ; but the majority of the polypi and excrescences so easily and certainly detected by laryngoscopy have not produced the symptoms hitherto described as pathognomonic. Most of the patients had suffered merely from hoarseness, aphonia, or troublesome cough, and many of them had in vain been sent to Obersaltzbrunnen, Ems, or even to Cairo or Algiers, there to recoA7er from their supposed laryngeal catarrh or consumption. It is just this class of cases Avhich shoAvs what high time it is that a greater number of physicians should pay more attention to the laryngoscope, so as not to leave this very important art, so essential for the diagnosis of disease of the larynx, and which is not so very difficult to learn, in the hands of a feAV specialists. With the aid of the exceUent books of Czermak, Turk, Bruns, Lewin, Ilalbertsma, and by dint of assiduous practice, the necessary skiU may be acquired to enable us, in doubtful cases, to make use of laryngoscopy, to effectually confirm our diagnosis. It is not necessary to examine aU patients who are suffering from an acute laryngeal catarrh; and, as the procedure is always a fatiguing one, it Avould be cruel to subject patients to it AA'ho have advanced pulmonary phthisis, AvTith hoarseness and aphonia, and A\dio, in their desolate condition, so often turn to the specialists. If, hoAvever, hoarseness, a harsh cough, and other symptoms which Ave had supposed dependent upon a simple catarrh, persist in spite of sedulous treatment, even though no signs of laryngeal stricture may exist, Ave (EDEMA GLOTTIDIS. 45 ought never to neglect to ascertain positively, by means of the laryn- goscope, Avhether a tumor be not the source of the affection. In others of the neAArly-observed cases, hoAvever, besides the signs of chronic laryngitis, the other symptoms formerly regarded as pathog- nomonic Avere actually present, so that it Avould have been possible to decide as to the existence of these tumors in the larynx, even before the introduction of laryngoscopy. There was that long-drawn, laborious, stridulous respiration, characteristic of stricture of the larynx, particu- larly when, after any bodily exertion—mounting stairs, rapid running, and the hke—the dyspnoea had increased, and the inspirator}' movements be- come more energetic and frequent. Czermak and Lewin have caUed to our attention, that in tumors above the glottis it is frequently inspira- tion alone Avhich is impeded, AAdiile if the growth be beloAV the glottis expiration may be embarrassed. It finally remains to be told that contrary instances have been met with, AA'hich not only evinced no signs of laryngeal stricture, but in which there was neither harsh cough nor hoarseness. The sole complaint of these patients Avas, of an ill-defined feeling of distress in the throat, or the sensation as if an accumulation of mucus were sticking in the larynx. The great variety in the symptoms of laryngeal tumors is easily comprehensible, after Avhat we have taught in the first chapter, about the physiology of the voice. It is only in the cases in Avhich the tumor hinders the approximation of the vocal chords, or interferes with their vi- bration, that they, of necessity, occasion hoarseness or aphonia. On the other hand, all tumors Avhich do not implicate the functions of the vocal chords cannot possibly give rise to such symptoms. Thus it depends entirely upon the seat of a groAvth, and upon its size, as to Avhether it cause the symptoms of laryngeal stricture or not. The treatment of groAvths of the larynx comes under the domain of surgery. Since the year 1861, AA'hen my coUeague Bruns, with the aid of the laryngoscope, and Avithout incision, first extirpated a laryngeal polypus from the throat of his brother, the operation, Avhich forms one of the most brilliant advances of modern surgery, has been performed repeat- edly, both by Bruns and by other surgeons famihar Avith the use of the laryngoscope. CHAPTER A* 111. (EDEMA GLOTTIDIS. , Etiology.—During inflammation of a part Avhere the skin-is attached to the subjacent region by loose areolar tissue, effusion into the latter often takes place AA-ith extraordinary rapidity. 46 AFFECTIONS OF THE LARYNX. Let us recaU to mind the oedema about the uninteUigible, and it accounts for the action of venesection in pneu- monia, pleuritic effusion, etc. 4. Finally, Ave have aheady stated that a rarefaction of the air in the alveoli produces determination of blood to the lungs, just as a cupping- glass or the boot of Junod causes fluxion to the skin. The suspended or diminished pressure to which the capillaries of the air-cells of a child Avith occluded glottis are subjected, Avhen it expands its chest, is, as Ave haA'e seen, the main reason for the consecutive bronchial catarrh and pulmonary oedema in croup, and of the poor success of tracheotomy. II. Stagnation of the blood, passive hypoxemia, from AA'hich AAre 132 DISEASES OF THE PARENCHYMA OF THE LUNG. illogically separate the mechanical form, takes place in aU cases in Avhich the pulmonary veins are abnormally filled and their Avails unduly stretched. Here the blood Aoavs from the capiUaries Avith difficulty, Avhile the arteries continue to convey blood to them, even though scantily filled themselves, since even then their Avails evince a greater degree of tension than the capiUary Avails. (Blood continues to flow from the arteries into the capillaries after the heart has ceased to con- tract.) Hence Ave see that stagnation results in a far greater dUatation of capillaries than fluxion does, as when there is much obstruction of the venous current in the capillaries, Avhich have become, as it were, blind appendices to the arteries, the blood continues to enter them until the tension of the capiUary Avails is equal to that of the artery, or until the delicate membrane can no longer support such a pressure, and be- comes ruptured. Stagnation, or engorgement of the pulmonary capil- laries, occurs most typicaUy— 1. From contraction of the left auriculo-ventricular opening and in- sufficience of the mitral valve. Both forms of disease of the heart are accompanied by the most intense hyperaemia of the lung. We know that the brown color of the indurated hypertrophied lung depends upon rupture of the dilated capiUaries, the chief cause of Avhich we have found to be valvular disease of the mitral. Whether the evacuation of the auricle be retarded, or Avhether the blood be regurgitated during the systole into the auricle, either process must impede the emptying of the pulmonary vein, and give rise to overcharge of the capillaries. 2. Enfeebled action of the heart results in imperfect evacuation of its cavities, and hence in impeded efflux of blood from the veins. Here the supply from the arteries is not diminished in proportion as the out- floAV from the capillaries is obstructed, and thus asthenic fevers, in which the contractions of the heart are frequent, but incomplete, such as typhus, puerperal fever, or pyaemia, are constantly accompanied by en- gorgement of the pulmonary capiUaries. When the heart's action is weakened, gravity furnishes a new impediment to the evacuation of the capiUaries in dependent portions of the body. AVhile such an obstacle is easily overcome when the heart contracts Avith energy, yet when its action is depressed, Ave soon see evidences of the effect of gravitation, and hyperaemia begins to form at the more dependent places. A healthy person may lie in bed for months AAdthout the development of this form of hyperaemia (hypostasis) in the capiUaries of the back, or the forma- tion of bed-sores, or the different phases of pulmonary hypostasis which are the almost constant accompaniment of a typhus of long duration. We have learned that SAvelfing and succulence of the mucous mem- brane, and increase and alteration of the follicular secretion, are the constant result of hyperaemia of a mucous membrane; similar processes HYPER/EMIA OF THE LUNG. 133 take place in the alveoli in all cases of severe hyperaemia. Here, too, the Avails SAvell up, become more moist and succulent, but the secretion, or, more properly, the transudation, Avhich is poured into the ceUs differs from the bronchial secretion, being liquid and serous. If AAre bear in mind that there are but feAV mucous follicles even in the finer bronchi, and none at aU in the air-ceUs, and that the structureless cell-waU is coa'- ered merely by imperfect pavement epithelium, it must be e\ddent that the secretion from the vesicles, which have no mucous membrane proper, must be very different from bronchial mucus. AVHile, in other organs, the term oedema is applied to an effusion of serum into the interstitial tissues, the term oedema of the lung is only used in cases Avhere such infiltration is combined Avith an effusion upon the free surface of the lung, i. e., into the pulmonary vesicles. QMema of the lung, hoAvever, is not, in all cases, a consequence of hyperaemia, or of increased pressure of the contents of the capillaries upon their Avails, but, as in other organs, serum filters out of the pulmonary capiUaries into the tissue and into the vesicles, under slight pressure, whenever the serum of the blood has but Arery little albumen in solution, or whenever a dropsical crasis has developed. AVe shall consider this subject more fully in treating of Bright's disease. If oedema arise from a hypostatic hyperaemia, it is caUed hypostatic oedema. As Ave have learned, hoAvever, there is a double reason for the vascular engorgement in hypostatic hyperaemia, and hence it is easy to understand that in this form the capiUaries become extremely overfilled, and that their Avails undergo an excessive pressure. In this form of hyperaemia it is not merely a transudation of a solution of dilute albu- men Avhich takes place, but all portions of the serum of the blood, even the fibrin, pass through the now porous Avail of the \-essels, and Ave call this condition hypostatic pneumonia, a process Avhich takes place simply from stagnation of the blood, and has nothing in common AAdth inflam- mation proper. Anatomical Appearances.—AVIien the hyperaemia is moderate, the lung is bloated, dark red in color, and its vessels are fiUed to bursting. The tissue is succulent, relaxed, crackles but Httle, blood floAA'ing freely OArer the cut surface; a bloody, foamy Hquid is contained in the bron- chi. AATien of longer duration and greater intensity, the parenchyma looks dark, bluish red or blackish red. The interstitial tissue and the alveolar walls are so much SAVollen that the condensed parenchyma scarcely giATes any indication of its cellular structure. The lung, thus solidified, presents a certain simUarity of appearance to the tissue of the spleen, and is therefore said to be splenified. If oedema have developed in the lung, it seems SAVoUen, does not collapse when Ave open the chest, and is tense to the touch. If recent, 134 DISEASES OF THE PARENCHYMA OF THE LUNG. it does not pit on pressure; after longer duration, the parenchyma has lost its elasticity, and the lung retains the impression of the finger longer and more distinctly. If the oedema be consequent upon an in- tense hyperaemia, the oedematous lung is colored red, but, if it be one of the symptoms of a general dropsy, it may appear quite pale. If Ave cut into the oedematous spots, an enormous quantity of liquid, sometimes clear, at others of a red color, mixed more or less with blood, flows over the surface of the cut. This Hquid is fuU of bubbles, frothy, and copi- ously mixed with air, if the air-ceUs have not been entirely fiUed up with serum and stiU contain air. In other cases, the Hquid hardly con- tains any bubbles, except a feAV from the larger bronchi. Here the serum has expeUed all the air from the vesicles. In cases of hypostasis Ave find the same conditions; intense hyperaemia, amounting to splenifica- tion, or a more or less complete oedema, uniformly occupying the poste- rior portion of the lungs next the vertebrae. If the patient have lain continuaUy upon one or other side, the hypostasis is often confined to this side alone, and may be very extensive, while the other lung may be healthy. If the contents of the air-vesicles at the condensed portions of the parenchyma cannot be completely evacuated by pressure, if the section shows an indistinct granular aspect, if the Hquid AA'hich flows out be clouded by little coagula of fibrin, Ave have the so-caUed hypostatic pneumonia before us. Symptoms and Course.—A moderate degree of fluxion to the lungs presents no symptoms. The dilated capUlaries present a greater surface to the air, the circulation is accelerated, and with this accelera- tion the change of the blood in the lung grows more brisk, as both cir- cumstances promote and facilitate oxygenation. When, however, the fluxion is more considerable, the enlargement of the dense capiUary net and the sweUing of the ceU-walls from augmented transudation may diminish the capacity of the air-\*esicle. An obstacle to respiration is thus set up. The lungs cannot inhale so much air. Those narrow- chested youths and girls, of AA'hom Ave have spoken, in their attacks of palpitation, complain of shortness of breath, nay, they Arery correctly call the sensation which they experience in the chest a " fulness " or " stricture." A short, dry cough is added to this condition ; far more rarely a frothy expectoration, Avith scattered streaks of blood. There is no pain in \the chest. Physical examination shoAvs no abnormities. We may as Avell state here that " habitual determination of blood to the chest" is sometimes the forerunner of tuberculosis, though perhaps not as often as AveVare apt to beHeve. The violent hyperaemia of the lungs, mentioned in the pathogeny, and Avhich musA be regarded as consequent upon excessive action of the heart, sometime! arises rapidly, and threatens life Avith unexpected sud- HYrEIUEMIA OF THE LUNG. 135 denness. Hence such cases are caUed pulmonary apoplexy {Lungen- schlagflxss). The shortness of breath quickly increases to a serious ex- tent ; the breathing groAVS hurried and scarcely to be counted. The feehng of fulness ana cmrrp^^rion causes fear of death and a sensa- tion of choiring; every cough fills the mouth Avith a copious, frothy, bloody expectoration. The heart beats Adsibly, the radial pulse and the carotids betray the tension of the arteries. The face is reddened. The oedema, Avhich foUoAvs this form of hyperaemia, soon makes itself felt. The vesicles, filled Avith serum, can admit no more ah; an acute surcharge of the blood with carbonic acid changes the scene. The restless patient becomes stiU and droAvsy, the face paler, the muscles of the bronchi, palsied Avith the other muscles, cannot rid the tubes of their serous cedents. Coarse, moist rales, audible eATen in the trachea, announce the approaching end, the threatening suffocative effusion. The symptoms of acute fluxion, brought on by the inhalation of irri- tating gases, are modified by the coexistence of irritation of the larynx and bronchial mucous membrane, and are accompanied by violent coughing-fits. The hyperaemia to Avhich tuberculosis, cancer of the lung, etc., give rise, and Avhich most generally produce pulmonary and bronchial haemorrhage, are to be treated of in the next chapter. Collateral fluxion to the lungs forms a grand feature in the descrip- tion Avhich Ave shall present of pneumonia, pleuritis, and pneumothorax. Here a large part of the dyspnoea depends upon the overfilling of the capillaries and SAvelling of the vesicles, in the portions of the lung un- affected by the inflammation. Without this compHcation, or, to speak more properly, if no such condition arose when the circulation is im- peded, the unaffected A'esicles could better obtain their supply of air. If the blood pressure be lessened by venesection, the collateral fluxion is reduced, the dyspnoea often completely disappears^ although the chief disease continues unabated. AVdien patients die in the first stages of pneumonia or pleuritis, or shortly after air has penetrated into the pleural sac, and compressed the lung, they die of collateral hyperaemia and coUateral oedema. If Ave examine the records of post-mortem examina- tions, Ave shall not fail to find evidence of this form of hyperaemia, although it is but little appreciated in interpreting the symptoms. PassiAre hyperaemia {Blut-stauung), even Avhen unaccompanied by pulmonary oedema, creates greater dyspnoea than fluxion to the lung. Patients Avith insufficience and contraction of the mitral, even if they have no bronchial catarrh, and Avhen the engorgement does not extend from the alveolar capUlaries into their anastomoses so as to produce tumefaction of the mucous membrane and contraction of the tube, nevertheless usually suffer from a very distressing shortness of breath, aggravated by the sfightest movement. This is easily accounted for, 136 DISEASES OF THE PARENCHYMA OF THE LUNG. when Ave reflect that in passive congestion {Blut-stauung) the circula- tion is as much retarded as in fluxion it is accelerated, that hi the former a double cause of dyspnoe aprevails, in the latter but one. Intense dyspnoea and all the symptoms of pulmonary apoplexy and suffocative effusion, which Ave have described, are often suddenly and unexpectedly added to the constant shortness of breath of disease of the heart. Effu- sion into the air-vesicles noAV exists beside SAvelHng of their Avails; the respiration, merely impeded hitherto, has now become inadequate. A great number of those Avho have disease of the heart die of acute passive congestion and acute oedema, without discoverable cause for the sudden increase in the impediment to the circulation. In other cases the symp- toms of effusion of serum into the pulmonary A'esicles, the inadequate respiration, and final death of the patient, take place more graduaUy in cases of disease of the heart. If, in the course of an asthenic fever, Avhether it be a symptom of typhus or of pyaemia, the respiration should become shaUoAV and incom- plete, should percussion indicate a condensation of the parenchyma of the lung, near the spinal column, should sputa be ejected more or less tinged Avith blood, Ave have to do Avith an obstructive engorgement of the lung Avith hypostasis or with its sequelae. It Avould be unnatural and artificial to make a distinction between the symptoms of hyperaemia and of oedema. If a hyperaemia be intense, oedema occurs as one of its most important symptoms. AVe infer that this normal and necessary result has taken place, in the first place, from the grade of the dyspnoea, AArhich never becomes so severe from SAvelHng of the alveolar waUs alone, as from oedema. Almost universally where hyperaemia has produced death, serum has been found in the air- vesicles. The characteristic sputa give a second point for diagnosis. Such liquid secretion is seldom or never discharged from the bronchial mu- cous membrane, and the expectoration of liquid transparent, profuse, sputum, more or less mixed Avith blood, if it supplant the viscid, scanty sputum of pneumonia, is very properly regarded as of serious omen. Auscultation also gives information as to the occurrence of oedema. A dry rale, that is to say, a rale which is formed in viscid fluid, may easily be distinguished from a moist one, that is, from a rattle which takes place through the medium of a thin Hquid. In the secretion of the bronchial mucous membrane we seldom hear such moist ratthng sounds occur as those which arise Avhen the serous transudation of the vesicles fills up the bronchi. In other cases we hear no respiratory sound in spots at which the vesicles are fiUed up by oedema, and AA'here no air can enter. Bronchial breathing is only to be heard in rare instances.* * Bronchial breathing takes place when the vesicles, filled with serum, do not HYPEREMIA OF THE LUNG. 137 Percussion, finaUy, AA'hich undergoes no change from hyperaemia alone, sometimes indicates that oedema has supervened upon hyperaemia. The sound upon percussion Avhen the alveolar walls have lost their elas- ticity through oedema, and are but fightly stretched over their contents, is sometimes distinctly tympanitic. If, hoAvever, all the air have been driven out of the air-cells by the oedema, and the lung have become void of air, the sound upon percussion becomes duU and flat, as Avith every other condensation of the lung. If these manifestations appear in the characteristic places for hypostasis, we have to do Avith this form, or Avith its sequela?. With regard, finally, to that form of oedema of the lung Avhich arises in general dropsy, the appearance of dropsical SAvelling of the subcutaneous cellular tissue and of effusions in the serous caAdties fur- nishes the best grounds for interpretation of the dyspnoea AA'hich accom- panies these symptoms. Should serous sputa, moist rattles, a tympanitic or dull sound, upon percussion, supervene, Ave are Avarranted in regard- ing pulmonary oedema as their cause. Diagnosis.—Hyperaemia and oedema of the lung, if Ave keep in vdew the symptoms just described, are easily distinguished from other diseases of the lung. It may, hoAvever, be very difficult (easy as the matter may appear in the study) to make a distinction at the bedside betAvcen active and passive hyperaemia, betAveen fluxion and obstruc- tion ; and, moreover, confusion of the tAA'O may lead to the worst conse- quences, to mistakes Avhich not unfrequently threaten the life of the patient. The confusion occurs most frequently between the collateral fluxion, occurring in the course of a pneumonia and pleurisy, and the passive hyperaemia, to Avhich enfeebled heart-action and asthenic fever give rise. AVe so frequently notice the occurrence of passive pulmonary hyperaemia and oedema of the lung, upon the final exhaustion of the patient, upon the diminution of the pulse, upon the delirium, and the dry tongue, that Ave are apt also, in cases of recent pneumonia, if the pulse be small, and the patient delirious, to think of passive hyperaemia and of obstruction from commencing paralysis of the heart, and instead of A'enesection to prescribe Avine, camphor, and musk. In treating of croupous pneumonia Ave shall go more fully into detail upon the subject of pulmonary fluxion and engorgement, symptoms of the utmost importance in that disease, and demanding especial considera- tion in its treatment. Prognosis.—The prognosis of hyperaemia and of oedema of the contain any air, but where, at the same time, the bronchi, which lead to the con- densed spot, are not filled up by the secretion. It is easy to see that the latter con- dition, requisite for bronchial respiration (of the origin of Avhich we shall speak more 'Sully while treating of pneumonia), is almost ahvays wanting in pulmonary oedema. 13S DISEASES OF THE PARENCHYMA OF THE LUNG. lung depends essentially upon its exciting causes. Fluxions, if they dc not proceed from adventitious productions in the lung, are generally of less serious character, and are more amenable to treatment than obstruc- tions, the causes of AA'hich are usuaUy difficult to allay. Prognosis of the various forms can be derived from the description of the course of the disease. Treatment—Indicatio causalis.—As increased action of the heart is a frequent cause of fluxion to the lung, and as, in youthful subjects, habitual palpitation of the heart, accompanied by hyperaemia of the lung, is often the forerunner of tuberculosis, a regimen and treatment suitable to such condition are demanded. Strictly forbid the use of spirits, tea, coffee, and order aU food or drink to be alloAved to cool somewhat be- fore it is taken. In like manner inexorably forbid dancing and riding, and other violent bodily exertion, at the same time enjoining regular and moderate exercise. Shield the patient, as far as possible, from all psychical excitement. Besides these precautionary measures, the lung is to be protected from injury. Let aU hot and smoky rooms and aU dusty places be avoided, and do not let the patient inhale very cold air. Acidulated drinks, lemonade, cream-of-tartar water, are to be recom- mended. The milk and Avhey treatment is especiaUy suitable for such cases, and, above all, the " grape cure" of Diirkheim, Meran, on the lake of Geneva, and other places with a mild dime, where sweet grapes, Avliich do not purge, are cultivated.* It merely hastens the end of patients, in an advanced stage of phthisis, to remove them from the quiet and comforts of home in order to try the grape or Avhey cure. On the other hand, these cures often do most brilliant service in the instances under discussion, which may not incorrectly be regarded as cases of incipient tuberculosis. In the coUateral form of pulmonary hyperaemia the indicatio causa- lis coincides with the treatment of the main disease. In obstruction in the lungs the indicatio causalis cannot be met. In disease of the heart, above aU, in contraction of the mitral valve, the use of digitahs is to be recommended as a palliative untU the heart's action have become retard- ed. The Aveaker the action of the heart becomes in the course of an asthenic fever, so much the more urgently are stimulants and nourish- ing food indicated. In Hke manner cause the position of patients AAdth threatening hypostasis to be changed from time to time, in order to pre- vent a setthng of the blood. With regard to the indicatio morbi, bold venesection from a large opening is demanded in fluxion to the lung, arising from excessive car- * The very fine sweet grapes, which grow in the better vineyards of my present home, purge so strongly as to be inapplicable to the grape-cure. I have seen a severe diarrhoea set in after eating three to four pounds of Wiirtemberg grapes. HYPEREMIA OF THE LUNG. 139 diac action threatening Hfe. The result here is astonishing. As soon as the volume of the blood has become lessened, the pressure diminishes in the arteries (as it depends upon two forces: first, the energy of the cardiac contractions; second, the fulness of the cavities of the heart). The patients often become able to breathe more freely, even during the operation, the bloody foam Avhich they Avere expectorating vanishes, and life may be rescued from the greatest danger by aid of the phy- sician. In cases Hke these, hoAvever, Avhich have been caUed pulmo- nary apoplexy {Lungenschlagfluss), the danger arises Avith such light- ning rapidity, that the physician usuaUy arrives too late. Collateral fluxion, also, when it threatens fife, requires venesection. If, thereby, the force of the heart be diminished, the pressure, too, in the arteries of the hyperaemic parts of the lung is also reduced, the capiUaries are less fuU, the transudation of serum, Avliich was threatening, or had already set in, does not occur or ceases; and here, too, Ave often see the patient breathe more freely and more deeply, Avhile the blood is yet floAving from the open vein. Since, hoAvever, in by far the greater number of cases, the venesection has an unfavorable effect upon the main disease by increasing the danger from exhaustion and impoATerish- mcnt of the blood, let us not be led astray by these striking instantaneous results, so as to let blood Avithout necessity, that is to say, unless Hfe itself be threatened; but if, in the course of pneumonia, or pleuritis, or recent pneumothorax, AA'ith intense dyspnoea, a moist rale become audi- ble, if the sputa become serous, etc., the danger is imminent; then pay no regard to the smaU pulse, or rather look upon it as a neAV reason for bleeding. The more recent the case, so much is collateral fluxion the more easy of recognition, and so much the more surely can Ave rely upon success. Should symptoms of oedema threaten in the course of disease of the heart, immediate danger to life may demand a diminution of the volume of the blood, and the rehef consequent upon venesection usuaUy satisfies the expectation Avhich has been entertained. In these cases, too, how- ever, it is of the utmost importance to restrict blood-letting to the cases ot the most urgent necessity. Persons AAdth disease of the heart do not bear repeated A'enesection Avell; their blood, Hke that of emphysematous persons, and for the same reasons, after long duration of the disease, is poor in fibrin and albumen, and has great tendency to form serous transudations. Venesection, by diminishing the A'olume of the blood, renders it thinner; the original mass is soon reestabhshed by absorption of Hquid from the tissues and from the intestines; but the tendency to dropsical transudation and even to oedema of the lung is aggravated in this Avav. In the other forms of hyperaemia of the lung AA'hich we have de- 140 DISEASES OF THE PARENCHYMA OF THE LUNG. scribed, venesection is absolutely hurtful. EspeciaUy is this the case Avith hyperaemia occurring in asthenic fevers, no matter hoAV great it may be, and though oedema threaten Hfe. In these cases every thing depends upon our supporting the depressed energy of the heart, as by this means alone can its cavities be emptied, and blood flow aAvay from the pulmonary veins. Blood-letting weakens the energy of the heart and augments the danger. As the latter class of cases are by far the most frequent, as they close the scene in almost all tedious and exhaust- ing diseases, strong soups, fiery Avines, camphor, musk, are much more frequently indicated for hyperaemia of the lung than is blood-letting. The difficulty of distinguishing between approaching heart-palsy and collateral fluxion in the course of pneumonia, Avhich, from its great exu- dation, leads to intense fever, and at last also to enfeebled contractions of the heart, has been discussed above. In addition to the procedures just spoken of, oedema of the lung- may require the employment of emetics, for reasons already explained, as soon as the cough lacks energy, and the palsied bronchial muscles cease to aid in expelling the serous contents of the bronchi. Should the discharge of sputa be arrested, should the rales in the chest be in- creased, even if the patient cough, give an emetic of sulphate of copper or ipecacuanha, with tartar-emetic, but only Avhen hope of saving hfe has not been extinguished. Traube recommends the use of acetate of lead—gr. j every hour—and the application of a very large bfister to the chest, as a very efficient mode of treating oedema of the lung. (Edema of the lung, as a symptom of general dropsy, demands the treatment of the main disease, but here, too, in the circumstances alluded to, an emetic may be indicated. HAEMORRHAGES FROM THE RESPIRATORY ORGANS. In the majority of cases in Avhich blood is coughed up, the bronchial mucous membrane is the source of the bleeding, but, as bronchial haemor- rhage is almost ahvays the attendant or forerunner of disease of the lung, Ave have preferred to treat of this subject simultaneously with that of haemorrhage from the pulmonary substance. Under the head of haemorrhage from the respiratory organs, accord- ingly* we shaR discuss: 1. Bronchial haemorrhage (broncho-haemorrahie), by far the most frequent cause of haemoptysis and pneumorrhao-ia. 2. Hemorrhagic infarction, a haemorrhage of the pulmonary tissue con- fined within narrow limits, and Avhich causes no destruction. 3. Pul- monary apoplexy proper, an abundant haemorrhage of the pulmonary BRONCHIAL HEMORRHAGE. 141 tissue, caused by rupture of some of its large vessels, and causing de- struction of the lung, with the formation of an apoplectic cavity. I hemorrhage from cavities and bleeding arising from the opening of an aneurism into the air-passages are to be treated of hereafter. CHAPTER VI. BRONCHIAL HEMORRHAGE. Etiologa'.—"VVounds and erosions of the larger blood-vessels of the bronchial mucous membrane are extremely rare. Capillary haemor- rhages of the air-passages, too, are seldom of traumatic origin, or due to sloughing or ulceration of the membrane. As a rule, haemorrhage proceeds from rupture of the capillaries, caused either by over-disten- tion, or else by a morbid dehcacy of their AA'aUs, a result of perverted nutrition. The trifling capillary haemorrhages which occur in the first stage of acute bronchial catarrh, in cases of Adolent irritation of the air- passages, and in the circulatory disorder attending organic disease of the heart, proceed from the first of these causes, AvhUe in most of the haemoirhages, in which large quantities of blood are poured into the bronchi, to be ejected thence by haemoptysis or bronchorrhagia proper, they are due to the latter condition. The fact, Avhich has been too little arjpreciated hitherto, that nearly all bronchial haemorrhages are mainly owing to a morbid state of the A'ascular Avails—to a Hemorrhagic diathesis* of the bronchial mucous membrane—and do not depend upon over-filling of the vessels, is of great practical importance. The truth of this is shown by the fact, not only that attacks of haemoptysis and bronchorrhagia are not usually preceded by bronchial hyperaemia, but that the spitting of blood almost ahvays persists, and, in fact, often does not assume an obstinate char- acter until after the patient has lost a good deal of blood, so that his \-ascular system is considerably depleted. A tendency to abundant bronchial haemorrhage—to a haemorrhagic diathesis, according to the above definition—1. Is met Avith in rare in- stances, occurring unexpectedly in young persons, apparently in bloom- ing health, and of vigorous constitution. In such cases, Ave as yet have absolutely no explanation of the disorder, Avhich is usually limited to the capUlaries of the bronchial mucous membranes, and Avhich is often folloAved by such sad results. * \Ve employ this general term merely to signify a morbid tenderness of the vas- cular walls, and not a morbid condition of the blood; although we admit that thu latter may sometimes so modify the nutritive state of the walls of the blood-vessels a: to impair their resisting power, and tbus to lead to a haemorrhagic diathesis. 14:2 DISEASES OF THE PARENCHYMA OF THE LUNG. 2. Much more frequently Ave find sinnlar tendency to profuse capU- lary haemorrhage from the bronchi in young people, betAveen the ages of fifteen and twenty-five years, of delicate health, and having marked Aveakness of constitution. Such patients frequently have been orphans from an early age, having lost their parents by consumption. They have suffered from rickets, or scrofula, in infancy, have often bled at the nose, and have rapidly groAvn tall, without at the same time acquiring any corresponding development of the various organs of the body. Their long bones are thin, their chest narrow, and even their skin seems unusuaUy dehcate and transparent; their cheeks redden easily, and blue veins may be traced over the ridge of the nose and the tem- ples. One might almost be tempted to attribute the remarkable fre- quence of bronchial haemorrhage in persons of this type to a deficience of vital material, which, haAdng been immoderately expended during the maladies of chUdhood, and by the rapidity of the groAvth, has proved insufficient to maintain normal nutrition of the capillary waUs, just as we are accustomed to ascribe the occurrence of spontaneous bleeding after severe Ulness, tedious suppuration, or great loss of blood, to a kindred source of exhaustion of the nutritive principle. Such an hypothesis, however, does not explain why the seat of haemorrhage should first be in the nose, and afterward in the bronchi, and Avhy haemorrhage scarcely ever occurs into the brain, or into other organs, in patients of this class. 3. There is a great predisposition to capiUary haemorrhage from the bronchi in persons suffering from tuberculosis and consumption. The frequence of abundant haemorrhage in all stages of these diseases arises partly because individuals Avho are liable to such bronchial bleeding are equally liable to tuberculosis, and to consumption of the lungs, and be- cause the tendency to bleed does not cease Avhen the lungs become affected, and partly because deposit of tubercle and chronic inflammation cause the pulmonary tissues and the .bronchial mucous membranes to become relaxed, so that the capillaries Avhich are imbedded in the relaxed tissues (noAv no longer capable of resisting their undue dilatation) suffer excessive distention and attenuation of their walls, Avhereby they be- come more easy of rupture. Finally, coalescent masses of tubercle and centres of inflammation, by compression of vessels, give rise to fluxionary and obstructive hyper- aemia, by Avhich rupture of the capUlaries is favored. Prejudice in favor of the narroAV Adews of Laennec and a belief in the ancient Hippocratic theorem, Epd ahnatos emeto phthoe kai ton puou katharsis ano, have seriously biased the judgment of physicians as to the relation between bronchial bleeding and pulmonary tuberculosis, and have given rise to extravagant and erroneous ideas. Many physi- cians do not hesitate to accept a brisk haemoptysis as a sure sign of in- BRONCHIAL HEMORRHAGE. 143 cipient, or even of established tuberculosis, although the patient may present no symptoms, either subjective or objective, of disease of the lungs, and when, soon after the occurrence of haemoptysis, signs of con- sumption have arisen, they confidently assume that the bleeding has been caused by the presence of tubercle, or by the process of its deposit in the lungs. I must earnestly protest against this opinion, as altogether unAA'ar- ranted, and fraught with danger to the patient. Cases undoubtedly occur, in Avhich tubercles and inflammatory processes form in the lungs, in a manner so latent that no tokens of the disease are manifested by the individual affected, untU he is suddenly attacked by a fit of haemor- rhage. Such instances, however, are excejitional. In the A'ery great majority of cases in AA'hich the first attack of hae- moptysis has not been preceded by either cough, dyspnoea, or other sign of pulmonary disorder, the lungs are free, and by no means the seat of tubecuular deposit, at the commencement of the bleeding. It is true that such subjects rarely die of haemorrhage, so that avc do not often have an opportunity of examining their condition post mortem. However, if Ave collate the reports scattered through our literature and compare their statements, Ave shall assure ourselves that they substan- tiate the correctness of the above remarks. I have repeatedly failed to find post-mortem traces of pulmonary tubercle, or of any other destruc- tive disorder in the lungs of individuals Avho haAre died suddenly of pneumorrhagia, Avhile in enjoyment of apparent health. That bronchial haemorrhage is by no means so rare an event, Avhere there is no grave disease of the lungs, is shoAvn, moreover, by the tol- erably numerous cases in Avhich persons, after suffering one or more attacks of pneumorrhagia, regain then health completely, and indeed often live to an advanced age, and after death present no discoverable traces of extinct tuberculosis in their lungs. That bronchial haemorrhage, as a rule, should precede the disease of the lung, in the cases Avhere the initial signs of consumption foUow im- mediately upon an attack of haemoptysis is also strongly in contradic- tion of the theories of Laennec, to Avhich, nevertheless, most modern physicians adhere Avithout question. According to Laennec's vieAV, there is but one kind of consumption—tubercular consumption. " As bronchial haemorrhage can never produce a deposit of tubercle, all genetic connection betAveen such haemorrhage and the consumption must be denied absolutely. Hence, AA'here the first symptoms of consumption folloAV close upon a haemoptysis or pneumorrhagia, AAre may assume confidently that the tubercular deposit has formed either simultaneously AA'ith or prior to the occurrence of the bleeding." Such argument, though logical, is fallacious, because based upon the erroneous hypoth- 144 DISEASES OF THE PARENCHYMA OF THE LUNG. esis that consumption of the lungs always arises from tubercular de- posit. Unbiassed and careful observation of patients, Avho, without AA'arning and often in the midst of exuberant health, have been attacked by pneumorrhagia or haemoptysis, and Avho, AAdthout rallying, have per- ished in a feAV months of a phthisis florida, a "gaUoping consumption," has taught me that such patients scarcely ever succumb to a pulmonary tuberculosis in its stricter sense, but that they usually die of a form of consumption as yet but little thought of, and of Avhich bronchial haemor- rhage is the immediate cause, Laennec to the contrary notwithstanding. When, after a bronchial haemorrhage, coagulated blood is retained in air-vesicles and bronchi, its irritating effect is quite as great upon sur- rounding parts as is that of a thrombus or coagulum Avithin a vein upon the A'ascular, tissues. The bronchitis and pneumonia arising from such a source may result in A'arious Avays. (See below.) A very common consequence is, that both clot and inflamed pulmonary tissue undergo a caseous metamorphosis, AAdth subsequent decay. These pathological and anatomical processes agree closely Avith the type which consumption assumes Avhen it imme- diately folloAVS a bronchial haemorrhage in an individual previously vig- orous and healthy, and proves fatal in the course of a few months. Finally, I may observe that the bronchial haemorrhages which occur in an established case of consumption also cause chronic pneumonia and destruction of the tissues, and thus hasten the fatal termination. The fact that the occurrence of haemoptysis in the course of a pneu- monia is a serious event, and that the disease often rapidly groAVS Avorse immediately afterAvard, is generaUy admitted by physicians, although, as a rule, it has been falsely interpreted; it being a common supposition (but one AAdiich is rarely the true one) that fresh tubercles have formed, which, by some, are thought to have caused the haemorrhage, and by others to have accelerated the consumption. As my opinions regarding the relations between bronchial haemor- rhage and pulmonary consumption differ in some respects from the prevailing vieAvs upon this subject, I propose briefly to state them in the following paragraphs: 1. Bronchial haemorrhage occurs oftener than is generaUy believed, in persons Avho are not consumptive at the time of the bleeding, and Avho neATer become so. 2. Copious bronchial haemorrhage frequently precedes consumption, there being, hoAvever, no relation of cause and effect betAveen the haemorrhage and the pulmonary disease. Here both events spring from the same source—from a common predisposition on part of the patient both to consumption and to bleeding. 3. Bronchial bleeding may precede the development of consump- BRONCHIAL HEMORRHAGE. 145 tion as its cause, the haemorrhage leading to chronic inflammation and destruction of the lung. 4. Haemorrhage from the bronchi occurs in the course of established consumption more frequently than it precedes it. It sometimes, although rarely, appears where the disease is as yet latent. o. When bronchial haemorrhage takes place during the course of consumption, it may accelerate the fatal issue of the disease, by causing chronic destructive; inflammation. Axatomical Appearances.—Upon post-mortem examination of those who have died of bleeding from the bronchi, the air-passages are ■ found more or less extensively and completely filled up Avith masses of j clotted blood. Sometimes the mucous membrane has a uniform dark- led stun, from effusion of blood into its tissues, and it is SAVoUen, re- laxed, and bleeds upon pressure. In other cases, again, the entire con- tents of the capillaries seem to have been discharged, the mucous membrane presenting a pale and bloodless appearance. The source of bleeding is never found to be of the nature of a mechanical or ulcera' tiAre lesion. The lungs, at points Avhere the blood has descended into the air- vcsieles, are heavier, denser, and more or less reddened. If the bronchi remain filled AA'ith their bloody contents, escape of ah from the air-cells is prevented, and the lungs remain inflated AA'hen the chest is opened. Where death has been caused by haemorrhage, there is extreme anaemia of all organs. In cases Avhere death has taken place some time after the haemor- rhage has ceased, either no trace Avhatever of the former bleeding is found in the lungs—and, indeed, this is most commonly the case—or else the signs are found of chronic inflammation in its different stages, Avhich, hoa\ ever, is never to be ascribed to the haemorrhage, unless a greater or less amount of broken-doAvn blood-clots, in a state of fatty degeneration, be also found in the bronchi. I have published a case from my cfinique, in Avhich the post-mortem appearances exhibited the entire process, in the most striking manner, in AAdiich coagula, bearing a perfect resemblance to old thrombosis of the veins,* Avere found in the bronchi. Symptoms and Course.—The admixture of small quantities of blood in catarrhal expectoration—occurring in the form of minute streaks traversing the mass—is a very common and quite harmless symptom. The expectoration of a someAA'hat larger amount of blood— either pure or mingled AA'ith bloody mucus—Avhich sometimes foUoAVS upon the inhalation of acrid A^apors, or after other severe irritation of * "Upon the relation of bronchial and pulmonary haemorrhage to pulmonary con- sumption." Inaugural dissertation of Doctor Burger. Tubingen, 1861. 10 146 DISEASES OF THE PARENCHYMA OF THE LUNG. the air-passages, and is of still more frequent occurrence in disease of the heart, from obstructive hyperaemia, seldom results seriously, and rarely imperils the patient's Hfe. Very profuse haemorrhages, of a very different nature, often arise from a morbid inability of the capUlary waUs to resist the pressure of their contents, and it is to these that we usually allude, when Ave em- ploy the terms " spitting of blood" (haemoptysis) and " bursting of a blood-vessel" (pneumorrhagia). In such cases an observant physician may long foreteU the occurrence of a haemorrhage in patients of the constitutional habit above described, especiaUy if they have often bled at the nose, and have suffered noAv and then from palpitation of the heart, and oppression of breathing. It is but occasionaUy, however, that the attack itself is preceded by Avarning symptoms or by sensations of constriction of the chest. Far more commonly the long-dreaded haemorrhage sets in suddenly. The patient feels as though a warm Hquid were oozing up from beneath the sternum; he perceives a strange SAveetish taste in his mouth, and, upon attempting to clear the throat, finds that he expectorates pure blood or bloody mucus,—" that he is raising blood." Such a discovery generally has a very depressing effect, even upon individuals of the utmost courage. The saying of Mephistopheles, " Blood is a quite peculiar juice," stands out here in its full reality. Though the bleeding may have been trifling, yet Ave often find the patient tremulous, pale, and almost fainting. Soon after " raising" the first blood, a sense of titillation induces inclination to cough. Coarse, moist rales and a gurgling sound are audible in the chest; a short, full, loose cough follows, and frothy, bright-red blood gushes from the mouth, and often, too, from the nose. Short pauses intervene between the coughing-fits, during which more blood seems to be escaping and coUecting in the tubes, and, in this manner, large quan- tities of it are often ejected in a short time. (The quantity of blood lost may vary from an ounce or tAvo to a pound or more.) The attack may subside in course of half an hour, sometimes sooner; at times not for several hours. The mucus continues to retain a bloody stain, or is mixed Avith blood, but the blood is no longer pure. Attacks of haemop- tysis are rarely sohtary, however. They almost always recur in course of a feAV hours, or perhaps the next day " in spite of the most careful treatment!" Indeed, the attacks are generaUy repeated for two or three days, or even a Aveek, untU at length the patient, Avho has grown pale and feeble, obtains a respite from his haemorrhage, which may last for months or even years. In such cases, and, indeed, in most others, the course of bronchial haemorrhage is singularly uniform, AAdiether it occur in consumption, or attack persons whose lungs are exempt from tubercle or any other known disease. BRONCHIAL HEMORRHAGE. 147 Very rarely is Hfe directly endangered. It is important that we should bear in mind that patients nearly always survive the attack, in spite of intense prostration, tendency to syncope, and other signs of im* pending dissolution. Death from bronchial obstruction and impeded respiration is someAvhat more common than death from haemorrhage. Physical examination of the chest gives negative results, AA'ith the excep- tion of a feAV coarse, moist rales; and it is both useless and imprudent to agitate the patient by constant and inconsiderate percussion and auscultation. If blood enough pass into the A'esicles to expel the air from any considerable portion of the lung, the percussion-sound over that point is flat and dull, and the respiratory murmur either feeble and indistinct, or else bronchial. In many cases the patients, after expectorating smaU masses of bloody mucus, and of clotted blood, for a AA'hile, recover rapidly. If blood have lodged in a bronchus, so as to close it and render it imper- meable to air, its color is no longer bright red, but grows dark, inclin- ing to black. In most patients, and even in those avIio soon regain their health after " a haemorrhage," by attentive observation, during the feAV days immediately following the bleeding, we shall discoAer a more or less A'iolent inflammatory condition of the lungs and pleura. I at least, ever since my attention has been drawn to the occurrence of this consecutive pleuro-pneumonia, have almost ahvays succeeded, tAvo or three days after an haemoptysis, in finding an elevation of temperature, and increase in the frequence of the pulse, constitutional disturbance, and lancinating pains of more or less severity in the sides of the chest. Moreover, I have frequently found a slight dulness, or a friction sound, Avith sub- crepitant rales. Even in cases where considerable time had elapsed since the haemorrhage, I have usually been able to discover, by careful examination, that, immediately after the occurrence of the bleeding, symptoms, more or less distinct, had arisen, of inflammation of the res- piratory organs. I cannot comprehend Avhy these sequelae of bronchial haemorrhage, Avhich are almost constant, should hitherto have attracted so little attention, and AA'hy they are hardly anywhere mentioned in books on the subject. The most frequent termination by far, of this consecutive inflamma- tion, is resolution. The symptoms often vanish in a few days, and the patient becomes completely convalescent. In other instances the elevTation of temperature and increased fre- quence of pulse continue. The general health is also influenced by the persistence of the fever. The pain in the chest, too, continues in a mUd form, and is generaUy ascribed, by the patient, to rheumatism. The respiration remains hurried, and the patient coughs, expectorating a 148 DISEASES OF THE PARENCHYMA OF THE LUNG. inuco-purulent sputum. If, besides these signs, Ave find dulness upon percussion at some point in the chest, the respiratory murmur feeble, or indistinct, if the patient manifestly be groAving thinner and more miser- able, we shaU have very strong reason to fear that a destructive process has been set up in the lung, and that the patient wUl die of phthisis; nevertheless, all hope is not to be abandoned. In many cases, after a feAV Aveeks, the fever, the pain, the dyspnoea, the cough, and the expec- toration, all subside, the patient " feels as though he had had a severe fit of sickness." His recovery is rapid and complete. Physical exam- ination shoAvs a depressed spot in the thorax, in the neighborhood of Avhich percussion is someAvhat deadened and flat, AA'hUe the respiratory murmur is enfeebled. The pneumonia has resulted in wasting and con- traction of the inflamed portion of the lung. In the dissertation before referred to, two cases of this land (one of which concerned a former assistant of mine) are carefuUy detaUed, and, since then, I have ascer- tained, by a large number of observations, that such a result is a very common one. If a chronic pneumonia, proceeding from profuse bronchial haemor- rhage, do not take a turn for the better; if the patient, on the contrary, fail more and more under the effect of intense fever with evening exa- cerbations, and profuse night-SAveats; if the sputa become more copious and purulent; if physical evidence of the formation of caverns arise, Ave may conclude that the chronic pneumonia has terminated in cheesy met- amorphosis and disintegration of the inflamed pulmonary tissue. I may finaUy repeat that persons, Avho have suffered a severe haem- orrhage from the lungs, even though it may not have been foUowed by any iU effects, and although they may have recovered from it entirely, are, nevertheless, in danger of dying, sooner or later, of pulmonary tuberculosis, or of pulmonary consumption. Diagnosis.—Haemorrhage from the bronchi, not unfrequently, is confounded with epistaxis, particularly if the latter proceed from the posterior nares, or if the patient He upon his back during the bleeding. Here the blood floAving into the pharynx reaches the larynx, and is then frequently coughed and hawked up, to the great terror of the patient and his relatives. Long before the physician makes his appearance, the regulation doses of salt and vinegar have been administered, and it is of importance, in order that he be not deceived himself in the midst of the general consternation, that he should dehberately inspect nose, gums, and palate, and inform himself precisely Avhether the patient have not bled at the nose on the previous evening. The distinction betAveen haemoptysis and haemorrhage from the stomach may also have its difficulties, particularly if Ave have to decide upon the source of a haemorrhage AAdiich has taken place years before. BRONCHIAL HEMORRHAGE. 149 In haemoptysis, the irritation of the cough often provokes retching and vomiting, or the blood may be SAvaUoAved, and afterward thrown up. Conversely, violent haematemesis is almost always attended by cough- ing, small quantities of blood getting into the larynx; hence, the pa- tients are not ahvays able to tell, exactly, whether they have coughed up the blood or vomited it up. In treating of haemorrhage of the stomach, Ave shaU enlarge more fully upon the distinction between the tAvo conditions, and merely remark, that we must, first of all, inquire Avhether the cough have been foUoAved by Amounting, or the vomiting by cough ; secondly, that Ave must accurately ascertain Avhether cardialgio distress have preceded the gush of blood or not; thirdly, examine care- fully as to AA'hethcr the bleeding have been foUoAved by black, tar-like stools, or whether the patient have voided mucus tinged Avith blood for a feAV days after the attack. If, moreover, Ave have opportunity to ex- amine the blood which has been discharged, that from the air-passages is usually bright red, frothy, with alkaline reaction. Should a clot form, it wiU be soft, and specifically light, as it contains bubbles of air. On the other hand, blood Avhich has been vomited is dark, and even black, excepting Avhere a great artery of the stomach has been eroded. It is not mixed Avith air-bubbles, but contains remains of food; its reaction is usually acid, and the clot, if it forms one, is firm and heavy. We have noAv to add a feAV Avords regarding the distinction of haem- orrhage of the bronchial capUlaries from the bleeding arising from a wound in the tissue of one of the larger A'essels, which traverse the AAralls of a cavity. It is admitted, by some authors, that a haemorrhage of moderate degree, a haemoptysis, proceeds generaUy from the capillaries of the mucous membrane, but that all profuse bleeding, amounting to a pneumorrhagia, springs from rupture, or erosion of larger Aessels. So convinced are they of the justness of this vieAV, that they assume that any one aa ho has had a A'iolent haemorrhage, be he neA'er so healthy in appearance, has cavities in his lungs, AA'hich have heretofore escaped ob- servation. The objection, that so large an effusion of blood cannot pos- sibly floAV from the bronchial capillaries, is untenable; since capillary haemorrhages from the nasal mucous membrane are often so profuse as to endanger Hfe, and a haemorrhage from the bronchi of equal activity, if it floAV from a sufficiently large surface, may very easUy yield so much blood as to fully Avarrant apphcation to it of the term "bursting a blood-vessel," instead of " raising blood." Moreover, many people Avho have spit blood are prone to exaggeration, and talk of " gushes of blood," and of " coughing up blood by the pint," Avhile the actual amount lost has not been nearly so large. Besides, it is highly improb- able that there should be undiscovered ca\dties in the lungs of aU per- sons avIio haAre suffered from severe and profuse bleeding from the air- 150 DISEASES OF THE PARENCHYMA OF THE LUNG. passages, but who, in other respects, seem to be in good health ; and it would be very extraordinary if haemorrhage from smaU, latent caA'ities were to be of much more frequent occurrence than from large and recognizable ones. But we have direct proof that the blood lost in pneumorrhagia does not come from a large vessel; at aU events, not from a branch of the pulmonary artery. According to the classical pic- ture of Rokitansky, the branches of the pulmonary artery, as a rule, soon become obliterated in the various forms of consumption. Some- times, however, they become perforated by erosion, or suffer rupture. In them runs the most venous and darkest blood of the entire body. Now, in almost every case, not only of haemoptysis, but of pneumor- rhagia, the blood is of a remarkably bright-red color, so that, in the differ- ential diagnosis between haemoptysis and haematemesis, great stress is laid upon the fight color of blood which flows from the lungs and air- passages. (See above.) It is only when large quantities of dark blood are ejected, that Ave are justified in inferring that a branch of the pul- monary artery has become eroded or ruptured. A striking example of this kind occurred in my clinique, and has been made pubhc {see Burger's treatise). Such accidents, however, are extraordinarily rare, in comparison with the frequence of haemorrhages of bright-red blood. This bright-red blood can only come from the bronchial mucous mem- brane ; or, at aU events, either from a branch of the bronchial artery or of the pulmonary vein. Prognosis.—The prognosis, as regards immediate danger to Hfe, is, as we have shown, on the whole, favorable, in spite of the alarming character of the symptoms. The prognosis, hoAvever, as to complete re- covery, is exceedingly bad. The slighter the provocation, the less ap- parent the cause of the haemorrhage, so much the graver is the omen. The prognosis is better when rupture of the capiUaries has been caused by excessive hyperaemia, due to direct injuries, excessive action of the heart, or other serious irritants, provided that the irritation thus" set up can be aUayed. Suppressed menstruation and repressed haemorrhoids can only be counted among these causes wdth extreme reserve, much as the patients may be inclined to attribute their blood-spitting to such anomahes, and readUy as they may become satisfied, Avhen the physician partakes in their befief. Absence of the menses is much more often the consequence of the disease than the cause of it, and the same holds good for any haemorrhoidal bleeding which may have existed prior to the attack, and which has ceased during or immediately after it. Treatjlent—Indicatio Causalis.—If excessive hyperaemia of the bronchial mucous membrane play a material part in the origin of a bron- chial haemorrhage, or if it be attributable solely to increased lateral pres- sure upon the capiUary walls from within, the indicatio causafis may, in BRONCHIAL HAEMORRHAGE. 151 such cases, but only in such cases, demand venesection. In most cases, lateral pressure has but Httle to do with the bleeding. It does not cease, though the pressure be relieved, the vessels empty, and the pa- tient be almost dead from haemorrhage. Let us but call to mind those Avaxy, paUid sufferers from epistaxis, Avhose nostrUs we often have to tampon, in order to master the bleeding, and our lancet aa'UI stay in its case as long as the heart's action is moderate. Indeed, we must restrict blood-letting to cases where, in spite of the bronchial haemorrhage, there is a persistent and alarming hyperaemia of the lung. Since avc are unable to assign a reason for the delicacy and thinness of the capillary Avails, AA'hich is the chief source of bronchial bleeding, Ave are forced to admit, that the indicatio causafis cannot generaUy be met—that it is not in our poAver to combat the haemorrhagic diathesis by any rationally specific means. At all events, it is scarcely possible, after haemoptysis has set in, to effect any rapid change in the abnormal state of the capillary AvaU. It is preferable, in dealing Avith patients threat- ened Avith this affection, or AA'ho have aheady suffered an attack, to pre- serve them AAdth peculiar care from all hurtful agents AAdiich could injure their nutritive condition. We should order simple, unexciting, nourish- ing food ; moderate bodily exercise in the open air; should carefuUy regulate the action of the bowels ; should prohibit all excess in baccho et venere, and enjoin avoidance of mental excitement. Where there is a decided Avant of red corpuscles in the blood, the exhibition of the milder preparations of iron, the employment of Pyrmont-AA'ater, or that of Driburg or Imnau, are to be recommended, and the neglect of these measures is a gross blunder. The indicatio morbi, aboAre all things, demands a cautious regimen. We should, in the first place, seek to calm the spirits of the patient, AAdiich are ahvays much excited ; and, inasmuch as these attacks are al- most ahvays repeated several times, it is AveU to save him from further agitation, by straightway informing him that there is more blood to come, Avhile, at the same time, we should absolutely deny the possibU- ity of his bleeding to death. Indeed, avc are certainly Avarranted here in deceiving the patient, by affecting to -make Hght of the affair, and even to represent the haemorrhage as a salutary process.* With a little tact, the physician may leave his patient in a state of comfort and peace of mind, Avhom he has found in the most painful un- easiness—a success of no slight importance. Take care that the cham- ber be cool; forbid all hot drinks, and let all food be eaten cold. In- terdict all conversation, and make the patient stoutly resist the provoca- tion to cough. Coughing in haemoptysis is quite as hurtful as is snuf- * I here call to mind the effect of conjuration and penance on the spirits, and in- directly upon hamorrhage. 152 DISEASES OF THE PARENCHYMA OF THE LUNG. fling and Aviping the nose in epistaxis. Finally, remove aU portions of the clothing which press upon and confine the chest, and cause the patient to assume a half-sitting posture in bed. The most poAverful means of combating the bleeding is the use of cold. We apply this in the form of cold compresses, and, when the bleeding is very severe, in the shape of frozen compresses.* In addition to this, let him SAvaUoAV small pieces of ice, or give smaU doses of ice-water; or Ave may apply the cold in the form of clys- ters, to which, from time immemorial, a Httle vinegar has ahvays been added. Besides cold, a number of substances have the reputation of ar- resting haemorrhage Avithout our being able, physiologically, to explain how they act. Under this head, before aU others, come two remedies: common salt, and the acids, which, curiously enough, Avhen taken in ex- cess, occasion a scorbutic state of the blood, a bad nutritive state of the capillaries, and lead to haemorrhage. HoAvever this may be, we must make the patient SAvaUoAV one or tAAro spoonfuls of finely-poAvdered, dry salt. Sulphuric, or phosphoric acids, are still more preferable, especial- ly the elixir acidum Halleri, of Avhich we give ten drops every two hours, mixed in a sufficient quantity of water. A series of other haemos- tatic remedies folloAV these, Avhich are not of such generaUy acknowl- edged efficacy as the acids, and Avhich, being less innocent, are therefore less highly esteemed. Among these is acetate of lead, of which the English physicians maintain that, for internal haemorrhage, there is " nullum simile aut secundum." Next come secale cornutum, oleum terebinthinae, balsam copaivae, ratanhy, and other medicines. Wunderlich particularly recommends the exhibition of secale cornu- tum, in doses of from five to ten grains, until a prickling and numb sensa- tion in the fingers sets in. A formula, much in use in very obstinate hae- moptysis, is—1£. Balsam copaiv., syrup balsam, aquae menth. piper, spirit. vini rectif. aa, § j ; spirit, ether nitrici 3 ss ; Til. S. 3 ij every two to four hours. These various drugs are only to be made use of in very danger- ous cases, and Ave should not forget hoAV impotent aU these styptics are in severe bleeding of the nose, where, moreover, we are able to apply them directly to the bleeding point. Latterly, inhalations of a solu- tion of sesquichlorate of iron (3j to 3 ss with § vj) has been recom- mended as exceedingly serviceable against haemoptysis. The most alarming haemorrhages are said to have been arrested, by this means, in the course of four or five minutes. My OAvn experience does not con- firm this recommendation. The narcotics should be employed freely. The more restless the patient, the more violent his cough, so much the * Fill a tin or copper Avarming-pan with ice, salt, and water, then lay it upon a well-squeezed wet compress, the moisture of which soon freezes. These compresses are greatly to be preferred to the heavy bladders of ice. HEMORRHAGIC INFARCTION OF THE LUNG. 153 more boldly should Ave order opium. Let a Dover's powder be taken at night, and during the day an emulsion, with hah0 a drachm of lauda- num, or half a grain of morphine. CHAPTER VII. I'ULMONAKY HEMORRHAGE WITHOUT LACERATION OF THE PAREN- CHYMA—HEMORRHAGIC INFARCTION—METASTASIS TO THE LUNGS. In former editions of my text-book I have treated of pulmonary haemorrhagic infarction, Avhich occurs from disease of the heart, and the so-called metastatic infarction in separate chapters, since, notwithstand- ing the complete identity in their essential anatomical lesions, the differ- ence in their extent and seat, and, above aU, the different manner in AA'hich they originate, seemed to me to demand it. But from an opinion of Roki- tansky, from an excellent essay by Gerhardt, and especially OAving to a series of observations of my oaati, published in the dissertation of Doctor Hopf* I have become satisfied that my former vieAvs Avere erroneous; hat the variations in magnitude and in the seat (neither of Avhich are constant) constitute no real difference, and that the modes of origin of haemorrhagic infarction in heart-disease, and of that of metastatic infarc- tion from thrombosis of a vein, or from external suppuration, or sanious ulceration, are identical. Etiology.—Haemorrhagic infarction consists in a capiUary haemor- rhage, confined to a small and sharply-defined section of the lung, and often bounded by the limits of a single lobule. The blood is effused, partly Avithin the cavity of the Aresicles and terminal bronchi, and partly lies in their interstices betAveen the fibres of elastic tissue by Avhich the air-cells are entAvined. The haemorrhage does not produce laceration of the lung-substance. The abrupt boundary of a haemorrhagic infarction is caused by the fact that the bleeding only comes from the capiUaries pertaining to a single tAvig of the pulmonary artery. The range of the capiUary system of an artery depends upon its size; hence haemorrhagic infarctions Avhich arise AAdthin the capillary limit of a large branch of the pulmonary artery are far more extensive than one AA'hich forms about a smaUer tAA'ig. As the main trunks of the pulmonary artery enter the roots of the lung in company Avith the great bronchi, and ramify toward j\e surface, constantly groAving smaller by repeated subdivision until each .itimate tAA'ig terminates in a single lobule, the reason is plain why the infarctions occurring in the Ulterior of the lung are large, and why * Zur Diagnose des Harmonhagischen Infarctes. Inaugural Dissertation von Dr Uopf. Tubingen, 1865. 154 DISEASES OF THE PARENCHYMA OF THE LUN'G. peripheral infarctions preserve both the size and the cuneiform shape of the superficial lobuli. Upon careful examination of an arterial branch within AA'hose range a haemorrhagic infarction has formed, Ave find in it a clot by which its calibre is more or less obstructed. This is easUy demonstrated in the larger vessels, but in the very smaU ones it is some- times difficult. That the obstructing coagulum has not formed at the place of its lodgment, but that it comes from some remote region of the body, whence it has become detached and swept into the current of the blood, < untU, finally, it has become impacted in some branch of the pulmonary artery too narrow to admit of its passage, has long been recognized as the conditions under AA'hich haemorrhagic infarction arises. The credit of this valuable discovery is due to Virchow. That investigator, by introducing particles of fibrin, muscle, elder-pith, and the Hke into the jugular veins of dogs, demonstrated by dissection that these foreign bodies blocked up branches of the pulmonary artery, and produced haemorrhagic infarctions, lobular pneumonia, and small abscesses, beyond the points obstructed. Conversely, he proved by dissection of bodies, in AA'hich the diseased spots so long knoAvn as metastases had been found, that the arteries leading to the affected points were occluded by an embolus—a fibrinous plug, which undoubtedly had proceeded from a thrombosis of a superficial A'ein, or from particles whose origin was in- disputably traceable to some region of suppurative or sanious ulceration upon the surface. Of late, the doctrines of pyaemia and of septicaemia have undergone many revolutions; but that of embohsm—that is, of the dependence of haemorrhagic infarction upon the introduction of clots, or of particles of tissue into the circulation—has remained unshaken. It is easy to understand why metastatic infarctions of the lungs are caused by emboli from disintegrating thromboses of peripheral veins, or from suppurating or sanious surfaces. When an embolus is detached from its point of origin by the current of the blood, it meets Avith no obstacle on its way to the heart, as the veins through Avhich it travels are constantly groAA'ing larger. It passes unhindered into the right heart and into the pulmonary artery, and is not arrested nor impacted until it arrives at some branch of the latter whose diameter is less than its own. Upon similar grounds, it is the rule for emboli, AA'hich originate from the roots of the portal vein, or Avhich enter the portal vein in cases of ulcera- tion or of sanious discharge from the intestines, to pass into the ramifica- tions of the portal vein Avithin the fiver, causing metastases in that organ, and for emboH AA'hich come from the lungs on the left side of the heart to occlude the arteries of the spleen, kidneys, or brain. Where exceptions to this rule occur, as when we sometimes find infarctions in I HEMORRHAGIC INFARCTION OF THE LUNG. 153 organs AA'hose arteries an embolus could not haA'e reached, Avithout first passing through the capUlaries of another organ (for instance, infarc- tion of the liver in thrombosis of a peripheral vein), it seems probable that the embolus at first has been minute, but that during its course through the system it has groAvn larger by accretion of fibrin. The very common occurrence of haemorrhagic infarctions after injuries of the skull, where the diploe have been penetrated, is simply due to the gaping of the aa;iUs of the Aeins of this region, AA'hich, being adherent to the tables of the skuU, are prevented from collapsing, so that the entrance of coagula into them of course is facilitated. In the haemorrhagic infarctions Avhich so often arise in diseases of live heart, especially in cases of disease of the mitral A'alve, the existence of clots in the arteries leading to them has long been knoAvn. But the explanation generally has been that the escape of blood into the vesicles and their interstices has compressed the capUlaries and prevented the outfloAV of blood from them, and that in consequence of the stagnation s< > produced the arterial contents have coagulated. This Avas formerly my opinion, although I could not ignore that the extreme obstruction of the blood in the pulmonary circulation, to AA'hich I ascribed the infarc- tion in disease of the heart, did not at aU account for the restriction of the capillary haemorrhage to separate and abruptly-defined sections of lung. I am noAV convinced that, in disease of the heart, haemorrhagic infarction also arises from embolism, as has been proved by Mokitansky and Gerhardt. The emboh which block the artery in disease of the heart do not come from the greater circulation, Hke the emboli which produce metastatic infarction, but from the right side of the heart, especiaUy from the right auricle, in AA'hich clots usually exist firmly en- tangled in the trabeculae, and which are one of the results of the slug- gishness of the circulation. If a particle of this clot be torn off and Avashed away by the current of the blood, a branch of the pulmonary artery becomes obstructed by it, and haemorrhagic infarction ensues. The fibrinous coagula thus detached from cardiac thromboses are gen- erally larger than those AA'hich come from the aortic circulation. We thus find a very simple explanation of AA'hy the infarctions of heart-dis- ease are more extensive than metastatic infarctions, as AveU as of why the former are often found in the interior of the lung, near its roots, Avhile the latter are generally situated near the periphery. As very minute particles also may be Avashed away from the thromboses of the right heart, Ave likewise see Hoav, besides the larger infarctions at the roots, smajler peripheral ones also occur in heart-disease. The process still remains to be explained by which obstruction of an afterent arterial branch produces capiUary haemorrhage in the region about the obstructed vessel, a process which, at the first glance, seems 156 DISEASES OF THE PARENCHYMA OF THE LUNG. by no means easy of elucidation. The theory of Rokitansky, " that occlusion of the minutest arterial branches of the lung and its capUlaries causes a collateral hyperaemia, which results in haemorrhage and exuda- tion," is unsatisfactory to me, for the bleeding does not proceed from neighboring capUlaries, but from those of the obstructed vessel. Nor does Virchow give a sufficient explanation of the capUlary haemorrhage. It is, therefore, aU the more welcome and interesting that Ludwig has furnished a complete and final solution of the problem, from an entirely unbiassed point of AdeAV, by shoAving the influence which the contraction of an artery has upon its capillaries. His Avords are as foUoAvs: " Ten- sion within the artery below the point of constriction is diminished, since a Hquid floAving through a narroAV tube loses more of its impetus than in flowing through a wide one. But Ave must not infer from this that, when an artery is constricted, the contents of its capUlaries are less- ened, and that the parts which they traverse groAv paler. The sluggish- ness of the stream thus produced in the capillaries rather has the effect of cdlowing the heavy blood-corpuscles to collect and become crowded together / noAv, as two or more blood corpuscles, if brought into contact, are apt to become permanently adherent, the blood itself can form a plug capable of closing the capillaries. Such an occurrence, which con- verts the capiUaries into blind appendices to the artery, must cause an increase in its internal pressure." Let us add that in consequence of the pressure, Avhich, after the stoppage, is as severe in the capiUaries with thin, dehcate AvaUs, as in their afferent vessels, a rupture of the distended waUs and an escape of blood ensue. This furnishes a simple and entirely satisfactory explanation of the origin of the haemorrhage, as Avell as of its limitation to the region supphed by the occluded artery. The utmost that can be advanced against the accuracy of this explana- tion is, that the artery leading to an infarction not only is narroAved, but is entirely closed. Such an objection, hoAvever, is untenable. The in- farction of an embolus, which Ave find usually takes place at the bifurca- tion of an arteriole, very rarely produces absolute closure of it at first, but merely causes in it more or less obstruction. Afterward, when the infarction has become estabfished—an event requiring but Httle time— fibrin is deposited upon the embolus, and closure of the vessel becomes complete. Under conditions similar to those under Avhich metastatic infarctions are observed, Ave sometimes find in their stead, or accompanying them, circumscribed pneumonic infiltration and smaU abscesses. As a rule, these appearances are manifestly the latter stages, the products of in- farction; and it is not surprising that such products should be very common, and should form very rapidly, when the emboH consist of fragments of sanious or gangrenous tissue, capable of most pernicious HEMORRHAGIC INFARCTION OF THE LUNG. 157 action upon the parts in contact Avith them. The truth of this idea is supported by the fact that in disease of the heart, where the emboli are simple fibrinous clots, Avhich are much less dangerous to the parts ad- jacent to them, destructive pneumonia and the formation of abscess are far more rare. The inflammatory reaction AA'hich occurs in the latter form is generally more of a nutritive than of a destructive character, and often results in a development of connective tissue, by which the infarction becomes incapsulated. In a feAV instances, both formation of abscess and circumscribed pul- monary gangrene seem to ensue, the latter being a rare termination of infarction. Here the extravasation and compression of the capUlaries above described cause secondary coagula to form, and this time it is in the nutritive vessels of the lung, the ramifications of the bronchial arte- ries, the pulmonary " vasa pricata." NutritiA'e material is thus Avith- hcld from the point of infarction, Avhich dies and putrefies, or becomes gangrenous. Anatomical Appearances.—We rarely find the blood liquid in dissection of recent infarctions; as a rule, it is coagulated. This circum- stance is easy to account for, if aa-c reflect that the locality impedes a discharge of the blood, and that, if the patient survive the attack for any length of time, the liquid part is absorbed, AA'hUe the coagulable portion is retained. The blood is easily expelled from the bronchi by coughing, by the action of the bronchial muscles, and by that of the ciliated epi- thefium, but forced expiration can only empty the vesicles in part, and they haA'c no muscles nor cUiary epithehum. Hemorrhagic infarctions AA'hich occur in disease of the heart gener- ally vary in size from that of a hazel-nut to that of a hen's egg. They are of a blackish-red or blackish color, completely inelastic, and void of air, so that they can be felt from Avithout like hard knots. Their cut surface presents an irregular, coarse, granulated aspect, from Avhich a brownish-black mass may be scraped off Avith the scalpel. In the im- mediate Adcinity of this sharply-defined spot the lung is usuaUy fuU of blood and oedematous from coUateral fluxion. Its seat, as aheady men- tioned, is usually at the middle of the loAver lobes, or near the roots of the lungs; more rarely at the surface. Microscopic examination sIioavs the capiUaries to be distended by blood-corpuscles, AA'hich are also col- lected in the tissue outside of the capiUaries. Where the infarction is of long standing, it looks paler and yeUoAv- isli, the fibrin haAdng undergone fatty degeneration, and the coloring matter of the blood being partially decomposed. StUl later, the fatty fibrin is absorbed, and part of the haematin has turned into pigment, and the only remaining trace of the infarction is a blackish induration in the lumr. In the rare instances in Avhich an abscess forms it may be- 158 DISEASES OF THE PARENCHYMA OF THE LUNG. come incapsulated, and its contents may thicken into a cheesy or calca* reous mass. Gangrene of the lung, as a result of haemorrhagic infarction, avUI be described in Chapter XII. In explaining the pathogeny of metastatic infarction, Ave have already alluded to the smaU volume, the cuneiform shape, and superficial situa- tion which it generally assumes. In color, consistence, and friability, metastatic infarctions are entirely simUar to those which arise from dis- ease of the heart. The microscope also gives the same appearances. When metastatic infarction terminates in metastatic pneumonia or abscess, discoloration and disintegration generaUy commence in the middle of the diseased part; caAdties form, fiUed Avith a yelloAV mass, Avhich consists of debris of the pulmonary substance, and of molecular decay of the extravasated blood and fibrin, but which at first does not contain any pus. Upon pouring water over its cut surface, we can see the vestiges of the lung floating in the holloAV. The disintegration spreads graduaUy untU scarcely a trace is left of former thickening, even at the periphery of the abscess. When situated immediately under the pleura, yellow croupous deposits form upon the latter, which cause the pleural surfaces to become adherent, and beneath it Hes the infarc- tion, " forming a rounded-nodular prominence Hke a furuncle " {Roki- tansky). Symptoms and Course.—We shaU treat separately of the symp- toms of haemorrhagic infarction arising from diseased heart, and of those of metastatic infarction; since the appearance of the two forms of dis- ease, in spite of their anatomical identity, varies in many respects on account of the difference in the diseases which cause them. In many cases of chronic disease of the heart, haemorrhagic infarction sets in with such AveU-marked and unequivocal symptoms, that its exist- ence can be demonstrated Avith perfect certainty. In other cases the proof is difficult, or quite impossible. The characteristic symptoms, from which we can infer the formation of one or more haemorrhagic infarctions in a case of disease of the heart, are, a sudden dyspnoea, which may threaten suffocation, and a cough Avith a peculiar sputum tinged with blood. In many instances there are the signs of a circumscribed condensation of the lung, which are not un- frequently followed by those of pneumonia or of pleurisy. It is manifest that the stoppage of one or more branches of the pulmonary artery aa-UI produce extreme dyspnoea. As the process of respiration can only be carried on normally, Avhen both the air in the vesicles and the blood in the capiUaries are properly reneAved, the arrest, either of access of blood, .or of entrance of air into part of the lung, the obstruction, either of a bronchus, or of an arterial branch, must have an equal and extremely HEMORRHAGIC INFARCTION OF THE LUNG. 159 embarrassing effect upon respiration. The sputa, from the strong admix- ture of blood Avhich they contain, bear a certain resemblance to pneu- monic sputa, but they are less tough and almost ahvays darker; and, moreover, the expectoration of this secretion is continued for a much longer time than is the expectoration of pneumonia. The former may persist for a Aveek or even a fortnight. Circumscribed condensation of the pulmonary tissue can only be detected Avhen the haemorrhagic in- farction is of comparatively large size, and has extended to the surface of the lung. The sound upon percussion then becomes dull, and crepi- tation and bronchial sounds are audible over a limited region of the chest. Although such cases occur, they are rare. The diagnosis may be confirmed, a feAV days after the attack of dyspnoea and bloody expec- toration, by the development of extensive pneumonic infiltration, or of inflammatory effusions into the pleural sac, as Ave find that haemorrhagic infarctions often produce inflammation of the surrounding pulmonary tissue, and stiU more frequently cause inflammation of the pleura. Besides the symptoms hitherto described, and Avhich are all imme- diately dependent upon stoppage of one or more branches of the pulmo- nary artery, there are, in many cases, other symptoms, Avhich proceed from the thrombosis of the right heart, and hence are to be regarded as indirect tokens of haemorrhagic infarction. These are, a sudden irregularity of the pulse, a sudden widening of the cardiac dulness, and the sudden cessation of an adventitious murmur, AA'hich had preAdously existed. This sudden subsidence of a loud, morbid sound is not only a most striking occurrence, but one Avhich is generaUy very significant. My attention Avas first called to the full meaning of this symptom by the Avork of Gerhardt above alluded to; but I can fully confirm both the occurrence of the sign and its full diagnostic importance from my own experience. The picture of a haemorrhagic infarction becomes very AveU marked, Avhen the latter grouji of symptoms coexists Avith those described above. But embofi may break off, and be Avashed aAvay from cardiac thromboses so smaU, that they produce no characteristic phe- nomena ; hence, even Avhere there are no signs of cardiac thrombosis, Avhere the pulse remains regular, and AAThere the cardiac dulness con- tinues unchanged, we may stUl confidently diagnosticate haemorrhagic infarction, Avhenever unequivocal signs of disorder of the circulation and capUlary haemorrhage of the lungs suddenly arise in the course of disease of the heart. Finally, if Ave bear in mind that the characteristic expectoration of the blood from the air-\-esicles is not ahvays observed in haemorrhagic infarction, and, moreover, that A'iolent fits of dyspnoea may arise from a great variety of causes in disease of the heart, and that infarctions, . seated deep Avithin the lung, cause no physical signs, it is easy to under- 160 DISEASES OF THE PARENCHYMA OF THE LUNG. stand why the disease, Avhich, in many cases, does not present the small- est difficulty of diagnosis, may sometimes elude detection and even sus- picion—as, for instance, where the patient is already extremely short of breath, and dropsical, and is otherAvise wretchedly ill. In the dissection of cases of diseased heart, therefore, we should be prepared to find haemorrhagic infarctions as " accidental discoveries" Avhere their exist- ence has not been suspected. The liquid products of inflammation or of ulceration almost ahvays pass into the circulation Avith the embofi; and, Avhile the latter give rise to metastatic infarctions, the former result in the symptoms of pyaemia, septicaemia, intense fever, rigors, purulent inflammation of serous membranes, and the like.* We thus see Avhy most patients Avith metastatic infarction of the lung are extremely depressed, why their sensorium is blunted by the intensity of the asthenic fever, and AA'hy they neither complain of pain in the side or breast, nor shoAV any incli- nation to cough. In most cases there are neither subjective nor objec tive symptoms of disease of the lung. It is even the rule, at the autopsy of persons who have died of pyaemia and septicaemia during some sup- purative or ulcerative process, to find metastatic infarction in the lungs, Avhich, during life, was quite indistinguishable. These latent metastatic infarctions are easUy accounted for, if Ave only call to mind the symp- toms upon Avhich diagnosis of the disease is based. The intense dysp- noea, AAdiich appears in cases Avhere large arterial branches in the lung are obstructed, does not exist in metastatic infarction, Avhere the occlud- ed arteries are nearly always very small. Dyspnoea of slighter degree is not noticed by the patient in his stupefied condition. In like manner the characteristic sputum is almost always absent, as generally the patient neither coughs nor expectorates. FinaUy, notAvithstanding their superficial position, metastatic infarctions scarcely ever occasion circumscribed dulness upon percussion, or produce bronchial breathing in the affected region. It is only in A-ery rare cases that patients com- plain of piercing pain in some point of the chest, and expectorate thin, reddish-broAvn sputa. If, besides, a friction-sound be audible in the region of the pain, and if the original malady be one frequently produc- tive of metastatic infarction in the lung—as, for instance, an injury of the skull affecting the diploe—we may pronounce our diagnosis Avith con- fidence ; but, I repeat, that cases Hke this are A'ery exceptional. * According to recent obser\rations, the introduction into the blood not only of decomposed liquids, but even the absorption of liquid inflammatory products Avhich are not decomposing, gives rise to violent fever, and to secondary inflammatory pro- cesses in distant parts of the body. It would thus seecn as though pyaemia, which has been in some danger of disappearing from the list of diseases, may maintain it* place by side of septicaemia. PULMONARY APOPLEXY. 161 Treatment.—The treatment of haemorrhagic infarction can only be a treatment of symptoms. When the affection proceeds from dis- ease of the heart, we must beAvare of attributing the dyspnoea to an aggravation of the pulmonary hyperaemia. We are aAvare that its real or chief cause is anaemia of portions of the lung. An injudicious A-enesection might have the effect of increasing a collapse of the lung already present, and of hastening a fatal issue. It is only when the obstruction of sundry arterial branches in the lung, has given rise to collateral liArperaemia, and to collateral oedema of the rest of the lung, and Avhen the dyspnoea is plainly due in great measure to this cause, that cautious blood-letting, either by cupping or Arenesectionj is ever ad- missible. As a general rule, until the pulse, which usuaUy is feeble, groAVS stronger, and until the skin, Avhich usually is cool, becomes Avarmer, Ave must confine our treatment to stimulation of the patient, and to the application of sinapisms and Avarm baths to the extremities. The expectoration of blood is rarely so abundant as to call for exhibition of the haemostatic remedies recommended in a preAdous chapter. The inflammation of the lung or pleura, which often sets in at a later period, may demand local depletion, the application of cold and other anti- phlogistic measures. CHAPTER VIII. PULMONARY haemorrhage avith laceration op the parenchy- ma.--APOPLEXY OF THE LUNG. Etiology.—In this form of pulmonary haemorrhage the tissues are destroyed by extravasated blood, and an abnormal cavity is established. CapiUary haemorrhage scarcely ever destroys the tissues of the lung. It is only erosion or laceration of the larger vessels, especially rupture of the arteries, Avhich produces destruction of this kind. In rare cases atheromatous degeneration of the pulmonary artery causes its aneuris- mal dilatation and final rupture; but, more commonly, Avounds, contu- sions, or concussions of the thorax, are the causes of pulmonary apoplexy. Anatomical Appearances.—A cavity is found in the lung, con- taining both liquid and coagulated blood, and surrounded by tatters of the lacerated pulmonary substance. If the apoplexy have its seat on the periphery, the pleura, too, is often torn, and blood is poured into its sac. Such haemorrhages are almost ahvays fatal, so that Ave have little knoAvledge of the mode of repair of an apoplectic centre. Symptoms.—Violent and rapidly-fatal haemoptysis, foUoAA'ing serious injury of the thorax, or, in other cases, suffocation from effusion of blood into the bronchi, faster than it can be expectorated, or sudden death ]1 162 DISEASES OF THE PARENCHYMA OF THE LUNG. from internal haemorrhage, may be the symptoms of this exceedingly rare disease, Avhich, being absolutely deadly, is susceptible of no treatment. INFLAMMATION OF THE LUNGS. Inflammation of the lungs may properly be regarded as of three kinds: 1. Croupous pneumonia, in which the air-ceUs are involved in a process identical with that which attacks the mucous membrane of the larynx in laryngeal croup. 2. Catarrhal pneumonia, a process intimately related to that already described as catarrhal bronchitis and laryngitis, producing an augmented secretion, and active generation of young ceUs (pus-cor- puscles), but in AAdiich no coagulable exudation is formed. In both these varieties of inflammation the inflammatory products are throAvn out upon a free surface, the tissue of the lung itself suffering no essential disturbance of nutrition. 3. Interstitial pneumonia, Avhich is an inflammation involving the walls of the air-vesicles, and the interlobular connective tissue. As in the human subject, this latter form is always a chronic disease; it has been also called chronic pneumonia, in contradistinction to the other varieties, whose course is usually acute. CHAPTER IX. CROUPOUS PNEUMONIA. Etiology.—With regard to the pathogeny of croupous pneumonia, Ave refer to Avhat has been said in the second chapter of the first section concerning croupous inflammation, and of its distinctness from diphthe- ria. In croupous pneumonia, also, a fibrinous, rapidly-coagulable exu- dation is throAvn out upon the free surface of the air-vesicles, involving their epithehum, and including the neAvly-formed cells. Here, too, the vesicular Avails become completely restored after expulsion of the exu- dation. Sometimes pneumonia occurs under the influence of an acute dys- crasia, just as catarrh (as we have learned) attacks the air-passages in measles, exanthematic typhus, etc. This form.of pneumonia, which ac- companies typhus more often than it does other acute infectious dis- orders, may be distinguished by the name of secondary pneumonia, from the other varieties Avhich arise more independently, and constitute a separate disease, Avhich we may caU primary pneumonia. It is CROUPOUS PNEUMONIA. 163 wrong, however, to regard all cases of this disease, which supeivene upon some chronic malady, as belonging to the secondary form. The liabihty to primary croupous pneumonia exists at aU periods of Hfe, doAvn to extreme old age. It is rare, however, among infants at the breast, and in the first years of childhood. Males are attacked more fre- quently than females ; not, however, because vigorous, full-blooded per- sons are pecufiarly subject to the disease. The latter, indeed, are by no means exempt; but feeble and broken-doAvn subjects, convalescents from grave diseases, individuals who already have repeatedly suffered from pneumonia, are, perhaps, more Hable to be attacked than the robust; and pneumonia often comphcates diseases which have already effected an impoverishment of the blood, with emaciation and consti- tutional exhaustion. Very many of the inmates of hospitals, sufferers from inveterate disease, finaUy succumb to intercurrent pneumonia. Its exciting causes are generaUy unknown. At times pneumonia becomes of very frequent occurrence, while croup, acute articular rheu- matism, erysipelas, and other acute inflammatory disorders prevaU at the same time, attacking their victims Avithout any obAdous provocative. This prevalence of acute inflammatory disease through the operation of unknoAvn atmospheric and telluric agencies is generally spoken of as inflammatory epidemic influence. We particularly observe the epi- demic occurrence of pneumonia in severe and protracted Avinters during the prevalence of a northeast wind. Sometimes, hoAvever, it arises under conditions precisely the reverse. The statistical statements as to the greater frequence of pneumonia in northerly and elevated localities have, of late, been regarded as untrustAVorthy. Direct irritants acting upon the lungs, the inhalation of very cold or very hot air, foreign bodies, which have entered the air-passages and stopped up a bronchus, fractures of the ribs, wounds of the thorax, may be counted as among the exciting causes, although scarcely any of these conditions are found to exist in one case of pneumonia out of fifty. Nor is the croupous form of the disease often found to attack the parts about a morbid grOAvth or around a haemorrhagic infarction. With regard to the influence of cold, it is difficult to decide in indi- vidual instances Avhether the attack has been preceded by an exposure to cold more severe than that to Avhich the patient has repeatedly exposed himself AAdth impunity. Opinions, therefore, are divided as to the effect of cold in producing pneumonia. Anatomical Appearances.—Croupous pneumonia almost always attacks a someAvhat extensive portion of the lung, commencing usually at the root and spreading thence to the loAver and afterward to the upper lobes. Sometimes an entire lung is inflamed, or the process may extend into the other lung, producing a double pneumonia. It is 164 DISEASES OF THE PARENCHYMA OF THE LUNG. curious that in old persons and in cachectic individuals the mode of exten sion is usually different, as here the upper lobes are generally the first to be attacked, the loAver not becoming involved untU a later period of the disease. We distinguish three anatomical stages in pneumonia: 1st, the stage of engorgement with blood {engouement); 2d, the stage of hepatization; 3d, the stage of purulent infiltration. In the first stage the pulmonary parenchyma is dark red, often red- dish brown. It is heavier and firmer, has lost its elasticity, and pits upon pressure. Upon section, the inflamed portion of the lung does not crackle much, and a broAvnish or reddish liquid, of a strikingly viscid and tenacious nature, bathes the surface of the cut. In the second stage, the air has disappeared from the air-vesicles, and the latter are fiUed by small, firm plugs of coagulated fibrin, to AA'hich an admixture of blood imparts a reddish color. A similar exuda- tion has taken place in the extremities of the bronchi. The lung has iioav become remarkably heavy, sinks in Avater, does not crackle, is firm to the touch, but is very tender and friable. The appearance of its cut surface is granulated, especiaUy Avhen vieAved by oblique light, and this is most distinct Avhere the air-vesicles are large; less so in children, Avhere they are small. The granules (Avhich are merely the fibrinous plugs so often mentioned) can no longer be extracted from the lung by scraping with the scalpel, but adhere firmly to the walls of the air-cells. The granulated aspect of the cut-surface, the rigidity, the friability, the redness of the condensed lung, impart to it a considerable resemblance to fiver, and thus the generally-adopted name of red hepatization has arisen. Sometimes, owing to spots of lighter color, and to deposits here and there of the black pigment which is secreted in the lung, together AAdth the whiteness of the interior of the bisected bronchi and vessels, the section, instead of a uniform red, presents a variegated, " marbled," granite-fike appearance. AfterAvard the redness fades more and more, either from cessation of the hyperaemia, or from disintegration of the haematin. The lung assumes a gray or yelloAvish appearance, Avhile the texture continues in other respects the same, the pulmonary substance remaining rigid and granular {yellow hepatization). Besides the amor- phous fibrin Avhich fills the air-vesicles, the microscope reveals a A'cry active formation of new ceUs, Avhich probably spring from the epithe- lium of the vesicular Avails. Should resolution set in, in the stage of hepatization, the fibrin and the young ceUs entangled in it undergo fatty metamorphosis and disintegration. An albuminous serum transudes from the walls of the vesicles; their contents become liquefied, con- verted into an emulsion, and finally are eliminated, partially by absorp- tion, partially by expectoration. There is a shght deviation from the above when the pneumonic exudation is less fibrinous and less coagu- CROUPOUS PNEUMONIA. 165 lable. The hepatized portion then is softer, its cut is smoother, and Avithout distinct granulation. This is most common in. the secondary pneumonia of typhus, and in that of old persons. When the pneu- monia passes into the third stage, that of purulent infiltration, ceU-for- mation assumes prominence, Avhile the fibrin undergoes disintegration as in other cases. The granulated appearance is lost, the cut-surface is of a pale gray, or grayish yellow. A reddish-gray matter bathes its surface, and may be expressed in large quantities. The tissues are ex- ceedingly tender, and are easily torn by the pressure of the finger. The minuter structure of the lung, however, is unaltered; the pulmonary tissue itself is stiU intact. Here, too, therefore, complete recovery may take place. The purulent contents may be ejected in part, and in part may undergo fatty degeneration and become absorbed. The rarer sequelae of pneumonia are. 1. Formation of abscess. The purely croupous form of inflamma- tion Avith which we have here to do essentially excludes the idea of a destruction of the inflamed tissue. When abscesses form, the process has more of a diphtheritic nature. The proper tissue of the lung be- comes infiltrated, and sloughs from the pressure of the fibrinous infiltra- tion. In this Avay small cavities, fiUed Avith pus and debris of the pul- monary substance, form in the lung, which itself is infiltrated Avith pus. Sometimes they are solitary and sometimes they exist in great number. These collections of pus may increase in size from continual melting doAvn of the tissues; several of them may coalesce, so that finally a huge abscess may occupy the greater part of the lung. These abscesses either end fatally through ulcerous phthisis, or else, in rarer instances, they open into the pleural sac. In other cases, a reactive interstitial pneumonia is set up in the parts adjacent, by which the abscess is in- capsulated in a firm cicatricial tissue, its inner Avail becoming smooth. Should a communication with the bronchi remain, its contents are evacu- ated from time to time, but are replaced by fresh matter generated by the interior surface. Should the cavity be closed, the pus may become thickened, and be converted into a cheesy paste, or, after disappearance of the organic substance, may change into a mortar-like or chalky con- cretion, Avhich lies imbedded in an indurated firm scar. 2. Gangrene of the lung is a stiU rarer sequel to pneumonia. It ap- pears only to occur when the supply of blood has been completely cut off from the inflamed portion of the lung by the formation of large coagula in the pulmonary arteries, and more especiaUy when they form in the bron- chial arteries, by whose means nutrition of the lung is carried on. The lung may become gangrenous even in the stage of red hepatization. The exu- dation then changes into a grayish ichorous Hquid, and the pulmonary tissue breaks doAvn into a blackish pulp. (See Chapter XII.) 166 DISEASES OF THE PARENCHYMA OF THE LUNG. 3. The termination of croupous pneumonia in cheesy infiltration (or, as it is stiU too often called, tuberculous infiltration) is more common. If, in the second or third stage of the disease, Avhen the fibrinous effu- sion and the ceUs which fiU the vesicles take on fatty degeneration, the supply of serum effused by the waUs of the vesicles prove insufficient, the fatty masses begin to dry up before their liquefaction is completed, and are converted into a more or less firm, yeUoAV, cheesy substance. Hereafter we shaU again refer to the subsequent changes occurring in this caseous infiltration of the lung, and shall express ourselves upon the inexpedience of permitting the imputation to arise of a sort of iden- tity of the products of the latter process Avith those of tubercular granu- lation, by applying a simUar title to both. 4. Cirrhosis of the lung, or induration, is finaUy to be mentioned as a rare termination of tedious pneumonia. This sequel is due to par- ticipation of the vesicular waUs and the interstitial tissue in the process, when the disease is of long standing. Of this we shaU treat more in detail in Chapter XI. That portion of the lung which is not attacked by the inflammation is the seat of intense hyperaemia, as before stated; in fact, pulmonary oedema is, in many cases, the actual cause of death. Wherever the in- flammation extends to the periphery of the lung the pleura also becomes impficated, showing minute arborescent injection and ecchymosis. It is then clouded and opaque, flabby, and covered with a thin layer of fibrin. Generally, the right side of the heart, from which the outflow of blood has been impeded by the stasis of the capillaries of the lungs, is over- flowing with blood; the left heart, its supply being abnormally dimin- ished, is less full. In like manner, and for the same reasons, stagnation of blood exists in the jugular veins, in the sinuses of the brain, and in the liver and kidney. The condition of the blood is exceedingly striking. The major part of that which is in the great vessels is not Hquid, but is coagulated into firm yellow masses. Lumps of curdled fibrin exist in the heart, where they are firmly entangled amid the trabeculae and under the valves; and long, firm, tough, polypous coagula may be drawn out of all the arteries. Symptoms and Course.—We shaU discuss the subject of secondary pneumonia in treating of typhus, etc., as it is impossible to draw up a picture of this disorder without making a detailed analysis of the symp- toms of the disease upon AArhich it depends. The commencement of primary pneumonia, in almost all cases, is announced by a rigor which may last for half an hour, or even for sev- eral hours, before giving place to a sensation of heat. As is well •knoAvn, the cold is a mere subjective symptom, and the temperature is appreciably elevated, even during the algid stage. CROUPOUS PNEUMONIA. 167 Tliis rigor is important both in a diagnostic and in a prognostic point of vieAV. In no other affections, excepting intermittent fever and septicaemia, do Ave encounter chiUs of equal violence; and in the latter disorders the paroxysms are repeated, whUe the rigor AA'hich ushers in pneumonia is almost always the only one throughout the entire course of the illness. It is from this chill that Ave calculate, in counting the duration of the disease. In children, convulsions often occur instead of a chill. The elevation of temperature, Avhich rises to 103° or 105° Fahren- heit (rarely higher), even on the first day, is accompanied by accelera- tion of the pulse, and by increase of thirst. The countenance is red; the patient complains of pain in the back and loins, and of a distressing soreness of the limbs. There is great prostration and muscular debility. The tongue is coated, and the appetite entirely gone ; occasionally there is vomiting. As these symptoms often precede the local manifestations by one and even tAvo days, they used formerly to be attributed by many to the accumulation of fibrin in the blood (hyperinosis). Some have even gone so far as to ascribe a critical significance to pneumonia {Dietl), and to declare that the disorder only disappeared after the ehmination of the superfluous fibrin from the blood. All these symptoms, liOAvever, appertain to the fever, and are more or less pronounced in all febrUe diseases, Avhether the fibrin of the blood be increased or diminished in quantity, or Avhether its quantity remain unchanged. We need not demonstrate more fully, that every fever, by increasing the rate of trans- formation and consumption of the tissues, must thereby alter the com- position of the blood, and that the products of the interchange of ma- terials are mingled Avith the blood in greater quantity. This febrile crasis and the elevated temperature of the blood sufficiently account for the perversions of nutrition and function, AA'hich take place in febrile affections—constitutional disturbance of fever. Although fever and derangement of the general health are of earlier occurrence than the symptoms of nutritive derangement AA'hich the lung has suffered, yet Ave may often observe the same thing in febrile catarrhs and other inflammatory fevers. We may assume in such cases that the inflammatory disturbances of nutrition commence quite as soon, at least, as the feA'cr, but that for a AA'hile they do not betray themselves by causing pain, cough, or dyspnoea, but remain latent. In other instances, symptoms of functional disturbance appear in the lung either simulta- neously Avith the chill or immediately afterward. The first of these is shortness of breath, a constant accompaniment of pneumonia. Assuming the normal rate of breathing of adults to be tAvelve, sixteen, or tAventy breaths a minute, Ave see it augmented in pneumonia to forty and eA'en fifty breaths, and find it to attain a still 168 DISEASES OF THE PARENCHYMA OF THE LUNG. greater frequence in children. The length of each respiration is propor- tionately short, the breathing is superficial, a fresh inspiration is required during the enunciation of even a short sentence, speech is interrupted. As the act of inspiration is executed rapidly, and AA'ith a certain degree of caution and anxiety, the levatores alae nasi are contracted with every breath, and the alae nasi dUated, causing the nostrils to " work." The shortness of breath is due, 1st, to the slowness with which blood is renovated in the inflamed part of the lung; 2d, to the diminution of breathing-surface, by exudation into the air-vesicles and consequent ex- clusion of air; 3d, to collateral oedema in the uninflamed part of the lung, AA'hich causes SAvelling of the vesicular Avails and decrease in their capacity; 4th, to the pain Avhich a deep breath causes to the patient, Avho therefore does not breathe deeply; 5th, and above aU else, to the increased need of air, since, in the augmented combustion and accelerated destructive assimilation which goes on during fever, more oxygen is con- sumed and more carbonic acid is given out in the organism. We shall presently see that, Avith the abatement of the fever, the dyspnoea ceases almost completely, although all the obstacles to respiration stiU continue. Pain is so constant a symptom in pneumonia as to be absent in but few instances. In most cases, but not in all, the patients assign the seat of the pain to the point at Avhich the inflamed lung comes in contact with the thorax. In other cases it is felt at more remote points, and even on the other side. It is, therefore, a doubtful matter, at least, Avhether the pneumonic " stitch " is solely due to participation of the pleura in the inflammation. Every deep inspiration, and especially every forcible expiration, such as accompanies coughing or sneezing, aggravates the suffering, as do also pressure upon the thorax and move- ment of the intercostal muscles. The character of the pain is usually described by the patient as piercing or stabbing. Its intensity varies. It rarely continues in all its violence for any length of time. It is one of the most burdensome symptoms at the commencement of the disease, and afterAvard diminishes or completely ceases. It is apt to be of an exceedingly transitory character, or even to be altogether wanting in the pneumonia of old persons and very feeble subjects, particularly if the seat of the inflammation be the apex of the lung or one of the upper lobes. It is of importance to be aware of these facts. Cough very soon associates itself Avith the fever, dyspnoea, and pain in the side. «■ It is hardly ever absent, excepting in the cases above alluded to, the pneumonia of old men, etc. It is at first short, ringing, and harsh. The patients endeaA'or to repress it; they dread to cough, make painful distortions of the countenance while so doing, so that observation of the manner of a child, Avhile coughing, furnishes ground for a distinction between bronchitis and pneumonia. In almost all CROUPOUS PNEUMONIA. 169 cases, a peculiar sputum, pathognomonic of the malady, begins to be ejected at an early period. This sputum corresponds essentially to the A'iscid adhesive fluid Avhich, as Ave have seen, appears in the air-ceUs during the period of engorgement. Like that liquid, it almost ahvays contains blood, as pneumonic exudation is almost ahvays attended by rupture of capiUaries and extravasation of their contents. The pneu- monia of old people alone forms an exception to this rule. In these, the exudation is often a non-haemorrhagic one, and the hepatization is not red, but yelloAv, immediately upon its estabfishment. At the com- mencement of the attack, the pneumonic sputa are so tough and adhesive that it is difficult to remove them from the mouth, and they are usually aa iped aAvay with a cloth. They cling so firmly to the receptacle, that the latter can often be inverted Avithout spilling its contents. The blood AAdiich they contain is more intimately mixed than it CA'er is Avith bronchial mucus. Their color, which ahvays corresponds to the amount of blood commingled, may be fight red, rusty, brick-red, or reddish broAvn. Microscopic examination usuaUy shoAVS great numbers of intact blood-corpuscles, easily recognizable by their form and color, besides a small number of young cells, and sometimes a feAV pigment ceUs from the pulmonary vesicles. Chemical examination sHoavs the existence of albumen, Avhich coagulates upon the addition of nitric acid; and of mucin, Avhich coagulates upon addition of dilute acetic acid, and forms a cloud of mucus upon the surface of the diluted sputa. The fibrinous plugs from the A^esicles are not expelled; but, upon the entrance of the pneumonia into its second stage, small, apparently structureless, lumps are found in the expectoration, AA'hich are susceptible of being disentan- gled, and by the employment of a Ioav magnifying power may be recog- nized as repeatedly bifurcated and ramifying coagula. These are fibrin- ous casts of the minuter bronchi. While, as a rule, aU these symptoms of pneumonia mature until the second day of the disease, Avhen physical examination of the chest leaves no further doubt as to its nature, the fever and constitutional symptoms continue to increase. According to the careful researches of Thomas, of Leipsic, the fever is neATer a continued fever, but is remittent or subremittent, that is to say, the daily fluctuation in its exacerbations and remissions may be considerable, amounting to 0.75° F. to 1.80° F., or else they may be slight, not exceeding 0.4 F. to 0.5 F. The temperature is at its lowest during the early morning hours, the exacerbation usually beginning in the course of the forenoon, attaining its height usuaUy in the afternoon, AA'hen, in bad cases, it may rise as high as 105.8° to 107.7° F. In most cases, a day or two before the occurrence of the crisis, the remis- sion increases. On the other hand, immediately before the fever sub- 170 DISEASES OF THE PARENCHYMA OF THE LUNG. sides, the temperature sometimes reaches a height greater than any pre- viously attained. The pulse, Avhose frequence in a pneumonia of average severity usually ranges betAveen ninety and a hundred and twenty beats a minute, may in severe cases, where the temperature is very high, attain a fre- quence of a hundred and thirty, or a hundred and fifty or more. While, at the outset of the attack, it usuaUy is large and full, as the malady progresses, it often becomes smaU and soft. In some cases, this is due to depression of the heart's action, by the high temperature (AA'hich always tends to produce asthenia), so that its feeble strokes scarcely overcome the resistance opposed by the aorta to the outflow of the blood. Under these circumstances (upon the principle that the effect is in proportion to the poAver, and in inverse proportion to the resist- ance), but little blood is expelled from the heart, causing a feeble pulse- AA-aATe, and a small pulse. In other, and probably in the majority of cases, it is not the Aveakness of the cardiac contractions, but the lack of blood in the left ventricle, which causes a deficit in the supply of the aortic system, and renders the pulse smaU and soft. The left ventricle is imperfectly filled, because afflux of blood to it is obstructed. In an extensive pneumonia, an obstacle to the circulation arises (partly from the inflammatory stasis, partly OAving to pressure of the exudation upon the capUlaries), Avhich cannot be fully compensated for by acceleration of the capillary circulation in the uninflamed portion of the lung. The consequence is, that too Httle blood enters the left heart, while the right heart and the veins of the aortic system are overloaded. (Upon cutting into a piece of hepatized lung, but little blood Aoavs from it. The redness in the beginning of hepatization depends upon extravasation. The lack of blood of the inflamed part is most conspicuous in yeUoAV and gray hepatization, and in purulent infiltration.) The blueness of the lips and cheeks, Avhich is observed in severe pneumonia, is also dependent upon the disturbance of the pulmonary circulation, and upon impediment to the outflow of blood from the right ventricle, and from the A'eins of the aortic circulation; but Ave have no acceptable explanation of the reddening of the cheek, which often occurs at the side upon AA'hich the pneumonia exists. In many in- stances a herpetic eruption develops upon the second or third day upon the lips, more rarely upon the nose, cheeks, or eyehds; and from the frequence of herpes during pneumonia, and its great rarity in abdominal typhus, and other diseases, the appearance of vesicles filled Avith a clear liquid may be of diagnostic value in doubtful cases. The headache, by Avhich the invasion of pneumonia is accompanied, usuaUy continues throughout the attack. It is generally combined with sleeplessness, or the sleep is tioubledby dreams; and, if the patient be CROUPOUS PNEUMONIA. tfi at all of an irritable temperament, there is apt to be sHght delirium. These symptoms are mainly due to the fever, and cease as soon as the fever subsides. We must beAvare of inferring the existence of grave cerebral disease from the presence of these signs alone. Even where there is no comphcating gastric disorder, the appetite usually is lost, the tongue is lightly coated Avith Avhite, and shows a tendency to dryness, the thirst is considerably augmented, and the stools are dry and constipated. These symptoms are also the result of fever, and occur in almost every other febrile complaint. The loss of appetite is the most difficult to account for. One Avould suppose, a priori, that the augmented destructive assimilation which takes place during fever, by means of Avhich the high temperature of the body is maintained, Avould occasion an increased demand on the part of the system for a compensating supply of nourishment to replace the Avaste, and Ave are quite at a loss to understand why no such want is usually felt by the patient. The coated tongue, its tendency to dryness, as Avell as the aggravated thirst (see catarrh of the oral mucous membrane), and the dryness of the stools, are satisfactorily accounted for by the in- creased evaporation of liquid from the skin, in consequence of which the tissues become dryer and their secretion is diminished. Obstruction to the flow of blood from the liver not unfrequently leads to a perceptible enlargement of that organ. Perhaps, in some cases, the slight jaundice which occurs during pneumonia is dependent upon this obstruction of circulation in the liver, and is analogous to the icterus AA'hich appears, from the same cause, with tolerable frequence in disease of the heart. As the hepatic veins are intertwined Avith the '*' biliary ducts, distention of the former may result in compression of the latter, and thus cause retention and absorption of bile. HoAvever, this theory of the origin of icterus is only to be admitted Avhen the HVer is greatly SAveUed and the patient is extremely cyanotic. Far more fre- quently, the symptoms of jaundice during pneumonia depend upon a catarrh of the duodenum and of the biliary ducts, or else it arises from " cUssolution " of the blood—that is to say, a disintegration of the blood- corpuscles, by AA'hich free coloring-matter of the blood is converted into bUiary coloring-matter outside of the Hver. The pneumonic process and the fever which attends it exercise an important influence upon the constitution of the urine. While the fever lasts the proportion of Avater in the urine is reduced by the insensible perspiration. The urine is scanty and concentrated, its color is some- Avhat dark, and its specific gravity is high. Among the sofid constituents of the urine, the urea is considerably increased in quantity. As is AveU knoAvn, the ultimate products of de- structive assimUation of nitrogenous tissues are eliminated under the foan 172 DISEASES OF THE PARENCHYMA OF THE LUNG. of urea and uric acid. The elation of the temperature of the body in febrile disease depends upon an abnormal generation of heat from a morbidly-active combustion of the constituents of the tissues, in which, of course, the nitrogenous elements participate. A short fever reduces the weight of the patient far more than does a fast, without fever, of much longer duration. But the patient not only groAvs thin because his fat is consumed in overheating his body, but the muscles undergo a marked atrophy, and a considerable period of time elapses ere a con- valescent from fever regains his former strength, and ere his muscles are restored to their original volume. The increased destructive assimUa- tion of the nitrogenous constituents of the body during fever is also susceptible of direct proof, by the absolute or relative augmentation in the production of urea. Patients suffering from pneumonia, AAdth violent fever, even though their diet be absolutely non-nitrogenous, eliminate quite as much urea in their urine, if not more, than a healthy person does AA'hose food consists almost entirely of meat and eggs. I have knoAvn pneumonia patients to excrete forty grammes of urea AAdthin twenty-four hours, while one of my pupils, Avho was in good health, and whose diet Avas precisely that of the sick man, passed but from thirteen to fifteen grammes in the same time. The urine very com- monly becomes turbid upon cooling, from precipitation of its urates; but it appears to me that this phenomenon is due rather to the reduced proportion of Avater in the urine, Avhich thus becomes incapable of hold- ing the urates in solution at a low temperature, than to an excessive formation of the salts themselves. By gently warming the urine the urates can ahvays be redissolved, and the cloudiness of the urine be dissipated. While the urea of the urine is increased in quantity, the amount of inorganic salts which it contains, especially its alkahne chlorides, is diminished, and at the height of the disease they may disappear com- pletely. If we add a few drops of a solution of nitrate of sUver to some of the urine, previously acidulated, the precipitate of chloride of silver, so distinct in healthy urine, is scarcely, if at all, observable. The greater part of this chloride of sodium depends, no doubt, upon the use of food containing salt, and the diet of a pneumonia patient might account for the diminution of alkafine chlorides in the secretion; but as, even in starving animals, small quantities of alkafine chlorides are found in the urine, as a product of transmutation of their tissues, its complete disappearance in pneumonia cannot be attributed solely to the diet of the patient: and we are warranted in supposing that the portion of alkafine chlorides produced by destructive assimilation is ex- creted from the blood with the pneumonic exudation. The concentration of the urine, the augmentation of urea, the dimi CROUPOUS PNEUMONIA. 173 nution of the chlorides, as AveU as the appearance of bifiary pigment in the urine, are simply due to the improper quality of the matter conveyed to the kidneys for the production of urea. The appearance of albumen in the urine, AA'hich not unfrequently occurs in severe pneumonia, is de- pendent upon other causes. Its presence is sometimes occasioned by engorgement of the emulgent Aeins. As is AveU knoAvn, albuminuria may be produced artificially in the lower animals by Hgation of these Aeins. The chief source of the albuminuria of heart-disease is obstruc- tion of the venous circulation of the kidney. The presence of albumen in the urine of pneumonia, hoAvever, is only to be ascribed to such a cause AA'hen it is accompanied by cyanosis, enlargement of the liver, and other evidence of intense venous engorgement of the greater circula- tion. In most cases its source is in the parenchymatous degeneration of the kidneys, of Avhich Ave shaU speak more fully in our second volume, and Avhich consists in a SAvelling and opacity and molecular destruction of the renal epithehum. This parenchymatous degeneration of the kidney, Avith its consequent albuminuria, occurs in a great variety of febrUe dis- orders, and is apparently a result of excessive eleAration of the tempera- ture of the body, or febrile crasis. The more intense the fever, so much the more probably will albumen be found in the urine of pneumonia patients, although there may be scarcely any sign of A'enous engorge- ment of the systemic circulation. The skin, which, at the commence- ment of the attack, usuaUy is dry and parched, after a day or two often becomes moist, and even bathed in SAveat, Avithout, hoAvever, affording any material relief to the patient. Hitherto avc have been describing the stadium incrementi, the form- ing stage of the disease. Its transition into the stadium decrementi, or stage of dechne, is not gradual, but takes place AA'ith a suddenness Avith- out parallel in any other disorder. In former editions of my book I have asserted AA'ith great positive- ness that the crisis of a pneumonia almost constantly arrived either on the fifth, seventh, or, in rare instances, upon the third day, and I believed this assertion to be Avarranted by the results of a large number of ob- servations. MeanAvhile I have become satisfied that the ancient doctrine, that the crisis of pneumonia ahvays occurred on the odd days, is unten- able, in spite of the high modern authorities Avho have pronounced in favor of its correctness. If, in calculating the duration of the disease, AAe take accurate notice of the hour at Avliich the initiatory chill began, and of that in AAdiich the decline of the fever commenced, it Avill be seen that the critical period of pneumonia takes place quite as often upon the even clays as upon the odd ones. For instance, a pneumonia, Avhich beo-ins by a chill on Monday at noon, culminates, no doubt, in many cases in course of the foUowing Sunday; but the crisis occurs quite as 174 DISEASES OF THE PARENCHYMA OF THE LUNG. often during the forenoon (hence during the sixth day) as in the after- noon or seventh day. (As I hear from one of my pupils, in a certain great university city, which is fond of being called the metropolis of in- telligence, aU the pneumonias at one clinique terminate on the odd days, and at another on the even ones.) The symptoms continue AAdth constant or increasing intensity until the critical day, Avhich generaUy arrives toward the end, less commonly about the middle, of the first week of the disease; and Avhile the con- dition of the patient, from the dyspnoea, the thirst, and the intense con- stitutional disorder, is beginning to awaken an earnest solicitude, a striking change takes place, often within a few hours. The temperature and the frequence of the pulse often sink rapidly, the dyspnoea abates, the patient feels easier and more free. In course of twenty-four hours convalescence is often fully established. The patient sleeps, calls for food, and merely complains of extreme debility. From this time the recovery of many patients progresses steadily. The temperature not unfrequently falls below the normal standard, and I repeatedly have seen the pulse sink to forty beats a minute, although the patient had not taken a grain of digitalis. The blood disappears from the expecto- ration, sometimes gradually, sometimes with suddenness. The sputa become somewhat more copious, but generally to so sfight a degree that we are compelled to suppose that the greater parts of the exudation must be absorbed, and that but little of it is expectorated. The tena- city and transparence of the sputum disappears with the blood; it becomes yeUowish—sputa cocta. The yeUowness depends upon an admixture of young cells, Avhich show more or less trace of fatty metamorphosis. Besides slightly granular pus-corpuscles, cells fiUed AA'ith oil-globules, fat granule-cells, and coUections of granules, and of free oil-molecules, and black pigment-cells in greater or less numbers, are found in the expectoration. Although reabsorption commences very soon after exudation is complete, yet a considerable period of time usually elapses before auscultation and percussion show that the pneu- monic infiltration has completely disappeared. In subjects previously healthy, the course of the vast majority of pneumonias is as above described. Indeed, with the exception of the infectious diseases, there are few maladies whose average course is so remarkably uniform. That we should not, until recently, have perceived its evidently cyclical character, is OAving to the active manner in AA'hich we used formerly to attack the disease whereby its typical course be- came deranged. One must bear in mind that not very long ago it would have been thought a crime to treat a pneumonia without blood- letting, and even Avithout repeated venesection. In some cases the crisis does not occur at the end of the first week, CROUPOUS PNEUMONIA, (0 or there is but a short remission, after which the disease groAvs Avorse again, and continues into the second Aveek. The pneumonic infiltration continues to spread, the temperature remains high, and is sometimes higher than ever. Signs of extreme prostration noAv set it, due in part to the elevation of the temperature, partiaHy also to exhaustion pro- duced by continuous and excessive calorification, and to the profuseness of the exudation, which I have repeatedly estimated at three pounds after comparison of the Aveights of the diseased and healthy lung. The fever, formerly of "inflammatory" type, noAv assumes an asthenic, " nervous " (typhoid) character. The pulse groAvs extremely frequent, small, and soft; the tongue becomes dry and incrusted; aU the senses are blunted; the patient not unfrequently voids his urine and faeces in- A'oluntarily, in the bed; some patients fie in a stupor from AA'hich they can scarcely be roused; others, again, are wUdly delirious, so that it is scarcely possible to restrain them in bed. In many such cases, especially if the patient have not been depleted by blood-letting, a change for the better may still take place toward the end of the second Aveek, and again the transition from a condition apparently desperate, to one of almost complete convalescence, may then occur in the course of a feAV hours. The crisis at the end of the first week fails to occur also, Avhen the stage of hepatization passes on into that of purulent infiltration, and the fever continues into the second Aveek Avith equal or even aggravated intensity. Here, too, the pulse is usuaUy small, and the mouth is dry and sticky. The patients are somnolent, or else delirious; the tempera- ture, especially in the evening, is greatly elevated, and sometimes there are slight chills. The sputa, AA'hich are generaUy profuse, contain great quantities of ceUs in a state of fatty degeneration. It is clear that aus- cultation and percussion alone can distinguish an extension of the pro- cess of hepatization from the transition into purulent infiltration. When the pneumonia attacks aged persons, or subjects of depraved constitution, adynamic symptoms may arise, even though the malady be not of unusual duration and although purulent infiltration have not occurred. Indeed, so promptly do they sometimes develop, so immedi- ately do they appear after the chiU, and the first onset of the fever, that the signs of pulmonary disorder are entirely eclipsed by those of grave asthenic fever. As Ave have stated already, many patients of this kind have no cough and no characteristic sputa / nor do they complain either of dyspnoea or of pain. The frequency of respiration is often ascribed to the fever, and patients sometimes die Avith the diagnosis of a " typhoid influenza," a catarrhal fever, or a " typhoid gastric feATer," Avhose autopsy reveals extensive pneumonic infiltration; the physician haAdng been deceived by external appearances, AA'hich really bear greatei 176 DISEASES OF THE PARENCHYMA OF THE LUNG. resemblance to typhus than to pneumonia of vigorous adults, And hav- ing neglected to make a physical exploration of the chest. Asthenic fever may also develop, sometimes, in subjects previously healthy and vigorous, Avhere pneumonia is complicated with acute gastric or intestinal catarrh. True, such cases, which are not rare, differ from the pneumonia of old persons, inasmuch as the pain, cough, and characteristic sputa are not at first absent; but the depressing effect of the complication as well as the fever, which is usually of great inten- sity, soon result in an extreme prostration and in other symptoms, Avhich create the terrifying impression upon the minds of the laity that the malady has become " typhoid" ("nervous"), or " that a nervous fever has set in." The disease is further disguised, and the diagnosis ren- dered doubly obscure, by the thickly-coated tonge, Avhich afterward often becomes incrusted with black scabs, by the distended abdomen and by the watery discharges from the bowels, and—if the intestinal catarrh haATe also involved the ductus choledochus—by the jaundiced hue of the skin, and sclerotica. Here, too, physical examination is our sole safeguard against error and mortifying post-mortem disclosures. Pneu- monia is apt to assume very peculiar characteristics Avhen it attacks per- sons of intemperate habits. The beginning of the attack seems rather to be a fit of delirium tremens, and the symptoms of perverted cerebral action are so prominent that the pulmonary affection is Hable to escape notice. The patient can hardly be kept in bed; he is exceedingly loquacious, does not complain, but declares that he is perfectly well. He is in a most cheerful humor, and his defirium and illusions are of that peculiar kind which is almost pathognomonic of defirium tremens. He sees smaU animals, especially mice and beetles, picks with great industry and persistance at his bed-clothes, or executes all the manipulations of his avocation in pantomime. Even though a patient in this condition have no cough, no expectoration, and complain of no pain, yet his chest should be explored with great care, especially if he have fever. Many a patient has died in a strait-jacket Avith a diagnosis of defirium tre- mens, Avhose real disease has been pneumonia. At a later period the scene changes. It is a Avell-known fact that drinkers are equally inca- pable, or even still less capable, of bearing an increase of calorification and an augmentation of their animal heat than aged or debilitated per- sons, and that a fever of very moderate intensity and brief duration exercises an exceedingly depressing and exhausting influence upon the vigor of the heart, the action of the brain, and upon all other functions. In a very few days the pulse, originaUy full, groAvs small and Aveak, the extreme excitement and busthng demeanor give place to a deep apathy, and to rapidly-increasing somnolence, the skin is bathed in SAveat (from incipient palsy of the cutaneous muscles), gurgfing CROUPOUS PNEUMONIA. 177 sounds arise in the chest (from commencing paralysis of the muscles of the bronchi)—and the patient dies Avith the symptoms of oedema of the lung. With regard to the termination of pneumonia, Ave have already seen that recovery is often rapid, Avhere the exudation liquefies, and is reab- sorbed after completion of the stage of hepatization. Complete resto- ration may also take place from the stage of purulent infiltration, only, as the patients are exhausted by weeks of fever, their convalescence is extremely tedious. Death, during the first and second stages of pneumonia, usually pro- ceeds from hyperaemia and collateral oedema, by Avhich the uninflamed air-vesicles are rendered incapable of carrying on respiration. Much more rarely it depends upon the excessive extension of the pneumonic infiltration alone. The intense dyspnoea, profuse frothy or liquid sputa, moist rales in the uninflamed parts of the lung, the sudden sinking of the patient, the droAvsiness, the vomiting, the coolness of the skin, arc all signs of insufficient respiration, and of imminent danger of carbonic- acid poisoning. Unless aid be at hand, the symptoms of palsy soon pre- vail, and the patient succumbs under symptoms of oedema of the lung, palsy of the bronchi, and of suffocative effusion. A fatal issue, during the stage of red hepatization, resulting from engorgement of the cerebral veins, Avith consequent effusion, is of far rarer occurrence. Simple blueness of the face need not lead us to fear cerebral congestion ; nor are even the headache and the defirium sufficient to Avarrant such apprehension, neither do they require the active treat- ment imperatively demanded by that condition. If, hoAvever, the pa- tient fall into somnolence Avhich cannot be ascribed to the embarrass- ment of respiration, or if he complain of a sense of formication, or of numbness of his Hmbs, or should slight convulsions occur, fife is un- doubtedly threatened by oedema of the brain, and death may ensue Avith the symptoms of coma. The third and most usual cause of death, during the stage of red hepatization in pneumonia, is exhaustion. From this cause a compara- tively slight attack of this disorder is extremely dangerous AA'here the pa- tient is old or debihtated, or Avhere he is a drunkard AA'hose nerves are in constant need of stimulus, Avho trembles until he has his dram, and in whom the privation of the supply, added to the prostration produced by the fever, soon brings on paralysis. In Hke manner, a complication Avith intestinal catarrh and icterus tends to hasten the exhaustion; or, finaUy, the longer duration of the fever, and the magnitude of the exudation in a protracted pneumonia, may expend the strength of a person previously vigorous and healthy. In aU these cases the obtuseness of the senso- rium increases to stupor, the pulse becomes smaller and smaller, the- 12 178 DISEASES OF THE PARENCHYMA OF THE LUNG. skin is bedeAved with clammy sweat, and the patient dies from passive hyperaemia, passive oedema, and suffocative effusion. Death takes place with symptoms quite like these in the third stage, that of purulent infiltration, Avhen the strength proA'es insufficient to Avithstand the duration and intensity of the fever. Sometimes the asthenic symptoms, which may arise during pneumonia, are accom- panied by another group of symptoms of a different kind. The pulse grows small and irregular, a shght jaundice appears, which manifestly does not depend upon biliary obstruction; the urine becomes albumi- nous, the mind of the patient is much disturbed, the defirium being vio- lent at first, afterward settling into stupor. When there is much jaun- dice, this description corresponds nearly with that of the bilious pneu- monia found in many of the ancient pathologies. In these cases we probably have to do Avith a parenchymatous degeneration of the heart, liver, kidneys, brain, and blood. In their appropriate sections we shaU consider in detail the subject of parenchymatous degeneration of these organs, as Avell as the relation of icterus to parenchymatous degenera- tion of the liver, and then dependence of this degeneration upon an increase of the animal heat, and upon intensity of the febrUe crasis. With regard to the rarer sequelae of pneumonia, we may have good reason to suspect the formation of an abscess, AA'hen the shght shiver- ing fits, Avhich accompany purulent infiltration, change into violent rigors; and when a yellow-gray discharge, containing more or less pigment, begins to be expectorated in large quantities; but the diag- nosis is only sure, AA'hen, by means of the microscope, Ave can discover elastic fibres, Avhich, from their structure, are recognizable as belonging to the lung, or Avhen physical exploration shows the existence of a large caAdty in the chest. When a pulmonary abscess ends fataUy, death takes place under conditions similar to those Avhich accompany death from purulent infiltration. If the abscess heal, the expectoration loses its yelloAV color, little by Httle, as the cavity graduaUy becomes enveloped in a capsule of connective tissue; and AA'hen the abscess is completely closed the sputa cease entirely. Should a permanent caAdty remain behind, lined Avith a pyogenic membrane, and surrounded by in- durated connective tissue, it affords the same symptoms, runs the same course, and gives rise to the same danger as do the bronchiectatic cavi- ties of AAdiich Ave have to treat in Chapter XI. The formation of new connective tissue and its contraction in the regions about the cavity also give rise to those depressions of the thorax which Ave shaU describe by-and-by. Gangrene—a A'ery rare sequel to pneumonia—is character- ized by most intense collapse, by the expectoration of a blackish sputum of a most foul, putrid odor, together with the physical signs of a cavity in the lungs (see Chapter XII.). CROUPOUS PNEUMONIA. 179 Caseous infiltration, as a sequel to pneumonia, is by no means con- fined to patients in AAdiose lungs old deposits of tubercle afready exist, but may also take place in subjects preAdously in good health. Espe- cially is this the case with emphysematous persons Avhen attacked by croupous pneumonia of the lungs, which is rare. In such cases. although the fever moderates someAvhat upon the critical day, it does not subside so completely as AA'hen it terminates in resolution. The pa- tients do not improve, the cough and dyspnoea remain. In the evening the pulse is more frequent; auscultation and percussion reveal a persist- ent condensation of the parenchyma of the lung. After some time, the infiltration dissolves, causing vast destruction of the lung, the symp- toms of AAdiich we shall examine more closely Avhen considering the sub- ject of pulmonary consumption. For the termination of croupous pneumonia in induration or cirrhosis of the lung, see Chapter XII. Physical signs of Croupous Pneumonia.—Inspection gives nega- tive results as regards the contour of the thorax. Both sides of the chest preserve their normal dimensions, and the intercostal spaces pre- sent their proper shape of shaUow furrows, a condition of great impor- tance in distinguishing pneumonia from pleuritis. There is, hoAvever, a decided modification of the respiratory movements, since at the begin- ning of the attack the patient favors the affected side on account of the pain; and, as in the later stages of the disease, the vesicles are filled Avith exudation, and hence are imperAdous to the air. It is often possi- ble to recognize the side upon AA'hich the pneumonia has its seat at the first glance, as the healthy side heaves normally, Avhile the inflamed side, as it Avere, lags behind. When both lower lobes are infiltrated, the diaphragm cannot descend; and the epigastrium does not project upon inspiration. The patient breathes by dilatation of the upper part of the chest alone (costal type). The first point AA'hich strikes the attention, upon palpation, is an intensification of the impulse of the heart, and (what is very important in distinguishing betAveen pleuritis and pneumonia) the heart-shock is felt in its normal situation. Palpation also reveals that, during the period of engorgement, and often during that of hepatization, the Adbra- tions of the chest are unusuaUy distinct and strong, Avhen the patient speaks—that the pectoral fremitus is strengthened. This important diagnostic sign may grossly mislead any one, who is ignorant of the fact that, in almost aU healthy persons, the pectoral fremitus is stronger upon the right side than upon the left. This is probably due to the circumstance that the right bronchus is wider, shorter, and stands ahnost at a right angle with the trachea, while the left is longer, and narroAver, and passes off from the trachea more obfiquely. {Seitz.) 180 DISEASES OF THE PARENCHYMA OF THE LUNG. The morbid intensity of the pectoral fremitus, during the stage of en- gorgement, depends upon the loss of elasticity Avhich the pulmonary tissue sustains at this period. Under normal conditions, the transmis- sion of the Adbrations from the trachea and larger bronchi to the thoracic AA'all is impeded by the tension of the elastic vesicles; moreover, the elasticity of the healthy lung exerts a sort of suction upon the inner surface of the thorax, Avhereby thoracic vibrations are held in check. These tAvo forces, by which the normal vocal resonance is enfeebled during health, are removed Avhen the elasticity of the lung is destroyed. The still further increase of the vocal fremitus, which is often observed during the stage of hepatization, is owing not only to the loss of elas- ticity of the hepatized lung, but also to the fact that the Adbrations Avhich the vocal chords have imparted to the air Avithin the trachea and bronchi pass unimpaired to the waUs of the chest, as the medium through Avhich they are transmitted is no longer an interrupted one (alternations of air and vesicular Avail), but a continuous one, the sofidi- fied pulmonary parenchyma. It sometimes happens that the trans- mission of the vibratile waves is checked by a temporary occlusion of the bronchi by secretion; but Ave not unfrequently observe instances, in which the pectoral fremitus over a hepatized point is permanently weakened or is entirely deadened, when there is neither bronchial obstruction nor pleuritic exudation. In such cases Ave may infer that the close contact of a compactly-infiltrated lung prevents the walls of the chest from vibrating. Percussion during the stage of engorgement often gives rise to a purely tympanitic, hollow sound. The elasticity of the normal lung- may be compared to that of a tightly-inflated bladder; its ring is not tympanitic. In the stage of hepatization the vesicles having lost their elasticity, its condition is Hke that of a cluster of imperfectly-inflated bladders. Its percussion-sound then is tympanitic. The "hollow" percussion-sound depends upon a diminution Avhich the exudation causes in the amount of air contained in the vesicles, thereby reducing the size of the vibrating body. We regard the expressions "fidl" and " holloio " as thoroughly inteUigible and practical. By universal cus- tom, the sound produced by the vibration of a large voluminous body is called a " fuU " tone, and that proceeding from the vibration of a small body is called a " hollow " tone. Thus, the percussion-sound of the stomach sounds fuU to the ear of the beginner; that of the smaU intestine IioUoav. I find that there are few practitioners Avho can recog- nize Avith facility that the tympanitic percussion-sound of engorgement also is IioUoav, Avhile for many it is difficult to make out its higher pitch. During hepatization, Avhen the solidified point lies in immediate CROUPOUS PNEUMONIA. 181 contact with the side of the chest—but only in such a case—the percus- sion-sound is deadened, and during the act of percussion an increase of resistance is felt over the point struck. This is because a hepatized lung, like any other compact body void of air, cannot be made to vibrate. The thicker and Avider the hepatized region lying in contact Avith the chest, so much the more marked are the dulness and resist- ance. When the dulness is but slight, it AviU generaUy be perceived that the sound is also hoUow; AA'hen the sound is perfectly dull, the full and holloAV tones cannot be appreciated. When the seat of the dis- ease is central, that is to say, at the roots of the lung, very extensive hepatization of the lung may exist Avithout alteration of the sound upon percussion. Auscultation during the stage of engorgement usually affords a crackling sound to the ear, like that which is heard AA'hen one throAvs salt into the fire, or Avhen a few hairs are rubbed betAveen the fingers before the ear. This crackling {Laennec's rale crepitant), Avhich is formed in the minute spaces of the bronchial terminations and pul- monary A'esicles, is the finest of all the moist rdles, and, as the fluid in Avhich it arises is extremely viscid, it is also the dryest of the moist rdles. Their mode of origin perhaps is, that the vesicular waUs, AA'hich during expiration became glued together, are forcibly separated by the air which enters upon inspiration. As soon as that portion of the lung which touches the thoracic wall is completely infiltrated, vesicular breath- ing is arrested, as the vesicles there are impenetrable to the air. In- stead bronchial respiration is heard, that is to say, Ave hear the sound which the to-and-fro movement of the air in the trachea and larger bron- chi is ahvays making, but AAdiich is not transmitted to the ear through the healthy lung, the structure of AA'hich, consisting of alternations of air and Ajesicular AA'aU, furnishes a poor conducting medium. When, instead of tins bad conductor of sound, a uniform medium lies betAAreen the ear and the bronchi, these bronchial sounds become audible; ahA'ays proAdded, that the bronchi communicate Avith the trachea, so that the air may either pass to and fro in them, or that the air Avhich they already contain may be set in vibration Avith every breath. MoreoA'er, the bron- chi in the condensed part of the lung form better conductors of sound than those which traverse the normal lung. If the bronchi should be filled up by accumulated secretion, as often happens temporarily in the third stage of pneumonia, the bronchial breathing ceases, and does not ao-ain become audible until the bronchi have become emptied by coughing. Bronchophony arises under conditions similar to those under AA'hich bronchial respiration is produced. The vibrations of the Arocal chords durino* speech are conducted along the column of air in the larger bron- 1S2 DISEASES OF THE PARENCHYMA OF THE LUNG. chi, but are only perceptible upon the surface of the chest as an indis- tinct buzzing, as long as the healthy pulmonary substance Hes betAveen the ear and the bronchi; the healthy lung-substance being, as Ave know, a bad conductor of sound. If the parenchyma become condensed, and its transmitting power thereby improved, the bronchi also becoming better conductors of sound, from the thickening of surrounding parts, the sound of the voice in the thorax is louder, constituting " broncho- phony ; " sometimes a tolerably distinct articulate sound is heard, Avhich is caUed "pectoriloquy." If the sensory nerves of the ear perceive an unpleasant jarring sensation from the thoracic AA'aU, we have the " strong bronchophony," AA'hich therefore in part means that the ear when laid upon the chest feels an increase of the pectoral fremitus. Some- times the voice as heard within the chest has a nasal, bleating tone, for AA'hich phenomenon {cegophony) there is no satisfactory explanation. Like the bronchial breathing sound, bronchophony ceases whUe the tubes are obstructed by secretion, and Avhile their communication with the trachea is interrupted. During the process of resolution of pneu- monia, moist rdles are heard. Sometimes, AA'hen the air again begins to enter the minuter bronchi and vesicles, the rale is extremely fine, but, as the secretion has less viscidity than before, the sound is not so " dry " as that " crepitation " heard during the stage of engorgement. This sound is called the crepitatio redux. The rdles produced in the greater bronchi, under conditions like those under AA'hich bronchial respiration and bronchophony arise, may become bronchial " consonant" {Skoda) and "ringing" rdles {Traube). The pleuritis AA'hich constantly accompanies pneumonia is not sus- ceptible of physical demonstration, excepting when it causes a copious effusion. There are scarcely ever any audible friction-sounds in the first stage of pneumonia, since the pleural surfaces rub together very Httle, if at all, at that period. They are heard someAvhat oftener during reso- lution, as the air then reenters the vesicles, and the patients breathe Avith greater freedom, producing friction of the pleural folds. The physical'signs of a great caAdty in the lungs, as a result of ab- scess or gangrene, are identical Avith those of a tubercular cavity. For a further description of them Ave refer to Chapter XIII. Diagnosis.—In chUdren, and in greatly prostrated subjects, particu- larly in old men, pneumonia is often overlooked. In children this occurs chiefly Avhen the disease sets in AAdth convulsions and a violent fever, attended by very little cough, as Httle chUdren do not expectorate, nor knoAV Iioav to tell the seat of their pain. Dyspnoea is then attributed to the fever, and, if the child have diarrhoea, the fever is often regarded as a " tooth fever," with inflammatory irritation of the intestinal mucous membrane; or, if the boAvels be confined, it may be mistaken for acute CROUPOUS PNEUMONIA. 183 hydrocephalus. We ought never to neglect carefully to auscult children aa ith A'iolent fever, brain symptoms, and hurried respiration. The risk of confounding the pneumonia occurring in old and greatly-depressed subjects AAdth typhoid fever is guarded against by the absence of the tumor of the spleen, the eruption, the tenderness in the Ueocaecal region, the initiatory chill, above aU, by the physical examination of the chest. The differential diagnosis between pneumonia and pleurisy aa'UI be more appropriately considered after we have made ourselves familiar AA'ith the symptoms and course of the latter. Valuable for the diagnosis of pneumonia as Ave haA'e seen physical examination of the chest to be, it nevertheless is not of itself sufficient to prove more than the existence of infiltration and filling of the air- vesicles. The character of the infiltration is to be ascertained from the history of the case. Prognosis.—The prognosis, first of all, must depend upon the ex- tent of the disease. Double pneumonia is justly regarded as the most dreaded form. The prognosis, however, depends much more upoh the accompanying fever, since, as Ave have seen, exhaustion from fever ter- minating in general palsy is the cause of death in the majority of fatal cases. An elevation of temperature above 106° F., an increase in the frequence of the pulse above one hundred and twenty beats, renders the prognosis bad. Pneumonia is an extremely dangerous disease to aged persons and to drunkards, OAving to their intolerance of even moderate degrees of fever; and AvhUe but a small proportion of middle-aged patients die of it, the mortality from this disease among old people amounts to betAveen sixty and seventy per cent. Complications of pneumonia AAdth tuberculosis, disease of the heart, Bright's disease, as AveU as the occurrence of endocarditis and pericar- ditis, should cause us to fear an unfavorable result. Among the individual symptoms, the sputum furnishes a clew to the prognosis. The absence of all sputa must, in the beginning, be regarded as unfavorable, as must also the appearance of very dark, broAvnish-red (prune-juice) expectoration. This signifies a poor state of nutrition and fragility of the pulmonary capillaries, and, as a rule, denotes a cachectic condition of the individual. Very copious liquid oedematous sputa are ominous of evil. Scanty expectoration during resolution of pneumonia, if the dulness continue to disappear, is of smaller importance; but ab- sence of expectoration, accompanied by gurgling sounds in the chest, signify palsy of the bronchi, oedema of the lung, and approaching disso- lution. Delirium at the beginning of the disease is a matter of no graAdtA', and is due to the derangement of nutrition in the brain, or to the high temperature of the blood Avliich Aoavs through the brain. At DISEASES OF THE PARENCHYMA OF THE LUNG. a later period it often accompanies exhaustion, so that, Avhen it is per- sistent and intense, it may be regarded as a sign of an adynamic condi- tion, and hence may furnish grounds for alarm. The same is true of the entire train of symptoms Avhich Ave are in the habit of calling " ner- vous" (typhoid). It has already been stated that drowsiness, transient tAvitchings, or palsy, are dangerous signs. FinaUy, the prognosis depends upon the sequelae of pneumonia. A transition from the stage of hepatization into that of purulent infiltra- tion is of far more unfavorable augury than the termination by Hquefac- tion and absorption. The formation of an abscess, caseous infiltration of the exudation, and gangrene, make the prognosis more and more grave. Treatment.—The indicatio causalis cannot be met in the majority of cases, inasmuch as almost every pneumonia arises from unknoAvn atmospheric or telluric influences. Indeed, it Avould be highly inju- dicious to treat a patient Avith pneumonia by diaphoresis, under the assumption that he had " taken cold." With regard to the indicatio morbi, Ave must not forg-et, in the first place, that the natural course of pneumonia is more decidedly cycfical than that of almost any other disease, and that, left to itself, in a vigor- ous patient, if uncomphcated, and of moderate intensity, it almost always ends in recovery. This fact has not been known until recently. We have to thank the so-caUed expectant mode of treatment of the Vienna school and the success of the homoeopaths for this important discovery, from Avhich the foUowing rules are to be drawn. Simple pneumonia attacking persons preAdously in good health requires no more active treatment than does erysipelas, smaU-pox, measles, or . other diseases of cychcal course, provided only that the extent of the disease be mod- erate, and that there be no complication. Indeed, it has been proved that, unless Avarranted by special indications, active interference has an unfavorable effect upon the course of pneumonia; and Dietl is right hi affirming that this disease, AA'hen treated by bleeding, more often termi- nates fatally than Avhere no venesection has been employed. It is quite a different matter to compare the cases in which Ave bleed, not because of pneumonia, but in spite of pneumonia, and for fear of certain com- plications, with those cases in Avhich, upon principle, blood-letting is never practised. Highly as I prize venesection, hoAvever, in certain emergencies AA'hich may arise in the disease, I had rather that any one, dear to me, and sick of pneumonia, Avere in the hands of a homoeopath than in the hands of a physician Avho thinks that he carries the issue of the malady upon the point of his lancet. The number of bleedings which used to be practised by Bouillaud and other disciples of the " saignee coup sur coup" school, likeAvise tends to support the experience of Louis, Died, and others, that bleeding CROUPOUS" PNEUMONIA. 155 is no specific, and that it does not even cut the process short. In fact, the bleedings had to be repeated and continued until the third, fifth, or seventh day—that is to say, until the terminal day arrived—Avhen the cycle of the pneumonic process was complete. Whichever one of the current theories upon inflammation Ave may adopt, none of them even partially upholds the efficacy of venesection in pneumonia. The fact is, unfortunately, forgotten, that the most in tense hyperaemia, by itself, cannot occasion croupous inflammation; that the enlargement and dilatation of the capillaries, Avhich Ave see in valvulai disease of the heart, although they may cause splenification and oedema, never produce croup of the air-vesicles. The subject of venesection can be more appropriately discussed while considering the symptomatic indications for treatment, under Avhich head it, strictly speaking, belongs. I have made extensive employment of cold in the treatment of pneumonia, and, relying upon a large number of \rery favorable results, can recommend this procedure. In all cases I cover the chest of the patient, and the affected side in particular, Avith cloths AA'hich have been dipped in cold Avater and Avell wrung out. The compresses must be repeated every five minutes. Unpleasant as this procedure is in almost all cases, yet even after a few hours the patients assure me that they feel a material relief. The pain, the dyspnoea, and often the frequency of the pulse, are reduced. Sometimes the temperature goes doAA-n an entire degree. My patients often retain this surprising condition of improve- ment throughout the entire duration of the attack, so that their outward symptoms AA'Ould hardly lead one to imagine the grave internal disorder. The relatiA'es of the patient, too, Avho do not faU to perceive the im- provement, noAv readily assist in the treatment to Avhich at first they Avere opposed. In a feAV cases, and only in a few, the use of cold affords no relief, and the troublesome manipulation for its apphcation increases the distress of the sufferers so much that they refuse to keep it up. In such cases I have not insisted upon the further application of cold. In the hospital at Prague every pneumonia is treated AA'ith cold com- presses, and, according to the statements of Smoler, it is exceptional for a patient not to feel material refief from this treatment. As, hoAvever, I have never succeeded in cutting short a pneumonia by means of cold applications, I should only ascribe a paUiative influence to their use, had not the duration of the disease in many instances been decidedly shortened and the convalescence hastened by means of their energetic and methodical employment. In fact, in but feAV cases have we seen the disease delay its departure until the seventh day. Many have im- proved on the fifth, and a very large number as early as the third day; nay, I have repeatedly found it impossible to keep patients Avith recent pneumonia in hospital for a longer period than a Aveek. Cold is rightly 186 DISEASES OF THE PARENCHYMA OF THE LUNG. regarded as one of the most efficient antiphlogistics in inflammation of external organs. Its action is directly tonic upon the relaxed tissues and dilated capillaries. It is harder to comprehend its mode of action upon inflammation of parts separated from the point of application, by skin, muscle, and bone. However, the contraction of the uterus and intestinal muscles, Avhen cold is applied to the abdomen, proves the pos- sibility of its operation upon the interior, and ice compresses have long and justly been held in repute for meningitis, as have also the cold com- presses in peritonitis, by Kiewisch. I have no experience of the effect upon pneumonia of the repeated envelopment of the entire body in cold AA'rappings, as has been practised often by hydropaths; although it may be assumed that it Avould reduce the temperature of the body, and tem- porarily moderate the fever, even if it were unattended by any great direct influence upon the local phenomena. At aU events, I am able to testify that, in the infectious diseases, active coohng treatment has such an effect upon the elevated temperature of the body in a large number of cases. All other modes of treatment recommended for pneumonia cannot be regarded as addressed directly to the cHsease, but, like blood- letting, belong to the indicatio symptomatica—being required only Avhen special symptoms arise. Venesection ought to be resorted to in the foUoAving three con- ditions only: 1st. When the pneumonia has attacked a vigorous and hitherto healthy subject, is of recent occurrence, the temperature being higher than 105° F., and the frequence of the pulse rating at more than one hundred and twenty beats a minute. Here danger threatens from the violence of the fever; and free venesection wiU reduce the tempera- ture, and lessen the frequence of the pulse. In those who are afready debifitated and anaemic, bleeding increases the danger of exhaustion. Should the fever be moderate, blood-letting is not indicated, even in healthy and vigorous individuals. It cannot cut the fever short, and indeed the fever is more apt to persist, although in a somewhat more moderate degree, so that the enfeebled patient is thrown into greater danger than if he had had to pass through a more violent fever, but AA'ith unreduced strength. 2d. When collateral oedema in the portions of the lung unaffected by pneumonia is causing danger to fife, the pressure of the blood is re- duced by bleeding; and, by prevention of further transudation of serum into the vesicles, insufficience of the lung and carbonic-acid poisoning are averted. Whenever the great frequence of respiration in the com- mencement of a pneumonia cannot be traced to fever, pain, and to the extent of the pneumonic process alone, as soon as a serous, foamy expectoration appears, together with a respiration of forty or fifty breaths a minute, and Avhen the rattle in the chest does not cease for a CROUPOUS PNEUMONIA. 1ST AA'hile after the patient has coughed, AAre ought at once to practise a copious venesection, in order to reduce the mass of blood and to mod- erate the coUateral pressure. The third indication for bleeding arises upon the appearance of symptoms of pressure upon the brain, not headache and delirium, but a state of stupor or transient paralysis. Having determined, for one or other of the above reasons, to bleed, the physician must not be misled by the fact that the pulse may be small and feeble instead of full and Adgorous. Among the practitioners of the old school, " a smaU, repressed pulse " Avas ahvays an indication for blood-letting, and a great number of cases may be advanced to shoAv that the pulse often improves immediately after, or even during the venesection, and indeed the rule obtained that Avhen the physician was in doubt as to Avhether the debUity of the patient was genuine or false, he must take notice Avhether the pulse became larger or smaUer after phlebotomy. The foUowing is the reason why the pulse often groAvs stronger and fuUer during or immediately after a bleeding: Ceteris paribus, the size and fulness of the pulse depend mainly upon the abifity of the heart to surmount the resistance opposed by the aorta. If the functional vigor of the heart be reduced by the depressing influ- ence Avhich results from an immoderate increase of the animal heat, and Avhich, in some constitutions, is induced by a very moderate elevation of the temperature of the body, the resistance opposed by the aorta remain- ing unchanged meanwhUe, the volume of blood propelled by the heart is diminished and the pulse-Avave is small. If, noAV, Ave reduce this vascular tension by letting blood, Ave diminish the resistance of the aorta, and enable the heart, although actually enfeebled, to propel an increased volume of blood, and the pulse rises. True, Ave may faU in obtaining this effect, Avhen, as sometimes happens, the effect of venesection is greatly to weaken the action of the heart, so that, although Ave diminish the resistance, Ave also diminish the propulsive poAver. Digitalis has been extensively employed, and AAdth great justice, in the treatment of pneumonia. Like A'enesection, it is a febrifuge, loAvers the temperature, diminishes the frequence of the pulse, Avithout exercis- ing so Aveakening and depressing an effect upon the system as bleeding. Its exhibition is indicated in pneumonia with a pulse of from one hun- dred to a hundred and tAventy in frequence. With a less frequent pulse it is not required. We usuaUy combine an infusion of digitahs ( 3 j— 3 ss. to 3 A'j) Avith the neutral salts of nitrate of potassa and soda. If the latter have any influence upon the progress of the disease, it is only upon the fever; they haA'e no antiphlogistic nor aplastic action. Next come the nauseants (antim. et pot. tart. gr. iv—gr. vj to § vj. S. 3 ss every two hours) and ipecacuanha; after these, quinine, veratrine, 188 DISEASES OF THE PARENCHYMA OF THE LUNG. \ and the inhalation of chloroform. By all of these agents the action of the heart and the temperature can be reduced, and the fever moderated, but they haAre no immediate local influence upon the nutritive disorder. The use of tartar emetic, formerly so common, has of late faUen some- Avhat into discredit. According to experiments Avhich I have made in the last feAV years in the administration of quinine, the indications show that Avhen there is great danger, arising chiefly or entirely from excessive eleAration of the temperature of the body, quinine should be gh'en in doses of tAvo grains every tAvo hours, or, Avhat is better, in two or three ten-grain doses Avithin a feAV hours. According to the observations of Biermer, veratrine (Avhich has already been recognized by Vbgt as a valuable antipyretic) is one of the most certain remedies for reducing the pulse and lowering the tem- perature in pneumonia. To obtain its fuH effect, the tAventieth of a grain of veratrine, or the sixth of a grain of resin, veratri viride, should be given in the form of a pill. The results reported by Biermer Avar- rant further trial of this article in cases of high fever. Its effects are very variable, and it is apt to occasion vomiting, diarrhoea, great pros- tration, and collapse. In the great majority of cases of pneumonia, all the remedies hith- erto mentioned may be dispensed AA'ith, and the disease Avill go on rap- idly to a favorable termination, under the use of cold compresses and some inert mixture of gum-Avater, " a tablespoonful to be taken every two hours," ordered to satisfy the patient " that something is being done for him." The more distinctly we keep in mind the particular phases of the malady Avhich call for active treatment, so much the more successful Avill treatment be. As the disease advances, the symptoms often demand measures the physiological operation of Avhich is exactly the opposite of all those hitherto described. We haAre seen that an extensive exudation, a pro- longation of the pneumonic fever, or, independently of either of these, a debilitated state of the constitution prior to the attack, may give rise to an acute marasmus, a state of the most complete adynamia, and, in- deed, that it is to this exhaustion that most people succumb Avho die of pneumonia. The feeble contractions of the heart tend to produce new dangers from passive oedema of the lung, and commencing palsy of the bronchial muscles embarrasses the evacuation of the bronchi. Stimu- lants must noAv be administered; the heart is to be excited into energetic action; the contractile power of the bronchial muscles must be raised. Fruitless as their extensive employment often is in other diseases, from the transitory character of then action, yet stimulants may produce very gratifying results if given in cases AA-here symptoms of exhaustion arise Avhile the pneumonic process is stUl incomplete. By giving large doses CROUPOUS PNEUMONIA. 189 of camphor, musk, and strong wine, Ave not unfrequently are able, for a period of about tAventy-four or thirty-six hours, to support the action of the heart, to arrest the progress of the oedema, and to facUitate expecto- ration. The " flores benzoes " (Benzoic acid, gr. v every two or three hours) is particularly recommended for this purpose. Compensation for Avaste of substance suffered by the system, Avhich feA'er and augmented combustion threaten to consume, is of far greater importance than is the use of stimulants. Do not carry the antiphlo- gistic diet too far, especiaUy in depraA^ed constitutions and in enfeebled persons, but as soon as distinct indications of asthenia begin to appear, in addition to the wine, give concentrated broths, mUk, etc. The bold administration of the preparations of quinine and iron are peculiarly appropriate in these cases. Rademacher's tincture of iron is especially applicable ( ^ ss to 3 vj Avater. S. § ss—tAvo hours). There is no form of pneumonia which, in the sense of Rademacher, " eine Eisen- affection des gesammt organismus darstellt," but an impoA-erishment of the blood often sets in during the disease, the obviation of AA'hich is quite as AveU promoted by the use of ferruginous preparations as is the chronic deterioration of the blood in chlorosis. A physiological explana- tion of the undoubted usefulness of the preparations of iron in chronic and acute impoverishment of the blood has not as yet been found. We only knoAV that, not only is the iron of the blood increased in amount, but the protein substances, particularly the globulin of the blood, whose quantity ahvays undergoes diminution, increases again under the use of iron. We shall easily convince oursebres that the action of the ferru- ginous preparations in acute impoverishment of the blood is quite as great as in chronic anaemia, if Ave use them AA'ith sufficient boldness in cases of exhausting pneumonic and pleuritic exudation; and, Avithout assenting to the principles of Rademacher, Ave cannot deny the success aa liich his school has attained by the use of iron in acute febrile diseases. Unfortunately, if diarrhoea exist, they are not Avell borne. The employment of stimulants, generous diet, and the preparations of quinine and iron, may be indicated from the very outset of the attack, Avhen an adynamic state develops early, as in the case of old persons, or of cachectic subjects; and it must be regarded as a serious blunder if a physician, avIio, by his stethoscope, has recognized pneumonia in a sup- posed " gastric " or nervous influenza, should proceed to treat the malady upon "antiphlogistic" principles. Local blood-letting, by means of leeches or cups, must be resorted to in all cases AA'here the pain is not mitigated by the employment of cold, or AA'hen the patient cannot bear, or will not submit to the latter. It almost ahvays mitigates the pain, and as pain is not only a troublesome symptom, but is one of the causes of the disturbance of respiration, its remoA'al may have a beneficial effect 190 DISEASES OF THE PARENCHYMA OF THE LUNG. upon the progress of the disease. On the other hand, it is better not to employ cutaneous irritants, whether sinapisms or bhsters, at aU, or at least not untU a late period, when resolution is going on too slowly. FinaUy, if the patient be plagued by cough or restlessness, or by sleep- less nights, the indicatio symptomatica may require the use of narcotics, and we must not fear to administer a Dover's poAvder at night under these circumstances, notwithstanding the persistence of the fever. CHAPTEE X. CATARRHAL PNEU3I0NIA—BRONCHOPNEUMONIA. Etiology.—The catarrhal process is a form of disease peculiar to the mucous membranes, and, as no mucous membrane Avith mucous glands exists in the pulmonary vesicles, the name catarrhal pneumonia is not quite applicable to the disease in question. Nevertheless, as catarrhal pneumonia never arises unless preceded by catarrhal bron- chitis, and as its characteristic pathological alterations are entirely analogous to those of bronchial catarrh, we shall retain the generally adopted title. In many cases catarrhal pneumonia arises solely through the extension of the morbid process from the bronchial mucous mem- brane into the air vesicles. In the great majority of instances, hoAV- ever, this disease develops in pulmonary tissue which has already col- lapsed, a circumstance which makes it more than probable that col- lapse of the air-cells essentially favors its occurrence. It is not sur- prising, moreover, that the capillaries of the alveolar wall, when lib- erated from the pressure of the air enclosed in the vesicles, should be- come enlarged and surcharged with blood, nor that after long persist- ence of this capillary hyperaemia, it should be attended by augmented transudation and copious cell-formation. Noav these are the very alterations which the anatomical appearances of catarrhal pneumonia present. This disease is most commonly observed as a complication of measles, and of AA'hooping-cough; but the reason for this seems to be simply, that capillary bronchitis occurs much more frequently in the course of the latter complaints than in healthy children. Causes of catarrhal pneumonia, other than those from which capillary bronchitis and collapse of the lung originate, are unknoAvn. We may very properly call it a disease of childhood, as it is in children that capil- lary bronchitis, and its sequel, partial pulmonary collapse—the pre- cursors and initial stages, as it Avere, of catarrhal pueumonia—are most commonly seen. Anatomical Appearances.—While croupous pneumonia extends, CATARRHAL PNEUMONIA. 191 1 as a rule, throughout an entire lobe of a lung, or at least throughout a large portion of a lobe, catarrhal pneumonia almost ahvays remains limited to single lobuli, and hence has also obtained the names of lobular, disseminated, insular pneumonia, in contradistinction to the lobar or croupous pneumonia. If the process have developed in the midst of pulmonary tissue AA'hich contains air, Ave observe in the affected lung distinct scattered firm points corresponding to the inflamed lobuli, AA'hich lie chiefly upon the periphery of the lung, and are then distinctly wedge-shaped. Their surfaces He upon a level with that of the surrounding parts. At first they are of a bluish red; later, if the transudation and cell-groAvth predominate, they have a lighter and more grayish color. Upon sec- tion, the surface presents a smooth homogeneous appearance, and there are none of the granulations characteristic of croupous pneumo- nia. Upon lateral pressure upon the inflamed spot, there Aoavs over the cut surface an opaque liquid, at first bloody, and afterward pale-gray in color, in AA'hich, under the microscope, we may see numerous cells, some of them already in a state of fatty metamorphosis. In a more advanced stage, these inflammatory centres undergo the same changes which we have described as taking place in the spots enclosed in col- lapsed pulmonary tissue. The gradual transition of atelectasis into catarrhal pneumonia has recently been studied and described AAdth accuracy by Bartels and Ziemssen. These observers agree in rep- resenting that the collapsed portions of lung exhibit alteration of structure even Avhen the collapse is quite recent. In slighter cases, this alteration is limited to the loAver sharp edge of the lungs, and to a vertical stripe about tAvo inches AAdde at their posterior edge upon either side. In severer and more protracted cases, the entire loAver lobes of each side are involved, the process sometimes extending as far as the back and inner side of the upper lobes. An attempt to inflate them will succeed; but an unusual amount of force is requisite for the purpose; and the reinflated portion does not resume its former pink color, but becomes of a deep scarlet or A'ermilion red, a proof that •the blood in it has increased considerably in quantity. When the collapse is of long standing, the collapsed parts become more A'o- luminous and resistant, and Ave find in them separate compact knots of irregular form and size. If Ave noAv inflate the lung, these knots remain unchanged Avhile the surrounding parts expand and fill AA'ith air. Upon section we constantly find in the centre of these spots a dilated bronchiole filled AA'ith tenacious secretion. The cut surface resembles that of the spots of catarrhal inflammation in the uncollapsed lung-substance (see above). In a more advanced stage, the numer- ous small centres of infiltration often coalesce into A'oluminous masses 192 DISEASES OF THE PARENCHYMA OF THE LUNG. of induration, so that a large portion of the posterior part of the lung exhibits a broAvnish-red, compact, but friable infiltration, out of which only small quantities of purulent but adhesive liquid can be expressed. If the disease be of stUl longer standing, Ave find that the color of the dark-broAvn infiltration has gradually faded from the centre toAvard the periphery, so that the middle assumes a grayish appearance, its firm- ness being at the same time materially diminished. Upon microscopic examination, Ave perceive a further advance in the fatty degeneration of the cellular elements, and a large admixture of granular multinuclear cells (pus-cells). The alterations which we have just described are analogous to those of red hepatization and purulent infiltration AA'ith AAdiich Ave have become acquainted as stages of croupous pneumonia; although fibrinous exudation never accompanies the cell-growth in catarrhal pneumonia. Abscesses may form as one of the rarer sequelae of this disease, AA'hile caseous infiltration is a far more common result of this disorder than of croupous pneumonia. Finally, catarrhal pneumonia often results in neoplastic formation of connective tissue with con- secutive Avasting and shrinking of the parenchyma. At all events, Bartels, in a series of cases, in which the disease had run a more chronic course than usual, found, instead of the changes described above, that large portions of the loAver lobes had acquired a pale, bloodless, strik- ingly compact and firm consistence. The cut surface also shoAved a pale-blue color, and presented a homogeneous, smooth, dry appearance. The parts of the lung thus altered could not be inflated. The bronchi Avere filled by yelloAAdsh caseous plugs. The most striking point was the great increase of the interstitial connective tissue. The condensed portions were traversed by thick grayish-Avhite cords, and bands of connective tissue, AA'hich ran in different directions, crossing one another repeatedly, and forming a Avell-defined netAvork. This termination of catarrhal pneumonia is analogous to the induration Avhich Ave have described as occurring in croupous pneumonia. Symptoms and Course.—It is difficult to draAv up a comprehen- sive picture of catarrhal pneumonia, as the disease is never of primary origin, but ahvays supervenes upon a catarrhal bronchitis or a collapse of the lung proceeding from bronchitis, and its only symptoms consist in modifications more or less distinct of the symptoms of the disorder by Avhich it has been preceded. With the exception of the physical signs, AA'hich, however, are not always characteristic, the kind and man- ner of the cough and the character of the fever furnish the most im- portant data for the recognition of the complication AA'hich has set in. It is highly suspicious if the sick child fear to cough, or Avhen Ave find, by its complaints, or, in a very young child, by the distressed expression of its countenance, during coughing, that coughing gives it pain. We CATARRHAL PNEUMONIA. I93 have already stated, Avhile speaking of whooping-cough, that the cessa- tion of the protracted coughing-spells and the occurrence, in their stead, of short, harsh, painful " hacks," are very serious symptoms; but, in the catarrh of measles, and in a genuine capillary bronchitis, attentive observers will rarely miss the modification of the cough just mentioned. A fact established by Ziemssen is of great diagnostic value, namely, that the temperature of the body always becomes elevated upon the superA-ention of a catarrhal pneumonia upon a catarrhal bronchitis. While the temperature of the body, according to Ziemssen, seldom reaches the height of 102.2° F. in simple capillary bronchitis, upon the development of a catarrhal pneumonia, it often mounts, in a feAV hours, to 105° F. and sometimes still higher. At the same time the pulse becomes more frequent, the face redder, and the child evinces great terror and restlessness, or, in severe cases, soon falls into a state of apathy and somnolence. Upon examining the chest of a child suf- fering from measles, whooping-cough, or genuine bronchial catarrh, AAdiose cough has begun to groAv painful, or Avhose fever has suddenly groAvn Avorse, or in Avhom intense fever has arisen where none has pre- viously existed, Ave must not expect for the first day or tAvo to discover the characteristic physical signs of catarrhal pneumonia. When the pneumonic spots are surrounded by healthy parenchyma, and are of no very great magnitude, neither auscultation nor percussion furnishes any diagnostic data throughout the Avhole course of the disease. On the other hand, if the complaint have developed from an extensive atelec- tasis in a feAV days, an adept in percussion Avill find a dulness, AA'hich is almost ahvays symmetrical, ascending posteriorly upon both sides of the spinal column in a narroAV stripe, AA'hich is characteristic of it, and Avhich does not extend toAvard the lateral regions of the thorax until a late period. As the collapsed portion of the lung at first presents but a thin layer, void of air, we must percuss AAdth feeble, short stroke, in order to recognize the dulness. The pectoral fremitus and the respi- ratory sounds are not as yet altered. At most, the rhonchi and rdles of the capillary bronchitis, in the A'icinity of the collapsed region, are someAvhat less loud and less distinctly audible than in other parts of the luno-. Should the collapse extend, and should the collapsed part become more A'oluminous and dense, the dulness becomes more distinct, extends more outAvardly, the pectoral fremitus becomes stronger. The breathing is bronchial, any rdles which may be heard have a ringing char- acter ; in brief, the signs of auscultation and percussion are now iden- tical with those of a croupous pneumonia at the stage of hepatization. If not called to see the sick child until this period, it may be difficult and even impossible to decide Avhether Ave haA'e to do Avith a croupous pneu- monia or Avith an extensh'e catarrhal inflammation of coUapsed lung. 13 194 DISEASES OF THE PARENCHYMA OF THE LUNG. (Physical exploration, as Ave have repeatedly stated, never gives infor- mation as to the quality of the condensation of a lung, or of effusion into the pleura.) If, on the other hand, we have had opportunity to observe the progress of the malady from its commencement, the dis- tinction betAveen the two is, as a rule, easy: as the occurrence oi double symmetrical condensation and the tardy lateral extension of the narroAV condensed stripes indicate collapse of the lung and catarrha, pneumonia; Avhile, on the other hand, a condensation at first confined to one side, and, afterward, spreading over the whole of one of the pulmonary lobes, denotes croupous inflammation of the lung. The progress of catarrhal pneumonia is sometimes, although not often, a very acute one. The disease may prove fatal in a feAV days, especially if it attack feeble children. In such an event the counte- nance, previously red, becomes pale and livid. The Hps assume a bluish hue ; the eyes groAv dull and lustreless; the restlessness gives place to apathy, and to a continually augmenting somnolence. Owing to the serious disturbance of respiration, the pernicious effects of incomplete oxygenation and overcharge of the blood with carbonic acid soon become apparent. It is also rare for a rapid resolution to occur in catarrhal pneumonia, and, even when it does take place, the sudden decline of the fever so characteristic of croupous pneumonia is scarcely ever seen; so that, in doubtful cases, the termination of the attack by a lysis or a crisis may decide the question as to the distinction between catarrhal and croupous pneumonia. It is much more common for catarrhal pneumonia to take on a subacute, and even chronic course. This is especially true of those cases Avhich set in upon a whooping-cough or chronic catarrhal bron- chitis. Here, as a rule, not only does the consolidation form slovA'ly and gradually, but it continues stationary Avith great persistence often for many weeks. The child becomes extremely emaciated, until death finally ensues with the symptoms above given; or, perhaps, after hope has almost ceased, resolution of the infiltration and complete recovery follow. Tubercular infiltration, abscess, and induration of the lungs following catarrhal pneumonia, present the same symptoms as when they appear as sequelae of croupous inflammation of the lung. Treatment.—It is easy to understand that if, in the course of capillary bronchitis, the cHsease extend from the mucous membrane of the bronchi into the air-cells, producing catarrhal pneumonia, the same general directions already given will apply for the treatment of this disease. This is especially the case with regard to local and general blood-letting. According to the recent experience of Bartels and Ziemssen, the latter never proves of service, and often does con- CHRONIC INTERSTITIAL PNEUMONIA. 195 siderable harm by reducing the strength of the patient, loAvering the energy of the inspirations, and thus tending to encourage the spread of pulmonary collapse; and here I will again briefly call to mind the value of emetics, transitory as it may be, and the frequent lack of suc- cess in their use. It has been of great interest to me, that both Bartels and Ziemssen strongly commend the application of cold com- presses to the cht t (proposed by me in croupous pneumonia), as by far the most efficiei*,; mode of treatment. CHAPTER XI. CHRONIC INTERSTITIAL PNEUMONIA—INDURATION OF THE LUNG-- BRONCHIECTATIC CAVITIES. Etiology.—The lung, AA'hen healthy, has but little connective tis- sue in its composition. A portion of this combines AA'ith numerous elastic fibres to form the pulmonary air-cells; another portion serves to bind together the lobules, Avhile a third belongs to the waUs of the blood-vessels and bronchi. There is a large class of cases in which, instead of these mere rudiments of connective tissue, we find larere sections of the lung converted into a callous, fibrous mass, the product of a chronic :nterstitial pneumonia, which must be regarded as one of the most frequent of diseases. In chronic pneumonia there is no free exudation either into the air- cells, or their interstices, excepting in that form of the affection knoAA'n as caseous infiltration, of AA'hich Ave shall speak by-and-by, whUe treat- ing of pulmonary consumption. While in croupous and catarrhal pneumonia the pulmonary tissues themselves suffer little or no nutri- tive disturbance, in the form of inflammation at present under con- sideration it is precisely this pulmonary intercellular and interlobular connecth'e tissue Avhich is attacked. The process consists in a hyper- plasia of the connective tissue, resulting in an augmentation of the substance of the lung, and in a diminution of its cavities for the recep- tion of air. The neAvly-formed material, by AA'hich the lung is sofidified, then undergoes further changes, as do all other neoplastic formations of connective tissue arising from inflammation. At first soft and filled AAdth blood, it afterward contracts, and is transformed into a callous, bloodless substance, occupying a smaller amount of space than was formerly filled by the healthy lung. Chronic interstitial pneumonia scarcely ever occurs as an indepen- dent and primary disease. Even in the interesting cases observed to folloAV the inhalation of iron or coal-dust, the induration is not a direct result of such inhalation of irritating substances, but only appears DISEASES OF THE PARENCHYMA OF THE LUNG. secondarily, as a consequence of the bronchitis induced by the irri- tant: 1. We have seen that interstitial pneumonia is one of the comjili- cations of prolonged croupous or catarrhal inflammation of the lungs, and that it results in induration of the latter. 2. Simple collapse of the lung appears sometimes to give rise to an inflammatory proliferation of the interstitial substance, resulting in in- duration of the lung. 3. The deposit of tubercle, and especially the softening of tubercu- lous deposits, cancer of the lung, haemorrhagic infarctions, pulmonary apoplexy, and pulmonary abscess, all produce interstitial pneumonia Avith "nutritive" exudation {Virchoio). It is thus that the capsules of connective tissue are found, Avhich separate the products and residue of the processes, above named, from the healthy lung. 4. Interstitial pneumonia not unfrequently forms a complication of chronic bronchitis, when it first involves the parts immediately around the' bronchus, but may extend thence, forming extenshre sohdification of the lung. The occurrence of bronchiectasis as a result of chronic interstitial pneumonia is easy of explanation. The space created in the thorax by contraction of the lung must be compensated for by atmospheric pressure. The thoracic wall sinks in as far as it is possible for it to yield; but, from the structure of the chest, this collapse is restricted within somewhat narrow Hmits, so that a vacuum would form within its cavity were it not that the bronchi become dilated by pressure of the atmosphere. This process is usually described as if the contract- ing tissue of the lung exerted a traction upon the bronchial wall, thus dilating the tubes into spacious canals and extensive cavities. But the extra bronchial traction, Avhich the contracting connective tissue exercises upon the bronchial wall, is not the only cause of bronchiectasis. The discovery of diffuse or sacculated dilatations in the midst of tissue Avhich is simply collapsed, or Avhich stUl contains air, compels us to ascribe the origin of some cases of bronchiectasis to other sources. Unfortunately, the condition in question is an extremely complicated one; and, in spite of the excellent work of Biermer upon the patho- geny and anatomy of bronchial dilatation,, its origin is, as yet, by no means satisfactorily explained. We must, therefore, content ourselves by briefly stating that, in some cases, probably the cahbre of the bron- chus is enlarged by the pressure of stagnant secretion upon its inner surface, especially Avhen the resilience of the bronchial Avail is impaired. In other cases bronchiectasis, perhaps, is a result of atmospheric pres- sure during the act of inspiration, in cases Avhere portions of the lung are incapable of expansion, other portions suffering abnormal compen- CHRONIC INTERSTITIAL PNEUMONIA. 197 satory dilatation. In such a case, if the resisting poAver of the bron- chial Avail be less than that of the pulmonary substance, or if an ob- struction in the smaller bronchi, or other impediment, hinder proper expansion of the vesicles, it Avould seem that compensatory bronchi- ectasis may arise in place of pulmonary emphysema. Finally, it is possible that some bronchiectases may be the result of dilatation of the bronchial Avail at points in the upper lobes of the lung, Avhere the tubes yield before the centripetal rush of air driven into them from the alveoli by the act of coughing, and, AvhUe giving Avay before the pressure, cause bronchiectasis instead of emphy- sema. Anatomical Appearances.—We rarely have the opportunity of examining interstitial pneumonia before it begins to contract. We then find the pulmonary substance solidified and void of air, in conse- quence of SAvelling of the Aesicular walls and scanty intervesicular and interlobular connective tissue. At first it is hyperaemic and reddened; aftenvard of a paler, bluish-gray color. In several cases in Avhich bronchiectatic cavities have been found at the base of the lung in the midst of indurated tissue, I have had an opportunity of obsendng ex- tensive tracts of pale-red homogeneous substance, composed of young connective tissue, and situated betAveen portions of the lung Avhicli contained air. Products of a later stage of the disease are much more frequently met Avith. They consist of bands, or irregularly-shaped masses en- tAvined in the pulmonary substance, are of a Avhitish color, or else are blackened by pigment, and of a dense structure Avhich " cries " under the knife. They surround old masses of tubercle, AA'hich have already become caseous, and tuberculous cavities, abscesses of long standing, *& and the residue of the latter sometimes found in the lung in the shape of calcified concretions. When croupous pneumonia terminates in in- duration, entire lobes of a lung may become converted into this black- ish, callous substance. In the autopsy of individuals Avho haA'e Avorked in coal-mines, or AA'ho have inhaled coal-dust in other occupations, the lungs and bron- chial glands are often found to be of a deeply-black hue. .From the results of recent investigation, there is no doubt that this coloration depends upon the penetration into the lung of particles of coal. As a rule, the pulmonary tissues sustain this intrusion of coal-dust remark- ably Avell, and there are cases in Avhich this anthracosis (that is, black- ness resulting from deposit of coal-dust) has been the only lesion found in the lung. In other cases, the black discoloration is combined vA'ith an interstitial pneumonia, originating from the bronchial walls, but often extending AAddely. In other instances, again, cavities are 198 DISEASES OF THE PARENCHYMA OF THE LUNG. found in the indurated tissue, which are undoubtedly to be regarded as suppurating bronchiectases. Zenker, in a valuable treatise, shows that disease of the lungs may also arise from the inhalation of iron-dust, which, in all essential par- ticulars, is simUar to anthracosis, differing merely in the nature of the dust inhaled, and in the color of the lung, which is of a slate-coloi instead of black. In one of the cases of this disease, reported by Zenker, for which he proposes the name of siderosis, or of pneumono- koniosis siderotica {!), the oxide of iron, which had entered the lung, had given rise to extensive induration and to the formation of large cavities. Rokitansky describes saccular dilatation of the bronchi as foUows: " We find a bronchial tube widened into a fusiform, or rounded pouch; in the latter case the dUatation often being greater upon one side than another, so that a greater part of the bronchial sac lies out of the axis of the bronchial tube. In rare cases, the size of such a pouch may equal that of a hen's egg. They will often contain a bean, a hazelnut or a walnut. We further find either that any one of the bronchial tubes may become expanded into a pouch of this kind, the tube retaining its normal calibre upon either side of the dUatation, or else quite a large tract of the bronchial ramifications may undergo enlargement. Then, many such sacs of different size are so grouped together that they form, as it were, a vast sinuous cave with many branches, Avhose individual pouches are bounded and separated from one another by ledges or valAadar folds of the bronchial wall." The inner surface of bronchiectatic caAdties is at first smooth, the mucous crypts haAdng flattened out and disappeared through excessive extension. The mucous membrane having thus gradually lost its char- acter, becoming more like a serous membrane, its secretion also at first bears some resemblance to that of a serous sac. We find in bronchi- ectatic cavities a synovia-like liquid, resembling that found in a greatly over-distended gall-bladder, or in an obstructed processus vermiformis. At a more advanced stage, however, the inner surface often loses its smooth character, and the contents of the cavity undergo change. OAving to the unyielding condition of the surrounding parenchyma, Avhich is not compressed even by the most violent coughing, and par- ticularly if the cavities are situated in the lower lobes of the lung, it becomes extremely difficult to get rid of the secretion. Hence, the latter, exposed to an elevated temperature, and in communication with the atmosphere, is converted into a foul, yellow, stinking ichor, which often acts as a corrosive upon the Avails of the cavity, producing sloughs, and depriving the Avails of their smoothness. It is not un- common for severe haemorrhage to take place AAdien these sloughs CHRONIC INTERSTITIAL PNEUMONIA. 199 separate. In other cases, the putrid contents of the dilated tubes cause inflammation or diffuse putrescence of the lung. In the very rarest instances, the bronchus leading to a cavity becomes obliterated, Avhen its contents may be transformed into a cheesy or calcified paste. Symptoms and Course.—In its first stage interstitial pneumonia can hardly be recognized Avith certainty. Should the resolution of a croupous pneumonia be very tardy; if Ave find, after the lapse of weeks, that the percussion-sound continues dull and the respiration bronchial or indistinct, Ave may anticipate that the disease avUI terminate in indu- ration, particularly if the patient have no fever, and gradually recover his health, so that Ave may exclude the idea of cheesy infiltration. We cannot diagnose the disease with certainty until the thorax commences to sink in at the affected side, and the signs of bronchiectasis appear. It is quite the same with regard to the interstitial pneumonia AA'hich accompanies tuberculosis, and caseous infiltration of the lung. As this is one of the constant complications of the above diseases, Ave may reasonably mfer that the dulness at the apex of the lung observed in consumption is due in part to interstitial pneumonia. The depres- sion of the supra and infra clavicular regions, AA'hich sometimes accom- panies pulmonary consumption, can only be ascribed to this interstitial pneumonic induration, since neither reduction of the dimensions of the lung, nor depression of the thoracic Avail, is produced either by tubercular deposit, caseous infiltration, destruction of the pulmonary substance, or by the establishment of cavities. Although this symptom (Avhich is often erroneously caUed a pathognomonic sign of consumption) is a very common one among consumptive patients, yet this is only because the process by Avhich the lung is destroyed is almost ahvays accompanied by a chronic pneumonia, which causes its induration and contraction. "When chronic pneumonia is associated with chronic bronchitis and emphysema, depression of the thoracic Avail is less com- mon. In such cases the only diagnostic signs are the coughing-fits, characteristic of the existence of cavities Avith rigid Avails, and the na- ture of the sputa. When the disease is somewhat extensive, signs of dilatation and hypertrophy of the right side of the heart are added to the symptoms above described; and at a later period, where hypertrophy of the heart is no longer capable of counteracting the effects of obstructed circula- tion, cyanosis appears, AAsith blueness of the lips, puffiness of the face, enlargement of the liver, and finally dropsy, symptoms Avhich, as Ave haAC learned, also accompany emphysema. An explanation of this is easy; the obstacle to evacuation of the right heart manifestly pro- ceeding from atrophy of the pulmonary capillaries. We rarely observe 200 DISEASES OF THE PARENCHYMA OF THE LUNG. cyanosis in the pulmonary induration which accompanies consumption, although in such cases there is a double hinderance to the pulmonary circulation. This is attributable to the circumstance that, simultanc ously Avith the destruction of the pulmonary capillaries, the volume of the blood is reduced by hectic fever. Easy as it often is to recognize bronchiectatic caAdries of the lung with certainty, the diagnosis in other instances is extremely obscure. The signs usually described as pathognomonic of bronchiectatic cavi- ties are only met with in cases which are uncompficated AA'ith tubercu- losis or cheesy infiltration, and where the caAdties are situated in the loAver lobes of the lungs. Bronchiectatic cavities at the apex of the lung, lying side by side AAdth tuberculous cavities, cannot be distin- guished from the latter even upon dissection, to say nothing about recognizing a difference betAveen them during Hfe. The manifestation afforded by a bronchiectasis in the loAver lobes of the lungs is readily explicable, if Ave only know the extreme difficulty of discharging the contents of cavities in such dependent positions. The Hquid contents of a vomica at the apex of the lung has no difficulty in flowing away through the obliquely descending bronchi, but the discharge from a similar cavity situate in one of the loAver lobes, through bronchi Avhose direction is obliquely upward, is either quite impracticable, or, at least, only practicable whUe the body is in particular attitudes. (Cases occur in Avhich copious volumes of the thick, yelloAvish-green fetid contents of a bronchiectatic cavity pour from the mouth of a patient, even be- fore he has coughed, Avhenever he stoops fonvard or alloAvs the upper part of the body to sink laterally Avhile lying in bed.) OAA'ing to the difficulty and incompleteness wdth which bronchial cavities in the loAver lobes of the lung are emptied, and to other un- known causes, the contents of the cavities often undergo putrefaction. This putrid sputum has an extremely penetrating, fetid odor (particu- larly at the moment of its expectoration), and is less viscid than most catarrhal sputa, often containing caseous plugs, in Avhich clusters of margarine crystals are found. When collected and alloAved to stand, it separates into three strata, an upper frothy layer, a middle layer of Avhitish-gray Hquid, and a thick grayish-green sediment; in short, it completely resembles the sputa of diffuse bronchial dilatation, and of putrid bronchitis. Nevertheless, in most cases, it is easy to decide Avhether Ave have to do Avith the latter form of disease, or with a sac- culated bronchus. In the former, the coughs folloAv AA'ith short inter- vals, and all the sputa Avhich the patient ejects are of similar quahty. On the other hand, patients with a bronchiectatic sac often announce of their oAvn accord, that they " have tAvo kinds of cough." Indeed, half a day, or even a whole day, may pass, and the patient Avill cough CHRONIC INTERSTITIAL PNEUMONIA. 201 but little, expectorating small quantities of catarrhal sputa. This will be folloAved by a violent paroxysm of coughing, in which, in course of a short time, the patient will eject enormous quantities of putrid secre- tion. YVlien the fit is over, another long period of exemption begins, the spit-cup remaining empty for six or eight hours, or receiving but a few expectorations of mucus, when another attack AAdll soon fill it to overflowing. The Avails of bronchiectatic cavities seem to be tolerably insensible, and the irritation of the putrefying secretion does not appear to give rise to cough. It is only AAdien the sac is completely full, and AA'hen its contents reach the neighboring bronchi, AA'hich stUl retain their normal sensitiveness, that the cough begins. We may, therefore, assert that violent coughing-fits, which recur at long intervals, and during Avhich large quantities of putrid sputa are expelled, are pathog- nomonic of the existence of a bronchiectatic cavity. In addition to the symptoms hitherto described, there is usually Avell-marked cyanosis, and, at a later period, dropsy. In bronchiectasis of long standing, I have hardly ever failed to find the clubbed enlarge- ment of the terminal phalanges such as usually forms in cases of per- sistent cyanosis. These signs of venous engorgement are not, hovrever, directly dependent upon bronchiectasis, being due rather to the con- comitant induration of the lungs (see above), and hence they are absent in the Aery rare instances in Avhich bronchiectasis is not accompanied by extensive induration. Physical examination ahvays affords Aery characteristic results Avhen the bronchial sacculation lies close beneath the thoracic Avail. When the pulmonary substance about the cavity is consolidated and contracted, the thorax is also depressed at the point corresponding, the percussion sound is exceedingly dull, and the sensation of resist- ance consiuerably increased. Upon auscultation, if the patient have not coughed for some time, Ave hear either an enfeebled respiratory murmur or else indistinct moist rdles. Upon compelling him to cough, so as to provoke copious expectoration, the enfeebled respiration is often replaced by loud bronchial or even caArernous breathing. On the other hand, there are some cases in Avhich physical examination furnishes no aid to diagnosis, because the cavity is situated more toAvard the centre of the lung, and is surrounded by normal paren- chyma. In spite, hoAvever, of the absence of physical signs of a cavity, Ave may diagnose its existence with positive certainty AA7hen a patient, Avithout suffering any precursory dyspnoea, expectorates half a pint or more of purulent secretion in the course of a feAV minutes. Such enor- mous quantities of matter could only come from a large caAdty, as its presence in the bronchi Avould render respiration extremely difficult, if not impossible. OQ2 DISEASES OF THE PARENCHYMA OF THE LUNG. Diagnosis.—It is often by no means easy to distinguish a diminu- tion and consolidation of the lung, resulting from interstitial pneu- monia from a similar condition arising from ■ continued compression. The thoracic wall sinks in after either process, and the heart, Hver, and spleen are displaced, so that the history of the case is often our sole guide. If it cannot be determined whether the primary disease have been pleurisy or pneumonia, the question often remains unsolved, al- though bronchiectasis is far oftener a consequence of interstitial pneu- monia than of compression of the lung. In distinguishing bronchiectatic caverns from tuberculous excaAra- tions, besides the difference of their situation, the following points are to be taken into consideration: 1. Patients AAdth bronchiectasis are generally free from fever, and hence often long retain a tolerable de- gree of strength, and suffer but little emaciation. 2. Secondary dis- ease of the larynx and intestine is of rare occurrence in cases of bron- chial dilatation; hence, hoarseness and diarrhoea, in a doubtful case, Avould indicate the tuberculous nature of the disease, although the coexistence of bronchiectasis is by no means excluded. 3. Saccular dilatation of the bronchi is so often accompanied by emphysema that, in forming a differential diagnosis between bronchiectasis and tuber- cular excavation, the evidence of the existence of emphysema would turn the scale in favor of the former. Prognosis.—As interstitial pneumonia scarcely ever is an inde- pendent affection, the prognosis depends essentially upon the original disease. This is especially the case when the malady accompanies tuberculosis. Extensive wasting of the lung, consequent upon tedious pneumonia, or accompanying chronic bronchial catarrh and emphysema, is often endured for a long time, even after bronchiectatic cavities have formed, the patients only succumbing at a late period, upon the establishment of marasmus and dropsy. At other times, life is sud- denly endangered by haemorrhage from the walls of the caverns, or by pneumonia from diffuse putrescence of the lung. Treatment.—In the stage at which interstitial pneumonia becomes recognizable, it is as impossible to do any thing for its reHef as it is to soften and resolve any other form of cicatricial tissue. We are equally powerless to effect the closure and obhteration of bronchiectatic vomicae. It only remains, therefore, for us to see to the emptying of these cavities, so that the foul secretion may not occasion still greater corrosion of the bronchial walls or parenchyma of the lungs. As a second indica- tion, we must endeavor to limit the secretion, both of the cavity itself and of the bronchi, from which secretion seems to flow into the cavity. Both indications are best met by the inhalation of oil of turpentine, as recommended above. It has already been mentioned that this pro- GANGRENE OF THE LUNGS. 203 cedure actually represses the secretion, and we can easUy convince our- selves that, after an inhalation of a quarter of an hour, violent coughing folloAvs, and evacuation of the cavities is effected. The inhalations are repeated three or four times daily, and I have seen patients raised by this means from a condition of extreme misery to one of tolerable comfort, Avhich lasted for some time. CHAPTER XII. GANGRENE OF THE LUNGS. Etiology.—Various forms of mortification have already come under our notice in the foregoing chapters, among others, that of abscess as a sequel of pneumonia, and disintegration of the pulmonary parenchyma as a consequence of haemorrhagic infarction. Mortification proper, gangrene of the lung, differs from these forms of necrosis, inasmuch as the dead part putrefies and undergoes chemical decomposition. Putre- factive decomposition of necrotic parts of the economy occurs most commonly in organs which are exposed to contact AAdth the air, such as the skin and the lungs, while in the brain, the liver, and the spleen, as long as they remain within their normal envelopes, putrefaction of dead tissue is not so apt to occur. The transition of necrosis into gangrene is materially promoted if a " ferment" (a bit of putrid ma- terial) come in contact Avith the mortified part. This explains Avhy, though circumscribed gangrene of the lungs may be produced by haemorrhagic infarction in disease of the heart, through obstruction of the nutrient arteries (the bronchial arteries), it is that such a result is far more common in metastatic infarction, caused by an embolus from some region Avhere putrefaction is going on. Diffuse pulmonary gangrene arises, in rare instances, during the culminating period of pneumonia, the inflammatory stasis causing the absolute arrest, both of circulation and nutrition, in the inflamed region. Such an occurrence is the more likely AA'hen stagnation of the blood in the capUlaries causes coagulation of that which is in the bronchial arteries. Pneumonia caused by entrance into the air-passages of food, or the residua of food, is especially prone to run into gangrene, OAving to the putrefaction of these foreign bodies. Gangrene may also arise with or without preAdous inflammation, from corrosion of the tissues surrounding a diffuse or saccular bronchi ectasis, and their implication in the putrefaction of its contents. It is difficult to explain the occurrence of diffuse gangrene of the lungs in drunkards, and in persons Avhose constitution has been much 204 DISEASES OF THE PARENCHYMA OF THE LUNG. debilitated by misery and deficient nourishment; as is also its frequent appearance in lunatics, even Avhere no foreign body has entered their air-passages, and its occurrence in the course of severe asthenic fever, measles, small-pox, and typhus. It would seem, indeed, as if a part, Avhich already has suffered derangement of its nutrition, Avere espe- cially liable to die Avhen its tissues are exposed to further inflammatory disturbance ( Virchow). Anatomical Appearances.—According to the distinction of Laennec, there are tAvo forms of pulmonary gangrene, the circum- scribed and the diffuse: 1. Circumscribed gangrene is the more common form. At isolated points varying in size, from that of a hazelnut to that of a walnut, Ave find the parenchyma of the lung converted into a bluish-green, moist, frightfully fetid slough, resembling the eschar of the skin produced by caustic potash. It is abruptly limited, and surrounded by oedematous tissue alone. This sphacelous spot, which is at first tolerably firm, and adherent to the adjacent parts, soon decomposes into an ichorous liquid, which merely contains in its interior a somewhat hard greenish-black core, mixed up with rotten and ragged debris of the tissue. The seat of circumscribed pulmonary gangrene is generally the periphery of the lung, and the loAver lobes. Not unfrequently a bron- chus opens into the gangrenous spot; the ichor of the slough enters the tube, and an intense bronchitis is the result. In a few cases, the pleura also mortifies; the slough softens, the ichor flows into the cavity of the sac, and thus a dangerous pleuritis is set up; and if the gangrenous centre at the same time communicates with a bronchus, pyopneumothorax may occur. In other instances, diffuse gangrene arises from circumscribed gangrene of the lungs. In very rare cases indeed, interstitial pneumonia arises in the surrounding parts, resulting in incapsulation of the gangrenous point; the sloughs are ejected and cicatrization folloAvs, such as Ave see in pulmonary abscess. 2. Diffuse gangrene of the lung not unfrequently attacks an entire lobe. We then find the parenchyma decomposed and converted into a putrid, tinder-like, black, stinking substance, saturated with blackish- gray ichor. UnHke the preceding form, the process is not abruptly limited, but is gradually merged in the oedematous or hepatized paren- chyma. If the mortification reach the pleura, it too is destroyed. Recovery never takes place, the patient dying of general constitutional disturbance. Either form of gangrene may lead to introduction of decomposed tissue into the veins, to embolism, and to metastatic abscess in the various organs of the greater circulation. GANGRENE OF THE LUNGS. 205 Symptoms and Course.—We have seen that the signs of haemor- rhagic infarction and metastatic deposits in the lungs are very obscure. Even circumscribed gangrene, AAdiich develops from haemorrhagic infarction and metastatic deposits, cannot generally be diagnosed until the gangrenous discharge reaches a bronchus and is ejected. Then, indeed, the foul odor of the breath, the blackish-gray liquid, and also the very ill-smelling sputa, leave no doubt about the nature of the case. Sometimes the fetid smell of the breath precedes the characteristic expectoration by some days. The sputa, Hke those of the decomposing contents of a bronchiectatic caAdty, soon separate into several layers, a frothy superficial one, a liquid middle stratum, and a thicker sedi- ment. The color of the expectoration is of a dirty blackish or broAvn- ish color. It contains black, tinder-like masses, and frequently soft cores, containing acicular crystals of fat. In rare cases, it also con- tains fibres of Avavy, elastic tissue. Sometimes, physical exploration affords further information. The sound upon percussion is tympanitic, more rarely dull, and in a feAV instances cavernous sounds may arise. Some patients evince the greatest prostration from the beginning; the countenance is " pinched " and livid, the pulse small and extremely frequent, and the patient soon perishes from asthenic (putrid) fever. Others bear this serious disorder Avonderfully well. Their general condition is scarcely changed; they Avalk about, are Avithout fever, and the disease goes on for Aveeks. In these cases haemorrhage may arise at a later period, AA'hich may exhaust the patient; or, after a time, asthenic fever may develop, to AA'hich the patient may succumb, after lingering, noAV better, iioav Avorse, for a long time. Should recovery take place (a very rare event indeed), the odor of the sputum dis- appears, it gradually becomes yelloAV, and at last, if the gangrenous spot be incapsulated and atrophied, it may cease altogether. When diffuse pulmonary gangrene arises from pneumonia, Ave observe a sudden loss of strength during the progress of the latter disease, with a small irregular pulse, a disturbed countenance, and soon the fetid breath and blackish liquid sputum, Avith its penetrating odor, are added to the above symptoms. When diffuse gangrene arises independently of pneumonia, it is attended from the outset by signs of extreme adynamia, and by symptoms like those Avhich accompany the entrance of septic matter into the blood, rigors, delirium, stupor, hiccough, etc. The expectoration then often ceases entirely, either because the bronchial mucous membrane itself has become gangrenous and insensible, or else because the patient no longer can respond to any irritation AArhate\rer. They hoav not unfrequently swallow Avhat sputum still reaches the fauces, and thus bring on an obstinate diar- rhoea in lieu of the expectoration. 206 DISEASES OF THE PARENCHYMA OF THE LUNG. Physical examination in diffuse pulmonary gangrene at first affords well-marked tympanitic sound, and afterward a dull one on percussion. Upon auscultation, we hear indistinct breathing and rdles, and after- ward bronchial or even cavernous sounds. Treatment.—The treatment of gangrene of the lungs is some- Avhat ineffectual. The inhalations of turpentine, recommended by Skoda, deserve consideration, as being recommended by an author distinguished by his skepticism in therapeutics. Whether it be of service in other forms of pulmonary gangrene than those which arise about bronchiectatic caAdties, may be doubted. Nourishing diet, wine, infusion of bark, and stimulants may be required by the gen- eral condition of the patient. They are of no avail against the gan- grene itself, any more than is acetate of lead, creasote, or charcoal. TUBERCULOSIS OF THE LUNG. The term pulmonary tuberculosis continues to be the expression most commonly used to signify consumption of the lungs, a proof that the majority of modem physicians and clinical teachers still adhere to the teachings of Laennec, and only recognize one form of pulmonary consumption, the tuberculous form. I have long contested this doc- trine, and, upon various occasions, have declared, in direct contradic- tion to it, that destruction of the pulmonary tissues, the establishment of caAdties and consumption of the lung are much more frequently a result of chronic inflammation than of tubercular deposit. And I hope that these vieAvs, of whose justness any one may easUy satisfy himself Avho avUI only study the subject with calmness and without prejudice, Avill ultimately obtain general acceptation. The error into which Laennec and his disciples have fallen is not that they regard tubercle as a neoplasm, but that they look upon soHdifications of the lung, due to entirely different causes, as products of tuberculosis. Even according to modern views tubercle stUl ranks among the pathological neoplasms, although, however, but one form, the miliary form, and one mode of origin, miliary tuberculosis, is rec- ognized. It is one of the characteristics of tubercle, that it always appears in the form of small nodules, scarcely as large as a millet-seed, and that the individual nodules never groAv into voluminous tumors. The larger so-called tubercular nodules consist always of an aggrega- tion of many small mUiary tubercles. All the extensive indurations and enlargements formerly described as tuberculous infiltration, or as infiltrated tubercle, depend neither upon infiltration of the tissues with TUBERCULOSIS OF THE LUNGS. 207 tubercular matter, nor upon diffuse development of tubercle, but upon morbid processes of a different nature. In the lungs it is more especially the residua of chronic inflamma- tion Avhich Laennec and his pupils have regarded as tubercular infiltra- tion. The main source of their error was the idea that caseous meta- morphosis, to which tubercle of long standing almost invariably is subjected, Avas a specific peculiarity of the disease, and that it might be regarded as a diagnostic mark, by which the tuberculous nature of a groAvth, Avherein the process arose, might be determined. Accord- ing to such views, the product of chronic pneumonia, Avhich often ap- pears in phthisical lungs independent of tubercle, Avas ascribable to tuberculosis, since, generally speaking, this inflammatory product at first is moist, transparent, and of a grayish or grayish-red color, and, after a lapse of time, becomes transformed into dry, opaque, yelloAv, cheesy masses, and, subsequently, into a creamy or curdy, flocculent liquid ("tubercular" pus). But the point of AdeAV, from which caseous metamorphosis Avas con- sidered a characteristic sign of tuberculosis, is obsolete. It is well established that not only tubercle but many other formations with which it has nothing in common, such as old, cancerous nodules, lym- phatic glands enlarged by hyperplastic cell-growth, haemorrhagic in- farctions, incapsulated collections of pus, may all undergo caseous metamorphosis, and the term tuberculization, Avhich has been produc- tive of great confusion, and against Avhich I have long protested, has faUen into disuse. By this important step in pathological anatomy, for Avhich Ave are chiefly indebted to Virchow, the very foundation of the teachings of Laennec is swept away. His fundamental idea that all pulmonary consumption depends upon neoplasm, after having exercised a most baneful influence both upon the prophylaxis and the treatment of the disease, is no longer tenable, and it is really incomprehensible that the majority of physicians of the present day should still adhere to his AdeAvs. Although the consohdation and destruction of the pulmonary tis- sue in consumption is mainly a result of inflammation, yet the frequent coexistence in phthisical lungs of the products of chronic pneumonia and tubercle renders it improbable that the presence of the latter should be purely accidental, and suggests a causative connection be- tAveen tubercle and the inflammatory lesions. According to the com- mon opinion, this connection is, that tuberculosis is the primary affec- tion, to Avhich the pneumonic process is secondary and dependent. It cannot be denied that this view is right in certain cases; in a great majority of instances, however, the converse is true; the tuberculosis 208 DISEASES OF THE PARENCHYMA OF THE LUNG. supervening as a secondary process upon a preexisting pneumonia. It is, indeed, rare for tubercles to form in a lung AA'hich does not contain products of chronic inflammation. As the formation of tubercle never takes place unless preceded by a pneumonia terminating in caseous infiltration of the pulmonary tis- sue, and, as it occurs AA'ith equal frequence, AA'hether the. infiltration be a sequel to croupous, catarrhal, or to chronic inflammation, avc may as- sume that there is no direct and immediate relationship, or community of origin, betAveen tuberculosis and the inflammatory disorders AA'hich generally precede it, but that their connection is indirect, arising from the caseous metamorphosis of the pneumonic product. The truth of tins supposition is materially supported by the fact that, in the rare instances in AAdiich tubercles have developed in lungs Avhich were in other respects healthy, caseous deposits have almost ahvays been found in other organs, and no less so by the observation that, in exten- sive tuberculosis, the oldest and most numerous tubercles are ahvays found in the immediate vicinity of masses of cheesy degeneration. The peculiarly frequent occurrence of tubercle in the lungs is manifestly because there is no other organ in which diseases arise Avhich so often terminate in caseous metamorphosis. Having thus distinctly stated my belief in a causative relationship betAveen caseous infiltration of the lung and pulmonary tuberculosis, and having called attention to their frequent coexistence, in our next chapter, we may, Avithout impropriety, discuss the subjects of chronic pneumonia Avith caseous infiltration, and of chronic pulmonary tubercu- losis, under a common heading, as the tAvo diseases Avhich play the principal part in pulmonary consumption. In Chapter XIV. we shall speak of acute miliary tuberculosis, Avhich is not accompanied by chronic pneumonia, and Avhich never gives rise to destruction or con- sumption of the lungs. CHAPTEE XIII. CASEOUS INFILTRATION AND CHRONIC TUBERCULOSIS OP THE LUNGS-- PULMONARY CONSUMPTION. Etiology.—When pneumonia terminates in resolution, the inflam- matory product undergoes fatty metamorphosis; then liquifies, and is absorbed. When the disease is followed by caseous infiltration, the fatty metamorphosis is incomplete. The infiltration dries up; the cells AA'hich it contains are atrophied; they lose their rounded form, and shrink, through loss of their water, into irregularly-shaped clots. A large part of this process is evidently mechanical, and it is highly CONSUMPTION OF THE LUNGS. 209 probable that, OAving to the immense multitude in AA'hich the cells are generated, they become croAvded together so densely as to become mutually hurtful, and in consequence Avaste, shrivel, and degenerate (Virchow). We must emphatically express our dissent from the theory that caseous infiltration of the lung, AA'ith its concomitant formation of vomicae, has its source in a form of primary inflammation of peculiar nature, Avhich is distinguishable from other A'arieties of pneumonia. The hypothesis of a " tuberculous or caseous inflammation of the lung" is entirely untenable, and only tends to cause fresh confusion. On the contrary, it may be said, AA'ith perfect truth, that all forms of pneumonia may end in caseous infiltration under certain conditions, and that there is no form of pneumonia of Avhich caseous infiltration is a sole and constant termination. It is true that the difference is very great in the frequence Avith AA'hich the inflammatory products of the A'arious forms of pneumonia undergo cheesy transformation instead of liquefaction and absorption. In croupous pneumonia such a result is rare; in acute catarrhal pneumonia it is somewhat more frequent, Avhile in the chronic catarrhal form it is almost the rule. I regard the name chronic catarrhal pneumonia as the only title appropriate to the form of disease usually called infiltrated tubercu- losis, and gelatinous or tuberculous infiltration, and which latterly and with equal impropriety has sometimes received the name of tubercu- lous or of cheesy pneumonia. This lobular infiltration, or (Avhen the disease is extensive, as it often is) this lobar infiltration of the lungs, Avith its homogeneous section and its color and glitter of frog-spavra, is not dependent simply upon a filling of the air-vesicles Avith young spherical cells of indeterminate nature, that is to say, with the ana- tomical products of catarrhal pneumonia, but arises, AA'ith rare excep- tions, through extension of a chronic catarrh, AAdth a copious secretion of young cells, into the finer terminal bronchioles, and thence into the pulmonary vesicles. I certainly should attach Httle weight to the application of the name chronic catarrhal pneumonia to the so-called gelatinous pneumonia, did I not believe that, by calling the disease by its proper name, not only is our comprehension of the etiology and pathology of the malady facilitated, but its prophylaxis and thera- peusis are promoted. It is not difficult to understand why chronic catarrhal pneumonia should generally give rise to caseous infiltration, far more frequenth', indeed, than the acute form of the disease, or than croupous pneumonia. OAving to the slowness and tedious nature of its progress, the tendency of AA'hich is to a perpetual accumulation of voung cells in the air-vesicles, perhaps also by an inhalation of cells from the smaller bronchi, thus adding 'still more to those already ]4 210 DISEASES OF THE PARENCHYMA OF THE LUNG. generated in the vesicles, the cells are more and more croAvded to- gether, thus becoming mutually injurious, and undergoing degem eration. The knoAvledge that the majority of cases of consumption are not the result of neoplasm but of inflammation, and that, Avhen tubercles exist in phthisical lungs, the tuberculosis is almost ahvays preceded by a pneumonic process, which, by caseous degeneration of its products, has prepared the soU for the growth of tubercle, has been of material assistance in explaining the etiology of consumption. Numerous well-established facts, which had hitherto defied all interpretation (as long as consumption was always ascribed to neoplasm), are now fully reconcilable to the generally acknoAvledged laAVS of pathology. Predisposition to pulmonary consumption or, to speak more pre- cisely, the predisposition toward pneumonia terminating in cheesy in- filtration, is strongest in persons of feeble and delicate constitution. It is by no means meant by this that vigorous persons, possessing normal resisting power against noxious influences, enjoy an immunity from this disease. Indeed, although it is somewhat rare, even croup- ous pneumonia sometimes terminates in caseous infiltration, Avith sub- sequent disintegration of the lung, in individuals who, prior to the attack, were in perfect health, and gave no signs whateA'er of weakness or dehcacy of constitution. In similar manner the most Adgorous and blooming children may be attacked by acute catarrhal pneumonia, during the measles or whooping-cough, and may soon perish through caseous metamorphosis of the pneumonic product. The origin of the many deaths Avhich have been observed to take place after an epi- demic of measles or of whooping-cough, and Avhich, until recently, has been chiefly ascribed to tuberculosis, is, in most cases, really traceable to the effect of a catarrhal pneumonia contracted during the course of the above-named disorders. But even a simple, genuine catarrh may extend into the air-vesicles in a person of apparently perfect health and vigor. Healthy men should never feel sure that they Avill not die of an acute or chronic catarrhal pneumonia, proceeding from a cold, and resulting in caseous infiltration and destruction of the pulmonary substance. That feeble and ill-nourished persons should be in far greater dan- ger of becoming consumptive than vigorous, well-nourished ones, will not appear extraordinary from this point of Anew. Daily experience teaches us that a bad state of nutrition is usuaUy accompanied by a feeble poAver of endurance of noxious influences. Even Avithout especial knoAvledge of the fact, it is usually assumed, a priori, that feeble, badly-fed persons are " sickly "—that they are especially prone to disease,' and that they do not recover as rapidly CONSUMPTION OF THE LUNGS. 211 from its attacks. The frequence Avith Avhich the various organs of the body are affected by disease differs according to the age of the indi- Addual. Persons Avho, during childhood, have often suffered from croup. pseudo-croup, cerebral irritation, and moist eruptions, are liable during and after the period of puberty to bronchial haemorrhage and to in- flammatory disorders of the lungs. But delicacy and a Hability to pneumonic and other inflammatory disorders are not the only distinctive marks between feeble, ill-nourished subjects and those who are well nourished and strong. AU the inflam- matory derangements of nutrition occurring in the former class give rise to a very profuse formation of young, indeterminate and perish- able cells. It is said of such persons, that their " flesh does not heal," that is, that a trifling wound is apt to be followed by severe irritation, and copious suppuration of the Avounded part. This peculiarity is partially attributable to an increased irritability which accompanies constitutional weakness, and partially to the fact that badly-nourished or ill-developed organs, AA'hen inflamed, are more prone to the formation of cells of a decrepit and perishable nature, than to the formation of such as are capable of development into neAV tissue. The main points of the subject hitherto discussed may, then, be summed up as folloAvs: The consolidation and destruction of the lungs, which form the anatomical basis for consumption, are usually the proelucts of inflammatory action, and the greater the quantity of cellular elements collected in the vesicles, and the longer the duration of the inflammation, so much the more readily icill pneumonia leael to consumption, since these are the conditions most favorable for the production of caseous infiltration. Secondly : pneumonia resulting in caseous infiltration occurs most frequently, but not exclusively, in puny, badly-nourished subjects. This is par- tially because such persons are especially delicate, and, in part, because all inflammatory nutritive disorders by which they may be affected show great tendency to copious cell-formation, with subsequent caseous degeneration. We may noAV, in feAV Avords, define our position Avith regard to that greatly-vexed question, the relations of scrofula and pulmonary consumption. It very frequently happens, especially during chUdhood, that the lvmphatic glands participate in this morbid tenderness, which, as a rule is accompanied by augmentation of irritabUity and a strong ten- dency to profuse cell-production. While, in persons exempt from this peculiar tendency, the lymphatic glands neither enlarge, inflame, nor suppurate, excepting in case of intense and malignant inflammation of the parts from which they derive their lymph, very trifling irritants, 212 DISEASES OF THE PARENCHYMA OF TEE LUNG. and mUd and innocent inflammation of the region AArhence the lym- phatic vessels originate, suffice to excite the glands, of individuals who are thus affected, into an active production of neAV cells. Inflamma- tion and suppuration of the glands do not take place in all or eAren in the majority of cases, the morbid action usually limiting itself to a simple cellular hyperplasia, that is to say, to an enlargement of the glands, from multiplication of their normal cellular elements. But, as the retrogression of all morbid processes in individuals of this class is extremely tedious, the glandular enlargements are exceedingly obsti- nate in character, and in many instances (and, the greater the mass of cells, so much the more apt is it to happen) a partial or diffuse caseous degeneration of the SAVoUen gland is the result. Persons whose lymphatic glands participate in the general delicacy of the tissues, and in their tendency to this profuse cell-formation un- der the stimulus of inflammation, are said to be scrofulous. We lay especial stress upon the circumstance that, in scrofulous individuals, the tendency to glandular enlargement by cellular hyper- plasia is constantly combined with a general tendency to disease, par- ticularly to inflammatory disease. This is so Arery marked as a rule, that the exciting causes of " scrofulous eruptions," " scrofulous ophthal- mia," " scrofulous catarrh," and other so-called scrofulous disorders, are apt to escape observation. It often appears as if such inflammations came on spontaneously (" of themselves," as the laity say). There is no anatomical sign by means of which a " scrofulous " ophthalmia or a scrofulous eruption can be distinguished from similar non-scrofulous disorders, and, with the exception of the implication of the lymphatic glands, it is only from the insignificance of the causes from Avhich the affections proceed, the frequence of their recurrence, and their obsti- nate persistence, that Ave can infer their scrofulous nature. Noav, if this feeble poAver of resisting noxious agents, this suscepti- bifity of scrofulous individuals, have not subsided at the period Avhen the lungs become more especially liable to disease, although the fre- quence of the moist eruption, the obstinate affections of the cornea and conjunctiva and the like, meantime have diminished, yet pneumonic processes are now apt to occur from causes equally trifling Avith those which formerly gave rise to the ophthalmia and the eruptions, etc.; and such pneumonic affections evince the same obstinacy which the other so-called scrofulous diseases used to shoAV, a circumstance which greatly favors their termination in caseous degeneration. Upon glancing over the various causes which experience points out to us as predisponents toward consumption, it aa'UI be strikingly apparent that they all agree in one particular, that they all retard 01 disturb the normal development and conservation of the organism. CONSUMPTION OF THE LUNGS. 213 The tendency to consumption is, in many cases, congenital. When the congenital tendency is due to the fact that the parents were con- sumptive at the time of begetting the offspring, it may properly be spoken of as inherited. But it is not (as is often asserted) the malady AA'hich causes the inheritance, but the weakness and vulnerability of constitution Avhich had already laid the foundation of the consumption in the parents, or AA'hich had arisen in them in consequence of that disease. The hereditary constitutional feebleness of the offspring may proceed from other disease of the parent instead of consumption. Parents afflicted by other exhausting maladies, or Avho are ruined by debauchery, or AATho are far advanced in years, are quite as Hable as consumptive parents to beget chUdren Avho come into the Avorld AAdth a predisposition to consumption. Among the influences by which a liability to consumption is ac- quired, or by Avhich a congenital predisposition to it is aggravated, that of an insufficient or improper diet stands first. Feeding a suck- ling-babe AA'ith bread, pap, etc., instead of the mother's milk, may sow the seeds of the malady. An erroneous regimen is often kept up throughout the entire period of childhood. The child is ill-fed (" ver- futtert") as the laity say, and consequently acquires a feebleness and susceptibility to disease identical with a scrofulous predisposition. The comparatively greater prevalence of consumption among the poor than among the more well-to-do classes is in great measure dependent upon the Avretched diet of the former, which consists chiefly of vege- tables. [Germany.] This also accounts for the increased frequence of consumption, according to the size of toAvns, or, what amounts to the same thing, the number of its pauper population. Hunger and want, as is well known, are less common in the country than in great cities. The influence of a want of fresh air is quite as baneful as is that of an insufficient or improper supply of nourishment. We have no satisfactory explanation of the mode in which continuous sedentary life, and especially an abode in a close atmosphere charged Avith effluvia, produces its pernicious effect upon the organism; but the fact has long been estabfished that both scrofula and consumption are far more com- mon in asylums for foundlings and for orphans, in houses of correction, prisons, and among factory operatives Avho spend the entire day at work in a close room, than among persons AA'ho take much exercise in the open air. The objection, that the prevalence of scrofula and con- sumption in such institutions proceeds from other causes than lack of fresh air, is untenable. The average diet of the populations of many poor Adllages is much Avorse, and the number of prejudicial influences far greater, than is the case among the occupants of prisons and houses of correction, and yet they are not equally subject to these diseases. DISEASES OF THE PARENCHYMA OF THE LUNG. Not unfrequently persons born with vigorous constitutions, and who have been Avell nourished, evince a decided tendency to consumption from the effect of some other disease, AAdiereby the prehension or assim- ilation of their food is prevented, or which is undermining their health in some other way. Many patients AA'ith ulcers of the stomach, with strictures of the oesophagus, lunatics who persistently refuse their food, finally die consumptive. In like manner persons afflicted with dia- betes mellitus, obstinate chlorosis, or tertiary syphilis, ultimately die of pulmonary phthisis. Among acute disorders typhus is especially apt, Avhen protracted, to leave behind it a predisposition to this disease. To these predisposing causes, acquired through other affections, may be added those AAdiich are provoked by persistent suckling, onanism, venereal excess, by depressing or exciting mental influences, immod- erate study, and inconsolable grief. ( Goethe, in his " Clavigo," instead of making Marie Beaumarchais die of a broken heart, very properly makes her pine away, cough up blood, and sink under consumption.) I regard the wide-spread doctrine that consumption is solely de- pendent upon a diathesis, from which it proceeds independently of all so-called " exciting causes," as equally gratuitous and dangerous. The circumstance, that the admission of the origin of this disease from ex- ternal irritation stood in direct conflict with a theory which no one dared to gainsay, has manifestly prevented an unbiassed interpretation of facts. The deliberate assertions of Laennec and his pupUs, that "catching cold," and other irritation, had no influence in producing pulmonary consumption, and that it never arose from a neglected ca- tarrh, has had the most pernicious effect, both upon prophylaxis and treatment of the disease; and it is fortunate that the laity, when they suspect a tendency to consumption, are more cautious than would be necessary if what is almost everywhere taught in the lecture-rooms Avere true. The exciting causes AA'hich may give rise to consumption, AAdiere predisposition to it already exists, consist, as I beHeve, in all influences capable of producing fluxionary hyperaemia of the lungs and bronchial catarrh. We therefore refer to Avhat has been stated already as to the etiology of the latter. The production of consumption by taking a cold drink while the body is heated must be looked upon as fabulous, or, at all events, as among the ill-explained facts. It is not the cold beverage, but the senseless dancing in the midst of heat arid dust by Avhich it is pre- ceded, or else immoderate exertion in running, or some other cause capable of provoking a determination of blood to the lungs, Avhich really is to blame, in the cases AA'hen the first symptoms of consump CONSUMPTION OF THE LUNGS. 215 tion show themselves shortly after the patient has SAvalloAved a cool draught, Avhile over-heated. Numerous examples exist in the practice of every experienced physician, in AAdiich the cough has commenced on some particular day folloAving a severe cold, soon after Avhich the other symptoms of con- sumption have made their appearance. A proof of the extremely important role played by the presence of foreign substances in the air-passages, as an exciting cause of con- sumption, is found in the great prevalence of the malady among opera- tives and other persons who constantly five in a dusty atmosphere, such as stone-cutters, file-grinders, hatters, Avool-carders, cigar-makers, etc. Of all foreign bodies AA'hich, by irritation of the bronchial walls, and of the pulmonary substance itself, give rise to consumption, the blood Avhich is retained in the air-vesicles and bronchi after a haemop- tysis or pneumorrhagia most frequently has that effect, as we have already explained Avhile treating of bleeding from the bronchi and lungs. Having discussed the etiology of the pneumonic process AA'hich plays the most important role in the production of pulmonary phthisis, Ave must noAv add a feAV AA-ords regarding the etiology of pulmonary tuberculosis. The development of tubercles in the lung, Avithout the preexistence of caseous degeneration of the inflammatory products, is less common in chronic pulmonary tuberculosis, Avhich is compHcated with chronic pneumonia, and terminates in consumption, than in acute mUiary tuber- culosis (see Chapter XIV.). The etiology of these exceptional cases is utterly obscure, although it would seem that persons predisposed to inflammation, ending in caseous degeneration, suffer from primary tuberculosis of the lung, in the stricter sense of the Avord, with greater relative frequence. The caseous masses, upon AA'hich the consecutive (secondary) devel- opment of tubercles in the lungs depends, are situated, in the great ma- jority of cases, in the lungs themselves, and consist of the products of chronic pneumonia, in a state of caseous degeneration. We have no hesitation in stating that the greatest danger, for the majority of con- sumptives, is, that they are apt to become tuberculous. The conditions AA'hich cause tuberculosis to accompany many cases of caseous infiltration AAdth formation of cavities, but not all such cases, and the reason Avhy the complication is sometimes early and sometimes late in its appear- ance, are at present unknoAvn to us, but it seems that incapsulation of the caseous mass affords a certain degree of protection against tuberculosis. Next to the caseous products of pneumonia, the exudation of pleu- risy and pericarditis in a state of caseous degeneration, and bronchial glands in similar condition, most frequently ghre rise to tuberculosis. 216 DISEASES OF THE PARENCHYMA OF THE LUNG. Under this category the cases may also be included in Avhich the cheesy inflammatory products of the results of tuberculosis of the genito-urinary apparatus, the intestines, mesenteric glands, joints, bones, or superficial lymphatics, are foUoAved by tubercular disease. In cases of doubt, the discoArery of cheesy residua in one or other of these organs may decide the question in favor of tuberculosis. We think it quite possible that, at a time not very far distant, the danger * of pulmonary tubercle, which the presence of the cheesy residua of enlarged lymphatic glands produces, Avill take a place among the indi- cations for the extirpation of peripheral lymphatic tumors, and even for the performance of resections and of amputations. With regard to the frequence of consumption, it is supposed that from a seventh to a fifth of all deaths are the result of this disease, and that in nearly the half of all cadavers Ave find traces of the nutri- tive disorders from which pulmonary consumption proceeds. During foetal life, and during early childhood, consumption is rare. Even in the latter years of childhood, bronchial catarrh, Avith SAvelling and cheesy metamorphosis of the bronchial glands, or "consumption of the bowels," is far more common than pulmonary phthisis. In the chapter upon scrofula Ave shall treat at large upon the subject of scrofulous bronchial catarrh, and of the softening of cheesy bronchial glands, and call attention to the liability of such an affection to be confounded Avith genuine phthisis pulmonum. Toward the period of puberty, and stiU more so between the tAven- tieth and thirtieth years, the malady attains its greatest frequence, be- coming rarer as life advances, AAdthout becoming quite unknoAvn even in extreme old age. Males and females seem to be equally liable. The former belief in the prevalence of the disease in cold climates, and its comparative rarity in Avarm ones, is not borne out. There are regions situated far to the north Avhich are well-nigh free from it (Ice- land, for instance). Hirsch, in his classical hand-book of historical and geographical pathology, declares that the mean temperature due to the geographical and territorial situation of a place has absolutely no influence upon the production or frequence of consumption; that great alternations of temperature and a high degree of moisture favor its de- velopment, Avhile in elevated regions its appearance is rare. The rarity of consumption in malarious regions is not constant, and is scarcely due to the influence of the malaria, but is dependent rather upon other causes, such as the paucity of the population and the lack of culture in many regions afflicted by malaria. Anatomical Appearances.—Upon dissection of subjects avIi© have died of pulmonary consumption, many lesions are found in the lungs, especially pathological cavities—or vomicae—extensive infiltration and CONSUMPTION OF THE LUNGS. 217 other forms of solidification of the parenchyma, Avhich, Avhen cut into, nearly ahvays exhibit small points AA'hich suggest the idea of mUiary tubercles. It is only in rare cases that the diffuse consolidation of the lung- substance presents the granular aspect and other characteristics of a lung hepatized by croupous pneumonia. Far more commonly, there is that homogeneous, dull-looking infiltration AA'ith smooth section, AA'hich we have described as the product of acute and especially of chronic catarrhal pneumonia. As a rule, the gelatinous infiltration has already undergone the transformation pecuhar to cheesy degeneration of inflammatory products. If the latter have but recently commenced, we sec, upon the gray or grayish-red dead lustre of the cut surface, a feAV yelloAV, lustreless marblings. If the caseous metamorphosis be further advanced, the yelloAV places are larger, until at last the entire solidified portion of the lung is converted into a yelloAV, cheesy mass. After the infiltration has become caseous, it may undergo immediate liquefaction, and, together Avith the tissues, break doAvn into a creamy puruloid matter. Thus cavities filled with the so-called tubercular pus are formed. At last a communication is set up Avith a neighboring bronchus, through Avhich its contents are discharged by coughing. The Avails of these cavities are irregular and interrupted; the pul- monary parenchyma about them is infiltrated Avith caseous matter, and is in a more or less advanced state of disintegration. The gelatinous or catarrhal infiltration, AA'hich, AA'hen attacked by cheesy metamorphosis, and softening of the infiltrated lung-substance, leads to the formation of these cavities, is at first generally confined to single lobules. If the diseased lobule be situated near the surface, the solidified spots bear the peculiar Avedge-shape of the peripheral lobules. When seated more deeply Avithin the lung, they form rounded indurations, or,Avhere the process is restricted to the immediate vicin- ity of separate bronchi, the consolidation runs along the course of the tube. By repetition of the process, and by confluence of many of the lobular centres, a Avhole lobe or eA'en an entire lung may be solidified and become the seat of vast destruction. But caseous infiltration of the pulmonary tissues, from Avhatever form of pneumonia it may proceed, does not in all, nor even in the majority of cases, result in immediate disintegration of the seat of the cheesy infiltration, and in formation of a caAdty. Such an event only takes place under peculiar circumstances, and perhaps when the dis- order is of extreme severity. It is probably brought about through the crowding together of the accumulated cells in the air-vesicles, Avhereby they not only encroach one upon another, but exert a pres- sure upon the surrounding tissues and their vessels, thus depriving the 218 DISEASES OF THE PARENCHYMA OF THE LUNG. alveolar Avails of their nutritive fluid, and causing them to perish and break doAvn. Perhaps the anaemia and necrosis of the pulmonary tissue are favored in severe cases by an extension of the process of prolifera- tion of cells from the surface into the tissues themselves. If the cell-groAvth be not of sufficient volume seriously to compress the vesicular walls and their vessels, the caseous masses gradually become still more inspissated, and the shrunken atrophied cells break down into a detritus. Little by little their organic matter dis- appears, Avhile calcareous salts are deposited untU there finally is left a chalky or mortar-like concretion. In other cases, again, the arrested fatty metamorphosis of the cells is reestablished; they become lique- fied, and capable of reabsorption. WhUe one or other of these processes is progressing in the cellular elements involved in the caseous degeneration, an extensive profifera- tion of the connective tissue is going on in the lung. The calcified deposits are incapsulated, and the space rendered vacant by the cells, Avhich have suffered fatty degeneration and liquefaction, is fiUed up by connective tissue. In such cases, the lung-substance does not again become penetrable by the air, but is converted into a dense callous mass; and as the connective tissue, which continues to shrink more and more, occupies less room than the healthy parenchyma which it replaces, the lung becomes reduced in size and the thorax sinks in. But, as depression of the thorax can only take place to a limited extent, the bronchi become dilated into rounded and elongated cavities. This is the most common form of cavity in phthisis where it runs a chronic course. The absorption of the caseous masses, through supplementary fatty degeneration and liquefaction, may be so complete that, upon dis- section, Ave may find nothing except pulmonary tissue in a state of induration from interstitial pneumonia, perfectly void of air, traversed by (bronchiectatic) cavities, and without a trace of caseous deposit. While the apex of the lung usually contains caAdties of greater or less capacity, and while a large portion of its upper lobes is solidified —partly by gelatinous or caseous infiltration, and in part through indu- ration and consolidation—upon section of the remainder of the lung which still remains permeable to the air, the small points of induration before alluded to are almost ahvays found projecting above the sur- face of the cut in the shape of yellow nodules. We must beAvare of immediately assuming such minute solid spots to be tubercles. Ex- perience teaches that many objects Avhich at the first glance seem to be miliary tubercles, and AA'hich Avere formerly regarded as such, prove, upon closer examination, to be transversely-divided bronchi Avith case- ous contents, or bronchi surrounded by alveoli, with thickened Avails and infiltrated with caseous matter. By avoiding such errors in post-mor CONSUMPTION OF THE LUNGS. 219 tern examination, Ave shall arrive at the conclusion that not a single tubercle exists in very many phthisical lungs, and that consolidation and destruction are solely due to a disorganizing pneumonia. We believe, however, that Virchow goes too far in asserting that the doctrine of mUiary tuberculosis of the lung is also almost entirely erroneous, and that nearly aU so-called miliary tubercles of the lung are foci of bronchitic, peribronchitic, or pneumonic inflammation. It not unfrequently happens that these translucent grayish nodules Avhich are scattered through the lungs, as well as in most other organs in acute miliary tuberculosis, and of Avhose tuberculous nature there can- not Avell be any doubt, are also met Avith in phthisical lungs. Hence, Ave must also acknoAvledge the yelloAV caseous deposits found in the lungs (notoriously regarded as mUiary nodules) to be of tubercular na- ture, Avhen they coexist with the gray mUiary tubercles, and AA'hen the latter, together Avith caseous tubercles, are found in other organs at the same time. There are no means of proving that the caseous nodules are the product of vesicular pneumonia, and not tubercle, as we haA'e no criterion for the distinction between caseous tubercles and caseous miliary nodules of inflammatory origin. I again express my opinion that, exclusive of tuberculosis of the bronchial mucous mem- brane, the development of secondary tuberculosis in phthisical lungs is of very frequent occurrence. Hitherto Ave have been describing the anatomical lesions found in pulmonary consumption, as it occurs in the vast majority of .cases, Avherein the malady, throughout its Avhole course, is solely dependent upon chronic pneumonia, or in Avhich tuberculosis does not appear until at an advanced stage of the phthisis, when, although it must be re- garded as a most serious complication, it takes but little part in the disorganization of the lungs. In tubercular consumption, in our acceptation of the term— that is, in the form of phthisis in Avhich destruction of the lung is caused by the breaking doAvn of tubercles, and by secondary pneu- monia dependent upon the tuberculosis—the tubercle generally first develops in the mucous membrane of the bronchi, as Avas first shoAvn by Virchow. Even in the trachea and larger bronchial tubes Ave often find extensive granular patches, consisting of innumerable miliary tubercles, or ulcers Avith the characteristic marks, according to Roki- tansky, of primary or secondary tuberculous ulceration. In addition to this, hoAvever, in the finer bronchi, besides the eAridences of purulent catarrh, Ave find small whitish or yellow nodules, and, upon examina- tion of a successfulty-prepared fine section, Ave may satisfy oursehTes that the development of the tubercle has spread from the bronchus to its lateral and tenninal alveoli. According to the line of the section, DISEASES OF THE PARENCHYMA OF THE LUNG. tubercular groups formed in this manner present the appearance of rounded or Avedge-shaped conglomerations of miliary nodules, an ap- pearance rarely or never found in acute mifiary tuberculosis AA'here the development of tubercle does not begin in the bronchial mucous mem- brane. The pneumonic process by Avhich the tuberculosis is attended in tuberculous consumption is much less extensive, as a rule, than that Avhich accompanies the consumption which is solely due to chronic pneumonia, or than the form in which secondary tuberculosis super- venes, at a late period, upon the process of induration and destruction, a circumstance of some importance in the diagnosis of tuberculous con- sumption. It is also quite an exceptional occurrence for a large part, or, perhaps, an entire lobe of a lung, to become solidified by pneumonic infiltration, nor does caseous infiltration often advance to the stage of induration and contraction. The cheesy infiltration almost ahvays breaks down at an early period, so as to alloAV cavities to form. It is true that Ave iioav and then find the apex of the lung to be the seat of callous induration, or of a deposit of thickened caseous matter, or a bronchiectasis, but it is easy to satisfy one's self that these lesions have no connection Avith the final disease, and that they are the results of some morbid process of prior date. As it appears from AA'hat has been stated above, the bronchi of phthisical lungs exhibit a great variety of conditions. Gelatinous and caseous infiltration is preceded and accompanied by purulent catarrh of the finer bronchi, with dilatation of their cavity. Disintegration of a deposit of caseous infiltration is ushered in by ulceration of the bron- chial Avail, and the liquefaction almost always begins in the immediate vicinity of the bronchus. In tubercular consumption, the eruption of mUiary nodules appears upon the mucous membrane of the bronchi. The majority of the cavities found in chronic consumption are of bron- chiectatic origin, while, on the other side, many of the minuter tubes which traverse the infiltrated and indurated lung-tissue become oblit- erated. The purulent contents of a closed cavity, resulting from the breaking doAvn of caseous infiltration, are discharged by perforation into a large open bronchus. We not unfrequently see several bronchi, Avith round or oval mouths, running either squarely or obliquely into such a cavity, but their entrance is ahvays abrupt, and never gradual or imperceptible. Finally, where the bronchial surface has suffered no profound or structural change, it is the seat of a catarrh whose profuse secretion is full of young cells. This bronchial catarrh is the main source of the expectoration of phthisical persons. Many of the blood-vessels, especially many branches of the pulmo- nary artery of the infiltrated and hardened tissue, are obfiterated. In the walls of cavities the obliterated vessels often form prominent CONSUMPTION OF THE LUNGS. 221 ridges, and sometimes stretch from one wall to the other in the form of ligamentous bridges. It is very seldom that, prior to obliteration of the Avails of a vessel, they become so eroded as to cause dangerous haemorrhage. We shall take this opportunity to call attention to a peculiarity in the circulation of the lungs which frequently arises in phthisis. Many branches of the pulmonary artery becoming destroyed, those of the bronchial dilate, and conduct arterial blood to the lungs. Many newly-formed vessels, springing from the intercostal arteries, also advance through pleuritic exudations into the lung. Thus the phthisical lung receives more arterial blood than the sound lung. Part of it passes into the pulmonary veins, a part into the bronchial veins, and a third portion passes through the pleuritic adhesions into the in^ tercostal veins. As the discharge of blood from the cutaneous veins into the overloaded intercostal veins is thereby impeded, they, too, are apt to become overfilled and distended, and a blue net-Avork of veins appears upon the skin of the thorax. A chronic form of inflammation of the pleura almost ahvays occurs as soon as the affection of the pul- monary substance commences to approach the periphery of the lung. The pleural surfaces become thickened and adherent. The thickening may be so great, especially at the apex of the lung, that it may be covered, as by a cap, Avith a thick, compact fibrous rind, and at such places it is generally impossible to separate the tAvo pleural surfaces AA'ithout tearing the lung. In many cases the tAvo pleural surfaces groAV together throughout the entire extent of the lung, so that a pleural caAdty no longer exists, and so that pneumothorax cannot occur, though the process of destruction advance to the pleura itself. It is only through the rapid disorganization of superficially-seated caseous deposits that perforation sometimes occurs before adhesion is estab- lished, or before the adhesions have groAvn strong enough to prevent air and debris of tissue from entering the pleural cavity. In tubercu- lous consumption, and in secondary tuberculosis, mUiary tubercles are often found, both in the pleura itself and in the pseudo-membrane, re- sulting from the chronic pleuritis. The cavities rarely enlarge in what Avas formerly supposed to be their most frequent mode of enlargement, that is to say, by caseous disorganization of secondary tubercular de- posit in their walls. Generally speaking, no matter in what manner the cavities have formed, their increase in size is the result of a diphtheritic process, an infiltration of their Avails, AA'ith subsequent decay. The frequent coexistence of laryngeal disease Avith pulmonary con- sumption has been afready spoken of in detaU. The equally common complication of pulmonary phthisis AA'ith ulcer of the bowels, intestinal tubercle, AA'ith fatty liver, AAdth amyloid liver, Avith parenchymatous in- * 222 DISEASES OF THE PARENCHYMA OF THE LUNG. flammation, and amyloid degeneration of the kidney, AviU be again referred to under their appropriate headings. In recent cases, the right heart, Avhose outflow is ahvays impeded, is found to be hypertrophied and dUated. In protracted cases, in AA'hich the volume of the blood is much reduced, the heart is generally flabby, small, and atrophied. A Avhite coating, Hke curdled milk, is often found upon the tongue and palate, which microscopically consists of vegetable spores and filaments. The cadaver is usually in a state of extreme emaciation; the skin is thin, remarkably white, and not unfre- quently covered with scales of epidermis (pityriasis tabescentium). The feet are often" oedematous, and one or other crural vein is fre- quently stopped up by a thrombus, the corresponding leg being tume- fied and dropsical. The entire body is bloodless, excepting the right heart, which, when dissolution takes place gradually, contains tolerably large and soft coagula. Symptoms and Course.—The course of pulmonary consumption varies in type according as its symptoms are dependent upon pneu- monia alone from beginning to end of the disease, or as they become complicated with tuberculosis at a later stage, or are tuberculous from the outset. In most instances these three forms may be distinguished from one another with tolerable precision. We shall first make a brief analysis of the various symptoms ob- served in the generality of cases of consumption, with especial refer- ence to the particular morbid process to which each symptom belongs, and shall then endeavor to draw a comprehensive picture of the prog- ress of each of the three main forms of the disease. Increased frequence of respiration, in greater or less degree, occurs in all forms of consumption, and proceeds from a variety of causes. Moderate acceleration of the rate of breathing is not always accom- panied by that distressing sense of shortness of breath requiring con- tinual forced inspiration for its relief, known as dyspnoea. Even pa- tients far gone in the disease often have no dyspnoea at all, excepting Avhen some transient increase of the destructive assimilation going on in the system demands an additional supply of air. While at rest they are fully capable of supplying their blood with oxygen, and of efiminating the carbonic acid formed in the system, Avithout any fatiguing exertion. On the other hand, the increased respiratory fre- quence may be combined with a severe and persistent dyspnoea, Avhich of course is liable occasionally to still further aggravation, and is one of the most burdensome symptoms of the malady. The augmented frequence of the respiration and dyspnoea of phthis- ical patients is due, in part, to a diminution of the breathing surface of the lung, in part to obstruction of the bronchi by the attendant catarrh; a* CONSUMPTION OF THE LUNGS. 223 partly, although rarely, to pain during respiration; and partly, and in- deed chiefly, to fever. As a rule, dyspnoea is only caused by the joint action of several of these factors. Thus the breathing surface may be excessively reduced in area Avithout the patient's feeling any dyspnoea, and Avithout any acceleration of the breathing whUe the patient is at rest, provided only that neither severe catarrh, pain, nor feA'er be pres- ent at the same time. Many patients, whose lungs are so much con- solidated and disorganized that scarcely half of their capUlaries remain to carry on the process of oxygenation, still breathe at the normal rate as long as they sit stiU or are lying in bed. This is simply because a healthy person, under ordinary circumstances, needs to employ but a Arery small portion of his respiratory apparatus, in order to obtain his proper supply of air. Nor ought we to overlook the fact that, Avhere the lung is indurated and disorganized, the surviving vesicles are more strongly distended by an inspiration of ordinary depth, and alloAV more air to escape upon expiration than do the air-cells of a healthy lung. The increased actiArity of oxygenation which thus goes on in the re- maining air-cells manifestly compensates, in a great measure, for the deficiency of those which have perished. The breathing-surface may be seriously diminished by the presence of miliary tubercles, Avhich, though they may elude physical demonstra- tion, fill up a large number of the disorganized alveoli, and close many of the smaller bronchi. Hence, great rapidity of breathing Avithout dulness on percussion, or bronchial respiration, is one of the most im- portant signs of tuberculous consumption, in the narroAver sense of the Avord. If Ave find that a patient, whose lungs are more or less solidi- fied and destroyed, but who hitherto has suffered but little, if at all, from shortness of breath, begins to exhibit an increase in frequence of respiration and a distressing dyspnoea, there being no increase in the solidification or destruction of the lung or aggravation of the fever to account for it, there is strong reason to fear the addition of a tubercu- losis to the phthisis which already exists. Cases arise in Avhich we can infer the existence of such a complication, solely from the dispro- portion betAveen the small degree of dulness upon percussion and the extreme frequence of the respiration. It Avould be superfluous to explain in detail AA'hy the respiratory frequence of a phthisical subject is aggravated by pleuritic pain and by exacerbation or extension of the bronchial catarrh, AA'hich accom- panies the malady, or by its complication AAdth the pleuritic effusion, liA'drothorax, pneumothorax, etc. That respiration is accelerated by fever is eAddent. Fever consists of a morbid increase of calorification Avhereby the body becomes OArerheated. The necessity for air is aug- mented in feA'er just as it is augmented by every bodily exertion; since 221 DISEASES OF THE PARENCHYMA OF THE LUNG. in either process, an extra amount of carbonic acid is formed, and an extra quantity of oxygen is consumed in the system. If Ave compare the rate of breathing with the elevation of temperature and the fre- quence of the pulse in phthisis, it will be seen that the Avant of air is partially relieved by the greater depth of the breaths draAvn; for the steep curves AA'hich generally are used to mark the character of the very considerable fluctuations of the morning and evening temperature hardly ever correspond to similar abrupt curves representing the rate of respiration. The evening acceleration of the latter seldom exceeds above six or eight breaths a minute, and in many cases is not more than three or four breaths. In some cases no acceleration at all can be detected. Pain in the chest and shoulders is a symptom which is often absent throughout the entire course of the disease. It more commonly accom- panies the pneumonic form than the tuberculous form of the malady. In cases Avhere physical examination leaves us in doubt, Avhether we have to do Avith tubercle or with small scattered pneumonic deposits, pleuritic pains may be of service both in the diagnosis and prognosis, especially Avhen accompanied by sputa tinged with blood. Consumption is preceded, in a large number of cases, by a more or less protracted period of cough and expectoration, depending upon the precursory catarrh, Avhich afterward leads to catarrhal pneumonia by extension into the air-vesicles; and, subsequently, to consumption of the lungs by caseous degeneration and disintegration of the inflammatory products. It is highly important to endeavor to ascertain of every patient whether his pallor, fever, and emaciation, have been preceded for some time by cough and profuse expectoration, or whether these symptoms have all appeared simultaneously and before the expecto- ration became copious. In the first case, formerly ascribed to a post- ponement of the fever and emaciation until an advanced stage of the tuberculosis (according to Louis, this is the case in four-fifths of all cases, Avhile in one-fifth only do the cough and fever begin together), it is more probable, ceteris paribus, that the disease is of pneumonic nature, Avhile the latter class of cases are probably of tuberculous origin. The duration of the precursory catarrh varies. Distinct eAddence of propagation of the process into the alveoli and of incipient phthisis is sometimes discernible as early as the second or third week. Most of the instances in AAdiich consumption is an immediate consequence of measles and of Avhooping-cough are of this kind, as well as those in Avhich tuberculosis develops under the disguise of a catarrhal fever or influenza. Conversely, a catarrh may have existed for months and years, groAving Avorse in Avinter and improving during the summer, and CONSUMPTION OF THE LUNGS. 225 may ultimately attack the air-vesicles. In such cases the physician is often entirely at his ease about his patient, as, in spite of the cough and expectoration, the latter has no fever, maintains his strength, and is in a fair nutritive condition, Avhen the scene suddenly changes and the symptoms of consumption appear. There is also some variety as to the original seat of this treacherous catarrh. Sometimes it is situated in the smaller bronchi from the very outset; but it by no means rarely commences in the larynx or trachea, AA'hence the process gradually extends into the air-vesicles. The fre- quence Avith Avhich such cases occur is shoAvn in the folloAving descrip- tion by Andred—an unqualified adherent of Laennec's—from the fourth volume of his " Clinique Medicale: " " The phlegmasia of the air-passages, the symptoms of which precede those of tubercle, does not ahvays commence in the minuter bronchial ramifications, nor even in the greater bronchi. So far from it, indeed, that Ave have more than once found its point of departure to be in the upper portion of the air- passage, and to consist at first of a simple laryngitis. Persons of this class (AA'ho are to be distinguished from those in Avhom laryngitis only supervenes at a more advanced period of tubercular consumption) do not at this time present any symptoms Avhatever indicating disease of the lungs, until they are attacked by an angina, Avhich at first seems of but little gravity. The voice, however, remains hoarse; the larynx is the seat of a feeling of uneasiness rather than of pain. Sooner or later, the cough returns in more fatiguing paroxysms. The unpleasant sensation formerly confined to the larynx, now extends successiATely to the trachea and to the bronchi. Each fit of coughing occasions an un- pleasant pricking sensation and a disagreeable feeling of heat, and sometimes a genuine pain beneath the sternum. Thus Ave may, in a measure, folloAV the phlegmasia, step by step, in its progress from the organs of deglutition through that of the voice and through the trachea to the bronchi and their ramifications. It is only at this period that the malady assumes a graver aspect. Circulation becomes disturbed, nutrition is impaired, and it becomes evident that tubercles have de- Aeloped in the pulmonary parenchyma." In badly-nourished, delicate persons, the extension of the catarrh into the air-ATesicles and caseous metamorphosis of the infiltration are more to be dreaded than they are in Avell-developed and robust ones. Individuals are especially threatened AA'hom Ave knoAV have often suf- fered from a catarrh, and Avhose previous catarrhs have been of very protracted character. Finally the sputa expelled duing the precursory catarrh sometimes furnish a means of estimating the danger. It is a bad sign if the sputa contain sharply-defined, deep-yelloAV streaks; for it sIioavs that. 15 226 DISEASES OF THE PARENCHYMA OF THE LUNG. the catarrh is seated in the finer bronchi, and that its product is full of cells. It is when thus situated and of this character, that its implication of the air-vesicles is most to be dreaded. According to most clinical teachers and physicians who do not share our AdeAvs, and Avho ascribe all consumption to tuberculosis, this " expectoration streaked AA-ith yellow" {Louis) is of course regarded as a symp- tom of an incipient phthisis or tuberculosis, instead of a sign of a mere preliminary catarrh. Absence of cough and expectoration during the disease itself is very rare; yet instances are met with noAv and then, in Avhich infiltra- tion of the lung and caseous degeneration have taken place without preAdous or concomitant disease of the bronchial mucous membrane. Such patients, at first, often have neither cough nor expectoration. Fever, general malaise, loss of appetite, debility, and emaciation, form a group of symptoms Avhich are often difficult to account for, until physical examination reveals the actual condition. When the pul- monary disease is accompanied by intestinal consumption Avith Adolent diarrhoea, the cough and expectoration may decrease or cease entirely, even in advanced stages of consumption of the lungs. This may in some degree be ascribed to the derivative action from the bronchi, caused by the intense intestinal irritation. A hoarse or inaudible cough is one of the chief signs of tuberculous consumption, or of the compfication Avith tuberculosis of a consumption originating in destructive inflammation. The exceedingly interesting cases in AA'hich alteration of the voice or of the tone of the cough of phthisical patients results from palsy of the vocal chords, from pres- sure upon the recurrent nerve by indurated pleuritic membranes, are of extreme rarity, in comparison Avith the instances in AA'hich simUar symptoms arise from tuberculous ulceration of the mucous membrane. The non-occurrence of hoarseness and inaudibleness of the cough, until an advanced period of the malady, is indicative of consecutive tuber- culosis. On the contrary, if the cough have been hoarse from the beginning, especially while the sputa were stUl viscid and transparent, and before physical examination showed any irregularity, the exist- ence of primary tuberculosis may be suspected. As Ave have said already, tuberculosis often begins in the trachea or larynx, and only extends into the finer bronchi at a later period. Although the sputa of consumption are mainly the products of the catarrh Avhich complicates the disease, yet they may exhibit certain peculiarities which serve materially to help the diagnosis. We thoroughly indorse the assertion of Canstatt, that it is a most suspicious sign, and one highly calculated to aAvaken our apprehension of tuberculosis, Avhen the sputa of a persistent cough, accompanied by CONSUMPTION OF THE LUNGS. 227 fever, long retain the crude character of the expectoration of acute bronchitis. The deA'elopment of tubercle in the bronchial mucous membrane is generally attended by precisely such obstinate and dis- tressing cough, and by that scanty sputa which contains feAV organic forms, the " sputum crudum" of the ancients, the " purely mucous sputum " of more modern Avriters. Should microscopic examination reveal that the deep-yellow, sharply- defined streaks above referred to contain elastic fibres, recognizable through their arrangement and curve as belonging to the air-cells, Ave knoAv that the event has happened Avhich the appearance of such sputa would lead us to dread. The profuse formation of cells has extended from the surface of the bronchial mucous membrane into its walls, and the parts surrounding. The discovery of such elastic fibres is a sure sign of phthisis. The intimate admixture of blood Avith the muco-purulent sputa, Avhereby the latter acquire a uniform yellowish-red color, is pathog- nomonic of chronic pneumonia, and we have good grounds for inferring, from the appearance of such sputa in the course of a chronic catarrh, that the air-vesicles have also become involved. When cavities have formed in the lungs, a peculiar form of expec- toration appears, which is generally described as pathognomonic of con- sumption, and is often and erroneously supposed to be characteristic of tuberculosis. Rounded, numulated grayish masses are found in the spit-cup, separated one from another, by a greater or less quantity of clear bronchial mucus. If the sputa have been collected in a some- Avhat deep glass, we see irregularly-rounded opaque lumps, having a ragged outline, sink slowly to the bottom. These sputa globosa f nu- dum petentia of the ancients are an almost positive indication that caAdties exist in the lungs. Under the microscope the lumps are found to consist of young granular cells, showing evidence of fatty metamor- phosis, together aa ith a Aery considerable quantity of irregular angular bodies, and granular detritus. They also often contain elastic fibres from the Avails of the air-vesicles. Their opacity and greenish-gray color are due to the unusual amount of definitely-formed solid constituents which they contain, AA'hich has been incorporated Avith them during their long sojourn in the cavity. The rotundity of form is owing to the gen- eral tendency of the sputa, after their ejection, to preserve the shape of the space in the lung Avhence they have been expelled. They tend to sink to the bottom of the vessel containing the bronchial secretion, because but little air becomes mixed AA'ith them in the cavity whUe the bronchial secretion, being agitated by the inspiration and expira- tion of air, encloses numerous bubbles, and is of lighter weight. The small, rounded, ill-smelling fragments of caseous matter sometimes < 228 DISEASES OF THE PARENCHYMA OF THE LUNG. found in the expectoration, and Avhich are often thought to be actual tubercles by the laity, consist almost always of thickened secretion from the tonsils, although now and then they are small diphtheritic sloughs from the Avails of the cavities. Chemical examination furnishes no test for the distinction between the sputa of simple bronchial catarrh and that of consumption. Fever is one of the most constant symptoms of consumption both in the tuberculous form and that Avhich proceeds from chronic pneumo- nia. Ziemssen has demonstrated that in children the invasion of the air-vesicles by catarrh is always accompanied by considerable elevation of temperature and acceleration of pulse. This is equally true of the commencement of catarrhal pneumonia in adults. The statement of Lotas, that, in the majority of cases of tuberculosis (four-fifths), fever only arises at a more or less advanced stage of the malady, is based upon the observations of that author, taken from Laennec's point of vieAV, according to Avhich the precursory catarrh itself is due to the presence of tubercle. We have repeatedly called attention to the dangerous consequences of this error, and beHeve that we may declare that, by precise observation of the temperature and the frequence of the pulse, and by the most careful treatment of all cases, in which fever arises during the course of a protracted catarrh, the development of pul- monary consumption may often be averted. Not only is the fever an important sign of the extension of the catarrh from the bronchi to the air-cells, but its continuance furnishes the main evidence that the pneumonic process has not subsided. The curves, by means of which we represent upon paper the morning and evening fluctuations of temperature, usually show a Avonderful degree of similarity, and we may infer the existence of a consumption from them Avith the same certainty Avith Avliich Ave diagnose abdominal typhus or pneumonia. The difference betAveen the morning and even- ing temperature is about a degree and a half or tAA'o degrees Fahren- heit ; very seldom less, and frequently much more. In the morning the temperature is often almost normal, Avhile in the afternoon and evening it may rise to 102° F., or even higher. Such fluctuations of temperature are not peculiar to all kinds of exhausting fever. Upon comparison of the thermal curve of a patient AA'ith pulmonary consump- tion with that of one who is suffering from a tedious peripheral caries, a great difference wUl be observable, particularly in regard to the regularity of the morning remission and evening exacerbation. After extended study of the hectic fever of phthisis, especially as to the cause AA'hich interrupts its regular march, Ave have as yet come tc no conclusion upon the subject. We may mention, however, that the variations in the morning and evening temperature of a true tubercu- CONSUMPTION OF THE LUNGS. 220 losis (in the narrow sense of the Avord), and of a tuberculosis superven- ing upon chronic pneumonia, are generally much less. Hence, if the fever be a remitting fever approaching the intermittent type, the prog- nosis Avill be better than if the fever assume a more continued form. In the former case we have often succeeded in moderating, or eATen in completely allaying the febrile action, and thereby greatly improving the strength and nutritive condition of the patient; but Ave cannot claim any such results AA'here there Avas no morning remission* When the caseous masses become incapsulated, or liquefy, and are absorbed, the fever may cease altogether. Patients are often seen avIio have large cavities in the apices of their lungs, but no fever Avhatever. In such cases (the pneumonia having resulted in induration) the physical signs presented, and the globular masses of sputa, AA'hich the patient spits up morning after morning, form a striking contrast Avith his apparent good health, his fresh, vigorous look, his nutritive condition and strength. We have already shoAvn that, in spite of their partial recovery, such persons are stUl liable to die of consumption, either through recurrence of the pneumonia or through consecutive tubercu- losis ; and Ave Avould advise that the condition of the patient as to Aveight and temperature be still kept under observation, that Ave may be apprised of it, in case either event occur. We see, then, that, in the diagnosis, prognosis, and treatment of consumption, the use of the thermometer is as great as, if not greater than, in any other disease. The subjects of emaciation and deterioration of the blood, the symptoms to AA'hich consumption OAves its name, properly succeed that of feArer, since there can be no doubt that it is to fever that they are mainly due. A most striking proof of the soundness of the theory, that the elevation of temperature in fever is dependent upon an in- r crease in the calorification, consists in the rapid loss of Aveight Avhich the body sustains eA'en in a fever of short duration. For years, at my clinic, the fact has been estabfished, by dint of innumerable measure- ments and weighings of consumptive patients, that their loss and gain in Aveight stood in direct proportion to the increase or diminution of their feA'er. There is a very pretty theory, that a continued fever of moderate intensity consumes less (especially if the patient keep his bed) than a hectic fever like that of phthisis, in which the temperature fluctuates daily betAveen a condition almost normal and one of a con- siderable degree of intensity. There is no doubt that both calorifica- tion and consumption of the constituents of the body go on Avith great rapidity during the rapid rise in the temperature, as has been proAred by Inimermann, but Ave stUl hesitate to accept the absolute truth of the above hypothesis. KnoAvledge of the fact, that it is the fever which consumes both the strength and substance of phthisical pa- 230 DISEASES OF THE PARENCHYMA OF THE LUNG. tients, is a matter of the utmost importance in the treatment of the disease. Physical Signs.—Inspection of the chest reveals the existence of a " phthisical habit" in many persons who suffer from phthisis, or who are threatened by it. This term is used to signify that peculiar buUd of the body indicative of a want of proper nutrition and development, and Avhich is found in persons who have been subjected to debilitating influence* capable of stunting the healthy growth of the system before their bodies have become fully developed. The bones of such persons are slender, their skin is thin, their cheeks have a delicate redness, the sclerotica is bluish, the subcutaneous connective tissue contains but little fat. The muscles are ill-developed; those of the neck allow the thorax to sink, causing the neck to seem too long. The intercostal muscles permit the ribs to spread widely apart, making the intercostal spaces broader; the angle at which the ribs are attached to the ster- num is acuter; the entire chest is flatter, narroAver, and longer than in robust, muscular persons. The shoulders also are apt to sink forward, and the inner edges of the scapulae are tipped up like wings. The diagnostic and prognostic significance of the phthisical habitus has been a good deal underrated of late, and, no doubt, many persons possessing such a conformation do live exempt from phthisis and attain a good old age. But such a circumstance does not in the least conflict with the belief that the phthisical habit is a valuable index of feeble- ness and delicacy of constitution, hence of a tendency to consumption. There is greater danger that a catarrh at the apex of the lung will in- vade the air-vesicles in a patient of this kind, than in a muscular and robust man. Depression of the supra and infra-clavicular fossae upon one oj both sides, which, hitherto, has always played a great role in the symptomatology of phthisis, is indicative neither of tuberculosis, noi of caseous infiltration, nor of disorganization of the tissues; but is ahvays and solely due to decrease in size of the apex of the lung, by induration and shrinking. As this is the only process capable of caus- ing depression of the thoracic Avail, the symptom is rather a favorable sign, indicating a comparative cure of the nutritive derangements which are the chief causes of consumption. We are not Avarranted, therefore, in forming a diagnosis of consumption, unless signs of an advancing destruction of the lung be also present, besides the symptom in question. Feebleness of the respiratory movement, AA'hen it corresponds to a depressed point in the chest, is of similar import. In such a case the contracted lung is impermeable to air, and cannot yield to the traction of the inspiratory muscles. If the spot, Avhich remains stationary upon CONSUMPTION OF THE LUNGS. 231 inspiration, retains its normal convexity, the percussion-sound over it however, being dull and flat, we may infer the existence of an extensive solidification of the lung, which is most probably a pneumonic infiltra- tion. A feeble respiratory movement at a point AAdiere the percussion- sound, instead of being dull, is normal, or somewhat holloAv and tym- panitic, is a suspicious sign of tubercle, but not a conclusive one, as small scattered spots of lobular pneumonia may also weaken the move- ments of respiration Avithout causing any dulness upon percussion. There is often an unusually wide extension of the shock of the car- diac impulse, and an outAvard dislocation of the apex of the heart, AA'hen the upper lobe of the left lung is indurated and contracted, thus laying bare the pericardium and draAving the heart to the left. This symp- tom, Hke depression of the thoracic Avail, denotes a partial recovery from the pneumonic process, and a patient is not to be pronounced consumptive unless it be accompanied by fever, loss of flesh, or other sign of inflammatory or tubercular destruction of the lung. Palpation, besides being serviceable in estimating the movements of respiration, and the degree of dislocation of the apex of the heart, often exhibits abnormity of the pectoral fremitus in phthisis. Over large cavities, containing air, and communicating AA'ith an open bron- chus, the fremitus generally is intensified. It is also rendered stronger by lobular infiltration and by extensive tuberculosis, AA'hich has occa- sioned a relaxation of the pulmonary tissue. According to Seitz, hoAA'- ever, for Avhose o]iinion I have great respect, the vocal resonance is of little diagnostic Aralue in consumption. Percussion furnishes several diagnostic points of the utmost im- portance. Since Seitz first caused me to observe that it Avas easy to mark out the upper boundary of the lungs, and that this Avas easier to do in front than behind, and Avhen the mouth is open than Avhen shut (since the t3'inpanitic sound of the trachea is then more definitely distinguish- able from the non-tympanitic sound of the apex), I never neglect this mode of examination of patients Avith chronic pulmonary affections. I can assert that the height of the pulmonary apex, which, under normal conditions, is equal upon each side, and which extends from three to five centimetres beyond the collar bone, is often found to be much loAA'er, especially upon one side, when the lungs are in a state of chronic disease. A depression of the upper boundary, therefore, like the depression of the supra and infra-clavicular regions indicates indu- ration and contraction of the apex of the lung. A dulness upon percussion, in the supra and infra-claA'icular region, extending over the clavicle itself, and posteriorly over the supra- scapular and supra-spinatus regions, is recognized even by many of 232 DISEASES OF THE PARENCHYMA OF THE LUNG. the laity as pathognomonic of phthisis. Most patients, Avhen they consult a new physician, can state precisely what the size and extent of the dulness was at the last exploration. Dulness in these regions sig- nifies that a large tract of the parenchyma is infiltrated or consoHdated by groAvth of connective tissue. Tuberculosis never gives rise to a consolidation of sufficient magnitude to render the percussive sound dull. Hence, as a general rule, it is a favorable sign Avhen the area of dulness accords Avith the other symptoms, and Avhen it extends its limits in proportion as the malady advances. If it be otherAvise, there is reason to fear the existence of tuberculosis. The presence of lobular infiltration and of miliary tubercles, by Avhich the lungs' capacity for air is reduced, may give rise to a percus- sion-sound Avhich is not dull, but holloAV and tympanitic. Much more commonly, however, the percussion is not affected by such a condition of the lungs. A distinctly tympanitic sound is most frequently heard over a cavity containing air. If the pitch of the ring be altered by opening and shutting the mouth, it is a sure sign of a cavity. From the metallic, tinkling sound upon percussion, which is of very rare occurrence in consumption, it may be inferred that beneath the point struck upon there is a large empty caAdty, Avith smooth, regular, and baggy AvaUs, but Ave must first make sure that there is no pneu- mothorax. The cracked-pot sound is produced upon percussion, OArer the seat of a superficial cavity AAdth thin walls, Avhereby the air is expelled into a neighboring cavity, or into a bronchus A\dth a hiss, Avhich is charac- teristic of the "bruit depot fel'e." Auscidtation, at the commencement of the disorder, and indeed often in its more advanced stages, shows no irregularity beyond the signs of a catarrh at the apex of the lung. There is a feebleness of respiration, at other times it is extremely harsh, or the breath may be draAvn in a series of jerks {saccad'e). But, above all, there is the greatest variety of moist rdles and peculiar squeaking rhonchi. Some- times, after the patient has coughed, the moist rales and the crackling, squealing sounds cease. More frequently they are only heard after the first breaths Avhich folloAV a cough {Seitz). It is, therefore, always advisable, in ausculting a patient, to make him cough from time to time. It is easy to understand why peribronchial and pneumonic deposits, which haAre not caused much solidification, and why tubercles and tubercular masses, and cavities enveloped in parenchyma, stUl per- vious to air, do not produce other symptoms than those of catarrh; but I must most decidedly express my disapprobation of that prevalent befief, according to which the signs of catarrh of the summit of the lung are pathognomonic of consumption, as being both false and pre- CONSUMPTION OF THE LUNGS. 233 judicial to the patient. I certainly regard catarrh of the apex of the lung as a serious symptom, and the longer it lasts, so much the more have we to fear that it may lead, or that it has already led, to those derangements of nutrition from Avhich consumption so often proceeds; but, avc are not at liberty to conclude that the catarrh has involved the substance of the lungs themselves, until fever, emaciation, pallor of the skin, the presence of elastic fibres in the expectoration, and other evidences of phthisis arise, besides the catarrhal signs. Bronchial respiration, bronchophony, and sonorous rdles are heard in cases of consumption, Avhen extensive induration enclosing large open bronchi, or cavities, has formed near the surface of the lung. Indurations of such magnitude never proceed from tubercle or tubercu- lar conglomeration alone. Whether they are the result of infiltration or of induration, Avhether they contain bronchi or cavities AAdth ah in them, must be determined from the other symptoms. When the caAd- ties or bronchi Avhich traverse the solid part of the lung are filled Avith secretion, no respiration is audible. Sounds are heard sometimes which place the existence of caAdties beyond all doubt, and Avhich therefore are called cavernous sounds. The caArernous sounds include—1st. Coarse moist rdles, audible over places AA'here there are no large bronchi, where large bubbles can form, as at the apex of the lung. 2d. The sudden transition (called metamorphosing by Seitz) from a sharp hissing or sucking sound to bronchial respiration, or into indistinct murmurs and sonorous rdles. This Arcry common and very characteristic sign is probably produced by the entrance of air into a caA'ity through an opening Avhich at the commencement of the respiratory act is narroAV, but AA'hich is enlarged as the chest becomes inflated. 3d. Amphoric breathing, the rale Avith metallic resonance, a sound like the bursting of single bubbles with a metallic ring, the metallic tinkling. These noises may be produced artificially by bloAving over the open mouth of a bottle, or by agitating a liquid in a bottle held before the ear, or by letting fall a drop into the bottle, the ear being placed against it. It is only Avhen there is a similar condition of the lung, when it contains a capacious cavity with symmetrical concaA'e Avails, capable of producing uniform reflection of the sound-waves, that amphoric breathing and metallic sounds are audible. It but rarely happens that diagnostic information of any Aalue in consumption is obtained by use of the spirometer, and by measurement of the capacity of the lungs, that is, of the volume of air expelled from the chest after draAA'ing as deep a breath as possible. There are cases of obstinate cough, Avhere percussion and auscultation, giving nega- tive results, excite the suspicion of the existence of lobular infiltra- 234: DISEASES OF THE PARENCHYMA OF THE LUNG. tion, or of tubercle in the lung. In Germany, the vital capacity of adult healthy men is about 3,300 cubic centimetres, but it varies according to sex, age, weight, and size, so that, when the stature is betAveen five and six feet, every additional inch increases the vital capacity by about 130 cubic centimetres. But even after making due alloAvance for all these conditions, there still remains considerable A'ariation, depending upon Avhether the patient be skilful and prac> tised, or aAvkward and inexperienced. Hence, although a normal or remarkably great capacity of the lungs indicates that they are healthy, no conclusions can be draAvn from a slight reduction of their capacity beloAV the normal standard, and it is only when the decrease amounts to several hundred centimetres, and when it cannot be ascribed to Avant of skill, or to lack of power, and after excluding all other sources of impediment to respiration, that spirometry can con- tribute toward the diagnosis of an incipient phthisis. We shall now endeavor to describe the main features which char- acterize the separate varieties of pulmonary consumption, beginning AAdth that form in AAdiich the symptoms and termination are solely due to inflammatory action. At the outset it not unfrequently assumes the aspect of an acute disorder, AA'ith symptoms of greater or less violence. This is the case Avhen a croupous pneumonia, instead of ending by resolution, passes into caseous infiltration, foUoAved by consumption. It also occurs AA'hen the blood effused into and coagulated Avithin the bronchi and air-cells during a haemoptysis causes intense and extensive pneumonia, as well as in cases of im'asion of the pulmonary vesicles by acute catarrh of the bronchi. In a croupous pneumonia, when the fever persists beyond the end of the first or beginning of the second week of the disease, when it becomes considerably aggravated toAvard evening, and remits toAvard morning, Avith profuse perspiration; when the dulness in the thorax continues, and AA'hen moist rdles still remain audible o\rer the affected region, and when the expectoration is profuse and muco-purulent, it is to be feared that the malady has terminated in caseous infiltration and consumption, Avhich is a someAA'hat rare occurrence. The discovery of elastic fibres in the sputa, and of cavernous sounds, dispels all doubt that the tissues are in a state of cheesy infiltration and decay. The majority of patients die in a few Aveeks, consumed by the intensity of the fever. Far more rarely, the malady subsides after exciting the very worst apprehensions; the sputa become scanty, and the patient slowly begins to improve. The dulness, hoAvever, remains. The thorax sinks in oaxt the affected region, and, after a AA'hile, Avell-marked evidence arises of induration and contraction of the diseased portion CONSUMPTION OF THE LUNGS. 033 of the lung, as Avell as of bronchiectatic cavities. The pneumonia AAdiich follows immediately upon a haemoptysis or a pneumorrhagia, and which, in my opinion, is caused by effusion and coagulation of the blood Avithin the bronchi and air-vesicles, is of a very similar character. The greater the area of dulness Avhich develops after an attack of haemoptysis, and the longer it lasts, the more pronounced the pleuritic symptoms, the more intense and persistent the fever, so much the more reason is there to fear that the retained blood and the inflamed paren- chyma have undergone cheesy metamorphosis, involving serious disor- ganization of the lung. As we haATe already explained, however, sub- sequent liquefaction and absorption of the caseous mass are stUl possible, as are also its incapsulation and induration of the affected lung through profuse proliferation of the connective tissue, followed by contraction. The invasion of a considerable number of air-cells by an acute catarrh is sometimes attended by such serious symptoms, especially violent feA'er and a rapid decline of the strength and nutritive condi- tion, that the diagnosis is sometimes difficult. It is excusable in such cases if for a while, and until reliable data can be obtained, the phy- sician ascribe the catarrh and intense fever to infection, or to acute tuberculosis of the lung. The case soon clears up, hoAvever. The sputa begin to assume the characteristic admixture of blood peculiar to pneumonia, pleuritic pains, of varying severity and extent, are felt, the percussion-sound becomes holloAV and tympanitic in the upper part of the chest, and, if the points of solidification, originally lobular, coa- lesce into one Aroluminous mass, the percussion-sound is dull. At the same time the rdles, AA'hich at first were indefinite, become ringing, and the respiratory murmur becomes bronchial. It is possible that an acute catarrhal infiltration may undergo complete resolution; far more generally, hoAvever, the infiltrated tissue suffers caseous metamorphosis, and soon disintegrates. Most cases of galloping consumption, Avhere Avide-spread destruction takes place in a lung Avithin a feAV Aveeks, the patient quickly Avasting aAvay and sinking under violent fever, arise from the extension into the vesicles of an acute catarrh, invohdng a considerable portion of the lung, and which may be called an acute phthisis, resulting from acute or subacute catarrhal pneumonia. When an entire lobe of a lung is involved in a process of this kind, subse- quent absorption or incapsulation of the caseous deposit, Avith indura- tion and aa asting of the affected part, rarely occurs. Such a termination is much more frequent where the disease is less extended. We may often trace back a depression of the supra and infra-clavicular region, AA'ith sinking of the summit of the lung, to an attack of acute catarrhal pneumonia, AA'hich has become chronic, and resulted in induration and contraction. We not unfrequently have the opportunity of observing 236 DISEASES OF THE PARENCHYMA OF THE LUNG. patients Avho have suroved such attacks again and again, at varying intervals, the area of dulness and depression of the thoracic Avail ex tending itself on each occasion, and who are finally carried off by a tuberculosis, or a less fortunate repetition of the pneumonia. In contrast to the form of disease hitherto described, the implica- tion of the air-cells in the bronchial catarrh may be unattended by any violent symptoms, and may even be entirely latent. Upon dissection, Ave often find the apex of the lung to be the seat of cicatricial con- tractions, of incapsulated caseous deposits, and callous indurations, resulting from a pneumonia which has totally escaped observation. And Ave find many persons Avhose supra and infra-clavicular regions are sunken in, and the summit of whose lungs is in a state of abnormal depression, without any cleAV as to the date of the pneumonia by Avhich the apex of the lung has become solidified and wasted. Still, Avhen- eA'er the inflammatory process is at all extensive, even chronic catarrhal pneumonia is almost always accompanied by fever. True, for a AA'hile, this insidious fever is generally unobserved, or else misunderstood by the patient, and sometimes, too, by the physician, as the more obvious subjective febrile symptoms, the shivering, sense of heat, thirst, and the like, are slight, and are thrown into the background by the wasting, and the pernicious influence of the fever upon the appetite, the diges- tion, the haematosis, and general nutrition. When a patient with chronic bronchial catarrh, which has no ill effect upon his general health and activity, begins to lose appetite, to groAV pale and thin, and to perceive a marked decline in his strength, there is reason to suspect that the pulmonary vesicles have become involved in the catarrh, and it is our imperative duty to ascertain the existence of fever, and of solidification of the lung, by careful measurement of the temperature, and by repeated physical examination of the chest. The chronic form of catarrhal pneumonia shows a decided tendency, under favoring cir- cumstances, to end in induration and shrinking, as AveU as to relapse under pernicious irritation. This is the reason Avhy so many persons, in spite of the callosities and bronchiectatic cavities in the summit of their lungs, feel tolerably well during the summer months, and gain in strength and Aveight, while in winter, especially if obliged to work, and to expose themselves to cold, they groAV feverish, thin, and pale, and suffer further induration of their lungs. Such alternations often go on for a number of years. Patients of this class furnish a large contingent to the hospitals, where (unless they present some physical signs of especial rarity) they are apt to be unwelcome guests, " chronic pulmonary tuberculosis," as it is called, being generally regarded as a someAvhat uninteresting disease. The striking manner in Avhich this form, which is by far the most common form of phthisis, yields to CONSUMPTION OF THE LUNGS. 237 treatment, and especially to dietetic treatment, in the Avider sense of the Avord, is perfectly comprehensible when looked at from our point of AdeAV, and furnishes an argument in favor of the theory. The development of tuberculosis in lungs Avhich are already con- sumptive, as a result of inflammatory action, sometimes takes place in a manner so latent as to make it extremely difficult, if not quite im- possible, to recognize the fact with certainty. On the other hand, there are many instances, especially where the lungs are the seat of very numerous tubercles, and Avhen the tuberculosis involves other organs, in Avlnch the diagnosis presents no difficulty. Where Ave find a consumptive patient to be groAving very short of breath, there being no perceptible increase in the dulness upon percussion to account for it; if, in spite of the most careful treatment the fever continue, and if it change from the remitting to the continued form; should diarrhoea set in in a patient Avho hitherto has been someAvhat inclined to constipation: if hoarseness and aphonia be combined Avith the other symptoms of consumption, or if signs appear of disease of the meninges of the brain, Ave may confidently infer that tuberculosis has developed in the already consumptive lung. In young subjects, Avho are peculiarly liable to tuberculosis of the cerebral membranes, brain-symptoms may aid in forming a diagnosis, Avhfie in persons of more advanced years the appearance of intestinal or laryngeal symptoms may do the same. The develorjment and progress of a tuberculous consumption differ essentially in type from any thing hitherto described, and its symptoms are so characteristic that the diagnosis of this form of consumption (AAdiich is not common) is, as a rule, easy. In the first place, it has no precursory catarrh. The fever and Avasting are not deferred until the sputa become profuse and purulent, the tubercular eruption being ac- companied by a marked elevation of the temperature and rapid emaci- ation of the body from excessive calorification. If we are informed that a patient did not begin to cough and expectorate until several Aveeks after he had begun to decline in strength, and to grow pale and thin, there is ahvays reason to fear that he has tuberculous consump- tion. Our suspicion will receive confirmation if the patient be un- wontedly short of breath, and if, at first, physical examination of the chest give negative results. At a later period the percussion-sound may groAV dull from consecutive pneumonia, the respiratory murmur becoming bronchial, and the rdles ringing, but the solidification is rarelv as extensive as in the forms of consumption previously described. The sound of the voice and of the cough soon groAvs hoarse, and if there be much tuberculous disease of the larynx, and if it spread rapidly, the Avell-knoAvn distressing symptoms of laryngeal consump- tion make their appearance. Nor is it long before the signs of intes- DISEASES OF THE PARENCHYMA OF THE LUNG. tinal tuberculosis and intestinal consumption set in. Exhaustion is accelerated by profuse diarrhoea. The abdomen becomes sensitive to pressure. The malady seldom lasts over a few months, and most pa- tients succumb even sooner. It would lead us too far Avere Ave to attempt to make a detailed description of the numerous modifications to Avhich the different forms of consumption are subjected by the manifold changes of acute and chronic disease, and the various intercurrent accidents and complica- tions. I am sure, hoAvever, that most cases of consumption Avhich Ave observe ourselves, or Avhich are properly reported to us, may be as- signed without difficulty to one or other of the above-given categories. It follows, from Avhat has been said, that death is the most frequent result of all forms of pulmonary consumption, and that it is the sole termination of tuberculosis, but that, in the forms of the malady which are dependent upon pneumonia, an improvement and approximative recovery are not as rare an occurrence as is usuaUy supposed. It has been satisfactorily established, moreover, that even persons in AA'hom all evidences of consumption have disappeared, and who are completely AveU of the malady, are still in greater danger than other persons of dying of a fresh attack of the pneumonic process or of tuberculosis. The fatal termination usually takes place through gradual con- sumption, " wasting away," " decline." The emaciation of the patient finally becomes extreme. The skin seems too loose for the body, OAving to disappearance of the fat and atrophy of the muscles. The zygomatic bones project from the sunken cheeks, the nose seems longer and more pointed, the orbits from which all the fat has disap- peared seem too large for the eyes, the nails become incurved, the pad of fat upon the last phalanges being gone. Not unfrequently the tem- per of the patient, which at first Avas sullen and perverse, now grows cheerful and kindly. Many have perfect confidence in their recovery up to the moment of death, and expire in the midst of plans looking far into the future. Toward the last, however, the suffering is often severe. If the larynx be also " consumptive," there is an incessant cough which robs the patient of his rest at night; aphthae form in the mouth and pharynx, rendering chewing and deglutition difficult; the decubitus causes severe pain; one or both of the feet become the seat of an extremely painful oedema, owing to thrombosis of the femoral vein. In such cases the final stage seems extremely wearisome to the physician and attendants, and even to the patient himself, Avho often longs for his release. Very much more rarely consumption results in death from haemor- rhage. This is most usually the consequence of erosion of an unoblit- erated vessel in the Avail of a cavity, or else of an aneurismal expansion ' CONSUMPTION OF THE LUNGS. 239 j of a blood-vessel, Avhich, being so situated in the AvaU of a cavity as to ' be deprived of support of the indurated pulmonary substance, yields f.i to the pressure of the blood and finally bursts. In these cases of pneumorrhagia the patient either rapidly bleeds to death or else suffo- cates, the trachea and bronchi becoming filled with blood, thus cutting off entrance of the air into the lungs. The occurrence of pneumotho- rax, Avhich Ave shall describe in detail hereafter, is a more common cause of death than haemorrhage, as are also secondary degeneration of the kidneys, intestinal phthisis, tubercle of the boAvels, pneumonia, pleurisy, and other acute diseases. Treatment.—The treatment of consumption has made great ad- vance since recognition of the fact that the disease depends, as a rule, upon inflammatory action, and is only now and then due to neo- plasm. This AdeAV of the case has not led to the introduction of any neAV remedies for consumption, but it has enabled us more definitely to establish indications for remedies already long in use, so that by their methodical application, better results ha\'e been attained than AA-ere formerly gained at a time AA'hen consumption and cancer Avere regarded as equally incurable, and were somewhat similarly treated. Prophyletxis against consumption requires, in the first place, that, Avhen an individual shoAVS signs of defective nutrition and a feeble con- stitution, especially if already he have given positive eAddence of un- usual delicacy, Avith a tendency to diseases Avhich result in caseous products, he should be placed, if possible, under influences calculated to invigorate the constitution, and to extinguish such morbid ten- dency. Delicate children, especially such as are born of consumptive or otherwise decrepit parents, should not be suckled by their own moth- ers; still less ought they to be reared artificially on "pap," but should be confided to good wet-nurses. After weaning the child, let its diet consist almost exclusively of coav's milk, instead of the customary pap of meal or bread, and after it has done teething let it eat a little meat. This diet must be kept up throughout the whole period of chUdhood, Avhcnever there is any indication of glandular enlargement, moist cuta- neous eruption, or any other so-called scrofulous affection, or even Avhen they merely give CAddence of a so-called scrofulous habit. It is better to prescribe the exact amount of milk the child must take (after drinking Avhich it may eat AA'hat bread, potatoes, or the Hke, it pleases), than merely to Avarn the parents in general terms against the immoder- ate use of bread and potatoes. When the chUd has drunk milk enough, the other food avUI do no harm. The common direction, that a " child shall not cat dry food," is Avrong. It is better that it should cheAV and at its bread dry, so that the amylum Avhich it contains may be prop- V 24:0 DISEASES OF THE PARENCHYMA OF THE LUNG. erly combined Avith saliva, Avhereby it is more thoroughly converted | into sugar and is easier of assimilation. Besides this, hoAvever, it will I drink all the more milk if it eat its bread plain. A similar plan of treatment is of course proper for children, Avho, instead of inheriting, have acquired a feebleness of constitution Avhich often sIioavs itself at an early date in the form of scrofula, and occasions a predisposition to consumption. A proper supply of fresh air is of equal importance Avith regula tion of the diet. The facts adduced above, illustrating the baneful effect of continual in-door life in producing scrofula and consumption, i are not sufficiently taken into account by many physicians. They very often suffer delicate, sickly children to sit day after day and six hours at a time upon the benches of a crowded school-room, after which they haAre their tasks at home to prepare, private lessons to take, the piano to play, etc. Cod-liver oil and an occasional month at a watering- j place cannot possibly repair the injurious effects of such a mode of life. ' As soon as the influence of this immoderate " schooling " begins to " tell," a reduction of it, or even a total cessation of it, should be im- peratively insisted on. Obstinate opposition to such demands wUl be often met Avith, but, in a series of instances in AA'hich I have obtained a complete and prolonged respite from education, and made the children spend most of their time in the open air, I have obtained effects at Avhich I Avas myself astonished, and which completely satisfied then \ parents that results fully outweighed the serious sacrifices AA'hich they had made. People in easy circumstances, Avho have delicate and scrof- ulous children, especially if subject to croup and bronchitis, should be induced to spend their Avinters in the South, so that the children may also pass those months in the open air, AA'hich in our climate Avould be too cold. This is a very common practice in Russia, Avhere the per- nicious effects of in-door life during the long winter are very con- spicuous. In adults, Avhen the signs of delicacy and Aveakness, combined with deterioration of the blood, appear, the use of ferruginous preparations is to be recommended, particularly the chalybeate springs of Pyrmont, Driburg, Imnau, etc. I think that this treatment deserves a more gen- eral adoption, as a prophylactic measure against consumption, than it has received hitherto. Prophylactic treatment of consumption further demands a careful aA'oidance of all agents calculated to cause hyperaemia of the lungs and bronchial catarrh, and AA'hich we have enumerated as exciting causes of phthisis. Persons in Avhom a tendency to consumption is suspected should be strictly forbidden to inhale an atmosphere charged Avith smoke or dust, or AA'hich is too hot or too cold, as Avell as to make CONSUMPTION OF THE LUNGS. 21-1 great efforts in running, singing, dancing, or to drink hot or spirituous beverages. Chilling of the skin is to be guarded against with the ut- most care, and the patient should be made to wear flannel next the skin. What Ave have already said regarding the prophylaxis against pulmonary hypaeremia and bronchial catarrh is equally apphcable in the present instance. Finally, Avhenever there is the sfightest suspicion of a predispo- sition to consumption, every catarrh, no matter Iioav slight, is to be treated Avith the utmost care, AAdiich is not to be relaxed until the catarrh is entirely well. This rule, so obAdous from our point of AdeAV, is Arery frequently Adolated. Many patients fall a victim to the deeply- rooted prejudice, that a neglected catarrh never leads to consumption. The rules Avhich Ave have laid doAvn for the prevention of phthisis must be carried out with equal strictness, AA'hether the disease have merely just commenced, or Avhether it already have made some prog- ress. It is, therefore, superfluous to make separate mention of the indications derived from the cause, as they are identical Avith those of prophylaxis. When the airwesicles of the lung become involved in the bronchia] catarrh, the indicatio morbi calls for the usual remedies applicable to chronic inflammation. Above all, the affected lung, like any other in- flamed organ, is to be shielded from the action of any neAV irritation. It is incredil >le Iioav much this simple rule (so obvious Avhere the nature of phthisis is rightly understood) is disregarded by many physicians. It is a matter of daily occurrence that patients from the better class, suffering from advanced consumption, are not sufficiently urged by their physician to AvithdraAV from their occupation, to throAV up their position at the counting-house or office, and to keep aAvay from club- rooms, Avith their over-heated and tobacco-laden atmosphere. It is often by exposure to irritants like the above, Avhose effect is so very injurious to the inflamed lung, that the extension of the inflammatory product is aggravated and made to terminate in disorganization, Avhile, by their careful aA'oidance, the disease is often promptly arrested and brought to a favorable issue. The beneficial effect obtained in con- sumption, by protecting the affected lung from further detriment, is still more marked among the poorer classes, Avho seek aid at the hos- pitals. Many patients are receh'ed in a condition so Avretched that a specdv death seems imminent, and yet they leave the institution, in the course of a feAV Aveeks or months, in much stronger and better con- dition, and often Avith a material increase in Aveight. Soon, hoAvever, they return, seeking readmission, their condition having groAvn rapidly Avorse again, OAving to inclemencj' of the Aveather, and to other noxious influences, to AA'hich they ha\re been exposed. 16 242 DISEASES OF THE PARENCHYMA OF THE LUNG. Were it not for the very grave objections already detailed, I should counsel most consumptive patients to keep the house during our North- ern Avinter, and to maintain the utmost uniformity of temperature in their chamber, in. order to preserve their lungs from further harm. This dUemma may be obviated by malting the patient avoid the North- ern AA'inter, by sending him to some place AA-here he can spend the greater part of the day in the open air, without risk of taking cold, or of inhaling a raAV, inclement atmosphere. This, in my opinion, is the real benefit derivable from change of climate. When a patient has the means, Ave should never omit to enjoin upon him to make the sacri- fice, but the matter must be made plain to him, so that he may not suppose the air of the place to Avhich he is sent has any special cura- tive power upon his lungs. We need not expect any benefit from a residence in Nizza, Mentone, Pau, Pisa, Algiers, Cairo, or Madeira, unless the patient fully understands that he must take care of himself. OtherAvise, it Avere often better that he remained at home. Acting upon this principle, the patient should be sent during the autumn, and before the harsh Avinter sets in, to Soden, Badenweiler, Wiesbaden, and, above all, to the lake of Geneva, where he may try the grape-cure, and Avhere he is as well protected as he is at home during the summer. None but very intelligent and prudent persons, who Ave may be sure avUI stay at home in bad Aveather, should be alloAved to spend the Avinter at Nizza, Mentone, Pisa, or Pau. When the patients have the means, it is ahvays better to send them to Algiers, Cairo, or Madeira. The comparative merit of these Avinter abodes is not as yet positively determined, and the indications for preferring Madeira, Algiers, or Cairo, in particular cases, or for certain stages of the disease, are so indefinite as to be of little value. One principle, hoAveA'er, ahvays ob- tains : that the patient, wherever he may be, must live circumspectly, and remain under the charge of an intelligent and strict physician. For patients who are unable to seek a milder climate, the use of a " respirator," a wire gauze, warmed by the breath, through AAdnch the external air is inhaled, is advisable. A handkerchief held before the mouth, hoAvever, Avhich .also is soon warmed by the expired air, wUl ansAver the same purpose, and, indeed, is really better than a " respi- rator," as it is not, like the latter, liable to become too Avarm. When the invasion of the air-vesicles by acute catarrh, or the rapid spreading of a catarrhal pneumonia, is accompanied by violent symp- toms, Avhen high fever sets in, Avhen the sputa become bloody, and the patient complains of lancinating pain upon draAving breath, and upon coughing, local depletion, by means of leeches or cups, and the appli- cation of cataplasms, should be resorted to. At the same time, the patient must be required to keep his bed until all symptoms of the I CONSUMPTION OF THE LUNGS. 213 acute attack-, or of the exacerbation of the old inflammatory disorder of the lung, be past. The fits of shivering, which come on regularly every evening, in many cases of phthisis, and AA'hich sometimes actually amount to rigors, have often been observed to cease if the patient re- main in bed. And, upon closer observation, it has been found that not only does the chill which heralds the evening access of fever, but all the other febrile symptoms, especially the rise in temperature, undergo marked improvement Avhile the patient remains in bed for a few days. There is nothing strange about this, if, instead of regarding the hectic fever of consumptives as something peculiar, as an ens sui generis, Ave look upon it as a fever due to chronic inflammation. The fever AA'hich accompanies bronchial catarrh, pneumonia, or inflammation of any other organ, increases and diminishes as the disease groAvs better or Avorse, and it is just the same Avith the hectic fever of phthisis. Hence, if resting in bed, such as Ave generally recommend in other inflamma- tory disorders, have a beneficial effect upon the pneumonia of con- sumptives, it avUI tend also to mitigate their fever. The use of the alkafine muriate mineral waters, AA'hich is often so beneficial in simple catarrh, is equally useful in some cases of consump- tion. According to our vieAV of the disease, this effect (avIucIi of course all befievers in the theories of Laennec AviU deny) is not more enigmatical than that Avhich these waters produce upon a simple catarrhal inflammation, which does not involve the substance of the lung. The idea, that the use of the Avaters of Ems and Obersaltzbrun- ner is contraindicated by the presence of feA^er, is merely one of the results of imperfect observation. It is not the mineral waters AA'hich disagree AAdth the fever, but the journey to the Avatering-place, and the promenades at the springs. As Ave have said before, a patient aa ith any appreciable degree of fever ought to be in his room or in his bed. A continued abode in eleA^ated regions, AA'here, Avithout any appar- ent reason, consumption is rare, is also advisable for consumptives, Avhen their disease depends upon chronic pneumonia. I fuUy approve of the customary practice of sending phthisical patients to spend their summer at Heiden, Gais, Weissbad, Kreuth, etc., although I think but I little of the "curds and AA'hey treatment" AA'hich is practised there. \ In tuberculous phthisis, and in secondary tuberculosis, it is out of bur poAver to meet the indications derived from the disease itself. \ Indicatio Symptomatica.—FeA'er is the symptom AA'hich principally Snands treatment, Avhenever it persists at aU seA'erely, in spite of * remedies directed against the main disease. Anti-pyretics very perly plav a most important part in the therapeusis of consumption. \ not that these remedies exert any more direct influence upon / 244 DISEASES OF THE PARENCHYMA OF THE LUNG. chronic pneumonia than they do upon croupous pneumonia or typhus, or upon any other of the many maladies in AA'hich they are so much prescribed, often, indeed, Avithout any very clear idea as to Avhat is tc be expected of them. But, if Ave know that the discharge of mucus and of pus-ceUs has but little to do Avith the exhaustion of the patient (indeed, it is often far more profuse in a simple bronchial catarrh), and that the fever is really his most formidable enemy, it folloAvs, of course. that Ave must use every means at hand of combating this enemy. Digitalis and quinia have a AveU-merited reputation, as means AA'hereby Ave often succeed in arresting the abnormal calorification, and reducing the animal heat, in spite of the continuation of the dis- ease. Digitalis is the principal ingredient of the much-employed Heim's pill. (IJ. pulv. herb, digitalis 3 ss., pulv. rad. ipecac, pulv. opii puri aa. gr. v., extract helenn q. s. u. f. pil. no. XX. consp. pulv. rad. irid. flor. S. a pill three times daily.) The addition of a scruple of quinine to the above prescription be- comes all the more appropriate, the more periodical the type assumed by the fever, the more severe its evening exacerbations become, and the more pronounced the chills by Avhich they are ushered in. I am so much in the habit of using Heim's pill with or without quinine, in consumption, whenever the fever proves refractory to the other rem- edies heretofore mentioned, that it has become a very common pre- scription at my clinic. Now and then, when I am a good deal consult- ed by phthisical patients, I prescribe it three or four times in one day. At the clinic, exhibition of the pills is suspended whenever a distinct reduction of the temperature and of the frequence of the pulse becomes apparent, and is resumed as soon as the effect subsides. In consulta- tion practice, I have repeatedly found that the patients pretty soon learn to judge for themselves AA'hen it is time to stop the pills, and Avhen to resume them. The subject of antipyretic treatment of consumption may, Avith great propriety, be immediately followed by that of the diet of phthis- ical patients, for the same reason Avhich induced us to treat the sub- jects of fever and emaciation in immediate conjunction. A man AA'ho has fever Avhich is rapidly consuming him, stands in far greater need of a supply of nutriment than one Avho has no fever. The fever of a consumptive patient often lasts for months, so that the danger that it will Avear him out is greater in his case than in one of acute febril*/ disease of brief duration. Hence it follows that phthisical patient/ require the richest possible diet Avhich aaUI agree Avith them. It often said, but Avithout any proof Avhatever, that food excites the fev and (independently of the English practice) even here (in Germa we only keep a patient on fever-diet—that is, Ave only deprh^e hh CONSUMPTION OF THE LUNGS. 245 nourishing food until it becomes evidently dangerous to persist in sn doing. As soon as this is evident, the so-called laAV of nutrition is utterly ignored, or, rather, it is flagrantly Adolated. In selecting suit- able nourishment for consumptives, articles commended, time out cf mind, by rude experience, are found to be in complete agreement AA'ith the current physiological laAVS of assimilation and nutrition. All the food Avhich is regarded as especially proper for phthisical patients con- tains large quantities of fat or of fat-generating matter, and a compara- tively small portion of protein substances. This accords AA'ith our experience, that the production of urea, and hence the destructive assimilation of nitrogenous constituents, is augmented by an increase of the supply of protein substances, Avhile, by a simultaneous free sup- ply of fat or fattening food, the destructive assimilation and consump- tion of the organs of most importance in the body are diminished. Thus the use of milk, to AA'hich little chUdren OAve the plumpness of their limbs, and from Avhich corpulent persons do Avell to abstain, cannot be sufficiently urged upon consumptiA^e persons. It is altogether useless, hoAvever, and indeed Avrong, to remove the casein of the mUk, and to give it in the form of Avhey, unless, indeed, the Avhey agree Avith the patient better than the milk, Avhich is rarely the case. I often order my patients to drink a pint of milk " Avarm from the coav," three times a day, but have no other object in so doing than that of preA^enting the milk from being skimmed, Avhich is impossible immediately after milking. The milk of animals AA'hich pasture in the mountains, such as goat's milk, but, above all, ass's milk, is in espeoial repute, and it is desirable to send patients, Avho can travel Avithout danger, to places AA'here there are dairies where a supply of good fresh milk is to be obtained. Where this cannot be done, the " milk-cure " must be practised at home. The name is of importance, in order that the patients may haA'e faith in the treatment, and folloAV it out punctually. I have treated a great number of patients who, as soon as they found that they increased appreciably in Aveight, for half a year at a time drank three or four pints of milk daily Avithout repugnance. The use of cod-liver oil is also highly commendable, and, AA'hen it » agrees Avell Avith the patient, may be combined AA'ith plenty of milk. \ It is more than doubtful whether this oil, Avhich is hardly ever Avith- \ held in phthisis, at all events in Germany, exerts any specific influence upon the disease. The quantity of iodine in it is so trifling, that it ;nnot be taken into account, hence it is probable that all its beneficial fects are solely due to the large amount of fat AA'hich it affords. This 1 the more likely, as dog's fat is a popular remedy for consumption, ncient and well-tried as cod-liArer oU. Vf late years I have obtained very good effects from an extract of 246 DISEASES OF THE PARENCHYMA OF THE LUNG. malt, prepared by Trommer. This preparation of Trommer is not a strong beer, containing a large amount of alcohol and carbonic acid, like the Hoff's malt extract so greatly extolled, but is a genuine extract resembling other officinal extracts, and consists of the soluble constituents of the malt, and of the bitter extractive matter of the hops, and can be prepared by every apothecary. One hundred parts of it contain about seventy-six parts of grape sugar, or malt sugar, dex- trin, bitter of hops, resin of hops, and tannin, seven parts of albuminous or protein substance, eighty-two hundredths of a part of phosphate of lime and magnesia, eighteen hundredths of alkaline salts, and sixteen parts of Avater. The patients almost always enjoy two or three table- spoonsful of it daily, and it usually agrees well with them. It may be diluted in spring-Avater, mineral Avater, or warm milk or other Hquid. Broth, made of coarsely-broken rye-meal, which contains a good deal of gluten, besides the amylum, is a good food for consumptives, and has long enjoyed such a reputation. Soup of lentils and bean- meal (revalenta arabica), as well as the various preparations of choco- late, mixed with cacao-meal, and sold under various names, is also appropriate. Jellies of animal or vegetable substance are much less desirable, such as the snail-soup, and the jelly from the Iceland moss. With respect to the symptomatic treatment of the cough and ex- pectoration, Ave simply refer to Avhat has already been said regarding the treatment of bronchial catarrh. An indiscriminate use, one after another, of the so-called expectorants is as absurd in the treatment of the chronic bronchial catarrh Avhich accompanies phthisis as it is in any other form of catarrh. The sweet, mucilaginous, " soothing," demul- cent articles are least serviceable of all. Precisely according to the conditions laid doAvn above, the alkaline chlorides may be required at one time, at another senega, squills, or other stimulants may be indi- cated, and at still another the articles which diminish secretion. As Ave haA'e already expressed our preference for the balsams and resins for the latter purpose, I must again say a Avord or two in favor of the saccha- rum myrrhae, and of Griffith's mixture, adding, hoAvever, that acetate of lead is held in great esteem by many authorities as a remedy for the condition in question. (In almost every case Avhere acetate of lead is used it is given in combination Avith opium, to which some of the effect attributed to the lead is certainly due.) / The narcotics are to be employed in order to allay the cough, an/ are quite indispensable in consumption. As Ave have said already,,' is not the soothing, soporific action of the first few doses of the opi or morphine Avhich gratifies the patients, but it is because they / that they cough less and more easily, " that their cough is loos j ACUTE MILIARY TUBERCULOSIS. 247 and, indeed, Avhen Ave consider that coughing is an irritant to the bron- chial mucous membrane, which is the principal source of the secretion, it seems quite probable that a diminution of the inclination to cough may result in a decrease of the expectoration. Nevertheless, it is best not to commence using the narcotics too soon, and, instead of opium, Ave should begin AAdth small doses of something else, as, extract of lactucaria Adrosa, gr. ss to gr. j, in poAvder, or in the form of a syrup. By a too early resort to narcotics, it may happen that they fail of effect at a later period, when the need for them has become most urgent, as Avhen the tormenting cough of a laryngeal phthisis deprives the patient of rest both by night and by day. It seems also, that, as soon as it becomes necessary to give large doses of opium, the progress of the consumption becomes more rapid, an additional reason against a too hasty employment of a remedy Avhich becomes indispensable to the patient. For the night-SAveats Ave may order small doses of " Haller's acid," or the patient may drink a cup of cold sage-tea, if the antipyretic treatment fails to do good. The efficacy of the above articles is some- what questionable, no doubt, but it Avould be cruel to tell the patient that there are no means of relief from this distressing symptom. Some physicians recommend the boletus laricis (a very variable article), as a most efficient remedy against the night-sweats of consumption. With regard to the treatment required by the complication of laryngeal and intestinal phthisis AA'ith consumption of the lungs, as AveU as that demanded by the secondary diseases of the liver and kid- neys, etc., Ave must refer to the sections in Avhich affections of those organs are described. CHAPTER XIY. ACUTE MILIARY TUBERCULOSIS. Ehology.—Acute miliary tuberculosis, AA'hich is not to be con- founded Avith acute ("galloping") consumption, depends upon an eruption of tubercles in the lungs as Avell as in most other organs, ai,d is accompanied by the symptoms of an acute disease. In the o-rciit majority of cases the disease is seen in persons whose lungs or other organs contain old caseous deposits. This fact, and the cir- cumstance that the symptoms and course of acute miliary tuberculosis bear a strong resemblance to those of the acute infectious diseases, Avould niakc it appear highly probable that the malady arose from in- fection df the blood by the caseous products {Buhl), were it not that the occas!onal although rare occurrence of the disorder, unpreceded by. i \ \ 248 DISEASES OF THE PARENCHYMA OF THE LUNG. caseous deposit, contradicts this plausible hypothesis. We must, therefore, content ourselves by stating that, in most cases, acute miliary tuberculosis is a secondary disease, arising, in some manner as yet unknoAvn to us, from the pernicious effect of the cheesy deposit, but that may also proceed from other causes, of Avhose nature Ave are equally ignorant. Anatomical Appearances.—If Ave find, upon dissection, that the lungs are studded uniformly from top to bottom with miliary tubercles, if the miliary nodules present that gray, translucent appearance of fresh tubercle, if the surfaces of the pleura be also streAved with miliary tubercles, Ave may decide with positive certainty that the patient has had acute miliary tuberculosis, even though we know nothing of AA'hat the course of the disease has been. In chronic tuber- culosis this uniform dissemination of the tubercle is never found, and yellow, caseous granulations always coexist with the neAV gray tuber- cles, showing that the deposit has been a gradual one. In most cases of the acute disease, the peritonaeum, the liver, the spleen, the kidneys are covered by miliary tubercles. Finally, especially in young per- sons, numerous granulations are often found in the pia mater, particu- larly at the base of the brain, about the pons, and the chiasm of the optic nerves, together with acute hydrocephalus of the ventricles. The parenchyma looks injected and more or less infiltrated Avith serum, otherAvise it is generally free from inflammatory or other nutri- tive disturbance, with the exception of the traces of former disease Avhich may be there. The corpse of a person Avho has died of acute miliary tuberculosis resembles that of one Avho has died of an acute febrile disease, the resemblance commencing during life and con- tinuing after death. The blood is dark and liquid, and settles to the most dependent points, giving rise to extensive pulmonary hypostasis. The muscles are red, and even the spleen is often someAvhat SAVoUen and softened. Symptoms and Course.—When an acute miliary tuberculosis de- velops at an advanced stage of consumption, complicated Avith hectic and night-sweats, it is very difficult of recognition, inasmuch as it can hardly be decided whether the fever and the rapid decline of the pa- tient are due to the original complaint or to the complication. Physical examination of the chest gives negative information as to the new deposit of mifiary tubercles; as the innumerable little granules, being everyAvhere enclosed in tissue containing air, do not modify either the sound upon percussion or the respiratory murmur, although the dis- proportion betAveen the intense dyspnoea and the trifling extension of some old point of induration perhaps may aid the diagnosis. The disease assumes a different guise AA'hen it attacks persons iv ACUTE MILIARY TUBERCULOSIS. 249 good health, or those AA'hose chronic pulmonary affection has hitherto escaped attention. It then not unfrequently begins Avith repeated rigors, great frequence of the pulse, and severe constitutional disturb- ance, symptoms often hard to interpret, as they are attended by no tokens of local disorder. The frequence of the pulse often becomes exceedingly great, abundant sAveats set in, the patient sinks visibly from day to day, the tongue becomes dry, the sensorium deranged, he becomes delirious or lies supine in a state of stupor. A rapidly-increas- ing prostration, cough, and dyspnoea accompany these symptoms, it is true, but the most persistent physical examination of the chest reveals noAvhere that the substance of the lung is infiltrated. No sounds can be perceived, save a feAV fine rhonchi and scanty rdles. The symp- toms Avhich avc have depicted are so very like those of typhus, that the most experienced diagnosticians acknoAvledge to having met AA'ith instances in Avhich a diagnosis between the tAvo Avas absolutely impos- sible, and AAThere patients dying with a diagnosis of typhus really had died of tuberculosis, and conversely. The less A'iolent the symptoms of catarrh in acute miliary tuberculosis, the smaller the clew afforded by the spleen, the more rapid the march of the malady, so much the more difficult does the distinction become. The patient may succumb to miliary tuberculosis, after the lapse of a fortnight, or a feAV days longer, or about in the same time in AA'hich patients usually die of typhus. More rarely death does not take place until the end of the fifth or sixth week. The patient perishes, as Ave have said, consumed by fever, just as he falls a prey to fever, too, as a rule, Avhen he dies of typhus. The pulse becomes smaller and more and more frequent; finally, the pulmonary veins are no longer able to pour their blood into the imperfectly-emptied heart, and oedema of the lungs, palsy of the bronchi, and suffocative effusion are established. If tuberculous basilar meningitis accompany the attack, its course is modified (see appro- priate chapter) and the fatal termination takes place Avith eAren still greater rapidity. Diagnosis.—At the outset of the disease, if the chills recur with some degree of regularity, it may be mistaken for intermittent fever. We shall soon observe, however, that the intermissions are not com- plete, that quinine fails in its effect, that the complaint is attended by a disturbance in the respiratory function, Avhich is unusual in inter- mittent ; that the frequence of the pulse is constantly on the increase, and that the entire character of the complaint is more pernicious than that of simple intermitting fever. In other cases the disease, at its commencement, resembles an ex- tensive bronchial catarrh, accompanied by fever, especially if the cough be very Adolent and distressing; but here, too, all difficulty of distinc- 250 DISEASES OF THE PARENCHYMA OF THE LUNG. tion soon vanishes, as the Adolence of the fever, the rapid collapse, and the malignant course of the malady, but especially the shortness of breath AA'hich often renders it impossible for the patient to breathe in a recumbent position, and which is in striking contrast with the absence of physical signs of disease, afford data for diagnosis. A differential diagnosis between miliary tuberculosis and typhus is based upon the following points : 1. In tuberculosis, the cough and dyspnoea appear, as a rule, at an earlier period and Avith far greater intensity than in typhus. In exan- thematic typhus, it is true, Ave likewise find early and violent bron- chitic symptoms; but here the distinction is easy, as the eruption of exanthematic typhus is highly characteristic and scarcely to be over- looked, AA'hile there is no eruption in acute miliary tuberculosis. 2. In abdominal typhus (typhoid), likewise, we rarely fail, after careful and repeated search, to discover a few spots of roseola upon the upper region of the abdomen, AA'hich do not exist in acute miliary tu- berculosis. 3. Enlargement of the spleen can rarely be found in acute miliary tuberculosis, and Avhen found scarcely ever is an enlargement of much magnitude, Avhile Ave hardly ever fail to find it in abdominal typhus : and even though it Avere not found, in exanthematous typhus the ex- istence of the eruption would render this clew almost unnecessary. 4. Meteorism, liquid stools, tenderness in the ileo-ccecal region, are seldom absent in abdominal typhus. These symptoms are not ob- served in acute miliary tuberculosis. 5. Typhus rarely supervenes upon chronic disease of the lungs, while acute miliary tuberculosis seldom attacks any save those who are suffering from such disease. Dulness at the apex of either lung is therefore of great diagnostic significance. 6. Wunderlich has observed that the temperature in acute mil- iary tuberculosis is much lower than in typhus, seldom reaching 104° F., and is out of all proportion to the enormous rapidity of the pulse. Prognosis.—Prognosis as to the issue of acute miliary tuberculo- sis must be almost absolutely unfavorable. Only a very few observa- tions (Wunderlich) alloAV us to suppose that tubercles thus deposited may become atrophied, and the malady terminate in recovery. The cases, too, in AA'hich the acute disease has become arrested, and chronic tuberculosis and phthisis have foUoAved, certainly must be considered as among the greatest of rarities. The more violent the fever, the more pronounced the brain-symptoms, so much the sooner is the end to be expected. Treatment.—The treatment of acute mUiary tuberculosis is of course a mere treatment of symptoms. The most important symptom CANCER OF THE LUNG. 251 is the fever; for it is of the fever alone that the majority of those at- tacked perish. Large doses of quinine should be given, particularly at the outset of the disease and as long as the rigors continue to occur, and at a later period use digitalis, nitre, and the acids. Little success, hoAvever, is to be anticipated. For the dyspnoea, cold is to be applied. Combat the cough AA'ith narcotics; and, should appearances lead us to suspect the existence of meningeal tuberculosis, apply ice to the head. CHAPTER XV. CANCER OF THE LUNG. Etiology.—The pathogeny and etiology of this malady are as ob- scure as those of the malignant neoplasms in general. Cancer of the lung is a someAvhat rare disease, and primary cancer of this organ is of especially unusual occurrence; that is to say, the substance of the lung is scarcely ever the point at Avhich the first traces of it develop themselves. Cancer of other organs, particularly of the breast, almost ahvays precedes cancer of the lungs. Anatomical Appearances.—In the lung, cancer assumes almost exclusively the medullary form, far more rarely that of the scirrhus or of alveolar degeneration. It sometimes assumes the form of rounded isolated masses, varying from the size of a hemp-seed to that of a fist, constituting cancerous nodules of a marroAvy appearance and soft con- sistence, which, when they touch the pleura, are apt to show a flattened or umbilicated depression. Sometimes the disease appears as the so- called infiltrated cancer. Unlike the previous variety, the latter form does not present a distinct Hmit between the cancer and the surround- ing parenchyma, but makes a gradual transition; nor does the disease present the rounded contour of cancerous nodules. The old hypothesis, that, in the latter case, Ave had to do Avith a conversion of an infiltration into cancer, has been abandoned; and it is noAV believed that, in the origin of infiltrated cancer, after the trans- formation into cancer-cells of a few of the connective tissue-cells of the matrix of the lung, and of a feAV of the epithelial cells of the vesicles, this conversion is propagated into the neighboring connective tissue, and into the connective tissue-cells of the adjacent ahreoli. On the other hand, AAdth regard to the appearance of isolated cancerous nodules in the lung, Ave must suppose that here, too, the cancer-cells originate from the elements of the tissue, and then proliferate Avithout further imphcation of the contiguous tissues in the disease. The enlargement of the tumor, therefore, is due to proliferation of the original cancer-cell 252 DISEASES OF THE PARENCHYMA OF THE LUNG. alone; the surrounding pulmonary substance being pushed aside and compressed. It is exceedingly rare for medullary fungus of the lung to soften, and break doAvn, so as to form cavities. The disease is much more liable to extend into the pleura, and, as the pleural folds rapidly adhere, to spread through them into the Avails of the chest, which it often penetrates. Symptoms and Course.—In the great majority of instances, no characteristic marks of cancer of the lung are to be observed, and it is hardly ever possible to prove the existence of the disease with cer- tainty, except in cases Avherein a carcinomatous breast has been extir- pated, or in which extensive cancerous disease of other parts of the body can be discovered. Should dyspnoea, cough, blood-spitting, and pain in the chest, symptoms indicative of chronic disease of the lung, appear in such a case, instead of apprehending the formation of tuber- cle, Ave should bear in mind the rarity of tuberculosis in cancerous per- sons, and of the frequent relapses of the malady, in the form of pul- I monary carcinoma, after extirpation of cancerous masses. Diagnosis avUI be confirmed if percussion and auscultation show a consolidation of the substance of the lung, especially as, unlike tubercle, cancer is not habitually situated at the summit of the lungs. We are very seldom able to prove the existence of any character- t istic objects in the sputa. The diagnosis is more commonly rendered ' certain by the perforation of the thorax by the disease and its extension into the integument. Treatment.—Of course, there can be no idea of treating a cancer of the lung. The hyperaemia in its adjacent parts, the oedema, the hemoptysis, must be treated according to directions already given. SECTION IV. DISEASES OF THE PLEURA. CHAPTER I. INFLAMMATION OF THE PLEURA--PLEURITIS, PLEURISY. Etiology.—As avc shall find presently, there are tAA*o forms of pleu< risy. The first form merely causes thickening of the pleura, and adhesion of its opposing surfaces. The second also produces thick- ening, but at the same time gives rise to an effusion into the pleural sac, containing more or less of fibrin and of young cells. The thick- ening and adhesion of the pleural surfaces are due to proliferation of the normal connectiA'e tissue of the pleura. The pleuritic effusion is the result of an interstitial exudation. The young cells, which the effusion contains, OAve their origin to a proliferation of the connective tissue cor- puscles of the pleura, and of the epithelial cells AA'hich cover its surface. Regarding the essential points in the etiology of pleurisy, Ave may refer to what has already been said Avith regard to the etiology of pneumonia. We must here denounce the impropriety of calling all cases of pleurisy secondary pleurisy, which, instead of attacking robust and A'igorous persons, occur in subjects AA'ith broken-doAvn constitution, or in individuals AA'ho have already suffered from some other disease. Even the pleurisy Avhich so often occurs in Bright's disease is not, in my opinion, a secondary disease, dependent upon fhe renal affection, but should rather be looked upon as a compfication. The frequence of such compHcations, and the especially common occurrence of pleuritis in debilitated and depraAed constitutions, and among convalescents after protracted disease, depend upon the increased predisposition, AA'hich such indh'iduals possess, for all kinds of inflammatory diseases, and especiallv for the one in question. A Arery trifling exciting cause is requisite in this class of persons to provoke the malady; but it never arises Avithout provocation of some kind. 254 DISEASES OF THE PLEURA. The case is different in the pleurisy Avhich sometimes accompanies septicaemia, puerperal fever, scarlet fever, and other infectious dis- orders. Such a pleurisy arises independently of the action of any neAV irritant, and forms one of the nutritive derangements AA'hich jDroceed from infection of the organism by putrid matter, scarlatinous poison, or the like. This secondary pleurisy, which generally produces a puru- loid exudation full of young cells, is attended by inflammation of other serous membranes. The exciting causes of pleurisy are— 1. Injuries of the ribs and pleura, and the entrance into the latter of foreign bodies, such as pus, blood, air, and the contents of caAdties. Such exciting causes generally give rise to a form of pleurisy, accom- panied by a Arery profuse sero-fibrinous exudation into the pleural sac. 2. Pleuritis often arises through propagation of inflammation from neighboring organs, as from the lungs to the substance of the pleura. In these cases the exudation generally is scanty and fibrinous, although it sometimes is very copious and sero-fibrinous. 3. Next in order come the very numerous instances in which pleu- risy is caused by the advance to the pleura of neoplasms, especially of tubercle and carcinoma. Here the pleurisy is dry, or else it results in adhesions of the opposing surfaces of the pleura, or else a more or less plentiful effusion into the sac may form, or, finally, tubercle or cancer may develop in the pseudo-membrane. 4. Pleurisy is often the consequence of exposure to cold, or to the action of other atmospheric or telluric influences, of which we have no definite knowledge. In this form, which is an independent, idiopathic disease, and Avhich is usually called rheumatic pleurisy, there is a great deal of variety as to the quantity and character of the effusion. Anatomical Appearances.—In commencing pleuritis, the pleura is reddened by injection proceeding from the sub-serous connective tissue, and producing fine rose-red points and stripes upon its surface. Besides this distention of the capillaries, Ave often find slight extrava- sations of blood, ecchymoses, forming irregular dark spots, in which the ramifications of small vessels are visible. The tissue of the pleura is infiltrated, the epithelium is nearly all cast off, the surface, fonnerly smooth and glossy, looks dull, the pleura itself is somewhat swollen. Gradually the free surface begins to assume a rough, shaggy appear- ance. This is due to the development of minute delicate folds, and papillary granulations, Avhich are firmly attached to the surface, and are not to be confounded Avith fibrinous deposits. Microscopically, these granulations consist of neAvly-formed fusiform cells, and tender filaments of waA'y connective tissue, Avith considerably-elongated capU- laries, Avhich are coiled into loops Avithin them {Foerster). INFLAMMATION OF THE PLEURA. 255 Thcsi- changes occur in every form of pleuritis, Avhether effusion take place in the pleural cavity or not, whether the latter be profuse or scanty, contain much or little fibrin, or many or feAV pus-corpuscles. It is to this source alone that pseudo-membranes and adhesions of the pleura oavc their origin. The most common forms of pleurisy are— 1. That in which no symptoms occur, excepting those just de- scribed, and to which Ave may give the name of pleuritis sicca, dry pleurisy, or pleurisy AA'ith purely nutritive exudation. It is true, that Ave but rarely have opportunity to make anatomical examination of a dry pleurisy in its earliest stage. However, Avhenever this has been possible {Foerster), no free exudation has been found to exist, the out- groAvths from the pleura just described forming the sole abnormity. Besides this, hoAvever, very extensive adhesions of the pleura are often found, Avhich have formed almost without giving rise to any symptoms, and this fact Avould indicate that they must occur Avithout exudation, for avc find that very small exudations are accompanied by very great pain. 2. Pleurisy with scanty, but very fibrinous, exudation. Such a pleurisy Ave almost ahvays see accompanying croupous pneumonia or complicating chronic affections of the lungs. It may also occur as an independent disease. Here the inflamed pleura, having undergone the alterations above described, soon becomes coated by an extremely deli- cate membranous coagulum of fibrin, AA'hich causes it to appear more opaque, so that Ave cannot discern the injection, or ecchymosis of the pleura itself, until Ave have scraped off the fibrin Avith the scalpel-handle. In other cases, this very fibrinous effusion is someAA'hat more profuse, and Ave may then observe upon the pleura a white deposit, half a line or more in thickness, someAvhat soft, and very much like a croup mem- brane. Of course, the exudation in these cases Avas originally liquid, and only coagulates at a later period; nevertheless, Ave are often unable to find any liquid effusion besides the coagulated one in the cavity of the pleura. When this form of pleuritis recovers, the fibrinous de- posit, after undergoing fatty degeneration and liquefaction, is absorbed, the outgroAvths of the opposing surfaces of the pleura are brought into contact, and adhesions generally ensue. 3. Pleurisy with abundant serofibrinous exudation. The altera- tions in the tissues of the pleura are usually very extensive in this form of the disease, both upon the pulmonary and costal surfaces; but, in addition to this, an effusion of serum takes place in the pleural sac, amounting, not unfrequently, to two or three, and, indeed, even to ten pounds or more. This exudation consists of tAvo components—a yel- loAAdsh-o-rcen serum, and a quantity of coagulated fibrinous masses. 256 DISEASES OF THE PLEURA. Part of the latter floats in the serum in the form of flakes and lumps. another part traverses the serum in the form of a loose net-Avork, Avhile a third portion is precipitated upon the pleura, upon Avhich it lies in the form of a membrane. The longer the effusion remains, so much the stronger and more rigid do the masses become, until they finally grow fibrous, Avithout, hoAvever, taking on any organization. Both in the serum and in the fibrinous deposit Ave find a feAV pus-corpuscles, so that the transition from this form of pleurisy to the next, in Avhich pus-corpuscles are far more abundant, is quite gradual. The greater the quantity of pus, so much the more turbid is the serum, and the more yelloAV the deposit. The proportion between the serum and the fibrin Aaries, although here, too, Ave are not Avarranted in regarding fibrinous exudation as the consequence of a hyperinosis (augmentation of fibrin in the blood). Indeed, according to the old-fashioned theory, it is far more probable that a pleurisy, in Avhich a great amount of fibrin is secreted in the pleura, also causes the increased quantity of fibrin in the blood. The exudation often seems to receive accessions, and to increase by fits and starts. As these after-floAvs do not come immediately from the vessels of the pleura, but from the thin-Availed vessels of the young connective tissue, Ave often find an admixture of blood in the serous effusion of chronic pleuritis, in consequence of rup- ture of the delicate capillary walls, thus forming pleurisy with haemor- rhagic exudation. We constantly find agglutinations of the opposing surfaces by fibrinous exudation, as Avell as commencing adhesions, sur- rounding the effusion, Avhereby the latter is often incapsulated. This is a condition of great importance in the symptomatology of the disease. According to the lucid and concise account of Rokitansky, the changes which take place in the thorax and its contents, in consequence of extensive effusion, are as folloAvs: "The thorax is dilated in a manner more or less apparent, the intercostal spaces are Avidened and prominent, the diaphragm is forced down into the abdomen, the medi- astinum and heart are displaced to the other side, or, Avhen the effusion is symmetrical, lie in the middle of the chest. The lung itself is com- pressed to a degree corresponding to the amount of the effusion, and, unless old adhesions offer resistance, it is constantly pushed upAvard and inward against the mediastinum and back-bone. We find it re- duced to the fourth, sixth, and even to the eighth part of its normal volume, and flattened into a cake, its color is pale reddish or bluish gray, or lead color, and its consistence is leathery, tough, and void of blood and air, and in a state of atrophy at the edges and surface. It is coated externally by the coagulum of fibrin, Avhich extends from the costal to the pulmonary pleura. In partial pleuritis, the displacement INFLAMMATION OF THE PLEURA. 257 and compression are limited to a portion of lung corresponding to its seat and extent." The lung upon the unaffected side is ahvays the seat of intense collateral fluxion, and, in fatal cases, of collateral oedema. Should re- covery take place in this form of pleuritis, the exudation gradually becomes more and more concentrated (so that the absorption proceeds at first far more rapidly than it afterAvard does). The liquid portion may at length disappear completely; the pleural surfaces, roughened by fibrinous deposit, coming into contact. The fibrin also undergoes fatty metamorphosis, liquefies, and is absorbed, and then an adhesion of the pleural surfaces, AA'hich are usually much thickened, ahvays takes place. Sometimes yelloAV, cheesy masses, consisting of remnants of unabsorbed fibrinous deposit and cellular elements of the exudation, are found imbedded between the adhesions. When absorption takes place early, the compressed lung may again become pervious to the air, and may expand; the intercostal spaces may return to their normal state, and the mediastinum, diaphragm, and the dislocated heart and liver, may all regain their proper places. In other cases the alveoli become agglutinated or adherent by con- tinued pressure, or else dense fibrinous deposits upon the compressed lung prevent its reinflation. The time required for the production of this condition cannot be. given AA'ith accuracy. If absorption of the exudation should afterward take place, a vacuum tends to form, to fill up which, the thoracic Avail and the adjacent organs suffer displace- ment. The affected side of the chest sinks in, and may present a con- cave instead of a convex surface; the intercostal spaces become nar- roAver, until the ribs finally touch; the shoulder sinks, and even the spinal column becomes curved. In pleuritis of the right side, the liver, previously deeply depressed, is noAv dislocated far in the opposite direction, sometimes as high as the third rib. In pleurisy of the left side, the heart, at first often displaced to beyond the right edge of the sternum, noAV is drawn back as far as the left axillary line. 4. Pleuritis icith purulent effusion. Empyema, Pyothorax.—The liquid part of the effusion is here so rich in pus-corpuscles as to form an opaque, yellow, thick fluid. The fibrinous portion also contains great quantities of pus-cells and seems soft, and of a A'ery yelloAV color. Here too, the exudation, and not only the serous part of it, but the fibrin and pus, after undergoing the often-mentioned metamorphosis, may be absorbed; but there is another sequel to pleuritis sometimes, and it most frequently folloAvs this form of the malady. Not only are pus-corpuscles generated upon the free surface, but they are also formed Avithin the tissue of the pleura itself. The latter becomes opaque and softens, and irregular losses of substance occur. Should 17 258 DISEASES OF THE PLEURA. they be situated upon the costal pleura and penetrate deeply, external perforation of the empyema may take place, and in fortunate cases, especially if the lung remain capable of redistention, recovery may be the result. In similar manner, a penetration of the empyema into the lung and its discharge by way of the bronchi sometimes happen, but a recovery in such instances is rare. Symptoms and Course.—Dry pleurisy has no symptoms, or, at least, if it have symptoms, they cannot be distinguished from those of the disease which it accompanies. We sometimes find adhesion of the entire pleural surface in the bodies of persons Avho never have been seriously ill. Extensive and rigid adhesions of the pulmonary and costal pleurae hinder the two surfaces from sliding upon one another, and thus prevent a uniform expansion of the lung during inspiration (see Adcarious emphysema). The consequence often is a slight dyspnoea, Avhich is only felt, when unusual bodily exertion or other cause excites a demand for an increased supply of oxygen. Pleurisy with scanty fibrinous exudation is accompanied by severe piercing pain when a breath is drawn; the suffering produced by the limited and slow movement of the pleura, during ordinary breathing, is far greater than that arising from the strong and rapid motion of forced respiration. Coughing and sneezing are especially painful to the patient, as these acts compress the inflamed pleura from Avithin. In like manner a pressure upon the ribs and intercostal mus- cles affects the pleura immediately, and greatly increases the pain. The respiration of the patient is shalloAV and cautious. The body is generally bent toward the affected side, as this attitude lessens the tension of the intercostal muscles and its inflamed covering. Besides the pain, some patients have a distinct sensation of friction, or of scratching at some point of the thorax. There is also cough, as a rule; although cases now and then are observed Avhere there is absolutely no cough, and it has not as yet been determined satisfactorily AA'hether the cough is a result of reflex action from the inflammatory irritation of the pleura, similar to that arising from irritation of the bronchial mucous membrane, or whether it is due to a compHcation of pneu- monia or bronchitis with the pleurisy. The pleurisy AAdth scanty fibrinous exudation, unless accompanied by extensive and severe inflammation of the lung, is usually unattended by fever, or other serious derangement of the health. Many patients never even keep their room, and often go on foot to the clinic, or to the office of their physician, for medical aid. We have already stated that the pleuritic stitch, Avhich is one of the most painful symptoms of croupous pneumonia, and Avhich indubi- tably OAves its origin to the almost constant complication of the latter INFLAMMATION OF THE PLEURA. 259 disease AAdth the form of pleuritis noAv under consideration, is generally of briefer duration than the other symptoms of pneumonia. Perhaps this is because the pleural surfaces cease sfiding upon one another, Avhere a large portion of the lung has become infiltrated. But even Avhen the disease occurs spontaneously, or when it supervenes in chronic disease of the lung, the pain usually ceases in a few days, especially if properly treated. Its persistence for weeks is an excep- tional occurrence, and should cause suspicion of grave disease of the lung. Pleurisy with profuse sero-fibrinous exudation sets in quite often, with violent general phenomena, and severe symptoms of local disease, in a manner very like the commencement of pneumonia. The malady begins acutely, and runs an acute course. Ushered in by a severe rigor, it is foUoAved by intense fever, with the full and frequent pulse, the headache, and pain in the back and limbs, the coated tongue, and the parching thirst, which Ave see in almost all violent inflammatory diseases. There may, however, be more than one chill, and there are often several, the succession of AA'hich may take on so well-marked a tertian type, that it is quite possible to mistake an incipient pleurisy for an intermitting fever. A sharp pain, usually referred to the side of the chest, is also felt at the beginning of this \-ariety of pleurisy, into AAdiich the form last described often passes, the exudation becom- ing more copious and richer in serum. As the disease advances, the pain abates someAvhat, and often ceases altogether, before the pleurisy has attained its climax, or, especially before the effusion is complete. The cough, AA'hich scarcely ever faUs, and Avhich is often extremely distressing and persistent, is sometimes plainly attributable to the col- lateral hyperaemia, and collateral oedema of the uncompressed part of the lung. At other times its source is obscure. Besides these symp- toms, there is dyspnoea, Avhich becomes aggravated as the effusion increases, and AA'hich often becomes extremely severe. It is important to bear in mind the fact that a part only of the dyspnoea is caused by pressure of the effusion upon a portion of the lung, and that the col- lateral hyperaemia and oedema arising in the uncompressed portion, and by Avhich the breathing surface of the latter is materially diminished, play an important part in the production of dyspnoea. At all eArents, eA^en AA'here the effusion is very large, the difficulty of breathing dimin- ishes, and often ceases altogether, just as it does in croupous pneumo- nia, as soon as the fever abates, and Avith it the need of additional oxygen. After increasing in intensity for six or eight days, a sudden im- provement may take place, just as in croupous pneumonia, the general disturbance and dyspnoea undergoing a marked decrease, or even ceas- 260 DISEASES OF THE PLEURA. ing totally Avithin a feAV hours. This depends upon a rapid abatement of the fever. In fortunate cases the reabsorption of the effusion also begins immediately and progresses rapidly. As already stated, the absorption goes on most rapidly at the outset, and, as the volume of the liquid decreases, and its concentration becomes greater, absorption grows slower and sloAver, so that, even weeks after the patient has apparently entirely recovered, a remnant of the exudation can still be found. Next to these cases, which are acute from beginning to end, come those AA'hich, being acute at the outset, afterward take on a slow and tedious character. The fever moderates at the end of the first Aveek, or a little later. The exudation makes no further progress; but Ave Avait in vain for a complete subsidence of the febrile general disturb- ance, and for absorption. At last the exudation begins to diminish; the air once more enters the compressed parts of the lung; but, in the midst of this apparently favorable prospect, Ave again one day find the patient short of breath, coughing hard, aneAV spitting bloody froth. The fever, too, has grown worse; and, if Ave now examine the chest, AA'e find that the effusion has increased by a hand's breadth, and ex- tends higher than ever. In this way the disease, originally acute, drags on AAdth fluctuating symptoms for months, and, as a rule, termi- nates fatally. Thirdly and lastly, there are a great many patients in Avhom this form of pleuritis develops slowly, and often AA'ithout attracting atten- tion, its subsequent progress being of an equally tedious character. There is no inflammatory fever, and often no pain, at least none of that severe pain which ushers in all varieties of the disease hitherto described. Not unfrequently the comparatively slight shortness of breath under which the patient labors escapes the notice of the patient himself, and he only seeks assistance of a physician because he " for some time past has become aAvare of a falling off in strength, and of having become pale and thin ;" or he perhaps may think that he has some chronic disease of the abdomen, the more so as, in pleurisy of the right side, the depressed position of the liver may cause the right hypochondrium to bulge, and create tension in that region. Every physician in good practice must have seen cases of this kind, in which the patient has never been confined to the house, where he is unable precisely to fix the date of the commencement of his attack, and in which physical examination demonstrates the existence of enormous quantities of effusion in the pleural cavity. The extreme prostration and debility of these patients are easy of explanation, Avhen we con- sider tha tthey are seldom free from fever, and that their pleurae are filled up by an exceedingly albuminous effusion, Avhich may amount to INFLAMMATION OF THE PLEURA. £61 a Aveight of tAveh'e or fifteen pounds. Such an effusion, under the most favorable circumstances, would only be very slowly reabsorbed ; but it is A'cry apt, as before said, alternately to decrease and to be repro- duced, and finally, as Ave shall see, it terminates in most cases in con- sumption of the lung. Pleuritis with purulent exudation, empyema, pyothorax, Avhen it occurs by the gradual multiplication of young cells (which are never entirely absent in any case, in effusions of the form already described), can hardly be diagnosticated otherAvise than by the long duration of the disease. The symptoms of compression, etc., are just the same as in effusions containing little pus. As already mentioned, pleuritic effusions often form during septicaemia and other diseases arising from blood-poisoning, in Avhich an abundant cell-formation takes place from the commencement. HoAveA'er, it is not on account of its insidious attack, but OAving to the serious implication of the system and to the blunted condition of the sensorium, that patients frequently make no complaint Avhatever, so that all subjective symptoms are AA'anting, and AA'e must rely upon the objecthre ones. With regard to the termination of pleurisy, all forms of the disease may end in recoA'ery. Adhesions of the pleural surfaces, Avhich ahvays or nearly ahvays remain, are hardly to be regarded as rendering the recovery incomplete, as patients may attain a very great age Avithout suffering any serious inconvenience on this account. It has already been mentioned that the reabsorption of large effusions, even if rapid at first, is apt to be extremely tedious toAvard the last. We must be careful of diagnosticating a diminution of the exudation in all cases AAdiere the line of dulness sinks in the chest. A decrease of the dul- ness may also be due to the fact that the thoracic Avail and intercostal muscles have become more yielding, or that the diaphragm has become relaxed and forced farther doAvmvard. These facts must ahvays be borne in mind in judging of the condition of the patient. An obstinate exudation, Avhich is very hard of reabsorption, should not be despaired of too soon, as its absorption may at last take place after Ave have given up all hopes of such an event. When the compressed lung, either being enclosed in a firm fibrin- ous sheath, or its alveoli being occluded or adherent, is no longer able to admit air and to expand, and Avhen the thorax collapses, the neigh- boring organs being employed to fill up the vacancy arising from absorption of the effused liquid, the pleurisy must be regarded as ter- minating in incomplete recovery. In persons thus affected, if other- wise in good health, the remaining portions of the lung can always oxygenate the blood sufficiently, and eliminate the carbonic acid, as long as the patient abstains from an overactive bodily exertion; and, 262 DISEASES OF THE PLEURA. notAAdthstanding that a part of the pulmonary capillaries has perished, the right side of the heart, which is then always someAvhat hypertro- phied and dilated, is still capable of so accelerating the current of the blood in the sound parts of the lung as to avert derangement of the circulation. When an empyema " points" or opens externally, an oedematous swelling of the integument makes its appearance, not, however, at the most dependent part of the chest, but generally in the neighborhood of the fourth or fifth rib. Soon a hard, firm tumor protrudes through the intercostal space, which, after a time, begins to shoAV fluctuation, and finally discharges a large amount of pus. This termination very rarely results in complete recovery, and in reinflation of the lung and reoccupation of the space restored by discharge of the pus. It is much more common in such cases for the thorax to collapse, and for secondary'displacements of the organs to occur. Still more commonly there remains an imperfect closure of the thoracic opening (after point- ing of an empyema), and a thoracic fistula forms, from which pus con- stantly fioAvs, either in a continuous stream or in occasional profuse gushes. A patient with such a fistula may five for many years. When empyema points inwardly, that is to say, into the lung, the perforation is sometimes preceded by the symptoms of a shght pneu- monia, bloody sputa, a reneAval of the stitch in the side, etc. At other times it takes place Avithout warning, the patient suddenly discharg- ing an enormous amount of purulent sputa after a violent fit of cough- ing. Here, too, in very rare instances, recoATery Avith or without retrac- tion of the thorax may ensue, but symptoms of suffocation, or of pyo- pneumothorax, are the more usual result (see Chapter HI.). Perforation of empyema through the diaphragm, or into neighbor- ing organs, produces violent peritonitis, and the signs of abnormal com- munications, upon the details of which we could not enlarge without undue prolixity. A fatal result in recent pleurisy most frequently arises from col- lateral hyperaemia, leading to intense oedema in the otherAvise healthy portions of the lung. Ratthng sounds, frothy and often bloody sputa, and great dyspnoea arise; carbonic-acid poisoning soon commences to develop, the sensorium of the patient becomes benumbed, and, with the general collapse, the action of the heart is Aveakened, the pulse groAvs small, the extremities cool, and the sufferer soon expires. In other cases, compression of the lung and its capUlaries gives rise to incomplete filling of the left A'entricle, and to engorgement and ob- struction of the right ventricle and the veins of the aortic system. This imperfect filling of the aortic system frequently gives rise, not only to a small pulse, but to an excessive diminution and concentration INFLAMMATION OF THE PLEURA. 263 of the urine {Treiube). Distention of the veins leads to cyanosis and dropsy. Finally, owing to obstruction to the outfloAV from the renal veins, albumen, blood, and fibrinous cylinders frequently appear in the urine. In other cases death ensues in consequence of bursting of empy- ema into the lungs, abdomen, etc. Death results still more frequently in unabsorbed effusions, in consequence of persistent, although mod- erate, fcA^er, AAdiich consumes the organism, and which, therefore, is called hectic. Finally, and, indeed, most commonly of all, tedious or imperfect ab- sorption of empyema results in tuberculosis, or in chronic destructiA'e pneumonia, the patient succumbing to the symptoms of consumption. Physical Signs op Pleurisy.— When the exudation is scanty, forming a thin membranous coating upon the pleural surfaces, or AA'hen it is liquid, and sinks to the more dependent part of the pleural sac, Avithout, HoAveA^er, materially encroaching upon its space, the results of infection usually are negative. It is only Avhen respiration is ex- tremely painful that Ave can perceive that the patients spare the af- fected side, and that its respiratory motion is not as free as upon the other side. When the pleuritic effusion is large, inspection reA'eals a series of appearances, depending upon the fact that the inner surface of the chest is no longer affected by the traction of the elastic lung (as it should be), but is exposed to the pressure of the exudation. 1. The intercostal spaces over the area of the effusion are no longer shalloAV grooves, but are upon a level Avith the ribs, " they are effaced," and, indeed, are sometimes somewhat prominent. 2. Where the effusion fills up the entire pleura, the affected half of the chest appears enlarged in all directions, but chiefly in the line of the vertebrc^mammUlary diameter. When the -effusion is not so laro-e, Avhen it is usually incapsulated in the posterior and lower re- gions of the pleural sac, dUatation of the thorax is limited to the region winch contains the effusion. Very much more rarely, incapsulated exu- dations in the pleura produce prominence of some other portion of the thoracic AA'all. 3. In effusion of the left side, displacements of the heart can often be made out 1 >y inspection alone, and it is the same with displacement e-f the liver when the effusion is upon the right side; in the former case the impulse of the heart being too Ioav, and too much toward the median line (sometimes, indeed, being perceptible to the right of the sternum) ; in the latter, the right hypochondriac region shoAVS an un- natural prominence. Besides this CAddence of pressure from Avithin, exerted by the effusion upon the surrounding parts, inspection shoAVS 264 DISEASES OF THE PLEURA. that, as far as the effusion reaches, the thoracic Avail does not take £>ari in the respiratory movement. This is, in some degree, OAving to in- filtration and palsy of the intercostal muscles from collateral fluxion, and partly because the dilatation of the chest is physically impossible Avhen the lung cannot expand. If the diaphragm be so much de- pressed as to form a projection into the abdomen, and if its muscles be not paralyzed, the contraction of the organ, with every inspiratory act, tends to flatten the convexity, Avhich noAv, of course, is on its lower surface, so that, in these very rare instances, the epigastrium, instead of rising, sinks, during inspiration, upon the side Avhere the effusion is situated. If, as absorption of a pleuritic effusion progresses, the compressed lung again undergoes perfect expansion, there generally remains no sign of the disease which has just passed aAvay. When the absorption is complete, the intercostal spaces again form shallow furroAVS, being once more exposed to the elastic traction of the lung. The dilatation of the thorax is corrected, the derangement of the respiratory move- ments has ceased, and the dislocated heart and liver haA'e returned to their proper situations. Sometimes, hoAvever, after perfect absorption of the effusion, the heart, haAdng become fixed by adhesions, remains out of place. If, however, the lung do not expand as the effusion be- comes absorbed, all the dimensions of the chest seem to undergo reduc- tion, and, more especially, its length and antero-posterior diameter, I the ribs coming close together, and even overlying one another. The more the thorax loses its rounded form, and the more it becomes flat- tened, so much the more is its capacity diminished, even although its circumference remain the same. Hence, in cases where absorption of the exudation has commenced, if we wish to Avatch the progress of the reabsorption, and of the restoration of the lung, it is urgently recom- mended not only, from time to time, to measure the tvvo halves of the chest, but to ascertain the length of the two vertebro-mammillary diam- eters by means of the callipers, and to compare the results of the two measurements. A still surer method is to draw accurate ideal sec- tions of the two halves of the thorax, by means of the Kyrtometer of Woillez, which can be laid one upon the other and accurately compared at leisure. The more the ribs of the affected side are pressed together, bo much the lower avUI the shoulder of that side descend, and so much the greater is the curvature of the spine. The collapse of one half of the chest, the depression of the shoulder, and the lateral curvature of the spinal column, the convexity of Avhich is toAvard the sound side, are often so great as seriously to deform the patient, aa4io is said to be "groAvn out of shape." Finally, in cases AA'here the lung has not reexpanded after absorp- * INFLAMMATION OF THE PLEURA. 265 tion of the effusion, inspection avUI often shoAV that the heart beats fai to the left, and even as far as the axillary line. The cause of this is that the heart, Avhich at first Avas pushed to the right by the pleuritic effusion, upon reabsorption of the latter, is noAv drawn as far into the left pleural cavity, in order to fill up the vacant space caused by the disappearance of the liquid. We may finally observe that the restoration of the normal dimen- sions of the chest, and even the secondary contraction of a chest pre- viously distended by effusion, is not, by itself, a sufficient proof of the complete absorption of the exudation. A compressed lung occupies very little space, and, even after the pleural cavity has been greatly reduced in size, there is ahvays room for a considerable quantity of liquid effusion. Upon palpation, a sensation of friction is perceptible in a large number of cases of pleurisy. The characteristics and pecu- liarities which distinguish this sensation from other sensible signs, as Avell as the conditions under Avhich it arises, will be discussed Avhile treating of the auscultatory phenomena. Palpation, moreover, often furnishes important diagnostic signs of pleurisy with profuse effusion, from the peculiar character AA'hich the vocal fremitus exhibits in cases of pleuritic exudation. In general terms, it may be asserted that the pectoral fremitus is much Aveakened, or entirely suspended, Avherever a liquid pleuritic effusion is in contact Avith the thoracic Avail; but, above the limit of the effusion, AA'here the compressed lung touches the side of the chest, the fremitus is intensi- fied. It is quite manifest that a profuse liquid effusion avUI impede the conduction of sound-Avaves to the thoracic Avail, and that it AviU also act as a poAverful damper upon the vibrations of the latter, and it is equally plain that the retracted pulmonary tissue forms a better con- ductor for the passage of the Adbrations to the chest-Avail, and disturbs them less, than does the normal unretracted lung. As, under normal conditions, the Arocal resonance is more plainly felt upon the right side of the chest than upon the left, feebleness or absence of pectoral fre- mitus upon the right side is of greater diagnostic importance than the occurrence of the same symptom upon the left side. In the anterior and lateral regions of the chest, the abrupt transition from absence to exaggeration of the fremitus is a A'aluable means of determining the limit of the exudation. Posteriorly, hoAvever, the signs change in a more gradual manner. According to some very accurate observations of Seitz, Avhen the exudation is slight, the fremitus is only more or less weakened; AA'hen it is extensive, the fremitus is lost over the loAver portion, but over the upper it is merely lessened, and even this dimi- nution decreases gradually toAvard the level of the liquid. When the patient has a Aveak, high-pitched voice, Avhose Avave-sounds hardly 266 DISEASES OF THE PLEURA. reach the thoracic Avail under any circumstances, Ave lack an important aid to the diagnosis of pleuritic effusion. Finally, palpation is of use in ascertaining the existence of the displacements of the heart and liver, alluded to in speaking of inspeo tion, and Avhich result from the effusion and its subsequent reabsorp- tion. In cases of copious exudation into the right pleura, the edge of the liver may often be felt several fingers' breadth below the border of the ribs, or even lower. Percussion affords no information of the presence of exudation Avhen it is scanty and lies upon the pleura in the form of a thin, coagu- lated coating. On the other hand, large effusions, by which a consid- erable part of the lung is separated from the diaphragm and thoracic Avail, furnish very characteristic signs upon percussion: 1. Over the region Avhere the bulk of the liquid effusion lies in contact Avith the side of the chest, all vibration is checked, and the percussion-sound is dull. 2. Over the space into Avhich the retracted lung (Avhich, hoAv- ever, may still contain air) touches the thoracic Avail, percussion is holloAV and tympanitic. The conditions under Avhich the duU, holloAv, and tympanitic sounds arise have already been fully and repeatedly explained. No disease is better adapted for the demonstration of the difference between the dull and the hollow percussion-sounds than pleurisy Avith copious effusion. The dulness proceeding from pleuritic effusion generally first becomes perceptible in the region of the back and beloAV the scapulae. As it ascends it spreads toAvard the front. The dulness scarcely eA'er extends as far upward in front as it does behind. In many cases the dulness which reaches far up the back is not found at all over the breast, but only reaches as far as the axUlary line. At other times, when nearly the whole pleural sac is occupied by the effusion, the upper boundary of the dull sound is but little loAver in front than behind. Anteriorly, the dull percussion-sound changes abruptly to the empty tympanitic sound; posteriorly, as the upper limit of the effusion is approached, the dulness gradually be- comes fainter and less distinct. The reason for this is, that the thickness of the body of effusion upon Avhich the dull sound depends gradually diminishes from beloAV upward. The form and boundaries of the dulness are not generally altered by changing the attitude of the patient, as agglutination and adhesions soon form about the effu- sion, which, although they still alloAV the pleural surfaces to sfide upon each other, oppose their separation by the pressure of the exudation. Upon auscultation, friction-sounds are heard AA'henever the sur- faces of the pleura lose their smoothness through fibrinous deposit or the groAvth of rugged vegetations ; but of course these sounds are only audible when the roughened surfaces are in contact, and Avhen INFLAMMATION OF THE PLEURA. 267 the respiratory movement causes them to rub together Avith a certain degree of rapidity. They are usually perceptible both upon inspira- tion and expiration, and give a distinct impression of scraping or of scratching, calling to mind the creaking of new leather, and there are often Httle jarring interruptions. It is most Hable to be mistaken for a buzzing rhonchus, Avhich is HkeAvise often perceptible to the touch. A friction-sound, hoAvever, is scarcely ever as loud as a rhonchus, and, besides, is not altered by coughing; Avhereas a rhonchus almost ahvays ceases after a vigorous cough, or, at all events, undergoes a change. It is also someAvhat characteristic of a friction-sound, that it is heard more distinctly when the stethoscope is pressed rather firmly against the chest. This sound is rarely heard in the beginning of the disease, as the fibrinous deposit is not rough enough at first, and the patients, while they continue to suffer pain, breathe cautiously, so that the pleural surfaces do not rub together Avith sufficient quickness. The time at AA'hich it is audible most frequently is when the exu- dation begins to be reabsorbed, Avhen the faces of the pleura, AA'hich previously AA'ere separated by the serum, now once more come into contact. They also become audible after evacuation of the liquid by tapping. Wlien the exudation is not very large, faint vesicular breathing, transmitted by the surrounding parts, can be heard over the Avhole region of dulness. When the effusion is very profuse, and Avhen not only the air-cells but the bronchi are compressed by it, no respiratory murmur AAdiatever is heard over the dull region, or, at the utmost, the sound is very faint and indistinct. It is only betAveen the scapulae and the spinal column, Avhere the compressed lung lies close to the thoracic Avail, that Ave can hear a feeble bronchial respiration and a faint bron- chophony, the latter sometimes having a bleating tone, knoAvn as ozgophony. In a feAV instances, AA'here there is severe dyspnoea, in spite of the compression of the lung, and although we are obliged to suppose that the greater part of the bronchi are compressed and do not contain air, loud bronchial breathing is heard over the AA'hole chest, even at points Avhere there is a large mass of liquid between the ear and the lung, that is to say, at the sides of the thorax. Over the un- compressed hmg, both upon the diseased and healthy sides, the respi- ration is loud and puerile, unless it be the seat of collateral hyperaemia and catarrh, aa hen rhonchi and rdles are to be heard. Of course, the physical signs of pleuritis are greatly modified Avhen- ever old adhesions of the pleura prevent the exudation from collecting m the most dependent part of the chest. It would lead us too far to detaU aU these modifications, and we shall merely state that incapsu- lated effusion of very considerable magnitude may form betAveen the 268 DISEASES OF THE PLEURA. diaphragm and the base of the lungs, and be very difficult of recog- nition, and often remain quite unrecognizable. Diagnosis.—It is not ahvays easy to distinguish a pleuritis with abundant exudation from a pneumonia, and the following are the chief points upon Avhich we may rely for the purpose : 1. Pleurisy scarcely ever begins with a single violent chill, while in pneumonia this is the rule. 2. The course of a pleurisy is never so cyclic, nor is there that sudden and complete change for the better, or crisis, which we observe in pneumonia. 3. In pleurisy the sputa are indicative of catarrh or of oedema, and sometimes contain streaks of blood; but there never is that peculiar tough expectoration, stained yelloAV or yelloAvish-red, by intimate admixture of blood, which is pathognomonic of pneumonia. 4. The principal physical signs indicative of pleuritic exudation are, dUatation of the thorax, effacement of the intercostal furrows, displace- ment of the heart and liver, faintness or absence of pectoral fremitus, absolute dulness upon percussion, feebleness or absence of the respi- ratory murmur; Avhereas, in pneumonic infiltration, the chest is not enlarged, the intercostal spaces are not effaced, the heart and liver retain their situation, the pectoral fremitus is seldom enfeebled, and, indeed, is often intensified, the dulness upon percussion is not so abso- lute, and the respiratory murmur is almost always bronchial. Patients having pleuritic effusions in their right side are not unfre- quently supposed to have disease of the fiver, and when we have ascer- tained by palpation that the liver reaches below the border of the ribs, and fills up the right hypochondrium, it is important that we should be able to tell whether the organ is enlarged or merely depressed. The folloAving are the points of distinction between the two con- ditions : 1. The liver rarely pushes the diaphragm upward ; hence, when the liver extends below tfie border of the ribs, and we at the same time find a dulness in the thorax AAdiich reaches farther upAvard than the normal hepatic dulness should do, we may reasonably infer that there is an effusion in the pleura and that the liver is pressed doAvnward. 2. In the very rare instances in which, through enlarge- ment of the liver (usually from an abscess, or a cyst of echinococcus), the diaphragm is abnormally pressed upward, and made to project into the cavity of the thorax, the dulness reaches farther up in the front of the chest, while in nearly every case of pleuritic effusion the opposite condition obtains. 3. When the liver is enlarged, its lower border, and Avith it the fine of percussive dulness, moves doAvnward upon inspiration and upward upon expiration. This does not take place Avhen there is large effusion in the pleural sac, as the diaphragm is then depressed, and kept in a state of permanent exphatory exten- sion. 4. The transition from the feeling of resistance, presented by the INFLAMMATION OF THE PLEURA. 269 thoracic Avail, to that produced by the enlarged fiver, is immediate; Avhereas a small yielding interval is usually discoverable between the border of the ribs and the surface of a liver which has been displaced doAviiAvard. 5. In enlargement of the liver, the loAver ribs not unfre- quently are someAvhat bowed outAvard, the intercostal spaces, how- ever, still remaining uneffaced, excepting in the rare instances in Avhich a huge cyst of echinococci, or an abscess of the liver projecting far into the thoracic caAdty, lies in contact Avith the side of the chest. The main point of distinction betAveen a small pleuritic effusion of the left side and an enlarged spleen consists in the change AA7hich takes place in the line of dulness during respiration, and Avhich does not occur in pleurisy, but is easily perceptible in enlargement of the spleen. Finally, the persistence of the feA'er, the emaciation and pallor of the patient, may aAvaken the suspicion that phthisis is developing. It should not be forgotten that both fever and Avasting may be solely dependent upon a latent pleurisy, but the threatening phantom of in- cipient consumption should ahvays be kept in vieAV, and physical ex- ploration of the thorax should be repeated again and again. Prognosis.—Dry pleurisy is an altogether insignificant affection, nor does pleurisy Avith scanty sero-fibrinous effusion, of itself, eArer cause danger, although the pain Avhich attends it, being a main cause of the dyspnoea, augments the danger from the pneumonia or tubercu- losis, or AvhateArer the primary disease may be. Among the varieties of pleurisy Avith profuse sero-fibrinous effusion, that AA'hich runs an acute course from the outset admits of the most faA'orable prognosis. When the malady is of a creeping, insidious type, the prospect is much more grave, as, even after complete absorption, tuberculosis fre- quently appears as a sequel. This is also true of empyema when it develops from the foregoing variety, AA'hile the effusions which are purulent from the commencement involve a bad prognosis, from the nature of the diseases AA'hich gh'e rise to them, namely, septicaemia, puerperal fever, etc. Decrease of the effusion is to be regarded as a favorable sign, in the diagnosis of aa Inch, however, Ave must beAvare of the sources of error already alluded to. As there is more or less danger from con- sumption in the majority of cases, it is to be regarded as of favorable auo-urv Avhen the patient possesses a vigorous constitution. Finally, the earlier reabsorption commences, so much the more reason have Ave to hope that the lung may expand again, so that no deformity of the thorax may remain behind. Symptoms of oedema of the lung and imperfect decarbonization of the blood at the commencement of the disease are to be AdeAved as un- 270 DISEASES OF THE PLEURA. favorable prognostic signs ; as is also a diminution in the amount of urine secreted, which indicates that the arteries are incompletely filled StUl Avorse are the symptoms of over-distention of the veins, with cya« nosis, dropsy, and the appearance of albumen, casts, and blood in the urine. The longer the effusion lasts, the more persistent the fever Avhich accompanies it, the greater the wasting of the patient, so much the worse should our predictions be. Finally, all sequelae, other than that of reabsorption, must be considered as prognostically unfavorable, although, as shown above, the danger may vary in degree. Treatment.—The causal indications can no more be met in treat- ment of pleurisy than they can in treating pneumonia. In fact, even if Ave were aware that an attack of pleurisy Avere caused by " catching cold," if the fever were at all intense, a treatment by diaphoresis Avould be absolutely injurious. Inelicatio morbi.—The "antiphlogistic system," Avith its general and local blood-letting, its exhibition of calomel, and inunction of mer- curial ointment until salivation is produced, and its subsequent deriva- tion by blistering, etc., wfiicfi formerly used to be the general practice in the treatment of pleurisy, but which, in the last ten years, has grad- ually fallen into discredit, recently has again been urgently recom- mended by Joseph Meyer, in a work which gives evidence of great in- dustry. The arguments of this author in favor of the former method of treatment, and against the less active modes of procedure, are, how- eA^er, based upon a very slender foundation. Thus great weight is laid upon the fact that a certain number of patients, Avith large pleuritic exudations, have been received into the Berlin Charite Hospital, who have not been bled, and who have never taken any mercury; and it is inferred that the profuseness of the effusion is a consequence of a neglect of active treatment. The enumeration of such cases as these proves nothing, unless the number of cases who Avere not bled, and yet who did not have large effusions, and who therefore did not seek admission at the Charity, be also given. But even the someAvhat limited number of cases observed by Myer and others, in which recent cases of pleurisy, being treated by copious blood-letting, did not result in effusion, have not converted me. The assertion that pleurisy which is ushered in and accompanied by very acute symptoms, if left to itself, almost always terminates in profuse effusion difficult of reabsorption, I consider as quite erroneous. In- deed, the greatest danger in this respect is to be apprehended from the pleurisies AA'hich come on in a manner almost imperceptible, and whose duration is extremely tedious. 1 still believe that venesection can be dispensed AA'ith in the treat- ment of pleurisy, AA'ith exception of a few rare cases, Avhere certain INFLAMMATION OF THE PLEURA. 271 symptoms demand it. I am conAdnced that it neither cuts short the malady, nor prevents the effusion; and, as this disease, OAving to its tedious course, is ahvays liable to lead to deterioration of the blood, and to consumption, I regard the practice of bleeding as still more dan- gerous in pleurisy than in pneumonia. At the commencement of an attack of pleurisy, hoAvever, I cannot sufficiently recommend the use of cold and of local blood-letting. It is highly essential that the proper moment for employing this impor- tant treatment should not be neglected, as much evil may then be pre- vented, Avhich, at an after-period, is difficult to repair. When the pa- tients dread the application of cold compresses, or if the latter do not relieve the pain and dyspnoea in an hour or tAvo, a tolerably large num- ber of leeches, or cut-cups, should be applied; and, if the pain, AA'hich is almost ahvays relieved by the depletion, recurs in the course of a day or tAvo, avc should not hesitate to repeat the local blood-letting until the relief becomes permanent. Besides this, and for want of remedies of more certain action, half a drachm of mercurial ointment may be rubbed into the affected side of the chest tAvice daily, but the inunction must be at once suspended the moment that signs of mercurial sore mouth appear. As a decided benefit is sometimes obtained from the inunction of mercurial ointment in inflammation of other serous membranes, particularly inflammation of the articular capsules, its efficacy should ahvays be tested in cases of recent pleurisy, although its action is then far less easy to obsen'e. Having conA'inccd myself, from my OAvn observation and from the cases reported in the work of Meyer above alluded to, that the fever is not materially aggravated by the use of blisters, I noAV retract my former adAdce not to resort to vesication Avhile fever lasts. Indeed, the apphcation of large vesicatories seems to be of service in certain cases, but, Avhen used at all, they must be used early. In protracted cases, large hot poultices, Avhich, hoAvever, must not be too heaAry, do good service. Internal medication, save Avhen called for by special symptoms, is unnecessary in treatment of pleurisy. The antiphlogistic action of nitrate of potash, of tartar emetic, and of calomel, I regard as highly problematic; and, moreoArer, the exhibition of calomel is not AA'ithout its dangers, as it tends to augment the impoverishment of the blood, and the tendency to exhaustion which already exists. Indiceitio Symptomatica.—Antipyretic treatment is ahvays proper Avhen the fever is very high at the commencement of the attack, or Avhen it is so persistent that there is reason to fear that it will exhaust the patient. With this object in view, the very customary use of di DILATATION OF THE HEART. 317 ment as it should be when that movement is complete. Blood continues to enter as long as the pressure of the afferent vessels upon their contents exceeds the poAver of resistance of the Avails of the cardiac cavity. Let us, for instance, suppose an obstacle to exist at the root of the pulmonary artery, or, Avhat is more likely, an obstruction in the current of the capUlary system of the lungs. Such obstacle can- not prevent a systolic contraction of the right ventricle, although no doubt it may have the effect of preventing the ventricle from expel- ling the Avhole of its contents. Noav, as long as the pressure upon the blood within the vena cava is greater than the resisting poAver of the thin walls of the right ventricle, the ventricle avUI be distended by an abnormal influx of blood. Moreover the diastofic relaxation is ter- minated by a contraction of the right auricle, Avhose contents are forci- bly propelled into the right ventricle. As the blood enters the heart by the A'eins, and enters it under quite a moderate pressure, it is mani- fest that the right auricle and ventricle, the thickness of Avhose Avails is only one and two lines, respectively, should be much more liable to dilatation tfian the left ventricle, Avhose ventricular wall has a thick- ness of five lines; and, in fact, Ave find that the auricles are the most frequent seat of dilatation; next to these, the right A'entricle, while di- latation of the left ventricle is the rarest of all. A considerable degree of dilatation* of the left ventricle arises in cases of deficience of the aortic valves, and a smaller degree in de- ficience of the mitral; and this circumstance, Avliich is taught in every text-book on pathological anatomy, also argues in favor of the correct- ness of the above deductions. Let us suppose that the aortic valves are insufficient, and that blood regurgitates from the aorta into the left ven- tricle during its period of diastole, the pressure Avhich the blood exerts upon the relaxed cardiac wall is then a very considerable one, and capable of overcoming the resisting poAver of the latter. Bamberger has made a careful examination of fifty fiearts AA'ith A'alvular disease of the aorta, AAdth regard to the coexistence of dilatation and hypertrophy of the left ventricle, and has arrived at the folloAving conclusions, AA'hich fully agree with our vieAvs as to the pathogeny of dilatation of the heart. He found that, in simple contraction at the root of the aorta, there is no dUatation, or else only a very slight dilatation of the left ventricle. Although the obstacle to the circulation is A'ery great in these cases, there is no increase of that internal pressure, during dias- tole, by which alone the dilatation of the ventricle is caused. On the other hand, in insufficience of the aortic A'ah'es, there is ahvays a con- siderable dilatation of the left ventricle, Avhich predominates over the coexisting hypertrophy. There is often room enough in the dilated ventricle to contain a full-sized fist. In such cases, as Ave have 318 DISEASES OF THE HEART. shoAvn, the wall of the ventricle is subjected to an extreme pres- sure. Bamberger found that the greatest degree of dilatation of the left ventricle arose when the aortic valves Avere the seat of simultane- ous contraction and insufficience, as then such a condition AA'Ould natu rally be the most favorable one for the occurrence of dilatation; since the stenosis prevents a complete emptying of the ventricle during systole, whUe, owing to the insufficience, the blood regurgitates into the A'entricle during the diastole, with all the force which the pressure of the aorta can impart. The occurrence of a slighter degree of dilatation in insufficience of the mitral is likewise easy to account for. When the mitral valve is not effectually closed, a considerable amount of blood regurgitates from the ventricle during the systolic movement, so that the auricle and pulmonary veins become overloaded and their walls tightly stretched. Blood consequently pours into the left ventricle with unnatural force during diastole. Perhaps the hypertrophy of the left auricle and the increased energy of its contractile power also aid in causing the left ventricle to yield to the abnormal pressure, when the mitral valve is insufficient. *".■ In stricture of the left auriculo-ventricular orifice also, there is a con- siderable degree of engorgement of the left auricle, and pulmonary vein, and the auricle itself becomes hypertrophied, but the augmenta- tion of propulsive power is neutralized by the obstacle to the entrance of the blood. This is plainly the reason why the left ventricle is dilated when the mitral valve is insufficient, but does not dUate where the valve is only contracted. DUatation of the heart, when arising solely from an increase of the pressure of the blood within the cardiac cavities, as a rule, is soon fol- loAved by excentric hypertrophy, the continuous and abnormally active contractions of the organ giving rise to a multiplication of its muscu- lar fibres. When we come to treat of valvular disease, Ave shall ex- plain more in detail that it is by this transition from dilatation into excentric hypertrophy that the effect of obstruction to the circulation, arising from derangement of the valves, is counteracted. 2. Dilatation of the heart may arise from the loss of tone of the cardiac wall, owing to disease of its substance, in consequence of Avhich the wall gives way even before the normal internal pressure exerted upon it during diastole. Even the simple serous infiltration to AA'hich the heart is subject in the various forms of inflammation AA'hich affect it, especially in pericarditis, diminishes the resisting poAver of the or- gan and causes it to dilate. Sometimes its muscles seem to undergo an atrophy, like that suffered by the muscles of the rest of the body after severe and protracted illness, and in consequence of Avhich the DILATATION OF THE HEART. 319 ivall yields to the pressure of the blood; but the cause AA'hich most frequently deprives the cardiac parietes of their tenacity is degenera- tion of its tissues and in particular fatty degeneration. After the subsidence of the collateral oedema which remains after the abatement of an inflammatory affection of the heart, the muscles of the organ may regain their poAver of resistance, and the dilatation may be repaired. In other instances hypertrophy foUows upon dilata- tion. The dilatation arising from typhus, or protracted chlorosis, usual- ly disappears Avhen the attenuated muscular fibres of the heart, AA'ith the rest of the muscles, recover their proper condition. On the con- trary, the dilatation proceeding from degeneration of the substance of the heart, is incapable of repair, and, indeed, always groAvs Avorse as it groAvs older. 3. Dilatation may proceed from the degeneration of the substance of an excentrically hypertrophied heart. This transition from hyper- trophy to dilatation occurs quite as often as does the transformation above alluded to from dilatation to hypertrophy; and, indeed, it often happens that both metamorphoses take place in the same patient at different periods of the disease. Thus it can be shoAvn that a valvular derangement first gives rise to dilatation ; and that this is subsequent- ly converted into a hypertrophy, Avhich compensates for the deficiency of the A'alve ; and that at last the substance of the heart undergoes degeneration, and the hypertrophy is again replaced by dilatation, Avhereupon the compensatory action ceases. The latter dangerous transformation often does not take place until long after the A'alvular disease has been established. So, too, in emphysema; years may elapse ere the excentric hypertrophy of the right ventricle, Avhich com- pensates for the obstruction of the pulmonary circulation, changes into dilatation, to the great detriment of the patient. Nevertheless, it Avould seem that a certain period of continued overaction of the heart suffices to determine the conversion of a true hypertrophy into a spuri- ous one, a circumstance Avhich has not been observed to occur in other OA'envorked muscles. Degeneration of the hypertrophied cardiac mus- cles is much accelerated if the patient's nutritive condition be allowed to deteriorate. One of the most common of the diseases of aged and decrepit people is an excentric hypertrophy of the left side of the heart, caused by endarteritis deformans, AA'hich, Avhen of long standing, grad- ually changes into dilatation by degeneration of its muscular sub- stance. These are the cases to AA'hich people allude Avhen they speak of enlargement of the heart as being one of the most severe and dan- gerous of the maladies of that organ, and Avhich is the most terrible bugbear of many old people. Anatomical Appearances.—Care must ahvays be taken not to 320 DISEASES OF THE HEART. mistake a heart distended by blood and relaxed from putrefaction for a dilated heart. Advanced decomposition of the rest of the body, ex- treme softness of the substance of the heart, and its saturation with the coloring matter of the blood, are the distinctive marks in such cases. When the dilatation involves the entire organ, its form is changed in the manner described in speaking of hypertrophy of the heart. As, however, in most cases the dilatation is partial, and far more frequently involves the right side of the heart than the left, a dilated heart usually appears wider without any corresponding increase in length. When the Avail of the dilated organ seems thinned, the de- gree of thinning must be accurately determined by measurement, as otherAAdse there avUI be danger of error. General statements, such as " moderate thinning " or " moderate thickening " of the Avails of the heart, are of no value AA'hatever. When the wall of the left ventricle is thinned, it collapses when cut open. This does not occur Avhen the organ is in normal condition. In cases of great dUatation of the auri- cles, the muscular fasciculi may be so Avidely separated that the walls, in places, have a membranous appearance. When the ventricles are much dilated, Avith Avasting of the muscular substance, we sometimes find some of the trabeculae reduced to the condition of fleshless ten- dinous cords. When the Avail of a dilated ventricle is thickened, it is sometimes possible to recognize that the hypertrophy is of the spurious kind, merely from the color and resistance of its substance. In other in- stances, the tissues of the heart appear normal upon cursory examina- tion ; but the general dropsy, and other signs of engorgement, Avhich are not ascribable to valvular disease, or to other obstacle to the circu- lation, give proof of the abnormal state of the muscular substance of the heart, and microscopic examination reveals its degeneration. At other times the microscope exhibits a much slighter degree of degen- eration of the substance of the cardiac wall than the intensity of the venous engorgement Avould lead one to suspect. As this latter condi- tion, Avhen unaccompanied by obstruction to the course of the circula- tion, is a most posith'e sign of lack of functional poAver in the heart, I feel warranted in making the following assertion, based upon a large number of accurate observations: that it is not possible, by means of the microscope, to recognize all the alterations of the muscular fibrillae, Avhich diminish the functional poAver of the heart. NotAvithstanding that the orifices of the heart also take part in the dilatation, the valves still remain capable of closing perfectly, in con- sequence of their enlargement, which keeps pace Avith their thinning, and OAving to elongation of the chordae tendineae. Symptoms and Course.—Dilatation of the heart renders its ac- DILATATION OF THE HEART. 321 tion more laborious, since, although its poAver is not diminished, the amount of blood Avhich it must expel is increased. Hence, the effect of dilatation upon the distribution and force of the chculation is pre- cisely the reverse of that of hypertrophy. HoAvever, as long as the substance of its Avails remains healthy, the organ still continues capa- ble of fulfilling its function, by dint of increased exertion, just as a healthy heart overcomes obstacles to the circulation by greater energy of its contraction. It is very different, however, Avhen dilatation of the heart is accompanied by degeneration of its muscles, as it is then un- able to sustain such augmentation of its functional energy. Its action is insufficient, and the consequences of this defective action become recognizable in derangement of the circulation which ensues. The amount of blood expelled from the heart being too small, the arteries are inadequately filled, their Avails contract, and the size of the indi- vidual A'essels is reduced. The consequence of the diminution of the arterial contents is an augmentation of that of the veins; but, as the number of the veins exceeds that of the arteries, the filling of the in- diA'idual veins never increases in proportion as that of the arteries di- minishes. Moreover, a part of the blood which should occupy the arteries is in the dilated and half-emptied heart. Accordingly, the signs of deficience of blood in the arterial system appear earlier and in slighter degrees of the disease than do the symptoms of engorge- ment of the venous system. The capillaries also become abnormally- full, OAving to the impediment to their circulation offered by the en- gorgement of the veins, Avhile the tension of the arterial Avails, even Avhen the vessels are imperfectly filled, still exceeds that of the capil- laries, so that the blood continues to flow into them. Finally, the quantity of blood set in motion by each systole being abnormally small, the circulation is retarded, and the blood acquires a more venous character, oaa ing to the greater quantity of carbonic acid which it re- ceives, and because it does not return so often to the lungs to obtain oxygen. When dilatation of a part of the heart is complicated by valvular disease, emphysema, or any other affection of the lungs by AA'hich the circulation is impeded, it is often difficult to decide Avhether and how much the lack of blood in the arteries, the venous engorgement, the retardation of the circulation, and the venous state of the blood, de- pend upon the primitive disease, and hoAV much upon the dUatation. (Thus, Traube ascribes the dropsy of pulmonary emphysema to dilata- tion and degeneration of the right heart alone, and not to destruction of a large number of the pulmonary capillaries ; while, in my opinion, both of these causes are to be taken into account, and the dropsy of emphysema is only to be dreaded when disorder of the pulmonary cir- 21 322 DISEASES OF THE HEART. culation ceases to be compensated for by the hypertrophy of the right heart.) But the fact that all derangement of the circulation is averted in valvular disease or emphysema, as long as the portion of the heart involved is hypertrophied, instead of being dilated, warrants the con- clusion, Avhenever there is much embarrassment of circulation, that either the original dilatation has not been followed by any great de- gree of hypertrophy, or else that the hypertrophy has turned into a dilatation through degeneration of the substance of the heart. Of course the extent of the disorders which arise in the circulatory system varies Avith the seat of the dilatation. In treating of valvular disease, Ave propose to describe more fully the conditions which result from dil- atation of the various parts of the heart, just as we have made a de- taUed description of the effect which the state of the right A'entricle exerts upon emphysema, in treating of that disease. There is but one symptom (palpitation of the heart) to which we shall draw attention at present, since its occurrence is quite as common in partial dilatation as in the complete dilatation. This distressing subjective symptom, consisting of a painful sense of pulsation in the region of the heart, often ceases when the dilated heart becomes hypertrophied, and re- turns when the hypertrophy begins to undergo degeneration. It is not the beat of a hypertrophied heart—AA'hich, though it often jars the chest Hke the blow of a hammer, is nevertheless performed Avithout [ effort—which gives rise to the sense of palpitation. This sensation isi rather the result of the laborious contractions of an unhypertrophied organ. Thin-blooded and chlorotic persons complain much more of palpitation than those whose heart is actually diseased ; and, of all the varied disorders of the organ, dilatation, inflammation, and degenera- tion of the cardiac substance, are the ones which are most generally accompanied by palpitation. In the total dilatation which generally is due to a morbid flaccidity of a degenerate fieart-wall, it is often difficult to say hoAV much of the derangement of the circulation depends upon the degeneration and how much upon the dilatation. The latter, however, plays an im- portant part in their production, as it is found that degeneration of the heart, without dilatation (which is common enough in anaemic persons), is much better borne, and deranges the circulation much less, than when it is accompanied by dilatation. The first symptoms which are observed in this form of dilatation consist, as we have said, of a complaint of palpitation of the heart, which form a striking contrast with the faintness of its objective and visible pulsation, and which soon is accompanied by a slight dyspnoea. The cause of the dyspnoea is easily traceable to the overloading of the pulmonary veins and capillaries, and to the retardation of the circula- DILATATION OF THE HEART. 323 tion. It is aggravated upon ascending stairs, walking up-lnll, and simUar causes, and at first is scarcely perceptible when the body is at rest. The aspect of the patient at this period is pale, OAving to the lack of blood in his arteries; but the overloaded state of the veins is not at first sufficient to produce cyanosis and dropsy, although the lips may be someAvhat livid. Besides this, there are a certain languor and apathy, with liabUity to fatigue upon slight exertion, symptoms which, as Ave haA'e repeatedly said, indicate a venous condition of the blood. If the disease advance, the palpitation and dyspnoea become more dis- tressing, the patient fears to make any exertion, because it "puts him out of breath." The lips and cheeks assume a distinctly blue tinge, the liver begins to swell, from the venous engorgement, and a slight oedema of the extremities begins to appear toward e\"ening. In the most aggravated stage of the disease the patient complains of great shortness of breath, even when in a state of complete repose, Avhich becomes almost intolerable upon his making the slightest effort. The pulse is small, and often is irregular and intermittent. The urine, Avhich is extremely scanty and concentrated, deposits a copious sediment of urate of soda upon cooling, the small amount of Avater Avhich it contains being insufficient to retain the salts in solution at a reduced temperature. At this period more or less albumen usually appears in the urine, and both lips and cheeks are decidedly cyanotic. The dropsy spreads from the ankles to the legs, thighs, scrotum, and abdominal integument. The upper extremities and face become oedematous, dropsical effusions also forming in the cavity of the abdo- men and the serous sacs of the chest. At length the patient suc- cumbs to the symptoms of bronchial palsy and oedema of the lungs. Every busy practitioner has repeated opportunities to witness cases Avhere old people die of this malady Avith precisely such symptoms, or with symptoms but slightly different. The smallness of the pulse and the diminution of the urine are the result of the constant de- crease of the arterial contents; the cyanosis, dropsy, and albumin- uria are necessary consequences of the ever-increasing venous engorge- ment. The symptoms of dilatation supervening upon an excentric hyper- trophy, arising from endarteritis deformans, are essentially the same as those described above. It is often impossible to determine AAdth which of these two forms Ave have to deal. This vAd.ll not seem strange, Avhen Ave consider that endarteritis deformans does not occasion any derange- ment of the circulation as long as the heart remains in a state of excen- tric hypertrophy, and that the evidence of disease only becomes appar- ent after the hypertrophy has become spurious by secondary degener- ation, and after its compensatory action has become imperfect. When 324 DISEASES OF THE HEART. we find, by physical exploration, that an old person, suffering from cya- nosis and dropsy, has a dilated heart, that his superficial arteries are tortuous, pulsate visibly, and feel hard to the touch, the case is prob- ably one of endarteritis deformans with secondary degeneration of a heart Avhich was once hypertrophied. If, on the other hand, there be no such condition of the peripheral arteries, the degeneration is prob- ably the primary disease to which the dUatation is secondary. Physical Signs.—Inspection never reveals the prominence of the precordial region sometimes seen in excentric hypertrophy. When there is much enlargement, the apex of the heart is found, upon palpation, to beat abnormally low down, and too much to the outer side of the chest. Its impulse is often extremely feeble, and may even be quite imperceptible. In other cases, particularly during moments of excitement, it may be unnaturally strong {Skoda), and may even be equal to that of an excentrically hypertrophied heart, although, indeed, the heaAdng pulsation is never seen in cases of sim* pie dilatation. Percussion shows an extension of the cardiac dulness Hke that arising in hypertrophy, so that in general an extension of the cardiac dulness Avith intensification of the impulse is indicative of hypertrophy, whUe a simUar extension with diminution of the force of the impulse signifies dilatation. Dilatation of the left ventricle, which accompanies the first stage of insufficience of the aortic valve, produces the same alterations of the percussion-sound which accompany the subsequent hypertrophy of the ventricle. The same is true of the right ventricle. In dUatation of the right auricle, the sound of percussion is dull under the sternum, and at its right edge, from the second rib to the fifth or sixth rib. Dilatation of the left auricle cannot be demonstrated by percussion, as the auricle lies too far to the rear. Upon auscultation, the normal sounds, which are loud and strong in hypertrophy, in dilatation are found to be unusually feeble, although pure; since both the auriculo-ventricular valves and the arterial Avails are set into very languid vibrations by the feeble action of the heart. In other cases, the sounds are muffled; perhaps because the papillary muscles, Avhich are atrophied as well as the Avail of the heart, produce a less Adgorous tension of the valves. Finally, and very frequently, too, we hear murmurs over a dUated heart instead of the normal sounds, from Avhich, hoAvever, we are not Avarranted in concluding that the A'alves have suffered alteration in their structure. These murmurs depend rather upon the irregularity of the vibrations, into AA'hich the Ul- stretched valves are throAvn by the current of the blood. They are nearly allied to those which Ave notice in cases of abnormal innervation of the organ, Avhere there is no dilatation of the heart, in febrile disease, ATROPHY OF THE HEART. 325 or in relaxation of the cardiac muscles, such as occurs in anaemia, com- bined with general loss of tone of the muscular system. Treatment.—The principles of treatment for dUatation of the heart are readily deducible, from the foregoing remarks upon its pathogeny and etiology. On the one hand, we have to see that the nutrition of the body goes on normally, as being the best preventive of flaccidity of the cardiac walls. On the other hand, the patient is to be protected from all causes which can render the action of the heart more laborious. Thus, a nutritious diet is very proper; but the patient must not eat much at a time, but should increase the number of his meals. Eggs, meat, and, above all, milk, are particularly com- mendable. Many patients do well to five exclusively upon milk for a while. Iron, Avhich, fortunately, no longer has the reputation of being " heating," should always be prescribed Avhen the patient sIioavs any signs of anaemia or of hydraemia. On the other hand, all violent mus- cular effort should be forbidden, and the use of spirituous liquors ought to be restricted, Avithout, hoAvever, entirely forbidding them to such patients as are habituated to their use. When the liver swells, if the feet become oedematous, or if the patient become distinctly cyanotic, digitalis should be used. Prepossessed by the doctrine of Traube regard- ing the effect of digitalis upon the contractile force of the heart, and the tension of the aortic system, I formerly regarded the use of this rem- edy in dilatation of the heart as unnecessary and even dangerous. Of late years I have convinced myself, from a great number of observations, that digitalis is a very efficient means of temporarily strengthening the heart's contractile poAver, and of thus allaying cyanosis and dropsy. In dilatation of the heart, digitalis, Avhen combined Avith an exclusively milk diet, is an invaluable remedy. I have repeatedly succeeded in obtaining complete removal of dropsical effusions of great magnitude, and produced considerable temporary relief, by this mode of treatment. It Avere A-ery desirable that cfinical teachers and physicians should en- deavor to promote the cause of therapeutics by a more rigorous analy- sis of the results of their treatment of disease in human beings, rather than make experiments upon dogs with their medicines. Indeed, the more recent researches of Traube have afforded results which are ab- solutely contradictory to his former conclusions, and Avhich are more in accord Avith experience at the bedside. CHAPTER III. ATROPHY op the heart. Etiology.—Congenital, or original diminutiveness of the heart, which strictly speaking, cannot be called atrophy, occurs by preference 326 DISEASES OF THE HEART. in the female sex {Rokitansky), accompanied by retarded develop- ment in general, but especially of the sexual organs. We knoAV nothing of the manner in which it originates. Acquired atrophy occurs— 1. In general marasmus, such as is developed in the course of tuber- cular consumption, cancerous cachexia, and cancerous suppuration, or in consequence of old age. Even attacks of acute disease, of long duration, such as protracted typhus, may cause atrophy of the heart. We also find that, although an abundant supply of nourishment is not sufficient, of itself alone, to cause the muscular tissue of the heart to grow, yet a scanty supply, or an abnormal consumption of it, may give rise to atrophy of the cardiac muscles, as Avell as to wasting of the muscular system at large. 2. The heart atrophies when exposed to unusual pressure from AA'ithout, just as the muscles of the extremities Avaste aAvay under con- tinued compression of shackles or bandages. Atrophy of the heart also accompanies extensive pericardial effusion, fibrous thickening of the epicardium, and may even result from large accumulations of fat upon the organ. 3. Contraction of the coronary arteries causes atrophy of the heart, by limiting the supply of nutritive fluid. Anatomical Appearances.—In congenital smallness of the heart, the heart of an adult may be like that of a child of five or six years of age, Avith thin Avails, small cavities, and dehcate valves {Rokitansky). Acquired atrophy is almost always concentric—that is, the thinning of the wall of the organ is accompanied by contraction of its cavities. Another characteristic sign, besides the reduction in size, and by which it may be distinguished from congenital smallness, consists in the dis- appearance of the fat of the heart, and in the serous infiltration of the connective tissue, in which the fat formerly lay. The pericardium is opaque, the Avhite specks, which Ave so often find in the heart (Sehnen- flecke), are wrinkled, and the coronary arteries remarkably tortuous. The endocardium is also clouded, the valves of the veins swollen. The substance of the heart is usually pale, and its consistence less firm; in other cases, it is hard and dark. Bamberger very properly calls to our attention that, in many cases of concentric atrophy of the heart, there is a considerable quantity of liquid in the pericardial sac. This bears a certain analogy with the collections of Avater in the skull in atrophy of the brain—AVith hydrocephalus ex vacuo. Simple atrophy of the heart is much more rare. Here the organ is of normal size, but its walls are thinned. Hence the normal size can only be the result of dilatation of the cavities, so that this form of disease is allied to that described in a previous chapter. This ap- ATROPHY OF THE HEART. 327 plies still more forcibly to the excentric atrophy. The latter almost completely coincides Avith simple dilatation. Indeed, it Avould be almost impossible to decide Avhether the walls have been thinned by excessive distention alone (dUatation), or Avhether atrophy of their elements have contributed to their attenuation (excentric atrophy). True, the effect of the two conditions is not quite the same, for, if the walls of a dilated heart be also thinned (as they sometimes are by accumulation of fat about the heart, and as is observed most typically in the indu- rated thickening of the epicardium AA'hich remains after a chronic peri- carditis), Ave find the propulsive power of the organ to be much more reduced than is the case in simple dilatation. We have, finally, to mention that, Avhen the contents of the left ventricle have been reduced as a result of contraction of the left auriculo-ventricular orifice, a most classical diminution in size and atrophy of the left ventricle is often observed. Symptoms and Course.—According to Laennec, congenital atro- phy of the heart is the cause of frequent attacks of fainting. Accord- ing to Hope, besides the tendency to faintness, the signs of defective nutrition of the body, great muscular debility, palpitation of the heart, signs of anaemia, and chlorosis, are to be found in persons suffering from congenital smallness of the heart. Acquired cardiac atrophy varies in its symptoms, according as it forms a part of a general state of marasmus, or stands alone, indepen- dent of poverty of blood or Avasting of the general system. In the first instance, the symptoms are not very prominent. In fact, in certain cases, it can hardly be decided whether the enfeebled propulsive power of the heart depend upon lack of energy in its contraction, or upon atrophy of its muscles. In either case, the arteries are incompletely filled, and the blood accumulates in the veins. As, however, the blood itself is reduced in quantity, there are no signs of extreme venous en- gorgement. Severe dropsy, or Avell-marked cyanosis, is hardly ever met5Avith in this form of atrophy of the heart. The bluish hue of the Hps, the varicosities upon the cheeks of old men, the small effusions into the subcutaneous tissue in the hands and feet, Avhich are usually cool and slightly bluish, are only partially dependent upon feeble pro- pulsiA-e power. Atrophy of the lungs, as Ave have already seen, con- tributes largely to the establishment of these symptoms. Atrophy of the heart, arising in consequence of local derangements of nutrition, long-continued compression of the heart, or stricture of the coronary arteries, has a very different character. In the first place, the patient often complains of a distressing palpitation, a symptom which, as stated in a previous chapter, generally exists Avhen the heart is unable to keep up the circulation without very great exertion. 328 DISEASES OF THE HEART. Moreover, in consequence of the emptiness of the arteries, the veins are over-filled, and the retardation of the current of the blood gives a venous character to the latter, and occasions shortness of breath. The patients may become exquisitely cyanotic. General dropsy appears, and Avith it there is often great dyspnoea. If the atrophied heart be also dUated, an additional cause of engorgement of the veins and im- pediment of the circulation comes into play, and all the symptoms are much aggravated. But the progress of the malady is still more rapid and serious upon addition of a third cause—fatty degeneration of the cardiac muscles—the effects of which are quite similar to those of the first tAvo, and which usually accompanies them. Such cases are tolera- bly common, and Avhen old and feeble persons become blue and drop- sical, Avithout having any valvular disease, it is generally OAving to dilatation and degeneration of the substance of the heart, or else to extensive endarteritis deformans. An approximate diagnosis, at least, may be made sometimes by physical exploration. As long as the pa- tient remains at rest the heart-shock may be very feeble, or quite im- perceptible. The pulse is remarkably small. In some cases, the area of cardiac dulness has decreased AAdth the diminution of the heart, a symptom which is only of value when it can be proved that diminution of the heart has caused vicarious emphysema, distending the lungs. In other cases, instead of extension of the lung, a large effusion into the pericardium fills the vacuum caused by shrinking of the heart, and the cardiac dulness is normal. In other cases, in which the luno-s are also reduced in size, the pericardial effusion may be so profuse as to render the cardiac dulness abnormally large. The same is the case in atrophy of the wall of the heart with dilatation of its cavity. As, in hypertrophy, the heart-sounds are stronger and louder, so in atrophy they are either feebler or indistinct, or else they are muffled, and some- times murmurs are audible, which depend upon the conditions AA'hich Ave have already mentioned, as causes of modification of the sounds of the heart. Treatment.—A real treatment of atrophy of the heart is out of the question. Of course, all violent efforts must be avoided, rich food be provided, and even the moderate employment of Avine, " vinum lac serum" may be permitted. CHAPTER IV. ENDOCARDITIS. Etiology.—We entirely agree with Virchow as to the pathogeny of endocarditis. He regards the hypothesis of the formation of a free exudation in this disease as not prcwen and even doubtful, and counts ENDOCARDITIS. 329 both this malady and the inflammation of the inner arterial tunics, from Avhich the so-called atheroma proceeds, among the parenchyma- tous inflammations. This term is applied by Virchoto to the active disturbances of nutrition Avhich are provoked by an irritation, but AA'hich, instead of producing an exudation between the elements of the tissues, causes a SAvelling of the normal elements themselves, and a proliferation of their cells. In endocarditis the inflammation does not originate in the deeper layers of the endocardium, but upon its more superficial portions. They become enlarged, are infiltrated by a liquid Avhose chemical properties resemble that of mucin, that is, it coagu- lates into the form of threads upon addition of acetic acid. In addition to this, a A'ast formation of neAV cells takes place, AA'hich immediately organize into connective tissue. It is only in very rare cases, in the so-called ulcerative endocarditis, that the proliferation of young cells goes forward AA'ith such activity that the tissue breaks doAvn under their pressure, producing a loss of substance, an ulceration of the endocardium. The cause of endocarditis is someAvhat obscure. It is seldom the result of direct irritation. Bamberger has only seen tAvo cases of traumatic origin. The frequence with Avhich the orifices and valves of the heart suffer from this disease scarcely leaves any doubt that endo- carditis, arising from internal causes, attacks those portions of the endo- cardium by preference Avhich are especially exposed to strain and fric- tion from the action of the heart. Just as the pulmonary artery, Avhich, though otherAvise rarely atheromatous, if exposed to abnormal tension by hypertrophy of the right ventricle, is often attacked by atheroma; and just as the A'cins even undergo atheromatous degeneration Avhen distended by a current of blood from a communicating artery, so in the heart, it is the narroAV places, the outlets, which are most often dis- eased, but especially those portions of the A'ah'es AAdiich strike against one another in closing, the auricular surfaces of the mitral, and tricus- pid, and the convex faces of the semilunar A'alves. Whether primary idiopathic endocarditis eA'er occurs, and Avhether the disease independently can attack a previously healthy person who has been exposed perhaps to cold, may be doubted, yet it is not impos- sible. The great frequence of valvular disease, in individuals Avho pro- fess never to have suffered from any acute sickness, makes it probable that an idiopathic chronic endocarditis is not uncommon. In the vast majority of cases endocarditis arises in the course of acute articular rheumatism {Bamberger), and all the more readily the greater the number of joints attacked. It is idle to indulge in speculations as to Iioav this complication comes about, as they cannot lead to any ser- viceable explanation. Although, liOAvever, acute articular rheumatism 330 DISEASES OF THE HEART. is the most frequent cause of endocarditis, yet the number of cases in 1 Avhich rheumatism runs its course without it is far greater than Avas ' supposed for a long time, after the frequent coexistence of the tAvo maladies had been recognized. The fact that a bloAving sound can be heard in the heart, during an attack of acute rheumatism, is not by any means a sufficient eAddence of the existence of endocarditis. Such a sound, which may be heard in at least one-half of all rheumatic attacks, depends, in a very great degree, upon the irregular tension of the A'alves, to Avhich the excited and uneven action of the heart gives rise. According to the careful \ statistical compilations of Bamberger, the frequence of the complica tion of acute articular rheumatism with endocarditis may be rated at about twenty per cent. Next in frequence, endocarditis complicates Bright's disease, ac- companying the acute form Avhich develops after scarlatina, as Avell as' the chronic form. Here, too, the tendency to inflammation in the heart, serous membranes, and lungs, set up by this affection of the substance of the kidney, remains inexplicable. The endocarditis which comes on during acute febrile maladies, especially acute infectious disorders, is closely allied to the above mentioned forms. The disease seems to arise frequently from puer- peral fever, Avhile Wunderlich regards measles as the most prolific 1 cause of endocarditis next to rheumatism. According to the experi- ments of Billroth and Weber, it seems not improbable that the blood , ' of a fever patient acts as an inflammatory irritant, and that individuals \ laboring under violent fever, no matter what its cause may be, are \ liable to secondary inflammation of various organs, and especially to \ inflammation of the endocardium. If this supposition be true, the fre- I quence of the complication of articular rheumatism and endocarditis is ' attributable to the intensity which rheumatic fever often acquires. The existence of a diseased valve is frequently the cause of endo- carditis. It is a matter of common experience, that a patient, at first, may have a simple valvular disease arising from acute rheumatism, but after a time, and Avithout his having had any fresh rheumatic at- tack, the valvular affection become a complicated one, compelling us to infer that it is the result of a latent endocarditis. The endocarditis which accompanies myocarditis, and pericarditis, must be considered as the result of extension of the disease by con- tiguity. As a very great rarity, inflammation of the lungs or pleura also spreads to the endocardium. Anatomical Appearances.—As nearly all the congenital defects of the heart which are attributable to a former endocarditis are found in the right side of the organ, it would seem that the right side of the ENDOCARDITIS. 331 heart is especially liable to this disease during foetal life. On the other hand, in extra-uterine life, it is almost as exclusively the left heart in which we find endocarditis. Inflammation hardly eA'er affects the whole lining of the organ, but confines itself rather to patches of vary- ing size. As Ave have already remarked, hoAvever, it is from the vah'es, and especially from the parts of them already alluded to, that the in- flammation is apt to proceed. It has been customary to mention reddening and injection of the endocardium as the first sign of endocarditis. Rokitansky, hoAvever, observes, that it is only possible in rare instances to obtain a \deAV of an endocarditis in this stage, and warns against confounding the red- ness of injection with the infiltration of the endocardium which takes place after death. Foerster points out that this reddening by injection, Avhich Ave find surrounding points AA'hich have already undergone fur- ther derangement of texture, may be distinguished from the reddening of post-mortem imbibition, as the latter is darker and merely involves the superficial coats, Avhile the reddening from injection exists in the deeper layers only, in Avhich, by means of the microscope, we may see the capillaries filled with blood to bursting. Very soon we find a puffiness and swelling of the endocardium, as its external layer thickens and enlarges. Virchow describes this in- crease in volume as " consisting of a homogeneous, translucent, toler- ably clear ground-substance, in Avhich so many cells are imbedded, that it might seem, at first sight, as though it Avere an accumulation of growing epithelium." Besides this diffuse swelling of the endocardium, reddish or grayish- red delicate villi often develop as the disease advances, which give the endocardium a fine, granulated aspect, and which, sometimes, rapidly groAV into tolerably thick, coarsely granular papUlae and Avarts. These are very hard and firm at their base, Avhile their round, bulbous, free ex- tremities appear soft and gelatinous. At the base Ave find perfectly- formed connective tissue, while the apex is stUl filled up by elements Avhich ha^e not as yet organized into connective tissue. These excres- cences, known as A'alvular vegetations, are outgroAvths from the endocar- dium, from proliferation of its connective tissue. Upon the auriculo- ventricular A'alves, these excrescences often form a border of varying Avidth, close to the free edge of the A'alve, and spread hence, particu- larly upon the chordae tendineae. On the semilunar valves, they generally proceed from the noduli Morganii. We must beAvare of mistaking the fibrinous deposits, Avliich are apt to form upon the rough and uneven surfaces of the valves, and almost always cover them, for the vegetations themselves. This SAvelling of the endocardium, Avhich is afterward converted 832 DISEASES OF THE HEART. from a gelatinous to a semi-cartilaginous consistence, and leads to per- manent thickening and rigidity of the valves, and the retraction and shrinking of the thickened valves, in which chalky masses often form, are much the most common causes of valvular disease of the heart. When the vegetations grow old, calcification may also take place in them, so that irregular lobulated masses, of stony hardness, cover the shapeless A'alves. While the anatomical alterations hitherto described are the most common results of endocarditis, there may appear as less usual accompaniments of the disease— 1. Laceration of the endocardium. This may readily be accounted for, from the relaxation and softening which the endocardium under- goes. It is the chordae tendineae which give Avay AA'ith the greatest frequence; and it is easy to see that the proper tension of the valve during systole must then be materially interfered with. In other cases the valve itself tears; in others, one surface of a valve alone is torn ; the blood which penetrates through the rent, causing the oppo- site surface of the endocardium to bulge in the form of a sac, consti- tuting an aneurism of the valve. It is rare for the endocardium to give Avay at any point in the muscular wall of the heart—although, should this happen (but only in such a case), it may be possible for the sub- stance of the heart-wall to take part in the inflammation—for the blood to force its Avay into the rupture, and more or less to tear asunder the cardiac muscles, so as to produce an acute aneurism of the heart, a rounded, circumscribed sac, seated upon the Avail of the heart, as an appendage, bounded at its entrance by torn and ragged endocardium, its Avail consisting of the forcibly separated fibres of the muscular sub- stance of the organ. 2. The adhesions of the chordae tendineae, and of the edges of the valves either to one another or to the wall of the heart, to which en- docarditis sometimes gives rise, are of quite as much importance, and produce consequences quite as grave, as do the lacerations; for, by adhesion of the edges of the valves, or of the chordae tendineae to one another, the auriculo-ventricular orifice becomes very much con- tracted ; and, by adhesion of the valves or chordae tendineae AA'ith the heart-AA-all, closure of the mitral orifice during systole of the ventri- cle is rendered impracticable. We shall discuss this subject more fully while treating of valvular disease. If Ave reflect that the heart is in constant action, and that during the formation of these adhesions the parts must have been in a constant state of alternate contact and sep- aration, the formation of these adhesions will appear more difficult to account for than any other anatomical change which occurs in endo- carditis. In ulcerative endocarditis there are irregularly-shaped, abruptly- ENDOCARDITIS. 333 defined losses of substance in the endocardium, which, immediately around the ulcer, is SAVollen and thickened. • The floor of the ulcer is fonned by the muscular substance of the heart, which is infiltrated Avith pus. Endocarditis is accompanied by myocarditis, that is to say, the car- diac muscles take part in the inflammation Avith far greater frequence than was formerly supposed. At other times, the inner layers of the cardiac AA'all Avhich lie next to the inflamed endocardium become the seat of infiltration, which fully explains Avhy the cardiac wall loses its tone, and Avhy endocarditis is apt to be folloAved by dilatation of the heart. The fibrinous deposits, Avhich almost ahvays cover the vegetations upon the valves, may, if broken loose by the current of the blood, occa- sion disorder of a different kind; and baneful as the ulterior effects of endocarditis are upon the system, yet almost the only source of dan- ger, during the height of the disease, consists in the liability of these little coagula (emboli) to Avash away. Should any of them be broken off by the current and borne into the circulation, haemorrhagic infarction and metastatic abscess avUI be the result. We have discussed the pa- thogeny of these processes in detail, Avliile treating of metastasis into the lung. Here, hoAvever, it is not the lungs in Avhich the infarctions arise, but, in the A'ast majority of cases, the embolus gets into the artery of the spleen, blocks up some one of its minuter branches, and, a Avedge- shaped spot, Avith the apex pointing inward and the base outAvard, is established, Avhich is at first of a blackish red, afterward assumes a yelloAV hue, and passes into a state of caseous degeneration. We sometimes see spots of this kind in the kidney; but they are far more rare than haemorrhagic infarction of the spleen, Avhich is met with post mortem, AA'ith extraordinary frequence. In the liver they are still less common, and, as Ave have just observed, they are rarest of all in the lungs. In the tAvo latter organs indeed, one could hardly conceive of the occurrence of infarction, unless a branch of the hepatic artery or bronchial artery, but not of the portal vein or pulmonary artery, were to be obstructed. That abscesses, instead of infarction, should be so rarely found in endocarditis, is explained from AA'hat Ave have said already upon the pathogeny of metastasis. The embolus Avhich here obstructs the artery does not come from a collection of putrefying material, as emboli of the lungs so often do, but consists of coagulated fibrin, a fact which is unfavorable for the conversion of the infarction into an abscess. Should a someAvhat large fibrinous clot pass into one of the caro- tids, or vertebral arteries, then, accordingly as the artery of the brain is 334 DISEASES OF THE HEART. totally or partiaUy occluded, it causes the formation of haemorrhagic foci (capillary apoplexy) with their consequences, or else gives rise to partial anaemia, and consequent necrosis of the anaemic portion of the brain (yellow softening). Indeed, occlusion of the greater vessels of the extremities, by a large embolus, may even occasion spontaneous gangrene of the toes. We are entirely unauthorized, by the occurrence of metastasis, to infer that perforation of an exudation from the deeper layers of the endocardium to its free surface has taken place, as the coagula entirely suffice to account for the symptoms. Nor are Ave warranted in diag- nosing a septicaemia, from the appearance in an endocarditis of signs suggestive of septic poisoning, since it is not to be supposed that any exudation which might make its Avay to the free surface of the endo- cardium could be a septic one, or could infect the blood. Symptoms and Course.—When endocarditis supervenes upon an attack of acute inflammatory rheumatism (and, as stated above, this is by far its most common commencement), there are often no subjective symptoms to warn the patient of the new enemy which is stealing upon him, and who frequently does not declare himself in all his malig- nance for weeks, months, nay, for years afterward. If we ask a patient, AAdth valvular disease, whether he has ever had articular rheumatism, he often answers in the affirmative; if, however, we ask him whether during his attack he has ever suffered from pain in the region of the heart, or from oppression or palpitation, he almost always will deny it. It is not very different if we watch the patient ourselves. Gen- erally he does not complain, even when Ave make special inquiry as to the existence of this kind of trouble; and we must depend for our diagnosis upon physical examination alone. In other instances, however, functional disturbance, more or less dis- tinct in character, certainly does arise. Pain in the cardiac region, how- ever, never appears to proceed from simple, uncomplicated endocar- ditis, even although we make pressure upon the thorax or epigastrium. In a feAV, but very rare instances, the frequence of the pulse increases Avith the commencement of the endocarditis, and may even become extremely great. We shall not lose ourselves in speculations as to the cause of this augmented frequence of the heart's action, which is sometimes enormous, nor shall Ave attempt to decide whether it be due to sympathy of the muscular portion of the heart, or to irritation of the ganglia seated in its walls, but shall confine ourselves to announ- cing the fact. It is at least equally hypothetical to assume that there is an ulcerative form of the disease in the cases of endocarditis marked by acceleration of the pulse. As increased frequence of the heart and pulse-stroke often coex- ENDOCARDITIS. 335 ist AAdth a reduction of the energy of the heart, which may fairly be at- tributed to its infiltration Avitfi serum, the pulse is frequently small, and the feA'er assumes the character of extreme adynamy, so that it be- comes liable to be mistaken for other asthenic fevers, typhus, etc. The statement that an unobserved endocarditis is the source of many fevers spoken of as nervous, febris simplex, versatilis, torpida, putrida, etc., is an exaggeration, as the disease seldom takes the latter form. When endocarditis is attended by metastasis, especially metastasis to the sjileen, the fever becomes aggravated, and rigors occur, but the presence of septicaemia cannot be inferred from such symptoms alone, since both of them arise (although they are not constant) Avhen metastases form in the spleen, from the detachment of clots, or frag- ments of the A'alves, in cases of long-standing A'ahoilar disease, AA'here septicaemia is out of the question. Palpitation of the heart is a more common symptom than excite- ment of the pulse. The reason for this is at once clear, Avhen Ave re- member that the action of the heart is always embarrassed by infiltra- tion of its muscular substance, and that palpitation is usually conv plained of the most Avhen the performance of its function has become laborious, as well as excessive, and that it does not proceed from the abnormally vigorous action of the hypertrophied heart. This serous infiltration of the cardiac muscles, Avhich sometimes arises in endocar- ditis, and the consequent debility and imperfect action of the heart, also account for the dyspnoea which accompanies the palpitation. In the chapter upon hyperaemia of the lung, Ave have explained Avhy these symptoms are attended by passive hyperaemia. If insuffi- cience of the mitral actually be established Avhile the endocarditis is still in progress, if blood be regurgitated into the auricle during the systole of the ventricle, the venous engorgement of the lungs and the dyspnoea are all the more severe. From Avhat Ave have said regarding the symptoms of endocarditis, especially from the fact that, in a great number of cases, there is abso- lutely no disturbance of the functions, it avUI readily be perceived that the malady seldom runs its course in a Avell-defmed manner, like in- flammation of other important organs. Neither does the commence- ment of the disease often admit of detection, nor can its progress often be folloAved up, nor, to say the truth, can Ave well fix the point where endocarditis ceases, and that malady begins AA'hich Ave call valvular disease. Disease of the A'ah'es is indisputably the most common sequel of endocarditis, the valves either remaining thickened, and aftenvard shrinldng, or the chordae tendineae and edges of the A'alves adhering or rupture of one or other of these parts occurring. As re- traction of the thickened A'alves commences gradually, and progresses 336 DISEASES OF THE HEART. slowly, and as adhesions of the valve-tips and chordae tendineae only take place by degrees, it may happen that, immediately after an attack of endocarditis, there may be no perceptible defect of the valve ; yet valvular disease may become apparent after the lapse of some months. If, hoAvever, the chordae tendineae suffer rupture, or if an orifice be blocked up by vegetations, the transition from endocarditis into val- vnlar disease is immediate. In a previous chapter Ave have shoAvn hoAV endocarditis may cause dilatation, and afterward lead to hypertrophy of the heart. The usual termination of endocarditis is death from disease of the valves, Avhich is almost always its sequel; but this fatal result does not generally ensue until years have elapsed, and it is rare for a patient to die suddenly of endocarditis alone. Such a termination hardly ever takes place in the form of disease, which complicates acute articular rheumatism. It is someAA'hat more common in the variety Avhich accompanies Bright's disease, or the infectious maladies, and here it usually is difficult to determine Avhat part in the fatal issue the original disease has played, and Avhat the complication. Palsy of the heart, engorgement of the lungs with consequent oedema, in very rare instances exhaustion through fever, symptoms of softening of the brain, of metastasis into the spleen, kidneys, and fiver, even gangrene of the toes, are symptoms Avith which death may then take place. Recovery from endocarditis may occur often enough if the valves be spared by the inflammation. White, thickened, and opaque spots, upon the interior of the Avail of the heart, are often found post mortem, without having produced any symptoms during life. Even inflammation of the valves may terminate in recovery, if the thickening, AA'hich probably always remains, does not derange their function. Experience does not shoAV this termination to be common. Although the valves may act normally at first, yet they are afterward liable to become the seat of fresh irritation, until, at last, deformities arise capable of deranging their function. We have hitherto described endocarditis such as complicates rheu- matism of the joints. The functional symptoms, the progress, and the consequences of an endocarditis which complicates an existing disease of the valves present no neAv feature to the picture. This is also the case in that form of the malady Avhich complicates acute infectious diseases. Here the symptoms of the main affection mask those of the complication so fully, that an exact clinical description of them can scarcely be given; in particular, the delirium, stupor, albuminuria, jaundice, etc., Avhich certainly are very common accompaniments of this form of endocarditis, do not depend upon the endocardial disorder for their cause, but rather are a result of the infection of the blood and ENDOCARDITIS. 337 of the intense fever arising from such infection. Physical examination alone can give us the required information, and it should never be neg- lected, though no special signs demand such investigation. With regard to the origin and course of endocarditis complicating chronic Bright's disease, as this form too usually presents no subjective symp- toms, it is overlooked in most cases if physical exploration be neg- lected. Physical Signs.—The impulse of the heart in the commencement of the attack is almost always stronger and more extended than natural. The smallness and softness of the pulse, Avhen the muscles of the heart are infiltrated Avith serum and contract feebly, in spite of their furious action, bear striking contrast to the aboA'e. The cardiac dulness is normal at first; but, after a feAV days {Skoda), the outfloAv from the pulmonary veins may be so much embarrassed that the blood accumulates in the left auricle, and the obstruction extends through the vessels of the lungs into the right heart. The right heart is imperfectly emptied, and soon becomes dilated by the blood entering from the vena cava. Hence, as Ave have already seen, the dulness is rendered abnormally broad. If the tissue of the valves be- come softened, and the valves themselves thickened by the inflamma- tion, it is easy to see that the heart-sounds must also undergo modifi- cation. It is impossible for the softened and thickened valve to A'ibrate, like the hard and delicate valve. As the first sound of the heart in the left ventricle proceeds from vibration of the mitral, the substitution of an abnormal murmur at the apex for the first cardiac sound is the most frequent and important sign of endocarditis, which usually has its seat in the left heart. Besides, the thickening of the delicate Aveb on the outer edge of the mitral prevents it from unfold- ing freely, and keeps the softened chordae tendineae from completely fixing tfie A'alve, Avhich, if the chordae tendineae be broken, may even be folded backward toward the auricle during the systole of the ven- tricle. All these forces combine to render it impossible for the valve to perform its function during systole of the ventricle, and to prevent regurgitation of blood into the auricle. That condition, where the valve loses the poAA'er of acting as a valve, is called "insuffi- eience." If, hoAA'evcr, the vahe be but partially fixed, if part of it be free to flap in either direction, if some of the blood pressing against it be opposed by a portion only of its loAver surface, while the rest, floAving back into the auricle, bathes its upper face, the vibrations of the mitral become entirely abnormal and irregular, and give rise to another murmur, AA'hich takes the place of the first sound of tfie left ventricle. We have seen that the second sound that we hear at the apex is, under normal conditions, produced by vibration of the semi- 00 33S DISEASES OF THE HEART. lunar valves of the aorta, AA'hence it is conducted to the apex. In the normal heart, the entrance of blood into the ventricle is unaccompanied by any murmur or other sound. If, however, in endocarditis, the auricular face of the mitral-valve be studded with Avarty excrescences, and if the blood have to flow over a rugged surface instead of a smooth one, friction of the blood-stream produces a murmur which is audible at the apex during the diastole of the ventricle. The second tone, propagated from the aorta, may also be heard with it, or the latter may be drowned by the intensity of the new murmur, and thus be im- perceptible. The larger the excrescences, and the more they encroach upon the orifice, so much the more intense is the friction of the blood, and so much the louder the murmur. In the extremely rare cases in which the right ventricle is the seat of endocarditis, similar symptoms may be made out at the lower part of the sternum, Avhere we listen to the sounds of the tricuspid. It would be exceedingly difficult, how- ever, to make a diagnosis here, as the right ventricle is hardly ever the sole seat of disease, and we should scarcely be able to distinguish whether the sounds were conducted from elsewhere or actually origi- nated at the tricuspid. The sounds of the aorta are usually pure, as its valves are far more seldom attacked by endocarditis. Should it occur, however, should warty growths form upon the lower sides of the semi- lunar valves, a murmur, produced by friction of the blood upon these asperities, arises during systole of the A'entricle, which is best heard at the root of the aorta—i. e., at the sternum, on a level Avith the second intercostal space, and which is conducted hence along the carotids. It is much less common to hear a diastolic murmur at this point than a systolic one. We hear normal heart-sounds at the pulmonary artery almost always, as the disease hardly ever extends as far as this. On the other hand, Ave often hear a remarkably loud and sharp accentuation of the second sound of the pulmonary artery, which is a sign of im- portance. The fuller the pulmonary artery becomes, so much the stronger does the shock groAV which its semilunar valves must sustain during diastole. Noav, as an acute insufficience of the mitral develops in the majority of cases of endocarditis, the pulmonary artery must suffer distention and its second sound must become intensified. Diagnosis.—Endocarditis occurring in the course of acute rheuma- tism is often overlooked, and quite as often its presence is diagnosti- cated Avhere it does not exist. In order to avoid the former error, never fail to auscult all patients Avith acute articular rheumatism daUy, even in the absence of all complaint or constitutional disturbance. That you may not rush from Scylla into Charybdis, hoAvever, beware hoAv you declare an endocarditis upon the mere occurrence of a blow- ENDOCARDITIS. 339 ing sound, audible at the apex. The symptom may, indeed, be due to thickening of the valve by inflammation, but it is quite as likely to be dependent upon mere abnormal tension of a healthy valve, caused by Adolence of fever or irregular action of the heart. Neither condition can be determined from the quality of the murmur, and diagnosis re- mains a matter of doubt until the signs of dilatation of the right A'en- tricle and overloading of the pulmonary artery, lateral extension of cardiac dulness and intensification of the second pulmonary sound, supervene upon the murmur. The differential diagnosis is still more difficult between a recent endocarditis complicating articular rheumatism and an old valvular de- rangement, which happens to preexist, especially insufficience of the mitral. Such cases are by no means rare. There are few maladies Avhich have so great a tendency to relapse as acute articular rheuma- tism ; indeed, we meet AA'ith sufferers who have had attacks of it, of more or less severity, every year since its first onslaught. If Ave have not previously seen or examined them, and if upon some fresh relapse we hear a systolic blowing at the apex, the cardiac dulness extending laterally, and the second pulmonary tone being sharply accented, Ave must remain in doubt, unless the signs of dilatation of the right ven- tricle have attained such a height as cannot be ascribed to acute in- sufficience. In other cases we may perhaps ascertain if, after any of I. lis previous illnosses, the patient have remained short of breath, etc. Prognosis.—Rarely as life is threatened by endocarditis itself, the prognosis of this malady as to complete recovery is bad. Indeed, in the cases in Avhich the disease is recognized, it almost ahvays leaves derangements behind it, which sooner or later imperil life. Endocar- ditis, AA'hich attacks the Avail of the heart, is, no doubt, far less dan- gerous ; but it occurs rarely, and, moreover, is quite unrecognizable. Symptoms AA'hich would lead us to fear an unfavorable termination to this disease are those Avhich indicate considerable implication of the muscle of the heart in the inflammation, such as an extremely frequent pulse AAdth scanty filling of the arteries. Rigors are quite as ominous, indeed more so, as well as acute SAvelling of the spleen, or pain in that region, vomiting, or the appearance of blood or albumen in the urine, or svniptoms of hemiplegia, in short, the signs of metastasis. Treatment.—The indication as to cause in treatment of endocar- ditis cannot, as a rule, be met, A genetic connection undoubtedly ex- ists between acute articular rheumatism and this disease, AA'hether the former merely predispose to the latter, or Avhether the alliance be still more intimate. Great, hoAvever, as is the number of remedies and modes of cure recommended for rheumatism, it is only equalled by their untrustworthincss. We are no less helpless against the morbus 340 DISEASES OF THE HEART. Brightii, the acute exanthemata, and the other infectious maladies, which give rise to endocarditis, or, at least, predispose toAvard it. With regard to the indications from the disease and the antiphlo- gistic apparatus, Ave have already and repeatedly declared that the majority of the so-called." antiphlogistics," and, above all, venesection, often as they are employed in inflammation, have no right to the name. But, in spite of contrary assertions on the part of French and English physicians, there is, perhaps, no affection in Avhich the practice of bleeding without special occasion, as well as the employment of calomel and "blue ointment to reduce the plasticity of the blood," is so dangerous as in endocarditis; and we must entirely agree Avith Bamberger, AA'hen he states his befief that most patients, who die during an attack of this malady, have perished less from the disease than from the treatment. Even local blood-letting should only be resorted to AA'here there is pain about the heart, and here Ave generally have to do Avith complica- tions. With regard to cold, which Ave have employed against inflam- mation of internal organs as freely as it lias been used in inflammation of external parts, we do not apply it in these cases, unless especially demanded by extreme excitement of the heart's action, inasmuch as, according to our experience, even Avhen applied upon inflamed joints in rheumatism, it has but trifling palliative effect. Indeed, although many cases of endocarditis, which used formerly to escape diagnosis, are now recognized through pleximeter and stethoscope, yet their treatment is no more successful than before; nay, if the physician find the evidence of the presence of endocarditis an occasion for meddle- some treatment, it were better for the patient had the doctor never learned auscultation. The indication as to symptoms calls for venesection in cases where- in overcharge of the pulmonary circulation imperils life by threatening oedema of the lungs, and demands prompt relief by diminution of the volume of the blood. A great acceleration of the pulse and signs of feebleness in the action of the heart, cyanosis, etc., indicate the exhi- bition of digitahs. Should palsy of the heart threaten, stimulants must be used. OHAPTEE V. myocarditis. Etiology.—Myocarditis consists of an inflammation of the muscu- lar fibres of the heart, whereby they are softened, become flabby, and finally disintegrate. This destructive process is accompanied by pro- liferation of the perimysium; the gaps formed by absorption of the MYOCARDITIS. 341 primitive fasciculi are filled up by connective tissue, and thus a scar is formed in the heart-waU; or else the perimysium breaks doAvn simul- taneously Avith the muscular fibrillae, and a mass of debris collects in the substance of the Avail. This is called an abscess of the heart. Myocarditis is not a rare affection, and Ave find post-mortem signs of its former existence in many cases of valvular disease of the heart resulting from endocarditis. Indeed, the etiology of myocarditis is, in a great measure, identical with that of endocarditis, acute articular rheumatism acting most frequently as the cause in either disease. Myocarditis, thus excited, usually appears in the form of mere circum- scribed spots, which terminate in scar-like alterations of a portion of the cardiac Avail; but in more rare instances it may result either in extensive degeneration, Avhich may give rise to a chronic aneurism of the heart, or else may produce cardiac abscess. In most cases avc may regard myocarditis accompanying acute rheumatism as an extension of a con- comitant endo- or pericarditis. In other cases, hoAvever, the disease runs a more independent course, is more extensive than any attendant endo- or pericarditis, Avhich, in their turn, may then be considered as de- pending upon the inflammation of the heart's substance. Chronic disease of the heart, particularly valvular disease, leads to myocarditis, and to formation of scars in the heart quite as often as to endocarditis. Emboli, proceeding from gangrenous lungs, not unfrequently enter the coronary arteries of the heart, and Ave then see numerous abscesses in its Avail, as Avell as abscesses in many other organs of the aortic circulation. Septicaemia, protracted typhus, tedious and malignant scarlatina, even though the occurrence of embolism be not proved, nay, though it be A'ery unlikely, may also give rise to abscess of the heart. The pathogeny of such abscesses is obscure. In the second A'olume Ave shall treat of syphilitic myocarditis, Avhen wc come to treat of syphilis in general. Traumatic myocarditis, Hke traumatic endocarditis, is one of the greatest of rarities. Anatomical Appearances.—The seat of myocarditis is almost ex- clusively the left ventricle, especially the apex; but quite as frequently (according to Dittrich) it occurs in the septum just beloAV the aorta. The papillary muscles, hoAvever, are often affected by the disease, which fact is of importance to the pathogeny of deformity of the valves. At the outset of the malady, the muscular substance appears of a dark bluish-red hue. Soon, hoAvever, the injection disappears, and dis- coloration of the muscular fibre arises, the diseased place becoming of a grayish color and softened. Under the microscope, after the trans- verse and longitudinal striae have disappeared, Ave see the fibrUlaa 342 DISEASES OF THE HEART. broken down into a finely-granular detritus, Avith a few fat-globules. We can rarely get opportunity to observe myocarditis in this stage. Much more commonly we find its results, in the form of irregular, rami- fying collections, varying in size, of a reddish-white or white color,-and of a scar-like density, scattered through the muscular substance of the heart. Sometimes this indurated tissue is spread over a large portion of the heart-wall, and forms its sole component. Here the degener- ated wall may yield to the pressure of the blood; a protrusion may form, and a true aneurism of the heart result, which is to be distin- guished as chronic cardiac aneurism from that form described as acute cardiac aneurism, in treating of endocarditis. Such sacs may attain the size of a hazel-nut or even that of a hen's egg, or larger. The scar-like walls usually grow thin from distention; they sometimes ossify, and quite often their cavity contains masses of stratified fibrin, such as we find in aneurism of arteries. The entire heart is generaUy dilated as AA-ell as the aneurism, and, even when there is no aneurismal pouch, numerous scars in the heart-wall will cause dilatation of the organ. On the other hand, large scars in particular situations, as at the approach to the aorta, may cause diminution of the capacity of the heart {Dittrich's true cardiac stricture). When endocarditis terminates in abscess, discoloration and soften- ing prevails more and more in the muscle, until at last a collection of yellow, purulent liquid, surrounded by softened and discolored muscu- lar substance, is formed. Such an abscess rarely becomes incapsulated and dries up; perforation nearly always takes place, unless death occur beforehand. If the perforation be into the pericardium, pericarditis follows; if into the cavity of the heart, the debris of its broken-down tissue passes into the circulation, and numerous metastases are often the consequence. The insertion of an aortic valve may be torn away by the inward pointing of an abscess ; or communication betAveen the two sides of the heart may be set up; even the entire cardiac wall may suffer rupture. Tearing up of the muscular structure of the heart by infiltration of the blood, which we haA'e described in a pre- vious chapter as acute cardiac aneurism, may, of course, occur Avith equal or even greater ease in consequence of the pointing of such an abscess to the interior. Symptoms and Course.—Myocarditis is but seldom diagnosticated Avith certainty during life. As a mild form of the disease compficates almost every case of endocarditis, we seem Avarranted in the inference that the substance of the heart is more seriously inflamed when the region around it appears unduly sensitive (which it never is in pure en- docarditis), still more so if there be great acceleration of the pulse, if the pulse groAV small, or, above all, if the heart's action become irreg MYOCARDITIS. 343 ular. Even then, hoAveA'er, our opinion Avill only amount to a some- Avhat vague suspicion. Diagnosis of myocarditis grows more sure, but not certain, Avhen symptoms appear in the course of acute rheumatism Avhich suggest diseases of the heart, Avhile physical examination affords negative evidence of endo- or pericarditis. If, now, rigors should set i-), or SAvelling of tfie spleen, or pain in the region of the spleen, vomit- ing, or pain in the region Of the kidneys, Avith the presence of albumen and blood in the urine ; in short, if metastases be estabfished, the diag- nosis becomes tolerably certain: but such cases are not common. If cicatrices have formed at numerous points in the heart, and if the heart be dilated in consequence, symptoms of dUatation appear, such as Ave have already described, only they are more severe; and it is impossible to say, in most cases, AA'hat parts the dilatation and de- generation respectively play in retarding the circulation and overload- ing the venous system. Thus, in the diagnosis of mitral insufficience, Ave may bear in mind that it may possibly have been induced by de- generation of the papillary muscles. Extensive scar-like degeneration of the heart-AA'all, as AveU as true cardiac stenosis of Dittrich and chronic cardiac aneurism, causes symptoms of extremely depressed ac- tion of the heart. The beat is scarcely perceptible, the arterial pulse is extremely small and weak as Avell as very irregular and intermittent. Extreme cyanosis and general dropsy accompany these symptoms. If railed upon for a diagnosis in a case of this kind, after exclusion of valvular deformity as a cause of the derangement of circulation, we must count diffuse cicatricial formation as one of the alterations of structure capable of producing the train of symptoms above described; but Ave shall hardly ever make an absolutely certain diagnosis by the system of exclusion of other anatomical changes, such as dilatation with atrophy, extensive fatty degeneration, etc., etc. As for abscess of the heart and the various results of perforation, we are rarely able to form more than a vague diagnosis after the nu- merous metastases have arisen. We have no means of ascertaining this condition AA'ith certainty. Treatment.—Wo can hardly speak of the treatment of myocardi- tis, haAdng almost denied the possibility of recognizing its existence. Should it be possible to diagnosticate the disease, the treatment Avould not differ from that of endocarditis. It is, of course, out of our power to remove the cicatrices, or to avert the embolism from perforation of an abscess, or to allay its effects. A mere treatment of symptoms is all that can be effected. DISEASES OF THE HEART. VALVULAR DISEASE OF THE HEART. By valvular disease of the heart, in its narrowest sense, we mean merely those anomalies of its A'alves Avhich affect the function of the oro-an, and thus react upon the circulation. Valvular anomalies Avhich give rise to no symptoms, and which hence are purely matters of pa- thologico-anatomical curiosity, and not of clinical interest, need but little notice in the following chapter. They are— The so-called simple hypertrophies of the valves, which are found chiefly upon the mitral near its free border, whence is found growing a series of little lumps of a jelly-like connective tissue. The fine web on the lower border, upon Avhose unfolding the valvular action mainly depends, remains intact in hypertrophy, while endocarditis usually has the effect of thickening it, and, as it were, rolling it up. The next deformity of the valves, which does not derange their action, is enlargement, which often occurs in them Avith simultaneous thinning, Avhen the ostium is abnormally (filiated. Most cases of per- foration of the valves also belong under this head. Small oval fissures or holes are often seen in them, which, however, do not seem to impair their efficiency. The most important valvular changes are those known as insuffi- cience and contraction. These tAvo alterations nearly ahvays coexist, one usually prevailing over the other, however, in degree. By insuffi- cience, Ave mean that condition of a valve Avhich renders it incapable of preA'enting regurgitation of blood into the cavity which, as a valve, it should close. If the entire contents of the ventricles be not throAvn into the aorta and pulmonary artery during systole, and if a portion of the blood regurgitate into the auricles, the mitral or tricuspid are insufficient. Again, if, during diastole of the ventricle, part of the blood Avhich had entered the aorta and pulmonary artery Aoav back into the ventricle, the semUunar valves are insufficient. By stenosis (constriction) of a valve, or, more properly speaking, of an orifice, we mean that condition by which the effluent blood meets Avith abnormal resistance through contraction of the outlet of the heart. Although valvular deformities have, in common, the effect of re- tarding the circulation, the influence upon the distribution of the blood varies according to the seat of the affection. The system can endure valvular deficience at one point much better than at another; hence we deem it better at once specially to describe its effects at the differ- ent outlets, rather than to go into a further general discussion of the subject. We cannot altogether avoid repetition, by this method of SEMILUNAR VALVES—THE AORTIC ORIFICE. 345 treating the subject, but shall thus have less to repeat, and, moreover, less to retract, than by any other mode. As the pathogeny of vah'ular defect of the aorta is much more simple than that of mitral disorder, as its symptoms are easier of comprehension, and as its consequence? are much longer and better Avithstood than are those of mitral defi- cience, Ave shall first take up the subject of aortic valvular disease. Derangement of the valves is of far less common occurrence in the right than in the left heart, so that Ave shall reserve the discussion of the former until the last. CHAPTER VI. INSUFFICIENCE OF THE SEMILUNAR VALVES, AND CONSTRICTION OF THE AORTIC ORIFICE. Etiology.—Closure of the semilunar A'alves takes place in a man- ner purely mechanical, Avhile a certain vital action is required to effect closure of the valves betAveen ventricle and auricle, namely, contrac- tion of the papillary muscles. If the mere pressure of the blood during diastole of the left ventricle do not suffice to deploy and press together the leaves of the semilunar valve, AA'hich Avere pushed up against the Avail of the aorta during systole, there Avill be regurgitation of blood into the ventricle, and the valve is insufficient. If, liOAvever, during systole, the semilunar valves do not yield to the current of the blood, and lie back against the aortic Avail as it emerges from the left A'en- tricle, but stand projecting into its outlet, Ave have constriction (steno- sis). Much more rarely the latter occurs from contraction of the aorta at the point of insertion of the valves, Avhereby the outlet is dimin- ished. The alterations AA'hich cause insufficience and constriction of the aortic Aalvcs are the results of inflammation, but less often of endocar- ditis, which Ave have described in Chapter IV., than of a more chronic form of inflammation, which attacks the arteries, and whose results are knoAvn as atheroma of the arteries. Hence it folloAvs, although not without exception, that valvular disease of the aorta is found at a more adA'anced period of life, AA'hen arterial atheroma is far more frequent than during youth, and that its development is more sIoav and gradual than that of the disorders caused by endocarditis. Anatomical Appearances.—If, upon autopsy, we remove the heart and aorta ; and if, upon filling the latter Avith Avater sufficient to distend its Avails, the Avater Aoav into the A'entricle because the edges of the valves do not touch, Ave may assume that such regurgitation has also occurred during life, and must regard the valves as insufficient. 346 DISEASES OF THE HEART. \ l The anatomical changes which cause insufficience are usually ' shrinking and shortening of the valves, so that, even if spread out by the blood, they Avould not meet. But thickening, and rigidity too, may 1 prevent closure, the pressure of the blood becoming insufficient to make U the leaves flap together. Much more rarely Ave find adhesion of the 1 A'alve to the arterial Avail, or laceration or detachment of one of the leaves from its insertion, as a palpable cause of insufficience. Besides these changes at the root of the aorta, we constantly find in the cadaver a degree of excentric hypertrophy of the left ventricle greater than is observed under almost any other circumstances. The Avail of the ventricle may be an inch in thickness, its cavity is often > capable of containing a fist. We have already seen that dilatation of the left ventricle is the necessary result of severe pressure sustained by it from within whUe in a state of relaxation, and that hypertrophy fol- Ioavs in consequence of the augmented effort which it must make in order to propel the increased volume of blood Avhich it holds. A large number of the signs of aortic insufficience are due to this enormous hy- pertrophy of the left ventricle. In a former chapter Ave have fully de- tailed all the alteration AA'hich the shape of the heart undergoes from this enlargement. We have seen that the rest of the organ participates in a less degree in the affection, and that bulging of the septum into the right ventricle materially encroaches upon the capacity of that chamber. The mouth of the aorta may contract to such a degree as barely to admit the insertion of the end of the little finger into the narrowed open- ing. The anatomical changes which occasion such strictures are gen- erally the thickening and shrinking of the flaps described above. These flaps may form unyielding prominences at the root of the aorta; so that it becomes equally impossible for the stream of blood to lay them back against the aortic Avail during systole, and for the weight of the blood during diastole to force them together again. Cohesion of the semilunar flaps is the next cause of stenosis, and is the more marked the more the point of adhesion approaches the centre of the valve. Old vegetations on the valves, of cartilaginous hardness, and Avhich are often the seat of calcareous deposit, assist in blocking up the constricted pas- sage, although they rarely constitute the sole cause. In simple stricture of the aortic valve, the left ventricle has no in- crease of pressure to support during diastole, and hence does not be- come dilated ; it has, however, to propel its blood through a contracted orifice, and becomes hypertrophied on account of the greater amount of effort thus required from it. In contradistinction, then, to Avhat we meet Avith in insufficience of the semilunar valves, we find a simple hy- pertrophy, instead of excentric hypertrophy of the left ventricle, Avhen the aortic outlet is contracted. DISEASE OF THE SEMILUNAR VALVES. 347 We have said above, that the two forms of valvular derangement usually coexist; as, however, insufficience soon predominates over ste- nosis, Ave find a gradual transition from simple to the most intense ex centric hypertrophy taking place in the left ventricle. Symptoms and Course.—The ultimate effect both of stenosis and of insufficience of the aortic A'alves must ahvays be a retardation of the circulation; the blood returns to the lung Avith diminished fre- quence, and hence assumes a more venous character. (Of course, AA'ith every systole, an abnormally small amount of blood is discharged from the ventricle, or a portion of it flows back again during diastole.) The consequences are, that the aorta and its branches are inadequately filled, wfiile, on the other hand, the pulmonary vein is gorged AAdth blood, Avliich is prevented from flowing aAvay into the left auricle, already almost full. Thus the entire pulmonary system becomes over- loaded; but, being incapable of containing the whole of the blood which should properly fill the aorta, the remainder gradually accumu- lates in the A'eins of the aortic system, and gh'es rise to cyanosis, dropsy, etc. As a rule, hoAveA'er, nothing of this kind takes place, until after the lapse of considerable time; inasmuch as simultaneous hypertrophy of the left A'entricle has the opposite effect, and neutralizes the baneful influence of the defective valves. While the latter tends to retard the circulation of the blood, and to render it Aenous, hypertrophy accel- erates its course and makes it arterial. WhUe valvular deformity causes decrease of the contents of the aorta, hypertrophy renders the aorta fuller; Avhile deficience of the valves hinders the outflow from the pulmonary A'eins, and lets the lesser circulation overcharge itself Avith blood, hypertrophy facilitates such outflow, and relieves the pres- sure upon the pulmonary system. By keeping these facts in vieAV, it is easy to understand hoAV it happens that persons AA'ith extreme deficience of the valves of the aorta i enjoy comparatively good health, if only there be a compensatory ! hypertrophy of the left ventricle; and, indeed, such persons are fre- quently not even short of breath, a symptom never missed in cases of valvular disease of the mitral.* There may be some palpitation of the heart, but it is not constant. It is A'ery remarkable, too, that the patients complain so little of jarring of the thorax. Sometimes attacks of pain in the chest and left arm occur, Avhich avc shall describe more closely in the chapter upon angina pectoris. * A huntsman in GreifsAvald, who suffered from extensive stenosis and insufficience, and immense excentric hypertrophy of the left ventricle, performed all the manoeu- vres and forced marches of the army without difficulty. 348 DISEASES OF THE HEART. This state of comparative good health is common to both stenosis and insufficience; in general, hoAvever, the symptoms differ Avidely, those of one or other malady usually predominating. Insufficience gives rise to symptoms, and dangers Avhich proceed from the consec- utive excentric hypertrophy, AA'hich, no longer merely compensating the disorder of the valves, produces an excessive action of the heart. The patients then usually complain of dizziness, headache, and of spots before the eyes. In other cases, they suddenly perish from apoplexy. More rarely asthmatic attacks occur, but all these symptoms are due to the hypertrophy (Chap. I.), and not to the valvular disorder. In stenosis, on the other hand, the symptoms of the circulatory impediment outweigh those coming from the hypertrophy, and although a patient may do Avell for a considerable length of time, evincing no signs of venous engorgement, yet there will be tokens that the arteries are but scantily filled, a symptom Avliich must ahvays precede those AA'hich indicate overcharge of the veins. The patients look pale, are prone to fainting-fits, and present signs of anasmia of the brain; just as others, aa'Iio suffer from insufficience of the valves, seem to incline to cerebral hyperemia and to apoplexy. This period of comparative comfort, enjoyed by patients with dis- ease of the aortic valves, often ceases in a someAvhat sudden and remarkable manner, after haAdng lasted, perhaps, for many years. Either because the hypertrophied heart has degenerated, or else from insufficience of tfie mitral, caused by chronic endocarditis, Avhich so often complicates valvular disease, or through increase of the original aortic defect, or finally because extensive atheroma of the aorta has set in, thus giving rise to a neAV hinderance to the circulation, the hypertrophy of the left ventricle is at last no longer able to compen- sate for the deficience of the valves, and to overcome the impediments to the circulation. Then the symptoms appear Avhich we have men- tioned at the beginning of this article. The patients grow short of breath, the veins of the aortic system become overloaded, cyanosis and dropsy arise. These symptoms set in much sooner in mitral dis- ease, and hence shall be described in the next chapter. Death takes place either from oedema of the lungs (or else, when there is insufficience, by apoplexy). Frequently, too, death results from embolism, to which valvular disease of the aorta gives rise with a frequence next to that of endo- and myocarditis. In most of the cases wherein embolism of the arteria fossas Sylvii has been found to haA'e caused necrosis of the brain, valvular disease of the aorta has existed. Physical signs of insufficience of the aortic valves.—Inspection and palpation furnish the usual signs of hypertrophy of the left ven- DISEASE OF THE AORTIC VALVES. 349 fcricle, namely, prominence of the cardiac region, an impulse often enormously increased, and AA'hich shakes a broad tract of the thoracic Avail and sometimes actually lifts it; considerable descent of the apex, even as far as the eighth rib, with displacement outAvard. Percussion also shows an elongation of the heart, AA'here the loAver limit of dulness is not obscured by the position of the left lobe of the liver. Upon auscultation (best at the right edge of the sternum, at the second in- tercostal space), instead of the second sound, we hear a murmur, aris- ing from irregular vibrations caused by imperfect tension of the rough- ened, misshapen valves. In very rare instances, besides the murmur, avc hear the normal second sound of the heart, although but feebly, and this occurs, as it would seem, Avhen one or other of the valves con- tinues sound, and is thrown by the blood into its normal state of vibra- tion. The murmur is usually conducted both to the apex and along the sternum, and may even be heard at the sides of the chest and along the back-bone. The first sound, as fieard at the aorta, is pure in the feAV cases in Avhich insufficience exists Avithout constriction of the valve or roughness upon its under surface. In the majority of cases, how- ever, it has undergone the modifications peculiar to constriction of the aortic orifice. The first sound of the mitral is inaudible in many cases, a fact accounted for by the following excellent explanation of Traube: As the left ventricle is supplied from two sources during diastole, as it receives blood both from the auricle and from the aorta, the force of its internal pressure soon exceeds that Avith AA'hich the blood enters the ventricle from the auricle. A reversed current is thus established, flowing from ventricle to auricle, and Avhich shuts the mitral valve be- fore the diastolic movement is complete. Sometimes, besides the dias- tolic murmur, another sound is heard, caused by the premature closure of the mitral A'alve. Unless there be some complication, the sounds of the pulmonary artery are normal. The phenomena observed in the peripheral arteries, although chiefly dependent upon the consecutive hypertrophy of the left ventricle, are A'ery characteristic in insufficience of the aortic valves. The carotids often pulsate in a remarkable man- ner. If Ave listen, Ave do not fiear tAvo distinct tones, as Ave should do under normal conditions (one supposed to proceed from the Adbrations of the Avail of the carotid, expanded by the blood-wave; the second, attributable to conduction of the second sound of the semilunar A'alves). The second sound is not heard, as the semilunar valves do not A'ibrate normally, or, as more rarely happens, Ave hear a murmur Avhich takes its place. According to Bamberger, the first sound is also deadened in the carotids or turned into a murmur, a phenomenon Avhich he attributes to immoderate tension of the carotid AA'alls. Even the smaller arteries at a distance from the heart produce 350 DISEASES OF THE HEART. a sound, during their expansion, by the A'ibration of their walls. Theix tortuous course and their pulsation, visible at the radial artery, and even in smaller arteries, are also strikingly characteristic symptoms of aortic insufficience. All these phenomena, excepting the diastolic murmur conducted to the carotids, occur also in hypertrophy of the left side of the heart, when there is no insufficience of the aortic valves; but there is one symptom appearing in the arteries which is pathog- nomic of the valvular disorder in question. This consists in a re- markably rapid subsidence of the arterial expansion, Avhich, indeed, is of but momentary duration. This jerking pulse {pulsus celerrimus) depends upon the fact that the artery, distended during systole of the ventricle, is emptied in two directions during diastole. In some cases of insufficience of the aortic valves the physical signs of excentric hy- pertrophy of the left heart are less distinctly marked. The apex beats in the fifth or sixth intercostal space, the impulse is not of a heaving character. Such patients usually suffer from dyspnoea because the valvular disease is not compensated for, and the lungs are loaded with blood. We are unable to account for this exception to the rule, which is not uncommon. Physical signs of stricture of the aortic valves.—Inspection and palpation show signs of simple hypertrophy of the left heart. The impulse is stronger, the apex dislocated dowmvard and outward, but not as much so as in insufficience. Upon palpation Ave often feel a distinct whizzing about the aorta accompanying systole, which is rare in insufficience. Upon auscultation we hear a systolic murmur over the valves of the aorta, Avhich is usually very loud, and extends so as to be heard all over the region of the heart, masking the other signs. During diastole of the ventricle, as the stricture is seldom uncomplicated, sometimes we hear a feeble sound, but far oftener a murmur. In the carotids, the systolic murmur is sometimes, but not always, conducted to the ear from the aorta; or we sometimes hear a short, ringing sound in its place. The second sound, too, is usually inaudible in the carotid. The pulse is as small and compressible as it is hard and full in insufficience. Treatment.—Treatment of insufficience of the aortic valves is essentially like treatment of cardiac hypertrophy. Immoderate eating and drinking, and bodily and mental excitement, are to be avoided with care; determination to the head is to be averted, by daily evacuations of the boAvels; venesection is never to be practised, unless the brain be endangered by immoderate " rush of blood." In this respect we should be the more cautious, as it is almost certain that the practice of bleeding favors degeneration of the heart; and attenuation of the blood undoubtedly promotes the tendency to dropsy. DISEASE OF THE MITRAL VALVE. 351 Stricture of the aortic outlet requires measures of quite a differen nature. Here we have no threatening hyperaemia to allay, or over- action of the heart to moderate. Much more depends upon furthering the nutritive state of the system, and, AA'ith it, that of the heart, so that its contractions may have force enough to prevail over the resist- ance at the outlet. Rich animal food, and even the moderate use of AA'ine, are quite as strongly indicated here as they are contraindi- cated in insufficience. Blood-letting must never be practised. Use of digitalis is to be confined to those cases in which compensation be- gins to become imperfect. It is most effective in the cases in which the action of the heart is so accelerated that the left ventricle appar- ently has not the time to expel its contents through the narroAved opening during the short period of systole. CHAPTER VII. INSUFFICIENCE OF THE MITRAL A'ALVE, AND CONSTRICTION OF THE LEFT AURICULO-VENTRICULAR ORIFICE. Etiologv.—The mode of origin of insufficience of the mitral is, in many cases, quite analogous to that of insufficience of the aortic A'alve; in other cases, hoAvever, it depends upon a morbid state of the papillary muscles and chordae tendineae; and, indeed, there have been instances in which, although during life the valve Avas deficient, yet after death no palpable alteration in it could be detected. Stenosis of the auric- ulo-A'entricular passage, Avliich is often found to accompany insuffi- cience, arises partially through contraction of the ring of valvxdar insertion, partially through adhesions of the valve-tips, or chordae tendineae. Valvular disorder of the mitral is almost always a consequence of endocarditis, or of myocarditis; more rarely of atheromatous degen- eration. It is only Avhen vah'ular disease of the aorta accompanies similar disease of the mitral that the latter depends upon the chronic form of inflammation caused by atheroma. Anatomical Appearances.—The most common lesion found in mitral insufficience is a marked shortening of the valve-tips, the valve itself being thickened and indurated, often enclosing large, flat plates of calcareous matter. The delicate, tender Aveb on the free edge of the valve has disappeared, the edge forming a thick, clumsy pad, upon AA'hich the chordae tendineae originating from the papillary muscles are in- serted. Of the secondary chordae; tendineae, AA'hich, springing from the primarv set, are inserted into the Aveb of the valve, there is hardly any trace. In other cases, instead of these lesions, or, in addition to them, 352 DISEASES OF THE HEART. the valve is torn. Still oftener, it is the chordae tendineae that have given way, and it can be distinctly recognized that the latter, which are usually thickly covered by the vegetations previously described, are inverted by the regurgitating stream of blood, and made to flap backAvard into the auricle. More rarely, the tendons are adherent to the Avail of the heart, so as to prevent the valve-tips from approaching one another. Finally, as more or less extensive tendinous degenera- tion of the papillary muscles not unfrequently constitutes a minor source of the disorder, and Avhere neither these nor other anatomical alterations are found to account for an insufficience Avhich has notori- ously existed, it is most probable that some invisible change in these muscles has been the cause of the symptoms. The lesions, which the cavities and Avails of the heart exhibit in cases of insufficience, are equally characteristic and interesting. The left auricle, into Avhich the blood is first driven during systole, is ahvays a good deal enlarged, and its Avails are considerably thickened. . The pulmonary artery and vein are in like manner dilated, as is also the right heart, both ventricle and auricle. The right ventricle, Avhose task is enormously increased, be- comes so much hypertrophied that its Avails grow as thick as those of the left. If cut open, they do not collapse as before, but the cut gapes as it Avould do if made in the left ventricle. There is almost ahvays a moderate degree of dilatation of the left ventricle, into which, as Ave have seen, the blood pours under greatly-increased pressure. In insufficience of the mitral valve, the valve-tips are shortened; in constriction of the orifice, tfiey have generally groAvn narroAver, and this contraction of the valvular ring is the most common cause of im- pediment to the flow of the blood from auricle to ventricle. It rarely happens, however that the valves thus thickened by endocarditis, and in AA'hich neAV connective tissue is groAving, contract in one direction alone; they almost always become narrowed and shorter simultane- ously, so that stenosis and insufficience appear together. In other cases, the loAver edges of the valve-tips, or of the chordae tendineae, are so intimately united, that the valve takes the shape of a funnel, broad toward the auricle, and ending toward the ventricle in a narrow opening, through Avhich it is often almost impossible to pass the tip of the finger. The vegetations, Avhich often cover the A'alve in the form of hard, wart-like concretions, may also contribute to occlusion of the orifice. Dilatation of the left auricle, and of the pulmonary arteries and veins, is also a constant accompaniment of stenosis of the mitral, and the walls of the dilated chambers exhibit hypertrophy similar to Avhat Ave have described above. The left ventricle, however, is in a condi- tion opposite to that which Ave find in insufficience. Instead of being « DISEASE OF THE MITRAL VALVE. 353 nypertrophied and dilated, it is generally small, and its Avails are thinner, rather than thicker. We haA'e already accounted for this cir- cumstance. In spite of the violent pressure under which the blood is throAvn into the A'entricle, its Avails encounter a moderate pressure only from within, as the increased propulsive power is neutralized by the greater resistance met with in the contracted ostium. Symptoms and Course.—The effect of mitral disease upon the circulation must, in the main, be the same as that which we have de- scribed as occurring in uncompensated aortic valvular disorder. If, in case of insufficience, a part only of the blood enter the aorta upon systole, the rest regurgitating into the auricle; or, in a case of constriction, if too little of it flow into the ventricle, upon diastole, it is clear that in either case the amount of blood propelled must be smaller than normal, and its flow must be retarded. In like manner the arteries of the aortic circuit contain too little blood, and contract by virtue of their elasticity, AA'hile the blood by which they should be filled is overloading the pulmonary system. If the latter be incapable of accommodating all the blood, engorgement of the venous system of the aorta must folloAV. We have seen that hypertrophy of the left ventricle neutralizes all these circulatory derangements in disease of the aorta. A greater portion of them, but not all, may also be reme- died for a time in mitral disease, by hypertrophy of the right ventricle. The dilated and hypertrophied right heart propels so large a mass of blood, and propels it Avith so much poAver into the vessels of the pulmonary circuit, that the blood in the pulmonary veins is subjected to heavy pressure. In consequence of this, to say nothing of the action of the auricle, the blood pours aa ith such force and rapidity into the left ventricle as to completely neutralize the effect of the constric- tion of the valve. In spite of the constriction, the ventricle receives blood enough ; the aortic contents are not lessened, nor is the circula- tion retarded. In the same Avay, the fulness and tension of the pul- monary vein prevent any considerable regurgitation into the ventricle, notAvithstanding the insufficience of the valve ; indeed, as Ave have seen, the left ventricle is usually both hypertrophied and dilated, so that, in spite of the regurgitation of a considerable amount of blood, it still re- mains capable of filling the aorta. Retardation of the circulation, AA'ith engorgement of the venous system, and a corresponding emptiness of the arteries, is thus averted by a compensating hypertrophy of the right ventricle ; but there is one anomaly, which, in aortic disease, is corrected by hypertrophy of the left ventricle, but which hypertrophy of the riplit ventricle is unable to obAdate when the mitral is diseased. This affection is overcharge of the A'essels of the pulmonary circuit. Clinical experience entirely corroborates this physiological, or, 23 354 DISEASES OF THE HEART. rather, physical demonstration. Patients Avith mitral disease are al- ways short of breath, in consequence of hyperaemia of the lung. As the vessels of the bronchi are less affected than those of the air-cells by this engorgement, the dyspnoea is not always combined with bron chial catarrh ; as, however, the bronchial and pulmonary arteries anas- tomose, nay, as part of the blood of the capillaries and bronchial arteries flows into those of the pulmonary artery, the dyspnoea is gen- erally accompanied by bronchial catarrh. Even at this early stage of the disease, unusual exertion, or other stimulant to the action of the hypertrophied right heart, may cause the death of the patient from acute pulmonary oedema, although such an event is of more common occurrence at a later period, after obstruction of the aortic veins and of the thoracic duct has thinned the serum of the blood. Patients with insufficience and constriction of the mitral valve often enjoy tolerable health, excepting that they are short of breath, and we should err greatly in supposing that disease of the mitral valve is ahvays accompanied by cyanosis. In constriction of the A'ah'e, par- ticularly if combined AA'ith insufficience, the compensation soon becomes imperfect. The patients look pale from lack of blood in their arte- ries ; but this derangement of distribution does not cause engorgement of the veins, mainly because most of the blood is collected into the pulmonary circulation. Sooner or later, the picture changes. Compensating hypertrophy of the right ventricle has its limits, while deformity of the valves grows worse and worse from fresh endocarditis, or else the conditions de- scribed in the preAdous chapter arise, and compensation becomes im- perfect. Then the contents of the aorta and its branches diminish more and more, the secretion of urine is lessened, the veins and capillaries become overloaded, the Hps and cheeks assume a bluish or even a deep-blue hue. The embarrassed outfloAV of the cerebral veins creates heaviness in the head, headache, etc. The lh'er soon becomes enlarged, the patient complains of fulness and oppression in the right hypochondrium; the liver forms a tumor, distinctly demonstrable by percussion and palpation, and which may extend down almost to the navel. Obstruction of the hepatic veins may so increase that the re- pleted vessels compress the bifiary passages, so as to give rise to re- tention and reabsorption of the bile. The mucous membrane of these passages may also become the seat of a catarrh, and the Aoav of mucus thus produced may so obstruct the bile-ducts as to cause biliary ab- sorption. A yelloAV color is thus added to the previous cyanotic as- pect, which may impart a greenish tint to the complexion. Chronic gastric and intestinal catarrh arises from obstruction of the gastric and intestinal veins; the haemorrhoidal veins SAvell; engorgement of the DISEASE OF THE MITRAL VALVE. 355 uterine veins occasions menstrual derangement. Finally, should any considerable congestion of the kidneys set in, there is derangement of the secretion of urine, such as may be produced by ligation of the emulgent veins. The urine is scanty, and contains albumen, blood- corpuscles, and the so-called fibrinous or exudation cylinders, that is, microscopic casts of the urinary tubules, the diagnostic importance of AA'hich is to lie considered more in detail Avhen AA'e come to study dis- eases of the kidney. Venous engorgement, moreover, leads to one of the most impor- tant, and, in long-standing cases, one of the most constant symptoms of mitral disease, namely, dropsy. As before observed, an impoverish- ment of the blood, particularly a diminution of its albumen, contributes essentially to the estabhshment of transudation of serum. This im- poverishment is easily traceable to engorgement. Embarrassment to the outfloAV from the veins extends itself to the thoracic duct, and ob- struction of this duct, of course, impedes the supply of nutritive mate- rial to the blood. The dropsy almost always begins in the extremi- ties, generally in the region of the ankles ; thence it gradually extends I over the thighs, the external genitals, the integuments of the abdomen, and so to the rest of the body. The serous sacs also become the seat of dropsical effusions, producing ascites, hydrothorax, and hydroperi- cardium. Years may elapse after the first appearance of oedema about the ankles, the patient alternately improving and groAving Avorse ; his feet now swelling and noAv growing smaller again, ere the general dropsy is established, of which he, in most cases, ultimately dies. In other cases, he rapidly declines as soon as the first signs of serous effu- sion shoAV themselves. In many cases an erythema is set up about the genitals, the groins, etc., which is very distressing to the patient, and AA'hich, not uncommonly, terminates in diffuse gangrene of the \ skin. When hydrothorax and hydropericardium develop, his condition 1 groAvs desperate. The dyspnoea becomes extreme; he can no longer ' lie doAvn. The serum finally so fills up the air-cells of the lungs, that the blood becomes surcharged Avith carbonic acid, and his last hours, at least, are relieved by a merciful stupefaction. While the majority / of cases thus terminate by dropsy and final oedema of the lung, death takes place, in a smaller number, in consequence of metastases, haemor- rhagic infarction of the lung, or of intercurrent maladies. How much Bright's disease contributes in producing a speedy death is difficult to decide ; at all events, Avhether due to it or not, albuminuria certainly promotes the tendency to dropsy. Physical signs of insufficience of the mitral—Inspection and Palpation.—Wo often see and feel a strong shock, or even a rise and fall of the thoracic Avail over all the region Avhich is in contact Avith 356 DISEASES OF THE HEART. the left ventricle. The apex is displaced outward and somewhat downward. Simultaneously with the shock against the thorax, the epigastrium is also shaken rhythmically. We have considered each of these symptoms Avhile treating of hypertrophy of the right side of the heart to AA'hich they are due. Percussion reveals an extension in Avidth of the cardiac dulness. Upon auscultation, instead of the first sound, Ave hear at the apex a murmur, generally somewhat loud, which arises from the irregular Adbrations of the valve, Avhich, being rough- ened and uneven, is in a very unfavorable state to vibrate normally. Sometimes Ave hear the murmur better, if we listen more above and to the outer side of the apex, as, from hypertrophy of the right heart, the left ventricle of which the apex is formed is, as it were, pushed off from the thoracic Avail. As the second sound heard over the ventricle is merely transmitted from the arteries, it presents no abnormity in pure mitral insufficience. Above the aorta, the sounds are feeble; over the pulmonary artery, they are remarkably loud, especially the second, and this intensification, Avhich is still more marked by contrast, is of great diagnostic value. Sometimes, even, Ave feel a distinct shock at the root of the pulmonary artery, during diastole of the ventricle. Pulsation of the veins, with rhythmical dilatation, does not occur in mitral insufficience, unless complicated by valvular derangement of tfie tri- cuspid ; although we often may observe a rhythmical undulation of the jugulars, isochronic with systole of the ventricle. This proceeds from transmission, the strong shock suffered by the tricuspid's being conducted along the column of blood above it, and continues uninterrupted, excepting by the delicate valves, as far as the jugulars. Although the valves in the veins prevent regurgitation of the blood, they cannot check the transmission of a wave of vibration along their contents {Bamberger). Physical signs of stenosis of the mitral.—Here, too, inspection and palpation show the signs of excentric hypertrophy of the right side of the heart. The impulse is not usually as strong as it is in insuf- ficience, as the left side of the heart does not take part in the hyper- trophy. Besides this, it is much more common in insufficience than in hypertrophy to perceive the fremissement cataire, that slight, whizzing sound at the apex, Avhich immediately precedes the beat of the heart, and which ceases suddenly as the beat commences. This phenomenon, the praesystolic purring, is often perceptible through thick clothing, and is so characteristic as in itself almost to suffice to establish the diagno- sis of stenosis of the mitral. Upon auscultation we almost always hear a long-drawn murmur at the apex during diastole. Although the blood, as it pours through the normal spacious orifice, occasions nc sound, this is by no means the case when it has to be driven forcibly DISEASE OF THE MITRAL VALVE. 357 through the narroAV passage produced in this disease. The sound is all the louder, the more rapidly the blood pours in, and the rougher and more uneven the surface over Avliich it flows. As a longer time is needed for it to pass through the contracted auriculo-ventricular orifice to fill the ventricle, the murmur heard in mitral stenosis is of longer duration than others, and almost ahvays extends over the whole pause, until cut short, as it were, by the next systolic sound. Traube there- fore calls a "praesystolic" murmur at the apex a pathognomonic symptom of stenosis of the mitral valve. If the contracted orifice be not also roughened, if the stenosis be moderate, if the volume of the blood be reduced, there may be no sound. In addition, we can, of course, hear the second sound propagated from the arteries, unless the murmur be too loud. Whether Ave hear the first sound, or a murmur be audible in its stead, depends upon the efficience of the valve. The second sound of the pulmonary artery is naturally considerably inten- sified. Treatment.—It is not to be supposed that we can cure valvular disease of the mitral by any therapeutical interference whatever. We are equally helpless against the consecutive hypertrophy of the right ventricle, Avhich, hoAvever, has a beneficial action upon the distribution of the blood. We are, therefore, reduced to a treatment of the more prominent and dangerous of the symptoms. Hyperaemia of the lung is an ineAdtable consequence of mitral dis- ease ; it cannot be averted nor permanently relieved. We should, therefore, never interfere actively unless it be severe, or unless there be danger of oedema of the lung. This is the more important, as blood-letting, the only acth'e remedy against hyperaemia, although for the time it may ward off the peril, is extremely dangerous for the patient. Perhaps, prior to the bleeding, there may haA'e been no effu- sion into the subcutaneous areolar tissue. Soon after it the blood avUI have regained its former volume; but its serum has noAv become so much attenuated as to transude under a pressure which Avould not pre- viously have caused transudation. The symptoms of dropsy often first set in immediately after the first phlebotomy. Such " curae pos- teriores," hoAveA'er, should not make us hold our hand, if the preserva- tion of life reaUy demand A'cnesection (see chapter on pulmonary hyperaemia and oedema of the lung). In digitalis AA'e possess a very powerful means of moderating, not only hyperaemia of the lungs, but also engorgement of the aortic venous system Avliich arises in mitral disease. If we can succeed in retarding the action of the heart by means of digitalis, we afford time to the auricle to drive its contents into the ventricle through the con- tracted passage. Sometimes systole and diastole can be so greatly 35 S DISEASES OF THE HEART. prolonged {Traube) that a pause intervenes between the murmur and the next systolic sound, so that it can no longer be called praesystolic. A marked improvement often accompanies such a result; the breath- ing grows more free, the swelling of the liver subsides, and the cyano- sis and dropsy abate. Latterly, since I have grown bolder in the use of digitalis, and rid myself of the theory of Traube, even in cases of insufficience of the mitral, particularly if the heart's action be much accelerated, I have seen the dropsy, cyanosis, and tumefaction of the liver diminish or disappear, while the urine became more copious after the use of an infusion of digitahs. I have come to the conclusion that, by proper administration of this drug, compensation, Avhich is be- ginning to fail, may, for a time, be reestablished. The action of diuretics upon dropsy, resulting from heart-disease, is, at least, a doubtful matter. If digitalis act here as a diuretic, it is probably because it readjusts the circulatory derangement, and thus permits more blood to fill the arteries and thereby affecting the glo- meruli of the Malpighian capsules. An agent, intended to relieve sup- pression of urine, caused by disease of the heart, must either have a special action upon the circulation like digitalis, or it must cause dila- tation of the arterioles of the kidney, so that more blood may enter them from the scantily-filled aorta; or else it must so alter the struc- ture of the walls of the renal vessels, as to facUitate the transfusion of liquids through them. True, as long as the class of diuretics has any reputation left, it will be difficult to refrain from prescribing cream of tartar, the alkaline carbonates, squills, etc., wfien we see the urine daily diminishing, while the serous effusion augments; but, at all events, their action upon the diuresis and dropsy of cardiac disease is inexplicable and remarkably small. Preparations of iron, on the other hand, are of signal efficacy in dropsy, as is also a nourishment rich in albumen and other protein substances. As already observed, we are totally unable to explain the effect of iron upon the composition of the blood, which consists in' an increase in the number of its red corpuscles and of the amount of albu- men. However, just as bleeding, by thinning the blood, favors drop- sy, so iron and a nitrogenous diet, by rendering the serum more con- centrated, have an antihydropic action, and deserve the utmost refiance in treatment of both mitral and aortic disease. We may afford great assistance, by the institution of a treatment of the symptoms adapted to the phase of the disease, while all exclu- sive treatment will do harm. DISEASE OF THE PULMONARY VALVES. 359 CHAPTER VIII. insufficience of the semilunar valves and contraction of the mouth of the pulmonary artery. As endocarditis scarcely ever attacks the right heart during extra- uterine life, and as atheroma of the pulmonary arteries is rare, it is easy to see that valvular deformities, which are almost always the con- sequence of one or other of these morbid processes, have been met with in the pulmonary artery in but few solitary instances. In these the insufficience depended upon the same causes which occasion valvular disease of the aorta. The feAV cases of stenosis on record do not ahvays affect the valve ring, some of them arising from annular indu- ration of the conus arteriosus. The symptoms of valvular insufficience of the pulmonary artery seem to be mainly those of hypertrophy of the right A'entricle, just as the eccentric hypertrophy of the left ventricle forms the chief sign of corresponding aortic disease. In the cases which have been observed, the quantity of blood in the lungs was not abnormally small, indeed Avas abnormally great. Dyspnoea, haemorrhagic infarction, and even consumption of the lungs, folloAved upon the insufficience. Stricture, at this point, too, seems to be less perfectly neutralized by consecu- tive lrypertrophy, so that cyanosis, dropsy, and other tokens of venous engorgement of the greater circulation soon set in in cases of contrac- tion at the root of the pulmonary artery. Diagnosis of valvular dis- ease of this artery is only possible by means of physical examination; as the functional disturbances, to Avhich the malady gives rise, admit of a too manifold interpretation. In either case, but more especially in insufficience, Ave find the signs of enlargement of the right heart, so often described; and over the region of the pulmonary artery (that is, OA'er the third left costal cartilage) a murmur during systole is audible in stenosis, Avhile in insufficience it is heard during diastole. These murmurs are produced just as those are which occur in the aorta; they are heard most distinctly over the right ventricle, and over the left upper region of the chest, but are inaudible in the carotids. On account of the extreme rarity of valvular disease at this point, we must employ the utmost caution in diagnosis, and make sure that the mur- mur heard in the region of the pulmonary is actually loudest at that point, and is not conducted from the aorta. The treatment can only be symptomatic, and the same rules which Ave have set forth in the foregoing chapter are applicable here in man- agement of the more threatening manifestations. 360 DISEASES OF THE HEART. CHAPTER IX. INSUFFICIENCE OF THE TRICUSPID, AND STRICTURE OF THE RIGHT OSTIUM ATRIO A'ENTRICULARE. A so-called relath'e insufficience of the tricuspid used formerly, upon theoretical grounds, to be regarded as a very common form of valvular disease. The ostium was seen to be enormously widened, and it Avas assumed that the valve Avas incapable of closure. This relative insufficience, if it ever occurs, is rare. When the ostium dilates, the valve groAvs in breadth and length, almost ahvays remain- ing competent to close the widened orifice. Primary and independent disease—thickening, shrinking, etc.—of this valve is also quite rare. It is more common for it to accompany similar disorder of the mitral. Bamberger, indeed, regards the combination of mitral and tricuspid deficience as the most frequent of all combinations of valvular defect, and I, too, have repeatedly observed contraction of the tricuspid, Avith rupture of the chordae tendineae, as an accompaniment of severe stric- ture of the mitral. In insufficience of the tricuspid, which is in general pure (stenosis being extraordinarily rare), the blood regurgitates into the vena cava during systole of the ventricle; but, as the right ventricle is generally hypertrophied in consequence of mitral disease, this regurgitation takes place with great Adolence. The vena cava and the jugulars become enormously dilated. The valves of the jugular, Avhich, if its calibre Avere normal, would set a limit to the regurgitation, become insuffi- cient from dilatation, and it is transmitted as far as the vessels of the neck. Real pulsation of the dilated jugulars, perceptible both to touch and sight, is a pathognostic symptom of insufficience of the tricuspid. Besides this, we hear a distinct systolic murmur at the loAver part of the sternum, which, in conjunction with the venous pul- sation, makes the diagnosis certain; but here also Ave must make sure that the murmur is really strongest at this point, and is not conducted thither from the aorta. As insufficience of the tricuspid causes the most intense engorge- ment of the veins of the aortic circulation, so, of all valvular disorders, this leads most rapidly to cyanosis and dropsy.* * When one valvular defect complicates another, the symptoms of the former one are modified. The modifications vary according as the complication has a similar or an opposite effect upon the circulation; and according as one or other defect predom- inates. The signs of complex valvular disease may easily be deduced from the analy sis of the foregoing chapters. FATTY DEGENERATION OF THE HEART. 3Q\ CHAPTER X. DEGENERATION of the substance OF THE HEART, GROAA'THS, PARASITES. Etiology and Pathological Anatomy.—1. An abnormal soft- ness, relaxation, and flabbiness of the substance of the heart, impart- ing to it "a parboiled look" {Rokitansky), are not uncommon in the bodies of those who have died of typhus, septicaemia, puerperal fever, etc. No important alteration can be detected in its structure, and Ave must beAvare of mistaking the relaxation resulting from decomposition for that Avhich has taken place during life. The state of other organs must form our criterion in this case. 2. Fatty Heart must be regarded as of tAvo kinds : a. Increase of the amount of fat normally found upon the surface of the heart. b. Fatty metamorphosis of the primitive fasciculi of the muscular substance. In the former Ave find a layer of fat, fialf an inch thick, covering the heart, particularly along the course of the coronary arteries, upon its edges, and in the sulcus between the two chambers. Beneath this fatty layer the muscle is either normal or has undergone atrophy and thinning from pressure of the superimposed fat. In many cases, atro- phy of the muscle occurs Avhile the fat-tissue is forming, and Avith- out the groAvth of the latter having become very remarkable. This groAvth, then, takes place at the expense of the substance of the heart, so that a cardiac wall of normal thickness may at last consist only of adipose tissue. This excessive production of fat in the heart often accompanies general obesity, especially that of advanced age, and in subjects otherAvise healthy. It is also seen, hoAvever, in cancer, and in other, cachexia, and especially among drunkards. Fatty metamorphosis of the primitive fasciculi consists in conver- sion of the fibrillae into fat-granules, which gradually fill the entire sarcolemma, and afterward combine to form large drops. Thus the substance of the heart becomes discolored, and is converted into a pale- yelloAvish mass Avhich tears readily. Sometimes the metamorphosis pervades large tracts of the organ, Avhile in other cases particular parts only are affected, as, for instance, the papillary muscles. Accom- panied by arcus senilis, and fatty degeneration of the arteries, it often forms one of the signs of marasmus senUis, or of other marasmic states, Avhich arise in cancer, Bright's disease, etc. Ossification of the cor- onary arteries, pressure of pericardial exudation, or even that accu- mulation of fat upon the surface of the heart just mentioned, may give 362 DISEASES OF THE HEART. rise to fatty degeneration of its Avails. Finally, in many cases of val- vular disease, Avith consecutive hypertrophy, a partial fatty metamor- phosis takes place. The origin of this " spurious hypertrophy " is somewhat obscure, and almost Avithout parallel; Avhile fatty degeneration of the cardiac muscles, in consequence of defective nutrition or pressure, etc., finds many analogies in the metamorphosis of other organs Avhose nutrition is impaired. 3. Amyloid degeneration, according to Rokitansky, occurs espe- cially in the hypertrophied right side of the heart, causing its cut sur- face to resemble that of a piece of bacon, and occasioning great rigid- ity of its AvaU. The sarcolemma is filled up by nodules, which glitter dimly and show the pecufiar reaction of amyloid degeneration, turning blue upon application of a dilute solution of iodine and Aveakened sulphuric acid. 4. Cancer is very rare in the heart, occurring only in general can- cerous infection, or by extension from the mediastinum or pericardium. It forms circumscribed tumors, usually of the medullary, or else of the melanotic kind, Avhich project either imvard or outward, and may sprout into the caAdty of the organ. In other cases, especially Avhere propagated from cancer of neighboring parts, Avide tracts of the sub- stance of the hearts become transformed into cancer (infiltrated cancer, see cancer of the lungs). 5. Tubercles scarcely ever occur in the heart. Yellow, cheesy nodules, sometimes found embedded in its walls, are not to be regarded as tubercles, and shall be accounted for when we come to treat of pericarditis. 6. Parasites.—The cysticercus has been found in the heart, enor- mous numbers of them existing at the same time in other muscles of the body. The echinococcus has also been met with. Symptoms and Course.—Relaxation of the cardiac substance, after typhus, exanthematic disease, etc., of course reduces the efficience of the organ, and is A'ery apt to occasion dilatation. It is only in the latter case that we are able to recognize it Avith certainty. If, after an attack of some exhausting disease, we find that the impulse of the heart is extraordinarily feeble, the area of cardiac dulness haAdng in- creased, we may also attribute the small pulse, the dropsical aspect, the spontaneous coagula in the veins, in part, at least, to the structural changes which the substance of the organ has undergone.* If the existence of dilatation cannot be proved, Ave must remain in * In such instances cyanosis is rare, as the volume of the blood is reduced and its quality is very poor; so that, even though it were to overfill the veins, it would nol give rise to the bluish complexion. FATTY DEGENERATION OF THE HEART. 363 doubt as to Avhether the retarded circulation and the scanty arteria] supply be due to general exhaustion or to relaxation of the heart. GroAvth of fat about the heart plays an important role among the people, in accounting for shortness of breath and other troubles arising among fat, pot-bellied individuals. Unless the accumulation cause atrophy of the muscular substance, which is by no means frequent, it it does not seem to occasion any functional disturbance whatever. Should atrophy result, the symptoms already mentioned (see atrophy of heart) avUI arise. Fatty degeneration of the cardiac substance, like simple relaxation of it, depresses the action of the organ, and in like manner, wfien it affects the Avhole heart, occasions dilatation. AU the circulatory dis- turbance Avhich we have so repeatedly described may ensue from fatty degeneration. We find a feeble heart-shock, a smaU and remarkably sIoav pulse, a tendency to faintness, from an imperfect supply of blood to the brain. If the volume of the blood be not diminished, that is, if the degeneration depend upon local rather than upon general nutritive disorder, there may also be cyanosis and intense dropsy. In the latter case, when the disease is usually combined Avith other affections capable of reducing the propulsive poAver of the heart (such as pericardial ex- udations, induration and thickening of the pericardium, etc.), it is difficult to determine what part is taken by these disorders, and what the degeneration plays in producing the train of symptoms; so that a positive diagnosis is impossible in most instances. The same thing holds good with regard to the transition from genuine to spurious hy- pertrophy, through fatty degeneration of the muscular fibres. If the impulse and contractile force of a hypertrophied heart become mani- festly weaker, or if compensation for an imperfect valve begin to fail, Ave may assume that the change from true to false hypertrophy has taken place. Fatty metamorphosis of the papillary muscles is also to be reckoned among the possible consequences of insufficience of the mitral or tricuspid. Of rupture of the heart, as a result of fatty degeneration, Ave shall treat hereafter. As for amyloid degeneration of the substance of the heart, evi- dence often easy to obtain, of existence of the disease in the fiver, spleen, or kidney, affords our only but uncertain cleAV as to its presence in the heart; and avc can never do more than vaguely suspect it. Cancer, tubercles, and parasites of the heart, also have the effect of depressing its action, but their diagnosis is almost ahvays impossible. Treatment.—If the heart be relaxed by debility following acute disease, the remedies so often named are called for Avhich have the effect of improving nutrition, together Avith mild stimulants. 364 DISEASES OF THE HEART. Persons in whom a general obesity has developed, through luxuri- ous living, and in Avhom an accumulation of fat may also be suspected about the heart, should be sent to Karlsbad, Marienbad, etc. It is an indisputable fact that, during treatment at these baths, the fat decreases and the garments of patients grow too loose for them, although we have no better physiological explanation of the circumstance than a someAvhat feeble hypothesis. In true fatty degeneration of the heart Ave must confine ourselves to a treatment of symptoms, and, if it form one of tfie accompaniments of general marasmus, we should prescribe a generous diet and cor- responding medicines. We may, perhaps, succeed in restraining the progress of the malady, if we do not entirely allay it. Treatment of amyloid degeneration, cancer, tubercle, and parasites, is out of the question, as the diseases are never recognizable. CHAPTER XI. RUPTURE OF THE HEART. We refer exclusively to the so-called spontaneous ruptures, and shall not allude to traumatic solutions of continuity of the heart. A healthy heart never bursts, in spite of the greatest strain. If the organ be diseased, strains of any kind may, no doubt, aid in causing its rup- ture. The most frequent cause of rupture is fatty degeneration; more rarely, myocarditis, cardiac abscess, and acute and chronic cardiac aneurism. As all of these affections usually arise in the left side of the organ, rupture nearly ahvays occurs there also. Upon autopsy, Ave find the pericardium distended by blood, and, if fatty metamorphosis have occasioned the rupture, an irregular but outAvardly smooth rent, of variable length, is found; Avhile at a deeper point the flesh is torn asunder and mangled. The rent is occasionally filled throughout by coagula ; again more than one rupture is found. Sometimes the heart bursts during some unusual exertion, or it may give Avay Avithout any apparent cause, and death usually ensues sud- denly with the symptoms of internal haemorrhage. The pressure of the extraA'asated blood, however, also seems to have some effect in pro- moting speedy death. In rare instances the rupture has been preceded by a brief period of violent pain under the sternum, shooting toward the left shoulder and along the arm. In cases equally rare, patients have survived rupture of the heart for several hours. This seems to happen when the extravasation consists, at first, of a mere filtration of the blood through the broken-down, disintegrated cardiac Avail, the rent gradually groAving larger. Symptoms then appear of a less active FIBRINOUS DEPOSITS IN THE HEART. 365 naemorrhage; and it is sometimes possible to make out the physical signs Avhich mark the progress of the Aoav into the pericardium. CHAPTER XII. FIBRINOUS DEPOSITS IN THE HEART. We seldom dissect a body Avithout finding in its heart a clot of fibrin, especially in the right side of the organ. Sometimes the clot is yellow, consisting entirely of fibrin, which has separated from the red portion of the blood; sometimes it contains red corpuscles, and is more or less colored. Their tenacity is variable, and they are usually en- tangled among the trabeculae, but may easily be separated from the endocardium. In the bodies of persons who have died of pneumonia, or other disease in Avhich the fibrin of the blood is increased in quan- tity, these coagula are found especially large, and, if removed from the heart, long clots, forming prolongations into the arteries, are draAvn after them. These fibrinous clots, or false polypi of the heart, have formed after death, or during the period of dissolution. The more pro- tracted the latter, so much the longer is the blood, as it Avere, Avhipped up in the heart, so much the more completely is the fibrin separated from the red blood, and so much the more colorless and intimately en- tangled in the trabeculae is the resulting clot. In other instances, the coagula seem to have formed some time before death. The fibrin has lost the elasticity and glitter of fresh fibrin, and is firmer, drier, and yelloAver. The clots are tightly adherent to the endocardium, and avc sometimes find tfieir interior decomposed into a puruloid, yelloAvisfi, or broAvnish-red emulsion, or converted into a yellowish, cheesy mass. No real pus is formed, but a mess of debris, in Avhich colorless blood- corpuscles must not be mistaken for pus-corpuscles. Sometimes we find fibrinous deposits in the heart, in the form of rounded, Avedge-shaped masses, in size from that of a millet-seed to that of a nut {Laennec's vegetations globuleuse). If Ave examine their mode of attachment more attentively, Ave perceive numerous roots pro- ceeding from the spherical vegetations, Avhich are prolonged deeply into and entangled among the meshes of the trabeculae. The source of the vegetations is to be sought there; the spherical form is the result of subsequent deposit upon the clots first formed. Here, too, the soften- ing just mentioned is found sometimes in the interior of the coagulum, so that at last they may assume the appearance of sacs, with thin Avails and puruloid contents. We have already spoken of the deposits Avhich form upon roughened places on the endocardium, from endocarditis, acute or chronic aneurism of the heart, and valvular disease. 366 DISEASES OF THE HEART. The coagula AA'hich form prior to death are mainly the result of the feeble manner in which the heart contracts. Hence, they are com- monly found among marasmic subjects, and in persons who have de- generation of the heart. Their points of origin are always the shalloAV recesses betAveen the trabeculae, which readUy dilate when the heart is relaxed or softened, so that, if its contractions be incomplete, the blood in them stagnates and coagulates. In very rare instances an embolus may, perhaps, form the nucleus of a clot. When coagula form in the heart during the death-throes, they may, no doubt, occasion some obstruction to the circulation, but it is impos- sible to knoAV how much of the feebleness of the circulation is due to the palsy of the heart, and how much to obstruction of the orifices by clots. Even if tfie clots produce murmurs, they cannot be distin- guished from the murmurs caused by irregular and imperfect action of the heart. This is true also for the clots Avhich form prior to the death-agony, as they, too, form in case of feeble cardiac action and impeded circulation. CHAPTER XIII. CONGENITAL ANOMALIES OF THE HEART. Etiology.—The majority of congenital defects of the heart are due either to arrest of development (the organ remaining in a condi- tion which Avas normal during foetal life), or else to foetal endocarditis or myocarditis. We are unacquainted with the causes of this arrest of development, as well as AAdth the causes of the foetal inflammation. Prominently in the former class of congenital deformities of the heart stands incompleteness of the septa; in the second class, the in- durated strictures produced by inflammation, and congenital stricture and insufficience of the \-alves, are the most important. The latter occur generally in the right heart, Avhich, after birth, is very rarely attacked by endocarditis or myocarditis. The causes of congenital malformation in position of the heart may be similarly classified. Sometimes they are to be regarded as cases of arrested development, the ribs, the sternum, and the clavicles being imperfectly formed, so that a greater or smaller portion of the heart is covered by soft parts alone. In other cases they depend upon inflam- mation during foetal life, Avliich has given rise to adhesions with neigh- boring organs. The pathogeny of dextro-cardia, in Avhich the heart lies on the right side of the thorax, the liver generally occupying the left hypo- chondrium, and the spleen the right, etc., is altogether obscure. CONGENITAL ANOMALIES OF THE HEART. 367 Anatomical Appearances.—Congenital deformities of the heart, Avhich are incompatible Avith life, and which cause chUdren to die either immediately, or else very soon after birth, belong rather to the proAdnce of pathological anatomy than to that of special pathology and thera- peutics. Entire absence of the heart, or of one of its chambers, is one of these. In anomalies Avhich permit the continuance of fife, even for a short time, we generally find every part of the organ represented, although some portions of it are only rudimentary. In most instances the aorta or the pulmonary artery is stunted, or quite undeveloped. If the pulmonary artery be deficient, the blood pours from the right heart directly into the left, as such cases are always combined Avith imperfection of the septa. The aorta then supplies the lungs AA'ith blood through the dilated bronchial arteries, or through the ductus Botalli, in Avhich it sets up a current counter to the foetal blood-stream. If the aorta be contracted or closed immediately above the opening of the ductus Botalli, it then can only supply the head and upper ex- tremities, AA'hile the pulmonary artery conveys blood to the loAver half of the body through the ductus Botalli. If the aorta be closed at its origin, the blood which comes to the left heart passes directly through the open septum into the right heart, the pulmonary artery then fur- nishing blood to the Avhole taortic system. When the septum betAveen the ventricles is imperfect, it may seem as if the aorta and pulmonary arteries sprang from both of them. If the septum stand too far to the right or left, the right or left ventricle avUI be too large, and both arterial trunks will originate from it, while the stunted ventricle has to discharge its blood into it through the open septum. In very rare instances, the aorta has been found to spring from the right, the pul- monary artery from the left ventricles. There also are anomalies of the veins discharging into the heart, to describe which, however, Avould carry us too far. Insufficience and stenosis of the orifices, and cicatricial strictures of tfie lieart consequent upon fcetal endocarditis and myocarditis, differ from those acquired after birth, in that their situation is in the right heart. Valvular disease is more common at the pulmonary valves than at the tricuspid. In these cases, too, the septum is not closed, so that trans- fusion of the blood takes place from one side of the heart to the other. Defects may exist in the septa of greater or less extent, but they do not afford complications and results like those just described, Avhich are of far less importance, and, indeed, may be Avithout any material influence Avhatever upon the circulation, and, hence, are to be regarded as independent, and proceeding from arrested formation due to un- knoAvn causes. In particular, Ave very often make post-mortem dis- covery of sfit-like openings, or even great holes, in the foramen ovale, 368 DISEASES OF THE HEART. Avhich openings have never occasioned any symptoms Avhatever during life. In the septum of the ventricles, likewise, especially at a point at the upper end, which normaUy is very thin, it is not uncommon to find imperfections, of more or less magnitude, Avhich have never given rise to any inconvenience. In the higher grades of ektopia, in which a greater part of the wall of the chest or belly is Avanting, the heart lying in the abdomen or upon the neck, continuance of life is impossible. There are persons alive, hoAvever, Avith smaller imperfections of the bony thorax, fissures in the sternum, etc., and who even have attained an advanced age. In such cases the deformity is covered by the skin, and the subject suffers little incom'enience. Symptoms and Course.—If Ave keep the effect in view, Avhich congenital malformations of the heart exert upon the circulation, turn- ing first to the most frequent and important of them, that namely, in Avhich the aorta or pulmonary artery with its ventricles is undeveloped, so that the blood passes through the open septum, from one side of the heart to the other, and is carried into the body through the more per- fect trunk alone, it avUI be apparent that the following derangements in the distribution of tfie blood must occur. First, the current of the blood-stream is greatly retarded, and hence the blood, tarrying long in the body and rarely returning to the lungs, is overloaded Avith carbonic acid, and assumes an intensely venous char- acter. Ceteris paribus, the rapidity of the chculation depends upon the volume of blood set in motion by every heart-beat. If the aorta or pulmonary artery be missing, if but one outlet from the heart remain, then, notwithstanding hypertrophy of the ventricle, the volume of blood set in motion must be far too small. The retardation of the cir- culation thus resulting sufficiently explains a series of symptoms ob- servable in congenital imperfections of the heart—the lassitude, lan- guor, intellectual apathy, depressed spirits, and, above all, the Ioav temperature of the body. If, hoAvever, the supply of blood to the greater and lesser circula- tion be furnished by only one of the ventricles, it must follow that tfie arteries are very scantily filled, and that venous engorgement of great intensity arises, as in all other cases, where the arteries have not their due supply. Accordingly, we find the pulse small, the breathing very short, and, above all, we observe cyanosis, the symptom which we have so often designated as the characteristic one of overloading of the veins. Since cyanosis arises here, as it does elsewhere, from obstruc- tion to the course of the blood through the capillaries and veins, the extreme intensity AA'hich it here exhibits must be owing to some other cause, AA'hich is to be sought in the excessively dark hue of the blood. CONGENITAL ANOMALIES OF THE HEART. 369 This blackness of the blood is not in itself capable of producing cyano- sis (as is shoAA-n by a case, related by Breschet, in Avhich the color of a left arm Avas perfectly normal, although it contained none save venous blood, the left subclavian artery springing from the pulmonary artery). It cannot be denied, hoAvever, that Avhere venous engorgement exists, ^ the degree of cyanosis depends upon the blackness or redness of the blood. Thin-blooded people never exhibit much cyanosis. In cases of congenital imperfection of the heart, in which the pulmonary artery is undeveloped, the dark color of the blood may be ascribed to the mixture of venous and arterial blood which then takes place. In the '/ converse cases, wherein the arterial part of the blood is throAA-n into the venous portion, the cause of the darkness of hue cannot be found in the mixture, but is to be attributed rather to the extreme retarda- tion of the current.* Induration and stricture at the conus arteriosus of the right heart, and the extensive valvular deformities which affect the pulmonary artery, have an effect quite similar to that of arrested development of the arterial trunks, especially as in these cases, too, the septa remain open. The deep-blue color of the skin, particularly that of the face, the lips, cheeks, and the tips of the fingers and toes, is the most con- spicuous symptom of congenital deformity of the heart. The collec- tion of Aenous blood in certain parts also causes their enlargement, due (as has been ascertained by the careful observation of Foerster) to serous infiltration, moderate thickening, and hypertrophy. The nose becomes bulbous, the bluish lips SAVollen, and the terminal phalanges of the fingers and toes so much thickened as to look like the knobs of drumsticks. The nails are wide and arched. Most patients have puny frames with long limbs, and shoAV great tendency to profuse haemorrhage. They are susceptible to cold; are sluggish, languid, and irritable. They often have imperfect develop- ment of the genitals and feeble sexual poAver. They suffer attacks of palpitation, oppression, and syncope, and rarely attain the age of forty or fifty years. They nearly ahvays die early of intercurrent dis- ease, which they are ill able to resist, or else they perish from oedema of the lung, dropsy, etc. It is remarkable that sometimes the cyanosis and functional dis- turbance just described do not manifest themselves Until the period of * That the great cyanosis of persons with congenital malformation of the heart is due to an especial cause, becomes evident from the fact that individuals with congenU tal cyanosis do not become dropsical nearly so soon as those suffering from acquired CA-anosis. This would not be the case if the cyanosis Avere due to venous engorge- ment alone. 24 370 DISEASES OF THE HEART. puberty. It may be that, for a time, compensation for the congenital deformity is effected by consecutive hypertrophy, but that insufficience of the heart only appears after the development and groAvth of the body and the increase of the volume of the blood have advanced so fast that the puny heart can no longer keep pace Avith it. Physical examination is of little value in the diagnosis, OAving to the great diversity of form Avhich such malformations assume. The impulse of the heart is usually strengthened and extended, the dulness greater; we feel the fremissement cataire and hear confused murmurs. In other cases the heart-sounds are normal. The ancient assumption, that imperfection in the septa caused cya- nosis, is erroneous. This defect, alone, never occasions blueness, etc., but is a harmless anomaly, Avhich gives no evidence of its existence during life. Treatment.—Treatment of congenital deformity of the heart must, of course, be purely symptomatic, and confined to combating tfie more dangerous manifestations. The same rules hold good here Avhich we have laid down for the management of acquired disease of the heart. CHAPTER XIV. NEUROSES OP THE HEART. Etiology.—There are a number of influences which tend to modify the functional energy of the healthy human heart, as well as the num- ber of its beats. We may assume that the greater force and frequence of the heart-beat, caused by mental or bodily excitement, or by the use of ardent spirits, are not the effect of any structural change in the muscles of the organ, but rather are due to a perversion of its inner- vation. The term neurosis of the heart, hoAvever, is not applied to functional derangements proceeding from causes of this nature, but only to those forms of perversion of its action or abnormity of its sen- sation Avhich, Avithout depending upon any structural change, arise either Avithout preceptible cause or else upon occasions which, in most persons, Avould not give rise to any functional disturbance. Under this head stand the so-called nervous palpitation and the train of symptoms known as angina pectoris. The character of these tAvo affec- tions, particularly the paroxysms and the free intervals observed in their course, entitle us in some measure to count them among the neu- roses of motion and sensibUity. It Avould be somewhat rash, hoAvever, to ascribe them as yet to any particular class of these complaints, as long as our knowledge regarding the influence of the cardiac nerves upon the function of the heart remains in its present imperfect state. NEUROSES OF THE HEART. 371 The nerves of the heart consist of branches of the par vagum and sym- pathetic, and, besides these, it has its pecufiar ganglia. If we sepa- rate tfie organ from the nerves, and cut it out of the body, it still avUI continue to contract rhythmically for some time ; and, even after ceas- ing to beat, will recommence, if we inject blood into the coronary arte- ries, or supply it Avith oxygen. Rhythmical contraction, then, is not dependent upon the pneumogastric or sympathetic nen'es, but seems to be brought about solely by the cardiac ganglia, although this too has been doubted. As to the effect of the pneumogastric upon the beat of the heart, Ave know that irritation of this nerve retards its action, Avhile section accelerates it, so that we may regard the nerve as a moderator of the activity of the heart. We know but Httle in this respect, and nothing of certainty, concerning the influence of the sym- pathetic nerve. It Avould, therefore, seem rash to count palpitation among the hypercineses, a condition due to extreme excitement of the motor nerves, as has • been done by Romberg, and more lately by Bam- berger. It is quite as possible that palpitation of the heart might proceed from reduced energy of the pneumogastric as from over-excite- ment of the sympathetic or cardiac ganglia. Besides, in many cases of nervous palpitation, an increased force of the heart's action cannot be observed, the symptom being merely subjective, and perceptible only to the patient. Such cases should more properly come under the head of hyperaesthesiae, and be regarded as an extreme excitement of the sensory nerves of the organs.* Romberg defines angina pectoris as hyperesthesia of the cardiac plexus. Bamberger calls it a hypercinesis AA'ith hyperaesthesia. The cardiac plexus is assumed to be the source of the pain; but this, too, must be pronounced a matter of theory only. At all events, the pain Avhich attends this " cardiac neuralgia " extends Avith great intensity along the brachial plexus. Ignorant as we are regarding the pathogeny of neuroses of the heart, avc still have some idea as to their cause. Nervous palpitation is principally seen in anaemic subjects, and is one of the most constant manifestations of chlorosis. Next in frequence, Ave find it in derange- ment of the sexual system, not only among females, where it plays an important part in hysteria, but also among males addicted to venereal excess, above all, among onanists. Palpitation is also common in hy- ' We should be equally Avarranted in calling every fainting-fit an aeinesis of the heart. When a person s^voons from psychical or other causes, the scene always com- mences by a depression of the heart's action, smallness of the pulse, and pallor of the skin • and it is not until then that the consequences of diminution of the supply of arterial blood to the brain, loss of consciousness, etc., appear. It is quite the same in a too-protracted inhalation of chloroform or ether. 372 DISEASES OF THE HEART. pochondriasis. As a striking instance of this hypochondriac palpita tion, Romberg relates the example of Peter Frank, avIio, Avhile en- gaged in study of disease of the heart, thought himself suffering from aneurism. We A'ery often see palpitation accompany rapid growth about the time of puberty. It affects other persons, in Avhom no defi- nite exciting cause can be discovered. Angina pectoris is found almost exclusively in persons suffering from organic disease of the heart. Either ossification of the coronary arteries, valvular defects, hypertrophy, degeneration, or aneurism of the aorta, has been found upon autopsy of most persons Avho have been afflicted in this manner. Nevertheless, we cannot regard angina pec- toris as indicative of any of these lesions. Not one of them is con- stant ; and the malady always takes the same form AA'hile the structural alterations differ most Avidely. It is always marked by paroxysm and intervals of immunity, so that we are forced to set it doAvn as a ner- vous disorder of the heart, to which organic changes merely afford a predisposition. In rare instances it has occurred where no organic disease existed, particularly in old and obese persons, males being affected oftener than females. Symptoms and Course.—Nervous palpitation is characterized by an accelerated and sometimes unrhythmical beating of the heart, ac- companied usually by a feeling of dread and dyspnoea. The impulse is generally short and bounding; in many cases Avithout perceptible increase of force, and in others so violent as to shake the hand at each stroke. Even in the latter cases the subjective feeling of palpitation experienced by the patient is greater than Avhat the apparent force of impulse would lead us to expect. The pulse and aspect of the patient are not always the same. Sometimes the pulse is full, and the face red; sometimes it is small and intermitting, and the countenance is pale, apparently as if the beats lacked energy, or as though they were of too brief duration effectually to fill the arteries. The length of an at- tack of this kind varies, lasting from twenty minutes to an hour or more. It is not unfrequently accompanied by nervous derangement of other kinds, dizziness, buzzing in the ears, trembling, etc. Its ter- mination may be sudden or gradual, the action of the heart returning to its normal condition, and weeks or months may pass Avithout the occurrence of a neAV attack, while in other cases the seizure recurs at very short intervals. The intermission and recurrence of the paroxysms Avithout known cause, their appearance under conditions which do not, as a rule, give rise to exaggerated action of the heart, its association Avith other ner- vous disorders, and, above all, the results of physical exploration, avUI Berve to prevent error, and yet the cHsease is not ahvays easy of re- NEUROSES OF THE HEART. 373 cognition. If the exciting cause be obvious and amenable to treat- ment, the malady wUl disappear sooner or later. This is especially the case Avith chlorotic girls, hysteric Avomen with curable disease of the Avoinb, and even in palpitation induced by excess in venery. At other times it is extremely obstinate, and persists throughout life. During the intermission, physical exploration reveals nothing anomalous; during the paroxysm, we often hear abnormal murmurs attributable to unnatural tension of the valves and arterial Avails. In angina pectoris, the patient suddenly experiences beneath the sternum a feeling of strangulation and pain, which almost always shoots in the direction of the left arm, less frequently toAvard the right. This is accompanied by a distressing feeling of dread and sense of im- pending dissolution. Tfie sufferer imagines that he cannot breathe; but, if forced to do so, succeeds in making a deep inspiration. He does not dare to speak, but groans and sighs. If the attack come upon him Avhile Aval king, he stands stUl, seeking a support, and clasping his breast. The hands are cool, the countenance pale, the features perturbed. After the lapse of a feAV minutes, or in a quarter or half an hour, the paroxysm gradually abates, nearly ahvays with eructations of gas. These attacks are repeated at first with long intervals ; after- Avard they become so frequent as to be of almost daily occurrence. As an exciting cause, mental emotion seems to be the most common agent; physical exertion and error of diet produce it more rarely. BetAveen the attacks health may seem unimpaired, Avhile in other cases evidence of serious disease of the heart may be detected. Treatment.—Treatment of nervous palpitation demands, above all else, the removal of every recognizable and remediable predispos- ing cause. In chlorotic or anaemic subjects, the preparations of iron often render signal service. Hysterical palpitation may require the application of leeches to the os uteri, and of lunar caustic to the ori- fice ; a treatment which, as we shall see in the proper chapter, will often effect a cure in a case preAdously hopeless. Hypochondriacs, \Adth varicosities of the anus, if affected by palpitation, often find great relief from tfie application of leeches to the fundament. Fuller detaUs of the appropriate remedies in tfiis affection Avould occupy us too long, as it Avould include the treatment of aU the maladies of Avhich palpita- tion is an accompaniment. Patients, in Avhom no special cause for the disease can be found, should be ordered to bathe in cold Avater, be sent into the country, made to travel, and forbidden all over-exertion and luxurious living. During the attack, the effervescent poAvders, A'egetable and mineral acids, cream of tartar, " eau sucr6," enjoy a certain reputation. It would be foolish to carry one's skepticism so far as to slight these 374 DISEASES OF THE HEAR1 medicines, because they are superfluous and impotent; as it is, the mental preoccupation afforded by the preparation of an effervescent poAvder, etc., is often of the greatest relief to any person afflicted Avitfi palpitation, and even shortens the paroxysms. The application of cold over the heart seems to be of decided efficacy in abbreviating the fits. The nervines, tincture of castor, tinctura Valerianae aetherea, often have the same effect. On the contrary, narcotics, especially digitalis, if used, must ahvays be employed with the greatest caution in cases of nervous palpitation, in the narrow acceptation of the term which we employ. It is doubtful Avhether it be in our power to relieve paroxysms of angina pectoris by means of any medication; but, after having once witnessed the impatient and hurried clutch of the sufferer for his medi- cine-glass, as the attack comes on, the physician avUI readily acknowl- edge that the " laisser aller" mode of treatment is sheer cruelty. Romberg advises the inhalation of sulphuric and acetic ether, a couple of teaspoonsful of it being poured into a saucer, and its edge held to the mouth of the patient while it evaporates. Complete narcosis must not be permitted. In these cases, too, I have seen decided abbrevia- tion of the fit by the use of tincture of valerian and castor aetherea. Opiates, and other narcotics, are to be avoided. During the intervals, treatment must be limited to combating Avhatever recognizable and remediable predisposing cause may exist. Fontanelles, setons, etc., much as they have been made use of, ought not to be employed. CHAPTER XV. Basedow's disease. The term Basedow's disease is applied to a train of symptoms of tolerably frequent occurrence, consisting of a subjective sense of pal- pitation, accompanied by acceleration of tfie action of the heart, beat- ing of the veins of the neck and head, swelling of the thyroid gland, and exophthalmos. This pecufiar series of symptoms is sometimes seen in patients Avith valvular disease of the heart, but is more fre- quently observed in persons free from any organic cardiac disease. The tumefaction of the thyroid body, which is not often very large, arises partially from dilatation of its vessels, and in part from infiltra- tion of its tissues Avith serum, and from simple hyperplasia. More rarely cysts, Avith serous or colloid contents, are found in the gland. The swelling of the intra-orbital fat, which is the cause of the ex- ophthalmos, seems in most cases to be due to hyperaemia and oedema, or to simple hyperplasia of the adipose tissue; since, AA'hen recovery BASEDOW'S DISEASE. 375 takes place, the prominence of the eyes subsides as completely as do the thyroid enlargement and the disturbance of circulation. That this it not a mere coincidence of morbid conditions, and that it is fully entitled to be regarded as a separate and distinct disease, is evident from the circumstance already alluded to, that the changes in the thyroid and eyes, not only appear simultaneously with the derange- ment of the circulation, but that they also subside together. In seeking for a common source to AA'hich the individual symptoms of Basedow's disease may be attributed, the idea of a derangement of innervation of the vascular walls naturally suggests itself. Palsy of the vaso-motor nerves fully accounts for the dilatation and increased pulsation of the carotids and thyroid arteries, as well as for the oedem- atous SAvelling of the thyroid gland and intra-orbital fat. The sub- ject of the innervation of the heart, indeed, is by no means satisfac- torily understood, in spite of the labor expended upon the subject; yet it is perfectly supposable that variation in the degree of fulness of the blood-vessels, Avhich traverse the substance of this organ, may have an important influence upon its function; and that palsy of the vaso- motor nerves of the cardiac vessels Avill cause them to dUate, thus aug- menting the supply of blood to the cardiac muscles, and producing essential modification of the heart's action. We have no hesitation in declaring our belief that the probable cause of the symptoms of Base- dow's disease consists in a subparalytic state of the vessels of the mus- cles of the heart. At the same time Ave deem it rash, or at least pre- mature, to ascribe such palsy pf the vascular Avails to coarse structural changes of the cervical ganglia of the sympathetic nerve. Apart from the fact that the lesions of the ganglia in some cases are entirely different from those found in others, and that in other instances again, in spite of the most careful search, no lesion AA'hatever has been found in the ganglia, it is improbable tfiat the nervous disorder of the vas- cular Avail should depend upon coarse and palpable alterations of tex- ture of the nerve-fibres and ganglion-cells, simply because such nervous derangement often subsides entirely. Basedow's disease is far more common among Avomen than among men; menstrual disorder, or perhaps the lack of red corpuscles in the blood, Avhich so often accompanies such disorder, also seems to have some part in its production; but it is altogether inadmissible to regard such disease of the vaso-motor nerves as a mere part of that Avide- spread disorder of innervation, which occurs in hysteria, and to attrib- ute the relaxed state of the vessels to faulty nutrition, either of the vessels or of their nerves, proceeding from the Avant of red corpuscles in the blood. Indeed, Basedow's disease is not especially preA'alent in cases of seA'ere hysteria or intense chlorosis, and in some cases even 376 DISEASES OF THE HEART. appears in persons free from both menstrual disturbance and impov- erishment of the blood. Men Avho are affected by this malady are usually somewhat advanced in fife, AA-hile among Avomen it generally appears during youth. The patients generally have long suffered from palpitation, Avith a remarkable frequence of the pulse, which sometimes rises as high as 120 or 140 beats, when the patient and his friends become aAvare that his eyes are more prominent than formerly, and that the neck is enlarged. If the hand be laid upon the thyroid gland, or the steth- oscope be applied to it, a remarkable rustling is perceptible both to ear and touch. Sometimes a bloAving sound is also heard at the heart. Generally these sounds are easily recognizable as " blood-murmurs," as there is no secondary dilatation, nor hypertrophy of the organ, Avithout Avhich it is impossible to ascribe a false murmur to valvular derangement. At a more aggravated stage of the malady, the prom- inence of the eye-balls increases to such an extent as to render the eyelids incapable of covering the eyes completely. This inability to close the eyes may have the most disastrous consequences. In some instances, infiltration, abscess, and perforation of the cornea, and even complete destruction of the eye, have been knoAvn to folloAV. Such acci- dents are no doubt due in a great degree to a Avant of proper cover- ing, and lubrication of the bulb, although it would seem that the graver .degree of destruction does not occur until after the establish- ment of a certain amount of anaesthesia of the cornea (attributable to strain upon the ciliary nerves), rendering the eye incapable of protect- ing itself properly. Sometimes the motion of the bulb is embarrassed, probably in consequence of palsy of the ocular muscles, resulting from stretching; but, excepting the affections of the cornea above alluded to, there is scarcely ever any other derangement of vision. Graefe speaks of a spasmodic contraction of the levatores palpebrae superioris as a very characteristic symptom which sometimes precedes the exoph- thalmos. It becomes recognized by the hesitating and imperfect manner in which the upper-lid is depressed Avhen the eye is made to look downAvard. In severe cases, the pulsation of the thyroid and carotids is so marked as to be apparent to the eye even at a distance. Most patients complain of oppression; some of dizziness and headache, and of other irregular symptoms. Generally the disease drags on for months and years. Instances when its course has been acute and rapid are exceptional. If the result is to be unfavorable, it is generally on account of a gradual dilatation of the heart with diminution of its functional power. The patient becomes cyanotic, and dropsical, the obstruction in the veins of the pulmonary circulation gives rise to extreme dyspnoea, and at BASEDOW'S DISEASE. 377 last to oedema of the lungs. More rarely death takes place Avith cere- bral symptoms, or in consequence of intercurrent disease. An im- provement terminating in complete restoration is by no means an uncommon occurrence. Indeed, recovery is a much more common end- ing of the disorder than is death. Bascdoio's disease often recovers under a treatment consisting in a strengthening diet, and in the use of iron. The secale cornutum has also been prescribed as having a reputed povver of causing con- traction of the Avails of blood-vessels, and a reduction of their calibre. Whether the improvement be really in consequence of this mode of treatment, or not, remains a matter of doubt. At all events, it Avould be well to try this remedy, or some similar one, and for the time to disregard the application of a constant and induced current applied to the cervical portion of the sympathetic, Avhich has been proposed upon purely hypothetical grounds. When the exophthalmos is very great, Graefe advises the use of a light bandage, and in extreme cases the diminution of the opening 01 the eyelids by means of a surgical operation. SECTION II. DISEASES OF THE PERICARDIUM. CHAPTER I. PERICARDITIS. Etiology.—With regard to the pathogeny of pericarditis, we may refer to what we have already said concerning its kindred affection, pleuritis. In many cases, Avhere the disease is partial, the inflammatory derangement of nutrition is not such as to produce interstitial exuda- tion and effusion into the sac; but a proliferation of the pericardium takes place, so that its normal tissue forms offshoots, and becomes thickened. Thus the so-called tendinous spots, etc. {Sehnenflecke) originate. In other cases, the cell-groAvth in the pericardium is accom- panied by a free exudation. This always contains fibrin, but in vari- able quantity, and we are not warranted in attributing this variation to differences in the crasis of the blood; indeed, accumulation of fibrin in the blood must be regarded rather as a consecutive and not as a primary alteration of its composition. Pericarditis may be caused, although rarely, by injuries, penetrat- ing wounds, Hoavs, concussions, etc.; to this class of cases we naturally annex those in Avhich inflammation has spread to the pericardium from a neighboring organ. It is extraordinarily rare for this malady to attack previously healthy persons as an independent isolated disease. When it does occur, it is chiefly at times Avhen pneumonia, pleurisy, croup, and other inflammatory complaints are rife, and epidemic influ- ence prevails. In such cases it is customary to assume that cold has been allowed to act upon the organism, although this is generally diffi- cult to prove. Pericarditis occurs much more frequently, allied to other acute or ohronic diseases. The most important of these is acute articular rheu- matism, particularly when several joints are successh'ely affected. According to Bamberger's carefully-collected statistics, about thirty PERICARDITIS. 379 per cent, of the cases observed have been complicated with acute rheu- matism. Next in frequence, pericarditis complicates Bright's disease, tuber- culosis, particularly tuberculosis of the lungs, chronic disease of the heart, and aneurism of the aorta. In all these cases, as it seems to me, the primary disease gives rise to a predisposition to pericarditis; but the latter is not a sequel, only a complication of tfie primitive com- plaint, and is not to be regarded as secondary in the narrow sense of the Avord. It is otherAAdse in the pericarditis which attends septicaemia and kindred conditions, puerperal fever, severe scarlatina, small-pox, etc. Here the disease belongs to the consequences, and is not a complica- tion ; the infection manifests itself by a series of inflammatory' disturb- ances, attacking the skin, the joints, and the pericardium. Anatomical Appearances.—In the bodies of many, and especially of old persons, Ave find upon tfie visceral surface of the pericardium a number of fine papillae, consisting of delicate, vascular connective tissue. Still more frequently we find irregular, AA'hitish, flat tendinous deposits, called maculee albidce, lactce {Sehnenflecke). These, likeAvise, consist of neAV connective tissue, springing directly from that of the pericar- dium, from Avhich they can only be detached by force, and by Avhose epithelium they are covered. If the pericardial proliferation be of in- flammatory origin (a matter still sub judice), like the thickening and adhesions of the pleurae, they appear to proceed from inflammation, Avhich produces a merely nutritive exudation, a pericarditis sicca. As the groAvth of villi and the formation of maculae albidae are not recognizable during life, but are mere accidental post-mortem discoA'er- ies, Ave shall give them no further attention. In discussion of the subject of exudative pericarditis, our attention will be occupied, first, Avitfi tfie changes undergone by the pericardium; second, the quality and quantity of the exudation. At the commencement of the disease the pericardium appears more or less reddened, in consequence of a dense capillary injection spring- ing from the deeper parts, Avith here and there extravasations in the form of irregular, dark-colored, homogeneous red spots. The tissue is relaxed by serous infiltration, and can be very readily torn; the sur- face, the epithelium having fallen, is dull and void of glitter. The membrane soon takes on a shaggy appearance; fine vdlli, papillae, and folds develop by the proliferation and generation of young connective tissue-cells, constituting tfie first step in the formation of pseudo-mem- branes, and of the adhesions of the pericardium, Avhich remain after pericarditis. Pericardial effusions present all the modifications which we have 380 DISEASES OF THE PERICARDIUM. described as occurring in pleurisy. The exudation soon separates into a liquid and a solid portion. Tfie former may be A'ery scanty in quantity, or may amount to several pounds. Small accumulations of it form in the upper and anterior part of the sac, at the root of the great vessels, while the heart gravitates to the loAver portion. When in larger amount, the entire sac is distended, the lungs compressed, particularly the lower lobes of the left lung; even dilatation of the thorax, in the region of the heart, may be the consequence. Although the exudation always contains some young cells or pus- corpuscles, their quantity is often extremely small, and the liquid is then tolerably clear, and either colorless or of a yelloAvish tinge. If more or less of coagulated fibrin be found in the liquid, it is called sero-fibrinous. A smaller quantity of fibrin imparts a slightly-flaky opacity to the liquid part of the exudation, or may produce a slimy, turbid deposit upon the pericardium. Sometimes delicate fibres, like cobwebs, pass across from one surface to another. This Ave find, chiefly, in cases in which inflammation has been transmitted from some neigh- boring organ to the pericardium. In other cases, the exudation is very heaAdly charged with fibrin, which is extensively precipitated upon the walls of the pericardium, forming reticulated and villous masses. The surface of the heart ac- quires the aspect of a cut sponge, or of one of tAvo surfaces smeared Avith butter, Avhich have been quickly pulled asunder after haAdng been brought into contact. A heart upon which this sort of Adllous, ragged precipitate has formed, is called cor villosum or hirsutum. This is the ldnd of exudation most commonly met with in the pericarditis of acute articular rheumatism. In many cases an escape of blood from the ruptured capillaries accompanies the exudation, thus producing a hemorrhagic exudation. If there be but little blood mixed with it, the serum has a reddish color; if the flow of blood be considerable, the effused mass may resemble a pure extravasation, and assume a blackish hue. Even the fibrinous deposit, otherAvise Avhitish yellow in color, is stained, either dark or bright-red, by admixture of the blood. Haemorrhagic exudation some- times occurs in recent pericarditis, AA'hich has attacked cachectic sub- jects, topers, tuberculous persons, or those suffering from advanced Bright's disease. It is still more frequently observed when the in- flammation, instead of invading the true pericardium, has attacked the young connective tissue which has developed upon it, and in which very large but delicate and thin-Availed vessels form, Avhich are very liable to rupture. In these cases we often find mUiary tubercles de- veloped in the young adventitious membrane, besides the haemorrhagic exudation ; and this is what we commonly find in the form known as PERICARDITIS. 381 chronic pericarditis, a disease which, during life, permits of our recog- nizing repeated outbreaks of the inflammation. If young cells (pus-corpuscles) be commingled in any great amount Avith the exudation, the effused liquid becomes yellow and opaque, like thin pus. The fibrinous deposits are remarkably yelloAV, unelastic, rotten, and even pasty. This Ave call purulent exudation {pyopericar- dium). It arises precisely hke empyema, sometimes from protracted pericarditis, Avith sero-fibrinous exudation; sometimes the inflammation sIioavs strong tendency to formation of pus-cells from the outset, so that even the recent exudation is purulent. Such a disposition is often seen in the pericarditis of septicaemia, puerperal fever, etc. In pyo- pericardium, pus-cells sometimes form in the substance of the serous membrane, producing ulceration; although this is more rare than in empyema. In cases of extraordinary rarity, pericardial effusion becomes putrid, fetid, discolored, emits gas ; and here, too, erosion may take place in the membranes. Ichorous exudation is the product of such decom- position. In recent cases, the substance of the heart often suffers no material alteration. In cases of longer standing, however, or AA'hen the disease has been very intense, it appears soon to become sodden Avith serum, softened, and flabby, so that extensive dilatation of the heart super- venes upon the pericarditis. In cases of haemorrhagic and purulent exudation, the muscles of the heart become very much discolored, flabby, and softened, the epicardial surface undergoing fatty degenera- tion ( VircJiow). Myocarditis, too, is a not unfrequent accompaniment of the disease. The effects of pericarditis depend greatly upon the degree of thick- ening of the pericardium, and the quantity of coagulated matter con- tained in the effusion. If the thickening be slight, and the amount of fibrin in the effusion small, it is soon absorbed, the liquid first, and then the solids, undergoing fatty degeneration, and thus becoming capable of absorption. Thickening of the pericardium leaves behind it thick tendinous spots, or else adhesions from between the tAvo sur- faces, a circumstance of but little moment if the pericardium be but moderately thickened, so that such a termination of the disease may be regarded as a recovery. If the pericarditis be of long standing, the thickening generally becomes so great'that permanent and serious disorder remains, eA'en after the exudation has been absorbed. The young connective tissue is converted into a firm fibrous mass, so that the epicardium at last forms a dense indurated capsule around the neart. The parietal surface is usually less thickened, and here, too, if the effusion be fully absorbed, it may be firmly joined to the Adscerai 382 DISEASES OF THE PERICARDIUM. portion. Frequently, absorption is incomplete; the folds of the peri- cardium are then only partially adherent; in other places, the residua of the exudation appear in the form of puruloid or cheesy masses, AA'hich afterAvard not unfrequently are converted into a chalky paste, which may seem embedded or impacted in the flesh. When death occurs at the height of acute pericarditis, or in the course of the chronic form, Ave find the traces of cyanosis, and not un- commonly discover dropsical effusions in the body. Symptoms and Course.—As pericarditis hardly ever attacks a person in good health, or appears as a solitary and independent disease, it is difficult to describe its course distinctly. Moreover, when this malady sets in upon some preexisting disorder, its symptoms often modify those of the latter so little that they are exceedingly apt to be overlooked. When pleuritis or pneumonia extends into the pericar- dium, a diagnosis, or even a suspicion, of the complication is often im- possible Avithout physical examination; and, as the latter too often fails us here, " a participation of the pericardium in the inflammation " often remains undiscovered until the autopsy is made. When acute articular rheumatism is the complicating disease, it is quite rare for attention to be called to the existence of pericarditis by any rigor, aggravation of the fever, acceleration or retardation of the pulse, pain in the region of the heart, palpitation, dyspnoea, or terror. It should be our invariable rule daUy to auscult the chest of a rheu- matic patient, even though he do not complain, for all the above-named symptoms may be wanting, and yet pericarditis, and even a copious effusion, may exist. Wfien subjective symptoms do occur, hoAvever, pain and palpitation are the more frequent of the signs. The pain usually affects the left side of the epigastrium, and spreads more or less over the chest. It is sometimes piercing, sometimes duller, and is almost always aggravated by a firm pressure upward upon the epi- gastrium. Excessive pain almost ahvays signifies implication of the pleura or lung in the inflammation. Palpitation is generally met with where the action of the heart is embarrassed, and Avhere the organ has difficulty in fulfilling its task. It is easy to understand that pericarditis can impede the function of the heart through pressure upon it by the exudation, by serous infiltration of its muscles, and by participation of the latter in the inflammation. On the other hand, it is singular that palpitation, and other symptoms indicative of embarrassment of the heart's action, should not be a more common source of complaint. Sometimes the pulse becomes very frequent Avhen the disease sets in in other cases, it is temporarily retarded. We have already spoken of this latter symptom while upon the subject of endocarditis, and have there expressed our view that it is a matter of pure theory to ascribe PERICARDITIS. obo these phenomena to irritation of the cardiac ganglia. If the pulse be both frequent and small, pericarditis may assume a strong resemblance to typhus and other asthenic fevers. The sick man is collapsed, is ex- tremely restless, sleeps badly, and starts from his sleep; he becomes delirious, until at last somnolence sets in. The more imperfect and hurried the action of the heart becomes, so much the more marked are the symptoms of circulatory obstruction; the countenance becomes congested and cyanotic, and the breathing rapid. If a fresh obstacle to respiration be added to this passive hyperaemia of the lung, should the lung be compressed by a huge pericardial effusion, the dyspnoea may become intense. The patient lies upon the left side, as it is the left lung which is the most compressed, and freer play is thus afforded to the right side of the thorax, or else he sits upright, or bent forward in bed. Even Avhen the function of the heart is not suffering mate- rially from the effects of the pericarditis, dyspnoea, and A'ery severe dyspnoea, too, may arise through compression of the lung, so that, as acceleration of pulse is not a very common symptom, pain in the car- diac region,palpitation, and subsequent dyspnoea, must be pronounced its most frequent subjective signs, if it produce any functional derange- ment at all. If pericarditis be a complication of tuberculosis, Bright's disease, chronic disease of the heart, or aortic aneurism, its invasion is equally as insidious as, if not more so than, Avhen it arises in rheumatism. With- out physical examination, its diagnosis Avould be impossible. After long duration, the malady develops a series of symptoms, AA'hich Ave shall describe as chronic pericarditis. If it set in in the course of grave blood-disease, there are absolutely no subjectiA'e symptoms. In such maladies the sensorium is usually much benumbed by the asthenic fever, and the great apathy of the patient renders him insensible to pain and distress far more A'iolent than any arising in pericarditis. It Avould seem that depression of the cardiac action is most intense in cases of purulent effusion, but, AAdthout physical proof, Ave are unable to decide Avith certainty whether the acceleration and contraction of the pulse, already rapid and small, be due to the prostration or to the pericarditis. With regard to its course and termination, the forms of the disease which accompany pneumonia, pleurisy, and acute articular rheumatism generally have a faA'orable issue; the disease is acute, and ends in complete recovery. If, as often happens, it have not given rise to any subjective symptoms, the change for the better is only to be recognized by physical examination. Palpitation, pain, and dyspnoea, if present, usually soon subside, as also does any frequence of the pulse which may appear. This favorable result is far less common in the forms of 384 DISEASES OF THE PERICARDIUM. the disorder Avhich complicate Brigfit's disease, disease of the heart, tuberculosis, and, rarest of all, in the purulent pericarditis accompany- ing septicaemia, etc. Death is not a common consequence of acute pericarditis; that is to say the disease is not often the sole and immediate cause of death. When it occurs in a rheumatic case, the disordered action of the heart suddenly, or else gradually, increases to cardiac palsy; the pulse be- comes small and irregular; the consciousness is completely lost; en- gorgement of the pulmonary veins produces oedema of the lungs, and the patient dies. Death may be all the more speedy, if the pericarditis be complicated by pleuritis or pneumonia. The termination of tuber- culosis, Bright's disease, etc., may also be accelerated by such a com- plication, but the disease then almost ahvays assumes a chronic form. Cases in which, from the beginning, the effusion has been purulent, almost ahvays end fatally; but it is difficult to decide Iioav much of this evil result is due to the local affection, the pericarditis, and hoAV much to the constitutional disorder AA'hich it complicates. As a third mode of termination, acute pericarditis may pass into a chronic state. A small number of cases of chronic pericarditis pro- ceed from the acute rheumatic form of the disease. It is more com- mon, however, as an accompaniment of the cachectic conditions and cardiac disease Avhich we have so often spoken of. The malady, Avhich probably ahvays at first assumes the acute form, does not get entirely Avell, and sooner or later (just as in many cases of pleurisy), the in- flammation breaks out afresh. The exudation is extremely profuse, the dyspnoea severe. After a while the symptoms abate again; but new relapses often folloAV, and the disease goes on for months. We have said that the substance of the heart becomes extremely soft, re- laxed, and discolored; and, accordingly, Ave often find the pulse very small and irregular, the veins overloaded, and the patient dropsical. The more copious the exudation in the pericardium, so much the more severe not only does the dyspnoea become, but the cyanosis and drop- sy. Much of the blood AA'hich ought to be in the arteries is crowded into the veins, and cannot gain access to the right heart; for the lat- ter, compressed by exudation, is unable to dilate, as in other cardiac diseases. It is only in very rare instances that chronic pericarditis terminates in complete recovery. Death by oedema of the lungs and slow suffocation is the most frequent ending, and, in almost every case, the disease is attended by sequelae: 1. First among the sequelae of pericarditis stands adhesion of heart and pericardium, to be treated of in the next chapter. 2. We have already learned how dilatation of the heart becomes a sequel of this disease (Chap. II.), and that the longer the attack lasts so much the more is this likely to happen. PERICARDITIS. 3S5 3. If the substance of the heart be not degenerated, the dUatation turns into hypertrophy, Avliich is usually total, and is to be set doAvn as a not unfrequent sequel. 4. The nutritive state of the organ suffers under the perpetual pressure of the pericardial exudation, and the constant infiltration of its substance, resulting in atrophy and fatty degeneration. Physical Signs—Inspection.—If the thoracic Avail be yielding, and the effusion large, inspection often reveals a distinct bulging of the cardiac region. Ossification of the costal cartilages tends to prevent this prominence, which, therefore, is to be found principally in chUdren / and youthful persons. Palpation at the outset of the disease often enables us to feel that the beat of the heart is in its proper position, and frequently, too, that the vigor of the beat is increased. When the exudation is more copi ous, the impulse is usually weaker than normal, unless the heart be hypertrophied or violently excited. Sometimes the beat is quite im- perceptible. It may frequently be felt Avhile the patient is standing upright, but is lost as soon as he lies doAvn, as the heart then sinks back into the liquid, and is separated from the thoracic Avail. The im- pulse often is situated too low down, the diaphragm having become depressed by the accumulation of liquids. Oppolzer's statement, that the shifting of the heart-beat as the patient alters his attitude is a characteristic token of pericardial effusion, is incorrect. According to a number of observations of Gerhardt, the truth of Avhich I can fully vouch for, the apex of the heart of a healthy person generally moves to the left about tAvo centimetres Avhen he lies upon his left side. Sometimes the hand laid upon the chest perceives a distinct sensation of friction, caused by the rubbing together of the rugged surfaces of the pericardium. Percussion.—If the lung intervene betAveen the pericardium and the thoracic AA'all, percussion avUI reveal nothing abnormal eA'en when the exudation is tolerably large (half a pound). At other times an un- natural dulness arises early, which, from the point at Avhich it first be- comes perceptible, and the form AA'hich it afterAvard assumes, is one of the most important signs of the disease. At first, as the liquid rises, and the heart takes the deepest position possible, Ave find a dulness upon percussion at the root of the aorta and pulmonary vessels. It extends upAvard to the second rib, or even higher, and passes beyond the right edge of the sternum. When very copious, the exudation bathes the entire organ, and the dulness forms a triangle AA'ith the base doAvmvard, and Avith an obtuse apex above. The dulness, Avhich ahvays groAvs broader as it extends loAver, often passes far beyond the left mammillary fine and the right border of the sternum. 25 386 DISEASES OF THE PERICARDIUM. Extension of the dulness to the left, beyond the point at Avhich the apex beats, is a positive sign of the existence of a collection of liquid in the pericardium. Gerhardt has pointed out that pericardial effusion forms an important exception to the rule according to which cardiac dulness remains the same, whether the attitude be erect or recum- bent, as in the latter case its limits become from one-third to one-half larger. Upon auscultation, unless the heart be hypertrophied, or in violent action, its sounds are remarkably feeble, and often nearly inaudible. The disproportion between the extensive dulness and the feeble im- pulse and loAvness of the heart-sounds is an important indication of pe- ricardial effusion. In addition to this, there are, in most cases, friction- sounds Avhich suggest the idea of scraping, rubbing, and scratching. These friction-sounds are unlike those of pleuritis, which are only audi- ble before the pleural surfaces are separated by the liquid, or after the liquid part of the effusion has been absorbed, as they sometimes may be heard when there is a great deal of Avater in the pericardial sac. As the sounds are produced both by the rubbing up and doAvn of the heart against the thoracic wall and its rotation upon its long axis, after the opposing surfaces have lost their primitive smoothness, and as the movements of the heart are of far longer duration than the nor- mal sounds which it causes, these friction-sounds, although rhythmical, are hardly ever isochronic with the normal cardiac tones, but outlast them, making a prolongation, or sometimes preceding them. About the lower lobe of the left lung the percussion-sound is often flat, from pressure, and we must beware of mistaking it for pleuritis. The presence of pectoral fremitus will guard against error. Diagnosis.—Pericarditis is most apt to be mistaken for endocar- ditis. The functional disturbances, when they occur, are very much alike in the tAvo diseases, although pain about the heart is far more common in pericarditis, as is also the case Avith dyspnoea and the cyano- sis. As it often happens, however, that neither of them furnishes any subjective symptoms Avhatever, differential diagnosis must mainly de- pend upon physical exploration : 1. In the first place, in endocarditis, Ave never find prominence of the cardiac region, which, although not common, does sometimes appear in pericarditis. 2. The form of the tract of abnormal dulness affords an important clew. In endocarditis the dulness may become abnormally widened in a feAV days, as when dilatation of the right ventricle occurs early. In pericarditis the dul- ness almost always begins in the vicinity of the great vessels, and afterward assumes a triangular form. If the left border of the dul- ness reach beyond the apex, the right considerably surpassing the right edge of the sternum, effusion is present in the sac. We have PERICARDITIS. 387 already dAvelt upon the significant fact that, notAAdthstanding the ex- tent of the dulness, the heart-tones are low, and the beat feeble and inaudible AA'hen the patient lies down. If the dulness commence at the second rib, Ave must take notice Avhether or not the diaphragm and heart be pushed upward. If so, it aa ill be impossible to form any positive conclusion as to the presence of liquid in the pericardium. The possibility of the existence of aneurism of the aorta, of excessive dilatation of the right auricle, of infiltration of the anterior edges of the lung, and of retraction of the lung, which alloAvs a larger portion of the pericardium to come into contact Avith the thoracic Avail, must also be excluded ere the diagnosis of pericardial effusion can be re- garded as established. Sometimes, notAAdthstanding the existence of a very large effusion, the cardiac dulness is not increased, although in the vicinity of the area of dulness the percussion-sound is someAvhat flat. In these cases the anterior edge of the lung has become immovable, OAving to adhesion of the pulmonary and costal pleurae. '■). The murmurs heard in the heart usually permit of a conclu- sion as to the nature of the existing disease. In the first place, then quality affords some information. Not only the pericardial sounds, but many of those arising in the heart are friction-sounds. In the one case, the roughened surfaces of the pericardium rub together; in the other, the roughened endocardial surface is rubbed by the current of the blood; but, in many instances, the sounds are so distinctly those of scraping or scratching, that we can have no doubt but that they proceed from the pericardium. The points at AA'hich they are best audible is of more importance. As it is mainly the right side of the heart AA'hich lies in contact Avith the side of the chest, and rubs against it during its diastole and systole, pericardial sounds are very often heard over the right A'entricle, where endocarditis and A'ahodar disease are very rare. The time at Avhich the sounds are heard is of great mo- ment. In endocarditis, they are isochronic with the heart-sounds, and supplant them. In pericarditis they precede the normal sounds, or come after them. AVhen the beat of the heart is very rapid, it is hard to say if the false sounds be isochronic AA'ith the normal ones or not. The extension of the sounds exhibits a further difference {Bam- berger). In pericarditis they are sometimes confined to a very small spot; in endocarditis they are transmitted along the current of the blood. Lastly, as the heart rises and falls in the liquid around it, pericardial sounds are mucli more liable to change Avith alteration of attitude in the patient than the endocardial murmurs. Rhythmical friction-sound of the pleura may arise in consequence of inflammation of that portion of the pleura Avhich overlies the peri- cardium, tfie roughened costal pleura being made to rub against the 388 DISEASES OF THE PERICARDIUM. pulmonary pleura by the beating of the heart. This extra-pericardia! friction can only be distinguished from the intra-pericardial sounds Avhen it ceases entirely during inspiration. I have seen one very well- marked case, in Avhich it could be demonstrated, by means of ausculta- tion and percussion, that the expanded lung entered the mediastino- costal sinus during inspiration, and separated the roughened surfaces of the pericardium and costal pleura. It is not ahvays easy to determine the character of the exudation in the cases in question, although the cause of the disease and its duration may enable us to form an opinion. The pericarditis which complicates rheumatism is, if recent, almost always accompanied by a sero-fibrinous effusion. That of septicaemia is nearly always purulent; the chronic variety often has a haemorrhagic exudation. It Avould be unsafe to infer the nature of the effusion from the character of the con- stitutional disorder, as the latter depends more upon the primitive dis- ease than upon the form of exudation. Even physical research only informs us, by means of friction-sounds, of the presence of rugged layers of fibrin. When the exudation is purulent, the surfaces are not rough enough to give rise to friction sounds. Prognosis.—As Ave have already said, pericarditis, supervening upon rheumatism, very rarely causes death, and this is also the case Avith primary idiopathic and traumatic forms of the disease. Out of twenty cases, seventeen of which were rheumatic, Bamberger did not find one fatal case. The prognosis is favorable also where the malady proceeds from pneumonia or pleuritis, as is shown by Bamberger's statistics. It is quite otherwise where it complicates incurable disease, as it then nearly always hastens, if it does not actually bring about, a fatal ter- mination. In discussing the terminations of pericarditis, we have seen how great the number of sequelae is, by which it is liable to be succeeded. According to their nature, these exert more or less influence upon after- life. Treatment.—Upon the subject of treatment of pericarditis, Ave may refer in great part to what we have already said regarding pleu- ritis and endocarditis. General blood-letting is never required in pericarditis as such. Its employment is to be confined to the very few cases in which the re- pressed outflow from the veins into the heart causes symptoms of pres- sure upon the brain, and demands a reduction of volume in the circula- tion. Local blood-letting moderates the pain somewhat, and is indi- cated where it is troublesome. It is best to apply from ten to twenty leeches, according to circumstances, to the left edge of the sternum. The effect is astonishing in most cases. The use of cold deserves ADHESION OF THE HEART AXD PERICARDIUM. 389 great refiance. Even ice-bladders have been applied upon tfie cardiac region. Digitalis is suitable in cases where the beat of the heart is very frequent and insufficient, causing cyanotic and dropsical symp- toms. Its effect here is often very marked. Calomel and blue oint- ment, in spite of the praise of English physicians, are not only useless but hurtful. As to the employment of diuretics, drastics, preparations of iodine, and blisters, Avfiat Ave have said, whUe treating of pleuritis, applies equally well here. Impoverishment of the blood, Avhich occurs in protracted cases, requires nourishing diet and iron. Threatening heart-palsy demands stimulus. When a recent pericarditis comes on in acute rheumatism, we may assume that it will do as well, and perhaps better, Avithout treatment. As long, therefore, as nothing save the physical signs betrays its exist- ence, it is better to refrain from active interference. The astonishing number of recoveries in Bamberger's collection of cases occurred under a thoroughly expectant treatment. It is only under conditions men- tioned above that Ave should apply leeches, cold, etc. In order to pro- mote absorption, Bamberger lays stress upon the application of Avarmth and moisture, and especially upon flying blisters. Paracentesis is to be performed wfien the distress of the patient, especially from the dyspnoea, imperatively demands aid. The result is merely palliative, as a rule ; but, even to afford the sufferer opportunity, after the opera- tion, to pass the night in his bed (perhaps for the first time in a long period) and to enable him to sleep a little, is a great gain. Whether in other cases the operation can effect a radical cure, our limited ex- perience does not permit us to decide. Particulars of the operation are to be found in the hand-books on surgery. CHAPTER II. ADHESION OP THE HEART AND PERICARDIUM. Anatomical Appearances.—Adhesion of the pericardium and heart is one of the consequences of pericarditis. Its pathogeny and etiology have been given in the previous chapter. The adhesion is sometimes partial, sometimes total. Sometimes it consists in a firm agglutination of the surfaces, sometimes long bands and fibres are the media of connection. In a clinical point of view, the condition of the epicardium is of much more importance. There is occasionally so little thickening of the adherent pericardial faces that the pericardium seems to haA'e disappeared; in other cases the epicardium is converted into an indurated, unyielding case, in AA'hich we find masses of even a bony hardness. Again, in circumscribed spots Avhere the fusion of the 390 DISEASES OF THE PERICARDIUM. two surfaces is incomplete, remnants of effusion now and then exist, as Ave have already described. Symptoms and Course.—As but a small portion of the pericar- dium is attached to the thoracic Avail, and even that is held by loose cellular tissue, a simple adhesion of the two surfaces does not seem materially to interfere with the movements of the heart. Functional disturbances, observed to accompany this condition, usually depend upon a concomitant degeneration of the heart, valvular disease, or, per- haps, upon a former carditis. The effect is very different Avhen the organ is enclosed within and adherent to a dense fibrous case, often of the consistence of cartUage. Such a condition reduces the pro- pulsive power of the heart in the very highest degree. The pulse be- comes extremely small and almost always is very irregular. Dysp- noea, cyanosis, and dropsy appear all the earlier, as the substance of the heart is nearly always degenerated. Physical examination must decide to what source disorders of the circulation are due. A lack of difference betAveen the percussion-sounds during inspira- tion and those during expiration has been given as one of the physi- cal signs of pericardial adhesion; but, whether heart and pericardium be or be not adherent, the lung will still intervene betAveen the latter and the side of the chest with every deep inspiration, and, conversely, will recede Avhen a forced expiration is made. In this respect, then, the signs avUI remain unaltered, unless, indeed, the outer surfaces of the pleura and pericardium be grown together {Cejka). There is a second symptom, of greater value. Sometimes, at the point AA'hereat Ave ought to feel the beat of the apex, instead of rising, Ave see the intercostal space sink Avith every beat. This phenomenon we explain as folloAvs: The heart is shortened during systole, and a vacuum would form, Avere not the space filled, either by the descent of the heart or the depression of the intercostal space; but, if heart and peri- cardium be adherent, no descent can take place, hence depression of the intercostal place must substitute it. This symptom is all the more important, if, during diastole, we find the space rise again, when, upon cessation of the systolic suction, the heart again becomes elongated, and the apex returns to its position. This symptom, too, is often Avanting in many cases of pericardial adhesion. If the pleura and peri- cardium be not adherent, the lungs may occupy the vacancy left by the withdrawal of the apex during systole, and vice versa. On the other hand, a systolic depression of the region over the apex may depend upon other causes than that of adhesion of the heart and pericardium. If the latter be likeAvise attached to the spinal col- umn, the loAver half of the sternum avUI also be draAvn down by the systole of the ventricle. Moreover, according to Friedreich, in such HYDROPERICARDIUM. 391 cases there sometimes is a peculiarity obsen'able about the veins of the neck. We see, namely, when the sternum, after having been drawn doAvn by the systolic movement, springs back again witfi the diastole, thereby creating an expansion of the chest, that the A'eins collapse. [n Friedreich's case this phenomenon only lasted for a limited time, and ceased as the action of the heart, and with it the systolic depres- sion, greAV more feeble. Thus, in solitary cases, physical examination may inform us of the existence of pericardial adhesion. In the major- ity of instances, however, the statement of Skoda, in the first edition of his book, still holds good, that " no symptoms are discoverable, through percussion and auscultation, Avhich can be ascribed to adhe- sion of the heart and pericardia." CHAPTER III. HYDROPERICARDIUM. Etiology.—Hydropericardium depends upon an increase of the normal liquor pericardii, a transudation which contains but little albu- men. We have already seen hoAV a decrease in the size of the heart, by reducing the pressure upon the pericardium from Avithin, results in an increase in quantity of the liquid in the sac. The same thing takes place Avhen the lungs become adherent to the pericardium and are reduced in volume, either from atrophy, failure to regain their normal size after absorption of a pleuritic effusion, or contraction from chronic pneumonia. This form of hydropericardium is analogous to the in- crease in the amount of cerebro-spinal liquid which takes place in atrophy of the brain, and, as the latter is called hydrocephalus ex vacuo, so hydropericardium ex vacuo Avould be a suitable name for the former. A second form of hydropericardium is that Avhich arises from an obstruction of the veins of the right heart. An abnormal pressure is thus throAvn upon the pericardial veins, and dropsy of the sac results just as it takes place in other serous sacs, or in the subcutaneous cel- lular tissue. The collections of water in the pericardium arising in A'alvular disease of the mitral, emphysema, cirrhosis of the lungs, and m other diseases in Avhich the right side of the heart is overloaded, all belong under this head. In all these cases dropsy may be of earlier occurrence in the pericardium than in any other part of the body. It is otherAvise in the third form, in Avhich dropsy of the pericar- dium, like that of other organs and structures, is to be regarded as the effect of a " dropsical crasis." Appearing in diseases in which the blood has a tendency to lose its albumen, and for its serum to transr 392 DISEASES OF THE PERICARDIUM. ude, as in Bright's disease, chronic affections of the spleen, cancerous cachexia, etc., the pericardium is not usually affected untU a late period. Anatomical Appearances.—According to the explanation of the foregoing paragraph, only collections in the pericardium, of a liquid containing but little albumen, are to be regarded as fiydropericardium. If the liquid contain fibrin, it belongs to the inflammatory effusions. Sometimes small quantities of disintegrated blood are mingled with the serum. In such cases the nutritive state of the capUlary walls has deteriorated so that they become ruptured. The frequent occurrence of small haemorrhages into the skin {petechia}), in general dropsy, is an analogous condition.* The quantity of the liquid effused is very variable. A collection of an ounce or an ounce and a half of liquid in the sac is not to be regarded as pathological. In cases which are not rare, the amount may be as much as four or six ounces; in others, particularly when the affection arises from disturbance of the circulation, it may exceed several pounds. When the effusion is very large, the pericardium is dull-white and lustreless, the fat has disappeared from about the heart. Sometimes its connective tissue is oedematous. Copious dropsical effusion into the pericardium distends it, com- presses the lungs, and dUates the thorax exactly Hke pericardial ex- udations. Symptoms and Course. — Our remarks upon the subject of hydrothorax are equally applicable to that of hydropericardium. Although, to the minds of the ancient physicians, " Avater on the heart" used to be a most formidable malady, as even now is the case among the laity, yet it has no real title to rank as an independent disease. But not only is accumulation of liquid in the pericardium al- ways a secondary affection, depending either upon some derangement of the circulatory or respiratory apparatus, or else upon a morbid con- dition of the blood, but the very symptoms imputed to water on the chest, and so much dreaded, proceed chiefly from the primary disease, and are not caused by the pericardial effusion. When, prior to the introduction of physical examination, a diagnosis of hydropericardium was often confirmed post mortem, it was due to the fact that the symptoms upon which the diagnosis was based nearly ahvays arose from such diseases as emphysema and valvular disease of the heart, which ultimately resulted in dropsical affections, and therefore in effu- sion into the pericardium. A large serous effusion into the pericardium undoubtedly has the * We shall treat of fibrinous dropsy in cancer of the pericardium, just as Ave have apoken of it in cancer of the pleura. PNEUMOPERICARDIUM. 393 effect of aggravating the dyspnoea arising from the primary disease. Such an effusion often helps to prevent the patient from lying down Avithout danger of suffocation, and compels him to sit day and night leaning forward upon his chair or bed. Moreover, the pressure exerted by the liquid upon the heart and mouths of the great vessels impedes '' the systemic circulation, causing the jugular veins to SAvell up, and aggravating the cyanosis and dropsy. Frequent as is the coexistence of such symptoms Avith hydrops pericardii, yet the presence of every one of them does not afford sufficient ground for a positive diagnosis of hydropericardium, unless supported by the evidence draAvn from / physical exploration. All these symptoms may be present Avithoia ( there being any increase in the amount of the pericardial liquid Upon physical examination, the prominence of the region of the heart is observable, although in a less degree than in cases of inflammatory effusion. The depression of the intercostal spaces is not obfiterated. The impulse of the heart is very feeble, and is often quite impercep- tible, especially when the patient lies upon his back. When the effu- sion is large, and provided that the lungs are capable of retraction, the cardiac dulness is extended, and has the same shape and exhibits the same modifications, upon change from the upright to the recum- bent attitude, which already have been described as characteristic of pericardial effusion. It happens more frequently in this affection than it does in pericarditis, that the lung is unable to retract, owing either to emphysema or to adhesions of the costal and pulmonary pleurae. In such cases, notAvithstanding the existence of a very large effusion, the area of dulness is not extended. Upon auscultation, unless the valves of the heart be diseased, the heart-sounds are pure though feeble. Friction-sounds are never heard. Treatment.—All the measures recommended for the treatment of hydrothorax are equally applicable to that of hydropericardium. The only rational procedure is to treat the primary disease. It rarely is practicable to reduce the liquid in the pericardium by means of diuretics and drastics. CHAPTER IV. PNEUMOPERICARDIUM. Air sometimes enters the pericardium through a perforating wound of the thorax; in other cases the pericardial sac suffers perforation by some destructive morbid process, and air is admitted into it from some organ Avhich naturally contains air. I have observed one instance of this kind (Avliich has been reported by Dr. Tutel, my assistant at the 394 DISEASES OF THE PERICARDIUM. time in the German Clinic), in which pneumopericardium arose after perforation of the pericardium by carcinoma of the oesophagus. Other cases have been reported of perforation of the pericardium by ulcers of the stomach, cancer of the stomach, or superficial cavities in the lungs. Finally, gas sometimes is generated in the pericardium, by the decom- position of the effusion which it contains. ! Upon post-mortem examination, the pericardium is usually much distended, partly by air and partly by a purulent or sanious Hquid. The latter is the product either of a recent pericarditis, caused by the entrance of air, or cancerous discharge, or of broken-doAvn pulmonary tissue, into the pericardial sac, or else, if the pneumopericardium be \ the result of a generation of gas from a putrefying exudation, of a peri- carditis of long standing. Upon puncture of the distended sac, the air usually escapes with a hissing sound. Pneumopericardium is far less common than pneumothorax, and nearly ahvays is easy of recognition. It is true, the subjective symp- toms, arising from perforation of the sac and of entrance into it of air and debris of the tissue, are not very characteristic. Besides, the oc- currence is usually attended by severe collapse, in Avhich the patient j lies in a state of apathy, making no complaint, and, if questioned, re- | plying with hesitation and incompleteness. Even at some distance from the patient a peculiar, clear, splashing sound can be heard, which comes and goes Avith short, rhythmical intervening pauses, and which, beyond all question, is caused by the agitation produced in the liquid contents of the pericardium by the movements of the heart. . In my case this splashing sound Avas distinctly audible to the room-mates of the patient, Avho lay at the other end of the ward. Upon inspection, , if the thorax still be flexible, the prominence of the cardiac region and \ the obliteration of the intercostal depressions are very marked. The ' cardiac impulse is indistinct or imperceptible. Upon percussion, there is no cardiac dulness, and, indeed, the percussion-sound about the re- gion of the heart is extremely full, clear, and tympanitic, often having a distinct metallic ring. Upon making the patient sit up, or upon making him bend forward, the beat of the heart becomes somewhat more perceptible, and, as the air now rises and the liquid presses for- ward, the former clear sound is replaced by a dull one. Upon auscul- tation, either nothing can be heard excepting the above-named metallic splashing, or else we may also hear feeble heart-sounds and friction- sounds. With exception of cases of traumatic origin, this disease, as a rule, rapidly proves fatal. The collapse and severe pericarditis Avhich almost always accompany pneumopericarditis sufficiently account for this. Recovery from traumatic pneumopericardium has been observed I TUBERCULOSIS AND CANCER OF THE PERICARDIUM. 395 j repeatedly. Of course, the treatment of this affection can only be a | treatment of symptoms, and in most cases it is limited to an exhibition i of stimulants. CHAPTER V. TUBERCULOSIS OF THE PERICARDIUM. Tubercles in the tissue of the pericardium are only seen in acute miliary tuberculosis. The grayish nodules here visible do not undergo further metamorphosis, and the patient dies, consumed by feA'er, Avith- 1 out betraying any symptoms of the existence of tubercles in the peri- cardium. It is far more common for tubercles to form in the young pseudo- membranes Avhich develop on the pericardium in the course of a chronic j pericarditis. We nearly ahvays find a haemorrhagic effusion in the sac in these cases, and obsen'e its walls to be studded Avith drusy I prominences, which are at first translucent, but may afterward become | yelloAV and cheesy, although they rarely soften into " tubercular pus." The symptoms of this form of tubercle of the pericardium are undistin- guishable from those of chronic pericarditis. CHAPTER VI. CANCER OP THE PERICARDIUM. 1 Cancer of the pericardium is almost ahvays an extension of can- cerous disease from the sternum or mediastinum. Sometimes it groAvs diffusely, so that a large part of the sac degenerates into cancer; some- times it forms solitary rounded masses, or flat nodules upon the mem- brane. More rarely it appears independently after extirpation of an external cancer; and then other nodules upon other organs and upon other serous membranes are nearly ahvays found. The formation of cancer in the pericardium is nearly always combined with a coUection of liquid Avithin the sac, Avhich, like the liquid found in cancer of tfie peritonaeum or pleura, contains " fibrin of tardy coagulation." It is pos- sible, only in the A'ery rarest instances after removal of a cancer of the breast, to diagnosticate the formation of cancer of the pericardium by the evidence of a gradually increasing effusion in the sac. SECTION III. DISEASES OF THE GREAT VESSELS. CHAPTER I. INFLAMMATION OF THE COATS OF THE AORTA. Etiology.—Inflammation of each of the three tissues of the aorta, the adventitia, the media, and the intima, is best studied by itself, just as AA'e have already successively discussed pericarditis, myocarditis, and endocarditis. Acute inflammation of the tunica adventitia is rare, and hardly ever occurs, excepting when inflammation or ulceration of the lymphatic glands, the oesophagus, the trachea, or other neighboring organ, ex- tends into the aorta. Chronic inflammation is far more common; but neither is it primary, being allied almost ahvays to pericarditis and at- tacking tfie root of the aorta; or "else to endarteritis, when its action may be very extensively diffused. The tunica media often.takes part in inflammation of the adventitia. In chronic inflammation of the intima, too, the media is almost always diseased, but is not often inflamed. It is much more commonly the seat of simple atrophy or of fatty degeneration. From Virchow's point of vieAV, chronic inflammation of the internal coat of the arteries is to be regarded as one of the most frequent of diseases. The reason for classing the gelatinous and semicartUaginous thickening of the inner arterial tunic (see below), which forms the in- cipient stage of ossification and atheroma of the arterial Avails, among the parenchymatous inflammations, is due to the fact that, in this dis- ease, we undoubtedly have to do with an active process, with genera- tion of cells, and that in many cases it can be shown that these nutri- tive disturbances owe their origin to certain irritants which have acted upon the tunics; as, undue strain, or distention (see pathogeny of endocarditis). In other cases, indeed, it cannot be proved that the arteries have been subjected to special irritants; as, however, the INFLAMMATION OF THE COATS OF THE AORTA. 397 anatomical changes are precisely the same, Ave may assume that the sources of irritation exist, but have escaped our observation. Endarteriitis deformans, as Ave may call chronic inflammation of the intima, according to Virchow, is an extremely common disease of ad- | vanced age; and it is ahvays at the points most exposed to strain or distention, such as the ascending portion and arch of the aorta and { the places of origin of the vessels which pass off laterally, that the disease is most apt to occur. In the second place, the malady is most . frequently found to affect gouty, rheumatic, or syphilitic persons, as AveU as drunkards. We are not* at liberty, hoAvever, to go so far as to suppose that in these cachectic subjects the disease proceeds from the composition of the blood, that an irritant circulates in the latter Avhich excites the internal coat of the artery to the point of inflamma- tion. Finally, endarteriitis accompanies hypertrophy of the heart in young subjects who are not cachectic, and here it seems to attack by prefer ence dilated portions of the arteries. These cases furnish strong evi dence of dependence of the disease upon local injury to the vessels. Anatomical Appearances.—We rarely have opportunity to see purulent and ichorous collections in the tissue of the adventitia. In durated thickening of the cellular tissue, as a residue of chronic in- flammation, is a far more common discovery. At first the calibre of the artery usually is narrowed; afterward it generally becomes AA'idened. Inflammation of the tunica media begins AA'ith a speckled redness, Avhich has its seat beneath the internal coat. The spots soon become of a whitish or yellow color, are elevated above the inner surface, and resemble small pustules. At first a mere sprinkling of the infiltration, in the form of amorphous granules, takes place upon the tissue, which still remains firm. It afterward liquefies, and pus forms, so that actual abscesses are established ia the Avail of the artery. Chronic endarteritis commences Avith relaxation and infiltration of the tunica intima. Tavo forms of it occur, distinguishable according to the grade of infiltration, and AA'hich have often been described as different stages of the same disease. In the first form, that of gela- tinous thickening of the inner coat, a gelatinous, moist, pale-reddish layer seems to lie upon the inner surface of the artery, sometimes in circumscribed spots, sometimes spread over a wider surface. These apparent deposits readily admit of being crushed or displaced in the form of jelly. They consist mainly of a liquid resembling mucus, in AA'hich fine elastic fibres and round or spindle-shaped cells lie embedded. They are immediately connected with the tunica intima, and are cov- ered by its epithelium. . 393 DISEASES OF THE GREAT VESSELS. In the second form, that of semi-cartilaginous induration, Ave fine opaque, bluish-Avhite plates, like boiled white of egg, lying upon the! inner surface of the artery. Here, too, the tissue of the tunica intima! is softened and infiltrated, but it remains firmer and more consistent than in the other form, and it afterward assumes a cartilaginous hard- ness. Under the microscope, numerous fusiform and reticulate cells can be seen in the semi-cartilaginous variety, but, above all, broad fasciculi of connective tissue are visible, Avhich plainly form an imme- diate continuation of the lamellar fibres of the tunica intima. The further changes which these inflammatory products undergo are: 1. Fatty metamorphosis; 2. Calcification or ossification. In the gelatinous thickening, fatty metamorphosis begins chiefly in the superficial portion, commencing in the cells of AA'hich we have spoken, while the intermediate substance breaks down, and the surface becomes rough and tufted. This process is called " fettige Usur"— " fatty consumption." In semi-cartilaginous thickening, fatty metamorphosis begins in the deeper layers. Here, too, at first, numerous drops of fat are deposited around the nuclei of the connective tissue-cells, so that they become transformed into star-shaped cells of fatty granules. The cell mem- brane ultimately perishes, and the fat molecules are liberated. The bun- dles of connective tissue also break down, and thus, deep in the interior, a pea-soup colored, fatty paste is formed, consisting of fat molecules, numerous crystals of cholesterin, and debris of connective tissue, con- stituting true atheroma. As long as the greasy paste remains sepa- rated from the current of the blood by a thin film of the internal coat, it is called an atheromatous pustule. Afterward, when the covering has broken down, after its contents have been washed away, and an irregular loss of substance, with ragged edges, has formed, we speak of an atheromatous ulceration. Atheroma and " usur " bear the same relation to one another as abscess and ulcer. Calcification depends upon a deposit of salts of lime in the deeper layers of the semi-cartilaginous thickening. In the plates of lime thus formed we sometimes find bodies analogous to bone-corpuscles, jagged in form, and furnished with prolongations, Avhich are the residua of connective tissue-cells, so that Ave then are warranted in employing the term ossification. WhUe the smaller arteries may become converted into tubes, Avith rigid walls, from deposit of earthy matter, ossification of the aorta usually appears in the shape of separate plates and scales, of variable size, Avhich form shalloAV depressions upon the inner surface ' of the vessel, and AA'hich are separated from the blood by the interven- tion of a thin film of the tunica intima. By-and-by the ossification reaches the surface itself; the scales of bone are completely exposed, INFLAMMATION OF THE COATS OF THE AORTA. 399 and are sometimes Avashed loose by the blood, and then form projec- tions, upon Avhich the fibrin of the blood is very apt to precipitate itself. At the outset of endarteriitis, the tunica media does not become perceptibly altered. In advanced atheroma it grows yelloAV, relaxed, and fissured. Large deposits of fat form betAveen its lameUae. The media is generally atrophied, and thinned by ossification of the intima. In the beginning of the process the adventitia is also normal, but after- Avard becomes SAVoUen, thickened, and indurated. In many cases Ave find all the various phases of the disease along- side of one another in the aorta: in one place gelatinous or semi-carti- laginous induration; in another, atheromatous pustules; here again ulceration; there calcification, in a sligfit depression, covered by the tunica intima; and at some other point we find plates of bone pro- jecting free into the aorta. Symptoms and Course.—No clinical description of acute inflam- mation and ulceration of the adventitia can be given, as, in the few in- stances in Avhich the process has been Avatched, the disease has ahvays been compHcated by other grave disorders. This is also the case in chronic inflammation of the adventitia, and in the instances of abscesses observed noAV and then in the tunica media. Chronic inflammation of the tunica intima and its results, generally comprehended under the term atheroma, in its Avider sense, furnish but feAV symptoms as long as they do not cause aneurism, rupture, or stop- page of one of the smaller arteries by detachment of a clot. We shall consider the subjects of aneurism and rupture in the second and third chapters. The results of embolism, as far as they affect internal organs, are treated of in various chapters of this Avork. If, in consequence of degeneration of its coats, the aorta haA'e lost its elasticity, and if, too, its branches take part in the disease, the de- mands upon the heart are increased, and hypertrophy arises (see hyper- trophy of heart). If the chronic inflammation spread from the arterial Avail to the valves, insufficience and stenosis may be the result. Hyper- trophy often fails to take place, OAving to depression of the general nutritive condition, or it is not sufficiently pronounced to compensate for the impediment Avhich degeneration of the aorta and its ramifica- tions presents to the circulation, or else the hypertrophy is soon con- verted from a genuine to a false hypertrophy, from degeneration of the substance of the heart. Symptoms of retarded circulation and over- loading of the A'enous system then arise, cyanosis, dropsy, and sup- pression of urine, as described in a previous chapter. The most important token in the diagnosis of chronic inflammation' of the inner coat of the aorta is the evidence of the existence of similar disease in the peripheral arteries, as the inference is thus Avar- 400 DISEASES OF THE GREAT VESSELS. ranted that the affection is also present in the aorta, in a still more advanced stao-e of development. As the vessels have become dilated, and their walls more rigid, the pulse generally feels hard and full; the course of the elongated arteries is remarkably sinuous, their curvature increasino- with the beat of the pulse, which becomes visible. The artery, even Avhen undistended by the current of the blood, can usually be felt as a hard, irregular cord. As long as there is no aneurismal dilatation of the aorta, percussion and auscultation do not aid the diagnosis. In rare cases, false mur- murs arise, in consequence of roughness of the inner coat of the aorta, and where there is no deformity at the ostia. According to Bamberger, the first sound of the aorta is often dull, muffled, or even inaudible ; the second, particularly if the Avails of the great vessels be studded with bony plates, and as long as the valves retain their efficiency, has a remarkably loud and metallic ring. CHAPTER II. ANEURISM of the aorta. Aneurisms, produced by Avounds, belong to the province of surgery. Spontaneous aneurism, that is to say, partial dilatation of a vessel caused by degeneration of its Avails, is the only form of the disease Avliich occurs in the aorta. Uniform dilatations of the entire tube, such as arise in hypertrophy, and which take place above stricture of the vessel, are not regarded as aneurisms. Etiology.—The degeneration of the aortic wall, which most fre- quently gives rise to aneurism, is the result of the chronic endarteriitis described in the previous chapter, and known as atheroma. Next in frequence, as a cause of aneurism, is simple fatty degenera- tion of the inner and middle arterial tunics, a disease which we have purposely avoided mentioning hitherto, as it has nothing in common Avith the inflammatory affection previously described. In simple fatty metamorphosis there is no preliminary thickening, and cell-growth in the tunica intima; but, from the very outset, we find opaque, whitish or yellowish-Avhite spots, grouped in a peculiar manner, and but sfight- ly prominent above the surface, which consist of deposits of fat mole- cules in the tissue of the arterial coats. Thirdly, simple atrophy, and thinning of the aortic wall, which seems to be by no means uncommon among elderly people, may be a cause of aneurism. Whether palsy of the vaso-motor nerves be also a cause of this ANEURISM OF THE AORTA. 401 disease {Roklteinsky), is questionable, at all events, as regards the aorta, AA'hich is but poorly provided Avith contractile elements. In consequence of these changes, particularly in the middle coat, the aorta loses its elasticity, sometimes at a circumscribed spot, some- times throughout a larger portion of its extent, and gradually yields and becomes dUated by the pressure of the blood. Not unfrequently, hoAvever, upon the occasion of some sudden strain, the tunic of circular fibres seems to give Avay suddenly, and the dilatation of the Avail, Avhich now consists only of the adventitia and intima, goes on more rapidly. Many persons suffering from aneurism believe that they knoAV the period, or even the moment, from which their malady dates, assigning, as a cause, some violent muscular effort, the lifting of a heavy burden, etc. It has already been remarked that a general contraction of the muscles, by compressing many of the capillaries, must throAV an in- creased strain upon the aorta. A violent jar of the frame seems to haA'e a similar effect; at least, many patients date their affection from some fall from a great height, or the like. Such accidents avUI not cause aneurism in a healthy subject; and, in many cases, an acknoAvl edgment of the immediate causes of the complaint is only forced upon the patient by the examiner. Aneurisms are rare in young people. They occur chiefly in per- sons of somewhat advanced age, in Avhom chronic inflammation of the arterial coats is a very common affection. Men are much more fre- quently attacked than women; but as the majority of aneurisms are found in persons who habitually make violent muscular efforts, this difference may be accounted for by the difference in the occupations of the sexes. Anatomical Appearances.—Scarpei's classification Avas mainly based upon the number of coats Avhich could be counted in' the Avail of an aneurism. If the wall contained all three tunics, it Avas an aneurisma verum • if covered by the adventitia alone, it was an ancurisma spurium, or mixtum externum. If, again, the Avail con- sisted of a protrusion of the intima through an opening in the media, the pouch being either bare or covered by the adventitia, it was an aneurisma mixtum internum seu hemiosum. This classification has been abandoned as unpractical. An aneurism may belong to the first class (aneurisma A'cra) at tfie period of its commencement, and, as it otoavs, become an aneurisma spuria; and, indeed, in the same tumor, one half of it may be of the true kind, and the other of the false. Classification of aneurisms, according to their form, is of more im- portance. Thus Ave distinguish the circumscribed and the diffuse aneurism. A diffuse aneurism inA'olves a considerable portion of the vessel, 26 402 DISEASES OF THE GREAT VESSELS. and its entire calibre. If the dUatation terminate abruptly, it is called a cylindrical aneurism. If it decrease gradually, it is a fusiform i! aneurism. Diffuse aneurism is always a true one, in Scarp>a's sense, ' and is most commonly met with in the ascending and transverse por- tion of the arch of the aorta. It is very often combined AA'ith the form next to be described, that is to say, circumscribed pouches often form upon the dilated portion of the artery. Circumscribed aneurism consists in the dilatation of a shorter por- tion of the artery. Here, too, the artery is sometimes widened in all directions, the tumor involving its entire diameter. Far more fre- quently, hoAvever, one side alone is dilated, and the aneurism, whose Avails form an angle Avith those of the normal part of the vessel, as- sumes the appearance of a tumor situated on its side. Secondary pouches, in the form of elevations of varying size, are often observed upon these sac-like dilatations, just as in the other kind. At the out- set, the disease almost always bears the character of a true aneurism of Scarpa, consisting of all three of the aortic coats ; but, when the sac has attained some magnitude, the inner tunic only extends for a short distance into it. When at its period of fullest development, the middle tunic, too, dAvindles, and finally disappears totally, while there still remain traces here and there of the tunica intima, in a state of degeneration. Aneurisms attached by a neck must be regarded as a peculiar species of the sac-like form. In these cases, a very small spot on the arterial wall gives way. If the dUatation be large, the wall of the aneurism wraps itself around that of the artery. Thus a duplicature is formed, which, looked at from within, presents a prominent ridge, while, from AA'ithout, the tumor seems to have been constricted at its base. In these' saccular aneurisms, the tunica media can only be traced for a short distance, and soon disappears on the far side of the neck, the wall then consisting of the intima and adventitia {aneurisma mixtum internum seu hemiosum). When very large, all the tissues gradually disappear under the pressure; and the adjacent structures, to which the aneurism becomes adherent, finally furnish its Avail. If the enlargement be sIoav, the neAv wall may become very firm by pro- liferation of the connective tissue ; but, if rapid, the wall remains thin, and soon bursts. If the tumor encounter any resisting body, such as bone, the latter undergoes absorption (usur), just like the sac-Avail, and, after destruction of the periosteum, the bone is laid bare, and projects naked into the pouch. In the cavities of aneurisms of large size, especially in the sac- shaped ones, Ave almost ahvays find deposits of fibrin arranged in sep- arate layers. Those attached to the Avails are yelloAV, dry, and firm ; ANEURISM OF THE AORTA. 403 I those next the blood are reddened and soft. Here and there, between their layers, there are frequently deposits of brownish-red or chocolate- colored blood. The vessels proceeding from the sac, independently of the contrac- tion to Avhich they are liable by ossification, are not unfrequently blocked up by clots of fibrin, and are impervious to blood. In otfier cases, tfieir moutfis are stretched into narrow slits, and in others again they may be narrowed or closed by pressure of the tumor. The con- dition of the vessels springing from an aneurism is important in a diag- nostic point of AdeAV. The size of aortic aneurism varies. Within the pericardium they rarely attain any great magnitude, but soon give Avay. When they originate beyond the pericardium, however, they may grow to the size of a man's head. The effect of an aneurism of the aorta upon the parts about it de- pends upon the amount of displacement and pressure which it inflicts. The trachea, the bronchi, the oesophagus, the great vessels of the thorax, or the nerves, may be dislocated or atrophied by the compres- sion to Avhich they are exposed. Atrophy, or " usur," of the bones may even open the spinal canal, and destruction of the bone and carti- lage of the thorax may permit the aneurism to emerge as a prominent tumor, covered only by soft parts. As partial dilatation of the aorta augments the labor of the heart, that organ is almost ahvays hypertrophied. Spontaneous cure of an aortic aneurism, by complete solidification of the sac by means of coagula and subsequent atrophy, is one of the greatest of rarities. Other forms of spontaneous cure, Avhich some- times occur in peripheral aneurism, are impossible in the aorta. When death does not result from the effect of the tumor upon the circulation, and its pressure upon neighboring organs, the aneurism usually bursts spontaneously, a mode of termination A'astly more fre- quent than that by recovery. If it open into the pericardium, or pleura, a genuine rupture at the thinnest point takes place; if into the oesophagus, trachea, or one of the bronchi, it gives way at some point of adhesion Avhich forms betAveen the tumor and one or other of these organs, and which, gradually growing thinner, at last breaks ; or else a slouo-li forms and separates, thus making an aperture into the sac. Opening into a neighboring vessel takes place after its Avails have become adherent, and communication is established by a gradual wast- ino- of the septum thus formed. More rarely, it is only the adventitia of the vessel that becomes adherent, and, after perforation at the ad- herent spot, blood is injected betAveen the adA'entitia and media of the vessel. The external rupture of an aneurism, Avhich has penetrated 404 DISEASES OF THE GREAT VESSELS, the Avail of the chest, occurs either by gradual atrophy anil final lacera- tion of the integument, or else, which is most common, by loosening and detachment of a slough induced by immoderate and incessant strain. Aneurism of the aorta is most frequently situated upon its ascend- ing branch, before the departure of the innominata, and is more com- mon upon its convex than upon its concave side. Those which arise outside of the pericardium, and Avhich are generally A'ery large, usually project toAvard the right half of the sternum, and become visible in the region of the upper ribs, and costal cartilages of the right side. In the majority of cases, they break into the right pleural sac, or else burst externally. Aneurisms Avhich spring from the concavity of the ascending aorta groAV in the direction of the trunk of the pulmonary artery, or toAvard the right auricle, which they may perforate. Those which arise from the convexity of the arch also extend to the right, forward, and upward, and make their appearance in the neighborhood of the right sterno-clavicular articulation. Those which proceed from the concavity of the arch press upon the trachea, the bronchi, and the oesophagus, Avhich they may perforate. Aneurisms of the descending limb of the aorta often compress the left bronchus, more rarely the oesophagus, and usually open into the left pleural cavity; they may destroy the back-bone, and may come to the surface at the left side of the back. Aneurisms of the abdominal artery often attain an immense size, may also erode the spinal column, and burst into the peritonaeum or retroperitoneal connective tissue. Symptoms and Course.—Persons suffering from aneurism of the aorta often perish suddenly and unexpectedly of internal haemorrhage, before the disease has given rise to any great degree of distress. At other times the symptoms are so obscure as to render a positive diag- nosis impossible. In other instances, again, it admits of a more or less certain recognition from the subjective and objective manifestations which it occasions. The signs to which aortic aneurism gives rise depend, in part, upon the croAvding and compression of the adjacent organs in the thorax, as described in a previous section; and in part, also, upon obstruction of the circulation, Avhich is one of the necessary consequences of any large aneurism. As a result of compression of the lung or greater bronchi, dyspnoea arises, which is often extremely severe. The most intense dyspnoea, accompanied by a peculiar whistling upon breathing and coughing, attends aneurism of the arch pressing upon the trachea. If the pneu- mogastric nerve or its recurrent branch be stretched or irritated, the dyspnoea may assume a spasmodic, asthmatic character, and appears ANEURISM OF THE AORTA. 405 to proceed from the larynx, and comes on in paroxysms. Dyspnoea is one of the most common and distressing symptoms of aneurism. A second set of signs proceeds from compression of the right auri- cle, the vena cava, or the vena anonyma. If the auricle or vena cava be compressed, the jugular veins SAvell, blue networks of veins appear upon the skin of the chest, the veins of the arms become distended Avith blood; indeed, it is not uncommon for dropsy soon to develop in the upper half of the body. The patient may complain of headache, dizziness, buzzing in the ears, and fits of unconsciousness may be ob- served. If but one of the vena innominata be compressed, the venous dUatation is limited to the corresponding side of the head and chest. In consequence of the pressure and strain to AA'hich the intercostal nerves and brachial plexus are subjected, most Adolent pain often arises in the right side of the chest, the armpit, and right arm. Like most other of the troubles to Avhich aneurism gives rise, this pain is often paroxsymal, and may deprive the patient of his sleep, and is reckoned by Lauth among the agents Avhich tend to produce speedy death by exhaustion. Compression of the arteria innominata, or of the left subclaA'ian, may render the radial pulse extremely small or quite imperceptible. Inequality betAveen the pulsations at the wrist of either side may also be a result of distortion of the arterial mouths, or of their stoppage by clots. To these symptoms of compression of adjacent organs, are added those of retarded circulation. Foremost among the latter is the pause, often so distinctly perceptible, which occurs between the beat of the heart and the wave of the arterial pulse, at a point below the aneu- rism. This phenomenon is most striking when the aneurism is sit- uated betAveen the points of origin of the great vessels of the arch. The pulse is then felt later at one wrist than at the other; or, if the tumor involve the descending aorta, the pulse beloAV the tumor cannot be felt until after that of the upper extremit}-. As hypertrophy can only temporarily compensate the impediment to the circulation, not only does palpitation eventually set in, such as avc encounter Avherever the heart's action is overtasked, but the de- rangement in the blood's distribution, so often described, finally is established; the arteries are ill supplied, the A'eins and capillaries are gorged, and general marasmus and dropsy ensue. If the patient do not die of disordered circulation or of embarrassed breathing, and should he not succumb to some other intercurrent disease, the aneurism finally bursts. It Avould be erroneous, hoAvever, to regard this mode of termination as constant or even as the most common mode of death. When, after coming to the surface in the form of a tumor, it breaks 406 DISEASES OF THE GREAT VESSELS. externally, the integument gradually grows thinner, turns dark blue, then black, and at last sloughs. After a time, the eschar separates. The blood, hoAvever, does not always escape in a stream. Sometimes it is restrained by the coagula, so that there is only a gradual trickling flow; and it may even be possible to stanch the first haemorrhages by means of the tampon, so that death may not occur until after re- peated outbursts of blood. It is otherwise when rupture takes place into the pleura, pericar- dium, trachea, or oesophagus. The patient then sinks, often Avith ex- treme rapidity and in the midst of great suffering, with the signs of an internal haemorrhage or of profuse haemoptysis or haematemesis. Life has been known to continue for some time after perforation of the pulmonary artery, or vena cava. The symptoms observed were those of extreme obstruction of the veins of the aortic circulatory system. Although the most important symptoms of aortic aneurism are de- rived from physical exploration, yet dyspnoea, cyanosis, varicosity of the veins, and dropsy of the upper half of the body, severe pain in the right side and arm, inequality of pulse at the wrists, the long pause between the beat of the heart and that of the pulse at the wrist, permit us to infer the existence of this disease with great certainty. The signs vary, of course, according to the position of the tumor upon the aorta. In aneurism of the ascending a orta, the vena cava and lungs are more especially encroached upon, so that cyanosis and dropsy of the upper half of the body, Avith intense dyspnoea, form the most constant symptoms. In aneurism of the arch, it is mainly the trachea and the par vagum nerve which are compressed, and corresponding functional disturbance ensues. In many cases, also, there is dysphagia, from pressure upon the oesophagus. Inequality in the pulses at the wrists, also, is most frequent in these cases. In aneurism of the descending thoracic aorta there is often severe pain in the back, sometimes inability to extend the spinal column, and, if destruction of the vertebrae be extensive, there may be paraplegia. There are also sometimes difficulty in deglutition and severe dyspnoea from compression of the lungs. The functional derangements and subjective symptoms, to which aneurism of the abdominal aorta gives rise, are manifold. It may cause the most violent neuralgic pain, and, at a later period, palsy of the loAver extremities, by pressure upon the nerves and erosion of the vertebrae. Compression of the digestive apparatus occasions colic, con- stipation, and vomiting. Pressure upon the liver and its excretory ducts may produce obstinate jaundice; Avhile suppression of urine ANEURISM OF THE AORTA. 407 may result from similar action upon the kidneys. If the aneurism be situated immediately beneath the diaphragm, the latter avUI be pushed upward in a painful manner, and the heart aa'UI be dislocated upward and outAvard. Physical Signs.—As long as the aneurism remains enclosed Avithin the thorax, Avithout touching its wall, diagnosis is not assisted by physical examination. The respiratory murmur may, perhaps, be di- minished upon one side or the other, or a constant whistling sound over a compressed bronchus may be audible; but such signs admit of too many and too different interpretations to Avarrant our founding a decided opinion upon them. When the aneurism touches the thoracic Avail, upon inspection, Ave can almost ahvays perceive a distinct pulsation at the point of contact, and this becomes still more evident upon palpation. The pulse is isochronic with the beat of the heart, or follows close upon it. It is usually stronger, also, and is almost always accompanied by a peculiar whirring " frlmissement cataire." The point at AA'hich pulsation ap- pears in aneurism of the ascending aorta is usuaUy on the right border of the sternum at the second intercostal space. In aneurism of the arch it is at the manubrium sterni; in the descending aorta, it is seen upon the left side of the loAver thoracic vertebrae. Where the aneu- rism has perforated the thoracic Avail, inspection and palpation dis- cover neAV symptoms. At first, one intercostal space projects in the form of a hemisphere. The tumor soon extends, admitting of no ar- rest of its progress. It sits firmly and immovably upon tfie chest, and fully conveys the impression that it has sprung from AA'ithin the thorax. Sometimes the hemispherical form aftenvard gives place to an irreg- ular shape. In cases of great rarity, Avhere there is an inordinate ac- cumulation of clot in the sac, there is no pulsation. Percussion is absolutely dull and flat all over the tumor, or oA'er the region where it lies in contact Avith the chest. The sense of re- sistance upon percussion also seems considerably increased. Upon auscultation of aneurisms Avhich lie in contact Avith the side of the chest, Ave hear either a murmur or a simple or a double " tone." Explanation of these symptoms is obscure. The main cause of the systolic murmur and systolic sound is A'ibra- tion of the aneurismal Avail. When the Adbrations, into Avhich the latter is throAvn by the entrance of the blood, are regular, a systolic sound is the result; Avhen it is otherAvise, there is a murmur. Perhaps, too, a systolic murmur sometimes arises Avhen the aorta or pulmonary artery is compressed by the aneurismal sac, and Avhen the blood enters the aneurism from the aorta through a narroAV aperture. Diastolic sounds and diastolic murmurs are respectively the result of healthy. 408 DISEASES OF THE GREAT VESSELS. regular vibrations, and inefficient irregular Adbrations of the aortic A'alves, AA'hich are transmitted to the aneurism. Generally speaking, hoAvever, even AA'hen the aortic valves are healthy, a diastolic murmur is heard above the aneurism, and not a normal diastolic sound. This, probably, is due to the recoil of a blood-wave, or to the actual regurgi- tation of blood from the aneurismal sac into the aorta, OAving to the narroAvness and roughness of the aperture of communication. Diagnosis.—The diseases for AA'hich an aneurism is most liable to be mistaken are carcinomatous tumors of the pleura and mediastinum. Like aneurism, the latter may encroach upon the interior of the thorax, may compress and distort the adjacent organs, and, if in contact with the aorta upon one side and with the thoracic Avail upon the other, may even present a circumscribed pulsating point and aftenvard a pulsating tumor. Distinction betAveen the tAvo affections is based upon the following points: 1. Carcinoma of the pleura scarcely ever appears primarily, but its occurrence is almost always consecuth'e to the development of cancer elsewhere, particularly after extirpation of cancer of the breast. If the etiological conditions for cancer of the pleura be absent, Ave may infer the existence of aneurism AAdth great certainty. 2. Pulsation in a cancerous tumor of the thoracic Avail never ex- hibits any lateral dUatation, whUe an aneurism sAvells up Adsibly with every beat. 3. A systolic murmur may proceed from pressure of a cancer upon the aorta, just as it may occur in any artery pressed upon by the stethoscope; but we never hear the double sound or double murmur in cancer of the pleura, which is so common in aneurism. 4. We rarely or never discover difference between the pulses at the Avrist, when a tumor presses upon the aorta. 5. The symptoms of aortic aneurism just described are distin- guished by alternate paroxysms and intervals. The symptoms of cancerous tumors, on the contrary, are steady. Tfie diagnosis between an aortic aneurism and an aneurism of the innominata cannot be made with certainty. The symptoms ascribed to the latter—pressure upon the vena cava superior, upon the right bronchus, the right bronchial plexus, feebleness and retardation of the right radial pulse, dulness, pulsation, and a tumor in the right sterno- clavicular region—all occur in aneurism of the aortic arch. Prognosis.—Aortic aneurisms rarely recover. Cure has never been observed in a case where the disease has been recognized. On the other hand, life has sometimes been preserved for years, AA'here early exhaustion of the patient has not been brought about by debil- itating treatment. RUPTURE OF THE AORTA. 409 Treatment.—Venesection repeated at short intervals, a treatment , formerly much in vogue, is entirely without benefit in the treatment of | aneurism. This is true also Avith regard to digitalis, AA'hich, like A'ene- i section, Avas supposed to reduce tfie pressure from AAdthin, and to re- strain further expansion of the sac. Nor is it otherAvise AAdth the plan of placing a patient, Avith aneurism, upon a " vita minima;" that is, almost starving him to death, so as to reduce the volume of the blood. The action of this method, formerly much in use, can only be to aid in rendering the sufferer dropsical, and in hastening his death. The sug- gestion of acetate of lead, and of drugs containing tannin as* a means to promote coagulation of the blood, and to fill the sac Avith clots, is f founded upon theory alone, and deserves no reliance. Having recognized the existence of an aneurism, Ave must see that the patient shun all agents which tend to increase the action of the heart. Let him live moderately; guard him from the temporary plethora which folloAvs every excess; prescribing, hoAvever, a nourish- ing nitrogenous diet to counteract the threatening impoverishment of the blood. When a tumor develops upon the wall of the thorax, and when the skin upon it begins to redden, let the patient Avear a tin vessel upon the prominence, shaped according to the shape of the tumor, and filled AAdth. cold Avater. Electro-puncture, AA'hich has been employed a feAV times even against aortic aneurism, in order to produce coagulation of its contents, has hitherto had too little success to Avarrant repetition of tfie operation. To allay the pain, we are reduced to the exhibition of narcotics. CHAPTER III. RUPTURE OF THE AORTA. The aorta seldom bursts, if its tunics be sound. In most cases of its spontaneous rupture, its coats are the seat of the degeneration de- scribed in the previous chapter, or of the simple fatty metamorphosis mentioned AvhUe treating of aneurism. This is the case, even Avhen an excessively-distended aorta gives way above a stricture, for then, too, the coats are almost ahvays diseased. In some cases the rupture at first inA'olves the inner and middle tunics alone, while the adventitia, which is more yielding, and more easily distensible, remains for a time unbroken. The blood then Aoavs in betAveen the tunica media and adventitia, and forces them asunder; and thus a fusiform tumor, filled AAdth blood, is formed, AA'hich commu- nicates AA'ith the artery through the opening in the media and intima— aneurisma dissecans. According to the observation of Rokitansky 1 410 DISEASES OF THE GREAT VESSELS. recovery from this condition is possible. Far more frequently, in the course even of a feAV hours or days, death ensues from bursting of the adventitia, and escape of the blood into the pericardium, mediastinum, or pleura. At the moment of rupture the patient sometimes' suffers violent pain; but soon becomes pale, cold, and pulseless, singultus appearing Avith profound syncope, and other symptoms of internal haemorrhage. CHAPTER IV. STRICTURE AND OBLITERATION OF THE AORTA. According to Rokitansky, congenital narrowness of the aortic system is sometimes found, and principally in the female sex. It is accompanied by pallor, tendency to syncope, retarded development of the entire frame, but especially of the sexual organs, symptoms simi- lar to those which attend congenital smallness of the heart. We sometimes see a partial contraction of the aorta as a persist- ence of the so-called isthmus aortae at a point betAveen the left sub- claAdan and the ductus Botalli. In other instances there is an obliter- ation of the vessel at this point instead of a contraction. In these cases we have no sufficient knowledge of the conditions occasioning the permanent narroAvness, or even obliteration of the isthmus aortae, AA'hich exists during foetal life as a narrow communication between the arch and the descending aorta, but which becomes dilated soon after birth. It has been supposed that the ductus arteriosus Botalli might become obstructed by a thrombus, and that this thrombus might ex- tend into the aorta; or that the ductus Botalli, AvhUe in process of obliteration, might, during its contraction, also constrict the aorta. Neither explanation is satisfactory, as both constriction and oblitera- tion of the aorta have been observed where the duct of Botalli re- mained open. The immediate consequence of contraction of the aorta is hyper- trophy of the left ventricle and dilatation of that part of the aorta Avhich lies betAveen the heart and the point of constriction. The enor- mous dilatation Avhich takes place in the branches of the subclavian, and its anastomoses Avith the intercostal arteries, are of great impor- tance. The finest ramifications are converted into large branches AAdth firm walls, and a collateral circulation so complete is set up, that the blood, in ample quantity, is conveyed around the seat of stricture into the descending aorta. The principal of these collateral channels is formed by anastomosis between the first intercostal, arising from the subclavian, and the second, Avhich springs from the descending aorta; but extensive anastomotic communication also forms from the dorsalis DISEASES OF THE PULMONARY ARTERY. 411 i Bcapuli, subscapularis, transversafis colli, and the intercostals. The in- , I ternal mammary becomes immensely enlarged, as do the anterior inter- ' costals Avhich proceed from it. Its terminal branch, the superior epi- / gastric, also dilates, and, by its communication with the inferior epi- [ gastrics, conveys blood to the Uiacs. Obliteration of the aorta, serious as the malformation appears to be, is, nevertheless, a tolerably endurable one. It may long remain latent, and the patient may attain a Aery great age (ninety-tAvo years). In other instances, in course of time, palpitation of the heart, distressing pulsation of the carotids, or symptoms of hyperaemia of the brain, may manifest themseh'es. By-and-by a cachectic condition develops, and, 1 in nearly half the cases reported, death has ensued with symptoms of marasmus and dropsy. Thus Ave see that an obstruction to circulation as grave even as that presented by obliteration of the aorta may be compensated for, temporarily, by hypertrophy of the heart, but that it finally becomes imperfect, and that symptoms then set in of retarded | circulation, venous engorgement, and impoverishment of the blood, i such as Ave have so often described. In other instances, death, by rup- j ture of the heart or aorta, is the result, the walls, probably, ahvays undergoing previous degeneration. Diagnosis of this affection is based mainly upon the signs of the anastomotic circulation above described, and upon the absence of pul- sation in the ramifications of the abdominal aorta. In such subjects we see varicose, worm-like, sinuous arteries, and groups of arteries, distinctly pulsating on the back along the shoulder-blade, and upon the arch of the ribs. At a point corresponding to the course of the internal mammary, Ave hear, near the sternum, a bloAving sound, AA'hich is audible, also, at all points where the existence of dilated arteries is perceptible to sight and touch. On the other hand, in the tibials, or even in the popliteals and femorals, the pulse is feeble or even imper- ceptible. Bamberger considers that the deformity can ahvays be recognized Avith certainty from these diagnostic points. Treatment of stenosis of the aorta is entirely analogous to that of stenosis of the aortic orifices, to AA'hich Ave therefore refer. CHAPTER V. DISEASES OF THE PULMONARY ARTERY. Acute inflammation, terminating in suppuration, is quite as rare in the pulmonary artery as in the aorta. The alterations of the tunica intima described by us as chronic endarteriitis, are often absent in this artery AA'here the entire aortic system is far advanced in the disease 412 DISEASES OF THE GREAT VESSELS. On the other hand, it is tolerably common even when the aorta is sound in cases of deficience of the mitral valve, AA'ith consecutive hyper-1 trophy of the right ventricle. To it Dittrich attributes the frequence I of haemorrhagic infarction in the lungs of persons with heart-disease. Aneurisms of the pulmonary artery are exceedingly rare, and never attain any considerable size. In a case observed by Skoda there was found in this artery an aneurism as large as a goose-egg. During Hfe the patient had' labored under signs of grave circulatory disturbance, Avas cyanotic and dropsical; but no diagnosis could be formed by physical exploration. Diffuse dilatation of the pulmonary artery occurs with extraordi- nary frequence in cases Avhich cause hypertrophy and dilatation of the right heart. It never produces any change in the percussion-sound over the chest {Skoda), but not unfrequently, and usually upon dias- tole, Ave perceive a shock, and, indeed, a distinct pulsation, in the A'icinity of the root of the pulmonary artery. WhUe treating of metastases of the lung, we have already learned that the minuter branches of the pulmonary artery may become ob- structed by the intrusion into them of wandering emboli. When one of the larger branches is thus occluded, intense dyspnoea arises, and even death may suddenly ensue from the extent of breathing-surface thus throAvn out of action from interruption of its circulation. Within the last feAV years I have seen tAvo cases in which death occurred in the course of a feAV hours, with all the signs of extreme dyspnoea and col- lapse, and in Avhich it Avas found post mortem that a large thrombus had been detached from the femoral vein, had passed into the circula- tion, and, by obstruction of the main branch of the pulmonary artery, had occasioned this peculiar kind of suffocation. One of these cases is reported in the Wurtemberger Correspondenzblatt by my then as- sistant, Dr. Spdth. CHAPTER VI. DISEASES OF THE GREAT VENOUS TRUNKS. It is of disorders affecting the vena cava and the pulmonary veins alone that Ave now treat, as diseases of the peripheral veins are treated of in the hand-books of surgery; those of the portal vein and veins of other organs are more appropriately discussed as diseases of the liver, etc. Primary inflammation does not occur in the vena cava, and it is rare to observe inflammation and perforation of the coats of the as- cending portion of it by an abscess of the liver, or of the ceUular tissue ] I ) ; DISEASES OF THE GREAT VENOUS TRUNKS. 413 . | behhid the peritonaeum. Inflammation of the pulmonary A'eins, termi- ' nating in abscess, is equally rare. Dilatation of the great venous trunks takes place in diseases of the ! / heart, AA'hich occasion engorgement of the venous system. Their con- \ striction is almost solely the result of compression by adjacent tumors. I Primary thrombosis—that is, coagulation of the contents of a vein, AAdth consequent inflammation of its walls—has been seen occasionaUy j in the vena cava ascendens, but then the coagulum almost always forms | first in one of the femoral veins, and afterward spreads to the vena i cava. Such a formation of thrombus may be recognized by the folloAv- i ing signs: If, in addition to the tense painful oedema of a phlegmasia alba dolens of the leg, there suddenly set in a painfiU swelling of the other limb, if the secretion of urine be suddenly repressed, or should it become scanty and bloody, we may infer that the thrombus has in- volved the A'ena cava and emulgent veins. DISEASES OF THE OKGrANS OF DIGESTION. SECTION I. DISEASES OF THE MOUTH. CHAPTER I. CATARRH OF THE MOUTH. Etiology.—The mucous membrane of the mouth is peculiarly ex- posed to the sources of injury which excite catarrh elsewhere. Hence catarrh of the mouth is a very frequent affection, but it is only recently that the name " catarrh of the mouth " has been given to those changes which, occurring in other mucous membranes, are termed catarrh. It is remarkable that this affection is rarely induced by exposure of the skin to cold, a cause which so frequently excites catarrh of other mu- cous membranes. Among the injurious influences that may excite catarrh of the mouth are— 1. Irritation which acts on the mucous membrane. Dentition fre- quently causes catarrhal stomatitis, which often attains great severity. Rough teeth, ulcerated teeth, wounds in the mouth, very hot, very cold, or chemically injurious ingesta, smoking and chewing tobacco, etc., excite catarrh. The same effect is produced by the use of mer- curial preparations, not only when mercurial salve is rubbed on the gums, or Avhen mercurial preparations, in powder or solution, are taken by the mouth, but by inunction of mercurial ointment, and by taking mercurial pills, well covered up. For since the mercury, absorbed from the skin or the intestinal canal, is excreted by the salivary glands, it stUl causes direct irritation of the oral mucous membrane. Often, very small amounts of mercury avUI induce mercurial stomatitis; we can readily understand this, if Ave bear in mind that the mercurial swallowed A\dth the saliva is again absorbed from tfie intestine, and reaches the mouth repeatedly before escaping from the economy. The CATARRH OF THE MOUTH. 415 sensitiveness of the mouth to mercury varies Avith the individual; hence, in one patient stomatitis may occur sooner than in another, just as, after frictions on the skin Avith mercurial ointment, one person is affected earlier than another Avith the superficial dermatitis, AA'fiich Ave shall hereafter describe as eczema mercuriale. 2. In many cases, oral catarrh is a propagation of inflammation from neighboring organs to the mucous membrane of the mouth. Wounds and inflammations of the face, particularly facial erysipelas, also inflammations of the fauces, are almost ahvays complicated wdth oral catarrh. Less constantly, nasal and bronchial catarrh extends to the mouth. While a thickly-coated tongue AA'as considered a certain sign of disturbance of digestion, this secondary catarrh caused facial erysipelas and angina to.be almost ahvays regarded as manifestations of gastric disturbance, and to be treated accordingly. Acute and chronic catarrh of the stomach is surprisingly often complicated Avith catarrh of the mouth. Beaumont, who had the opportunity of com- paring the gastric mucous membrane Avith that of the mouth, in the case of the Canadian, St. Martin, found that changes in the former instantly excited analogous changes in the latter, and daily experience supports this observation. But, although catarrh of the mouth A'ery frequently accompanies catarrh of the stomach, we must not sup- pose, on the other hand, that gastric catarrh occurs AAdth every oral catarrh. 3. Catarrh of the mouth is not unfrequently a symptom of consti- tutional affection. Among the acute infectious diseases, typhus and scarlatina especially are accompanied by peculiar changes of the mu- cous membrane of the mouth, Avhich are essentially catarrhal; these will be more accurately described Avhen speaking of the diseases in question. Coated tongue is found in almost all feverish affections; but it would be going too far, to say catarrh of the mouth occurs in every fever (see treatment). Finally, in many cases Ave do not knoAV the exciting causes. Pfeuffer gives sitting up at night, and other observers give mental excitement, as a cause. It is remarkable that in some patients oral catarrh obstinately per- sists for years, Avithout our being able to find any continuous cause. Anatomical Appearances.—We seldom fiave the opportunity of observing oral catarrh in its incipient stage. Only after severe irri- tation, and occasionally during difficult dentition, Ave see the oral mu- cous membrane at first dark red and A'ery dry, till, finally, in the stage of decline, there is a copious secretion, Avhich is clouded by contain- ing young cells. After less severe irritation, and in the oral catarrh Avhich usually complicates catarrh of the stomach, the intense redness 416 DISEASES OF THE MOUTH. and dryness of the mouth are either unobserved, or are seen only tem- porarily. Quite early in the affection there is decided SAvelling of the mucous membrane and submucous tissue, increased secretion, and excessive formation of young cells. The swelling is most eA'ident at the edges of the tongue and over the cheeks. The tongue appears too broad to lie betAveen the teeth, and its sides show impressions of the teeth. A turbid mucus covers the cheeks, gums, and especially the tongue. The mucus and young cells most readily adhere to the filiform papillae, thus giving a coated tongue. Chronic oral catarrh has similar symptoms. The SAvelling of the mucous membrane is usually even more decided ; on the inner surface of the lips and cheeks, and on the roof of the mouth, Ave not unfre- quently find small nodules as large as a barley-corn (sAvelled mucous glands) ; thick yellow mucus covers the gums, especially about the teeth; the elongated processes of the filiform papillae appear as small white threads, and give the tongue a felty or hairy look {lingua hir- suta). On microscopical examination {Miquel), it is found that the | coating of the tongue, even in chronic oral catarrh, consists mostly of epithelial cells. These contain fat globules and brown granules, and not unfrequently unite together into brown plaques. At the same time we see rod-like formations, tfie broken epithelial processes of the filiform papillae {Kolliker). Felt-like formations groAV on these, their matrix forming a granular border to the hardened epithelial cells. We also find fat-globules, Adbrioncs, and usually some remains of food. Symptoms and Course.—Besides what Ave have said in the pre- ceding paragraph, there is little to add to the objective symptoms. In the severe forms of acute oral catarrh, which we first described, there is a feeling of burning and tension in the mouth. Babies no longer bite the ivory ring or orris-root, which is usually given them to facili- tate the cutting of the teeth. They cry when Ave touch their mouths, and, on attempting to nurse, they soon let go of the nipple, as if it hurt them. In some cases, Avhose frequency is magnified by the laity, so-called " teething convulsions " occur, which may prove fatal Avithout leaving any"material changes in the central organs to be seen on post-mortem examination. From our present knowledge of the subject, these con- vulsions must be considered as reflex symptoms, Avhich are caused by the severe irritation of the sensitive nerves of the mouth being trans- ferred through the central organs to the motor nerves. Indeed, it is doubtful whether these attacks are caused by the acute oral catarrh, or are the result of direct irritation of the sensitive nerves from the pressure of the teeth. (See chapter on Eclampsia.) CATARRH OF THE MOUTH. 447 In moderate cases of acute oral catarrh, characterized by increased mucous secretion and excessh'e cellular formation, the patients com- plain particularly of a " bad taste," Avhich they generally describe as slimy or clamm}'. Accurately speaking, this " slimy, clammy taste " is a misnomer, as physiologists only recognize bitter, sour, SAveet, and salty tastes. The patients feel a slimy substance on the oral mucous membrane, and attempt to remove it by hawking and spitting. But the sense of taste itself is also influenced by oral catarrh. Usually the disturbance only causes the taste to be less acute, and not so sensitive. Since an insensitive layer lies between the substance to be tasted and the peripheral ends of the nerves of taste, only very irritant substances excite distinct sensations. In such cases, the patients usually say their taste is bad or stale. When they chew hard substances, and thus re- moA'e the insensitive layer from the mucous membrane, the sense of taste is for a time better. In some cases, patients suffering from oral catarrh complain of a bitter taste. The laity consider this a sure sign of " biliousness," and some physicians think there is a status biliosus, and not a status pituitosus. In far the greater number of cases the bitter taste is a subjective symptom ; it is not excited by bitter substances, but must depend on a perversion of the nerves of taste. Lastly, the patients not unfrequently complain of a " foul" taste; this term is also unphysiological and incomplete. This fold taste is caused by excitement, not of the nerves of taste, but of the olfactory nerAes, Avith Avhose peripheral expansions in the Schneiderian mem- brane the gaseous emanations from the coating of the tongue come in contact through the posterior nares. The foul taste, or, more cor- rectly, the foul smell, is not solely a subjective symptom; generally, other persons perceive a fetor from the mouth of the patient, especially in the morning, before breakfast; this disappears Avhen eating has re- moved the foul epithelial coating from the tongue. It is doubtful whether pain in the forehead, so frequent a symptom in acute catarrh of the stomach, occurs in simple oral catarrh. The above symptoms are by no means ahvays accompanied by disturbance of the stomach digestion. The patients often have a normal feeling of hunger; but, it is true, they usually choose very sour and salty, or highly-flavored articles of food, Avhich can excite the nerves of taste even through the epithelial covering. Frequently there is no evidence that the stomach lias not properly digested the food taken into it. After meals, there is no pressure in the epigastrium, no eructation, or other symptom of disordered digestion. It is often difficult, indeed, to persuade the pa- tient that his stomach is sound, and not filled Avith decomposing sub- stances. The thickly-coated tongue, the slimy, bitter, or foul taste, 27 41S DISEASES OF THE MOUTH. and the smell from the mouth, appear to him sc distinctly to indicale " an emetic, that he considers advice unnecessary. The milder grades of oral catarrh, such as occur in most smokers, cause but slight subjective symptoms. In the morning the epithelium, which has collected during the night, usually causes a slimy taste and disagreeable odor from the mouth ; but these soon pass off, and, during the day, the patients have nothing to complain of; neA'ertheless, they usually prefer the most piquant, to the bland and unirritating kinds of food. , In severe cases, chronic oral catarrh is a most annoying affection, j The victims of it occupy a considerable time in the morning in hawk- ing and spitting, in scraping the tongue and rubbing the teeth and gums with a hard brush to clear off the adherent mucus. The sensa- tion, taste, and smell of the mouth are perverted all day; the odor from the mouth does not pass away. The patients consult the physician on account of the " slimy taste," for which they have in vain taken va- rious kinds of spring water, Strahl's and Morrison's pills, and AA'hich occasionally gives them severe hypochondriasis. The healthy appear- ance and well-nourished state of the patients usually contrast with their complaints. . On questioning them, Ave find that even articles of difficult digestion are eaten Avith impunity. It is necessary to under- stand these states, in order to recognize them in special cases and to treat them successfully. Diagnosis.—The coating on the tongue, observed in oral catarrh, must not be confounded Avith that which is found in healthy persons, especially in the morning, on the back part of the tongue, and Avhich is ealled the normal coating. According to Miquel, this is caused by the air passing through the nose and fauces during the night, inducing evaporation from the neighboring parts of the mouth, so that the epi- thelium, which, under normal circumstances, is thrown off, becomes dry and forms an opaque coating. According to Neidhart, Avho, in a disser- tation, written under Seitz's supervision, makes serious objections to this explanation of the coating of the tongue, other causes have much to do Avith its production. The epithelium of the mouth and tongue under- goes continuous desquamation, which is to be regarded as a result of the mechanical action of speaking and cheAving. It is evident that where the movement of the tongue is greatest, and AA'here it is most brought in contact with other parts, the epithelium avUI be soonest and most effectually cleaned off. Now, this occurs particularly in the an- terior part of the tongue, which, with every movement, is brought in eontact with the roof of the mouth, and in the sides, which lie directly against the teeth. The back part of the tongue, on the contrary, where the normal coating mostly occurs, does not fie against the roof CATARRH OF THE MOUTH. 419 of the mouth, and only touches it in the act of SAvallowing. Hence it folloAvs, on the one hand, that the most superficial epithelial patches on the anterior part are soonest and most completely loosened, and also that they are soon removed; but, on the other hand, that they should remain attached longer at the base, and even Avhen loosened should remain longer in position, especially as the elongated processes of the papillae afford them a great protection. In most feverish complaints the Avhole top of the tongue appears whitish. This does not generally depend on an increased formation of cells due to oral catarrh, but occurs because, while there is an increased loss of fluid through the skin, the secretions of the mouth are dimin- ished, so that the epithelium is less moist and transparent. Besides this, patients with fever suffer from loss of appetite, and do not cheAv hard substances, such as best remove the epithelium. Just as, in ma- rasmic persons Avith dry skin, there is continued apparent desquama- tion of the epidermis without its formation or removal being actually increased, so in feA'er the horny processes of the papillae and the epithelium of the mouth become more eAddent Avithout their being formed or removed in greater amounts. The presence of the swelling and moisture of the mucous membrance, which exist in oral catarrh, prevents our mistaking the coating of the tongue, that occurs in it, for that which avc find in fevers, Avhere tfie tongue is flat, small, and some- times even very pointed, the mouth dry, and consequently the patient thirsty. If the tongue of a fever-patient is dry, Avithout the epitheli- um and processes of the filiform papillae being at least of normal amount, of course the tongue does not appear coated. For the difference betAveen simple oral catarrh and that accompany- ing gastric catarrh, see Section III., Chapter I. Prognosis.—If Ave except the spasms during dentition, which are sometimes dangerous to life, and Avhose dependence on oral catarrh is still doubtful, the prognosis as regards life is favorable. The progno- sis for a perfect cure, especially in chronic oral catarrh, is less favora- ble, although even here a suitable, judicious treatment, if carefully fol- loAA'ed by the patient Avhich is rarely done, may give a favorable result. Treatment.—The causal indications cannot be fulfilled in all cases. In difficult dentition, cutting tfie gums is of doubtful benefit; occasionally the incisions inflame and cause the catarrh to become worse. Sharp edges of the teeth, Avhich are easily overlooked, are to be carefully removed, Avounds of the mouth and ulcerated gums are to be properly treated. Where smoking, especially the use of strong cigars, causes troublesome oral catarrh, it must be totaUy forbidden, or at least weak cigars only should be smoked through a cigar-holder, I £20 DISEASES OF THE MOUTH. or, stUl better, a long pipe should be used. Oral catarrh, caused by the" use of mercurials, requires their discontinuance, and in such cases all i traces of blue ointment are to be carefully removed from the skin. The secondary oral catarrh usually disappears with the cure of the erysipe- las, angina, gastritis, etc. We shall hereafter see that the latter does not require emetics nearly so often as these are ordinarily used in practice. The fact of the tongue being for a time cleaner after the vomiting depends altogether on mechanical causes, and does not at all prove that the oral and gastric catarrh are benefited. When caused by some infectious disease, the indications are the same as those for the treatment of the original affection. The treatment of the disease itself is essentially local, just as for affections of other mucous membranes that are within easy reach. This direct treatment is especially required in those cases of chronic oral catarrh which prove very obstinate even after the exciting cause has disappeared. For this obstinate clamminess I can strongly recom- mend a well-knoAvn domestic remedy; namely, slowly chewing small pieces of rhubarb before going to bed. I cannot ascribe the very gen- eral improvement to the direct action of the rhubarb on the gastric mucous membrane, since it does not produce the same effect Avhen given in very soluble pills. X In chronic catarrh persisting Avithout cause, rinsing the mouth ; Avith solution of carbonate of soda, or sloAvly drinking a bottle of soda- i Avater, on an empty stomach, is very useful. This evidently depends on the Avell-knoAvn power of the carbonates of the alkalies to diminish the tenacity of the mucus and render it more fluid. If this treatment is inefficacious, we may confidently order the mouth to be pencilled with a solution of corrosive sublimate (gr. j—ij, to the pound of water), as recommended by Pfeuffer, or A\dth a solution of nitrate of sUver (gr. j to | ss water), as advised by Henoch. The effect of these pre- scriptions in oral catarrh is not inferior to that in other catarrhs from the same remedies. CHAPTER II. CROUPOUS STOMATITIS—APHTHAE. Etiology.—On the mucous membrane of the mouth Ave often see small AA'hite spots, surrounded by a red border, Avhich look Hke flat vesicles; after a short time these are thrown off, and an excoriation, which heals readily, is left. This affection of the oral mucous mem- brane is designated by most authors as " aphthae," a name Avhich is also used for other diseases of the mouth, especially cancrum oris and CROUPOUS STOMATITIS.—APHTH.E. 421 thrush. From numerous careful observations, Bohn has shoAvn that, Avhen these white spots are punctured even in their earliest stage, no fluid can be evacuated from them, and hence that they are not vesicles, but solid thickenings, consisting of exudation on the free surface of the mucous membrane under the epithelium. I consider this AdeAV, AA'hich in the main corresponds AA'ith that of Rokitansky and Foerster, as correct; but I think that, to be consistent, the affection, Avhich on other mucous membranes we call croupous inflammation, should have the same name AA'hen it attacks the oral mucous membrane; hence, 1 do not hesitate to define aphthae as a croupous stomatitis limited to a circumscribed portion of the oral mucous membrane. Aphthae are chiefly observed in chUdren. During the first few niontlis, fiowever, they are rarer than during dentition. Weakly, badly-nourished children are more disposed to them than strong and well-nourished ones. Among the exciting causes, cutting the teeth is the chief. Aphthae often accompany the affection of the skin in the acute exanthemata, especially measles. Occasionally also they occur as small epidemics, without any perceptible cause, and it then appears as if they spread by contagion. Lastly, aphthae accompany other severe affections of the mouth, particularly cancrum oris. Anatomical Appearances.—Aphthae chiefly occur on the anterior half of the tongue, and the inner surface of the lips, cheeks, and hard palate. They are about the size of a lentil, round, often quite numer- ous, and are either disseminated or run together into irregular figures. The grayish or yelloAvish-Avhite deposits separate gradually from the periphery toAvard the centre, making the red border broader. When the exudation has entirely separated, there is no ulceration, only an excoriation; this is characteristic of a croupous affection, and distin- guishes it from a diphtheritic. The excoriated place is soon covered with epithelium again; aphthae leave no cicatrix. Catarrh, Avith copi- ous production of mucus and cells, affects the rest of the mouth. Symptoms and Course.—The eruption of aphthae is often pre- ceded for several days by fever, restlessness, loss of appetite, and the symptoms of oral catarrh. The disease itself is accompanied by pain, which is increased by nursing, and in older children by speaking and cheAvino-. At the same time the secretion of saliva is so much in- creased, that a clear fluid almost constantly runs from the half-open mouth. From the decomposition of the accumulated epithelium and the exudation thrown off, there is a disagreeable, penetrating fetor from the mouth, especially in the not unfrequent complication of the croupous Avith diphtheritic stomatitis (see Chapter III.). By repeated relapses the affection may last several weeks. Of itself it is scarcely ever dangerous. 422 DISEASES OF THE MOUTH. Treatment.—Chlorate of potash has very properly attained the reputation of a specific for aphthae. In almost all cases, under the use of a watery solution of this remedy (gr. jv—vj. at a dose), improvement and cure very soon occur. If, contrary to our expectation, the chlorate of potash does not produce this result, Ave may paint the aphthae with dilute muriatic acid, or with nitrate of silver. CHAPTER III. DIPHTHERITIC STOMATITIS, STOMACACE, CANCRUM ORIS, MUNDFAULE. Etiology.—As has been repeatedly said, in diphtheritic inflam- mation a fibrinous exudation is deposited in the tissue of the mucous membrane, and the part of the membrane affected sloughs from the compression to which its vessels are subjected by exudation. After the detachment of the diphtheritic slough thus formed, which is some- times dry, sometimes moist, a loss of substance remains. Diphtheritic stomatitis results—1. From the too continued or too excessive use of mercurials. 2. It not unfrequently occurs Avithout perceptible cause, especially among people living under unfavorable circumstances (mal loges, mal vetus, mal nourris, Taupin, Bohn). The latter form is usually called stomacace or cancrum oris; exten- sive epidemics of it occur in foundling hospitals, orphan asylums, bar- racks, and other institutions, and also in armies not in barracks, but in the field, or otherwise living in the open air; it is not improbably ex- tended by contagion. Anatomical Appearances.—In the mUder grades of the diph- theritic form of mercurial stomatitis, at certain parts of the mouth, along the lateral borders of the tongue, and on the parts of the cheeks and lips which lie against tfie teeth, we at first find a Avhitish or some- Avhat dirty discoloration of the mucous membrane. These white spots cannot be wiped off, but after a few days the superficial layer of mucous membrane, with the exudation infiltrating it, falls off, and in its place is left an unhealthy-looking ulcer, Avhich cleans off slowly and finally cicatrizes from the margins. In more severe cases, where the exudation infiltrates and destroys the whole thickness of the mucous membrane, a large portion of the inner surface of the mouth is often converted into a soft, discolored slough. If this separates, a deep ulcer with irregular borders and uneven base is left. The loss of substance is but sloAvly filled with granulations, and as the lost mucous membrane is not regenerated, but is replaced by cicatricial tissue, contracted cicatrices, or even adhesions and false anchylosis, not unfrequently remain. DIPHTHERITIC STOMATITIS, ETC. 423 In cancrum oris the infiltration and ulceration ahvays begin on the gums, usually at their upper border on the anterior surface. In severe cases it advances to the posterior surface of the gums, and the adjacent parts of the lips, cfieeks, and tongue. The teeth become loosened, and occasionally the periosteum of the jaw is exposed and destroyed. In consequence of this, in some cases there are caries and necrosis of the maxillary bones. Symptoms and Course.—The diphtheritic form of mercurial sto- matitis is accompanied by severe pain, particularly when the sloughs haA'e separated and left ulcers. Chewing, or eA'en speaking, avUI ren. der this pain unbearable. The secretion from the salivary and mucous glands is enormously increased, the patients cannot sleep, as the secre- tion, if not ejected, runs into the larynx, and induces cough or suffoca- tion ; if they lie on the side and succeed in sleeping, they soon wake to find the pillow cold, wet, and saturated with saliva. On the parts of the tongue and gums, but especiaUy along the edges of the teeth, Avhich are free from sloughs or ulcers, there is an unusually thick, yel- Ioav, soft coating. There is a very penetrating bad odor from the mouth, caused by the decomposition of this coating, and of the slough of the mucous membrane. It is not decided whether or not this smell is caused by the formation of sulphuret of ammonium from the disintegration of the sulpho-cyanide of potassium, which is a normal constituent of the saliva, by the decomposition going on in the mouth. Even AA'hen the mercurials have been stopped, the pain, flow of saliva, and smell, pass off sloAvly, and even in mild cases it is usually from eight to fourteen days before the patient feels Avell. In severe cases the cure progresses even more sloAvly; as Avas mentioned above, there may even be permanent injury. At the commencement of cancrum oris, according to the excellent description of Bohn, the gums are dark red and greatly SAvelled by excessh'e hyperaemia. They appear loosened from the teeth, and bleed on the slightest pressure. After this stage has lasted two to four days, a gray membranous deposit almost ahvays appears on the upper border of the gums, particularly about the incisor teeth of one side of the loAver jaAA'. On careful examination, Ave find tfiat tfiis deposit, Avhich is a pulpy substance, does not lie on the gums, but consists of the o-angrenous tissue of the gums. After the separation of the pulpy mass AA'hich Ave, in opposition to Bohn, must consider a diphtheritic slough, there is found a loss of substance of the gums, on the surface and periphery of Avhich the same process is repeated as long as the affection lasts, until in severe cases the contours of the gums are lost, the teeth loosened, and the other eAdls described above have resulted. At the same time the neighboring lymphatic glands are swelled and 124 DISEASES OF THE MOUTH. painful; the parts of the lips and cheeks corresponding to the affected part are oedematous; the breath has a cadaverous odor; the saliva, which is often bloody and discolored, Aoavs constantly from the mouth; and every attempt to sAvallow, or even to drink, causes severe pain. The patients aA'oid closing the mouth and even keep the jaAvs apart, to prevent rubbing. Strange to say, the general condition and even the appetite are affected but little ; fever is slight or even absent; when properly treated, the disease almost always runs a favorable course, the diphtheritic sloughs separate, and the ulcers under them heal in a relatively short time. Neglected and improperly treated, the affection may exist for months, but it rarely endangers life. Fatal results probably ahvays depend on complications. Treatment.—In the diphtheritic form of mercurial stomatitis Ave must not neglect to tell the patient hoAV slow his cure avUI be. He avUI bear his sufferings much better if he does not find his hopes dis- appointed from day to day; but if we promise him that, if not cured sooner, he will, at least, be comfortable by the eighth or ninth day, he will be patient and submit to what is unavoidable. Frequently wash- ing the mouth with cold water, or with water and red Avine, at the commencement, subsequently painting the ulcers AAdth dilute muriatic acid, or, still better, wdth the solution of nitrate of silver, described in Chapter I., but especially the use of solution of chlorate of potash, are far preferable to the internal administration of iodide of potassium and mercurial antidotes, or painting the mouth Avith spirits of camphor, AA'hich is as painful as useless. Touching the ulcers occasionally Avith solid nitrate of silver is very beneficial, but exceedingly painful. Chlorate of potash is just as certain a specific against cancrum oris as against aphthae. To chUdren under one year we may give one, scruple daily, to older ones half a drachm, to adults one to tAvo drachms, dis- solved in six ounces of Avater. Under this treatment the bad odor very quickly disappears; the ulcers also commence to clean up in a few days and heal rapidly. We are very rarely obliged to touch the ulcers Avith nitrate of silver. CHAPTER IV. EXCORIATIONS AND ULCERS OF THE MOUTH. Etiology.—The rapidly-healing excoriations which remain after aphthae, and the ulcers caused by mercurial stomatitis and cancrum oris, were discussed in the last chapter and the one before it. Small vesicles, folloAved by very painful excoriations about the point of the tongue, appear to be caused by local injuries; at least, the • I EXCORIATIONS AND ULCERS OF THE MOUTH. 425 patients suffering from them ahvays say they must have burnt them- selves, smoked too much, etc. Diffuse catarrhal ulcers rarely occur in the oral mucous membrane; still I have observed them in some cases. In one instance the greater part of the surface of the tongue Avas the seat of an obstinate catarrhal ulceration. Folficular ulcers not unfrequently occur from stoppage, SAvelling, and ulceration of the large mucous glands, which are particularly plen- tiful on the inner surface of the lips. In some females these almost ahvays occur at the menstrual periods; in others, during pregnancy or lactation (stomatitis vesicularis materna). They are also seen in men AAdthout any apparent cause. Irregular ulcers at the angles of the upper or loAver jaAV occur quite often. According to Bednar and Bamberger, they result from the destruction of a fibrinous exudation, infiltrating tfie mucous membrane, but by their limitation to the above-named locality are distinguished from the ulcers left by cancrum oris. Variolous ulcers result from the eruption in variola passing from the skin to the mucous membrane of the mouth. Herpetic vesicles may attack the mouth and cause small herpetic ulcers. The callous ulcers on the tongue caused by sharp edges of teeth, and those of the gums resulting from the formation of tartar, belong to surgery. Syph- ilitic and scorbutic ulcers avUI be treated of in separate chapters. Anatomical Appearances.—The small vesicles and excoriations at the end of the tongue are only discovered on careful examination. If the A'esicle has ruptured, it looks as if the epithelial processes of one or more filiform papillae Avere broken off; AA'e see only a small, slightly-excaA'ated red spot. In diffuse catarrhal ulcers, there is a loss, not only of the epithelial covering of the mucous membrane, but also a superficial loss of substance of the mucous membrane itself, of varia- ble extent, and usually of irregular shape. The rest of the mucous membrane of the mouth shoAvs the above-described changes of catarrhal inflammation AA'ith extensive production of cells. Follicular ulcers are rarely numerous; frequently there is only one. This usually starts as a bright, pearly vesicle, which subsequently breaks, and becomes an oval ulcer, several lines long. Tfie base of this ulcer is quite yelloAV, or lardaceous, and covered Avith a thin secre- tion ; the edges are someAA'hat elevated, hard, and red. The irregular ulcers at the angle of the jaw are occasionally sym- metrical on both sides; they may be several lines long, are irregularly shaped, arid present a loss of substance of the mucous membrane, Avhich even extends into the submucous tissue. They often cause ob- stinate SAvellings of the cervical glands. 126 DISEASES OF THE MOUTH. The variolous ulcers occur particularly on the roof of the mouth. After the rupture of the flat pustules, Avith which the eruption begins, superficial, round, easily-healing ulcers are left. Herpetic ulcers usually occur on the insides of the cheeks, and on the roof of the mouth. The A'esicles, which form groups like the herpes vesicles on the lips, break early, and leave flat ulcers, which soon heal. Symptoms and Course.—The small vesicles and excoriations on the point of the tongue are annoying, but perfectly free from danger. They disappear without treatment in a few days. The inconvenience they cause contrasts strongly with the very slight anatomical changes. The diffuse catarrhal ulcers render the motions of the mouth, es- pecially of the tongue, very painful. After they have lasted some time, this pain seems to diminish, even if the objective symptoms con- tinue unchanged. Follicular ulcers also are accompanied by pain in speaking and cheAving, and by the symptoms of oral catarrh. The lardaceous base and hard edges of these ulcers greatly frighten half-initiated non-pro- fessionals, who have suffered from syphilis, because, from these appear- ances, they make up their minds that the ulcers are of specific nature. The ulcers at the angle of the jaw render chewing and swallowing difficult, and, in some patients, cause severe pain, while in others they ! are not discovered till the mouth is carefully examined. They are ' rarely dangerous, although they sometimes last for weeks. Variolous and herpetic ulcers rarely cause much pain. Treatment.—The small vesicles and excoriations at the point of the tongue disappear if the mouth is kept free from injuries for a few days, smoking and the use of hot food, etc., being avoided. Chlorate of potash is not so serviceable in diffuse catarrhal ulcera- tion as in other affections of the mouth. Continued and energetic local treatment Avith nitrate of silver, and particularly with a weak solution of corrosive sublimate, is most serviceable. The beneficial effects of the latter are analogous to those attained by the treatment of some skin affections Avith mercurials. In treating follicular ulcerations, we must look out for any disturb- ances of digestion. If tfiese have been removed, or are not discover- able, we confine ourselves to the use of chlorate of potash and energetic local treatment. Touching the ulcer Avith solid nitrate of silver is very painful, it is true, but it acts surely and quickly. The ulcers at the angle of the jaw require no internal treatment, but chlorate of potash is recommended for them also. Locally, we may use nitrate of silver or concentrated acetic acid, as recommended. by Rilliet and Barthez. Variolous and herpetic ulcers require no special treatment. SYPHILITIC AFFECTIONS OF THE MOUTH. 421 CHAPTER V. SYPHILITIC AFFECTIONS OF THE MOUTH. Etiology.—Primary ulcers and condylomata—that is, those de- veloping at the point where the transfer of the syphilitic poison has taken place—occur, according to my observation during the last feAV years, much more frequently than I had formerly supposed. In some cases the contagion passes from the nipple of a syphifitic nurse to the mouth of the nursling. Occasionally the infection is caused by un- natural debauchery; most frequently through so-called sugar-teats, which pass from the mouth of a syphilitic to that of a non-syphilitic person. From one town in the vicinity of Tubingen, I have treated, and shown in the clinic, a family of ten persons, children, parents, and grandparents, who all had syphilitic ulcers and condylomata of the oral mucous membrane from this cause. Among the secondary syphilitic affections (by which term we mean those that occur in the early stages of the disease only, not at the point of infection, but at other parts of the body), condylomata and ulcers often occur together in the mouth. Among the tertiary forms (those which occur in the later periods), Ave have the gummy tumors, or nodular syphilomata ( Wagner) of the tongue, Avhich are often mis- taken for cancer of the tongue. Anatomical Appearances.—Both the primary and secondary syphUitic ulcers and condylomata spring from circumscribed indura- tions, or from syphilitic papules of the mucous membrane. Then an excessive collection and milky cloudiness of the epithelium give a pe- culiar white appearance (as if it had been touched with nitrate of silver) to the surface of the affected part. Subsequently the papules of the mucous membrane form syphilitic erosions or ulcerations by molecular disintegration, or condylomata by papUlary proliferation, or both together. The ulcers occur most frequently at the corners of the mouth; here they are usually superficial, and it looks as if the com- misure of the lips were torn. On the edges of these ulcers there are almost always small condylomata. The ulcers occurring on the tongue, especially on its upper surface or sides, AA'hich are exposed to many sources of injury, form more or less deep fissures, or extensive losses of substance, Avhose uneven base is covered Avith a Avhitish-gray de- tritus. On the lateral edges of the tongue, the condylomata usually form elongated, shalloAV excrescences; on the dorsum of the tongue, on the contrary, they form round or oval Avarty vegetations, Avith broad bases, often separated by fissures. Not unfrequently, patients who have a bad conscience, and occasionally, also, inexperienced physicians £28 DISEASES OF THE MOUTH. mistake the circumvallate papillae at the base of the tongue for sypfii litic condylomata. Gummy tumors, or nodular syphilomata of the tongue, usually come on the anterior third. At first only an indurated spot is noticed; this soon swells to the size of a bean or hazel-nut, and subsequently softens and ruptures. After the rupture of the nodule there is left a deep, sharply-bounded ulcer, with inverted, thickened borders. Symptoms and Course.—The primary and secondary ulcers in the mouth cause pain in chewing and speaking, and are accompanied by the symptoms of chronic oral catarrh, described in the first chapter. The diagnosis rests partly on the history, partly on the objective symp- toms above given. When condylomata occur at the edges of the tongue, they cause little annoyance, and would be easily overlooked, if patients who have long suffered from syphUis did not pay such attention to themselves. They often recede at one place, Avhile new ones come at another. In other cases, without any treatment, they disappear for a longer or shorter time, but come back again, and, with any treatment, show great tendency to relapse. Condylomata on the dorsum of the tongue impede its movements, and thus become annoying. Inspection of the mouth renders the diagnosis certain, as the affection is not easily mistaken. The nodular syphilomata of the tongue develop Avithout pain, and even their ulceration does not cause much, but they render the tongue unwieldy and rigid, and thus interfere with speaking and cheAving. But the ulcers left, after their breaking doAvn, are very sen- sitive to the touch of the teeth, and to hard articles of food. Treatment.—The principles for treating syphilitic affections of the mouth will be given hereafter. The effect of preparations of mercury on primary and secondary ulcers and condylomata of the mouth is, as a rule, very striking. We may, almost with certainty, reckon that, under mercurial treatment, they avUI very shortly improve, and entirely disappear. Nevertheless, we must guard against the misuse of mercurials, especially in repeated relapses of syphilitic papules of the mouth, when they are the sole symptoms of syphilis. Even the nodular syphilomata of the tongue may disappear at any stage, under, proper treatment. CHAPTER VI. SCORBUTIC AFFECTIONS OF THE MOUTH. Etiology.—The affection of the gums is among the most constant and among the first symptoms of scorbutis. Tfie changes in the gums are exactly analogous to those caused by the disease in other tissues. SCORBUTIC AFFECTIONS OF THE MOUTH. 429 They compel us to suppose an abnormal condition of the capillary Avails, Avhich explains the various exudations and inclination to haemor- rhage, seen in scorbutis, better than would be done by an abnormal condition of the blood, the nature of Avhich is entirely unknoAvn, and AA'ho se presence even has not been proved. For the causes of scorbutis, and hence almost ahvays of this affec- tion of the gums, see chapter on scorbutis. Anatomical Appearances.—The seat of the scorbutic affection of the mouth is exclusively in the gums, but, where any of the teeth have been lost, the gums are just as free from the affection as other parts of the mouth, and, where all the teeth are gone, the patients do not have any scorbutic affection of the mouth. Occasionally the affec- tion is limited to one side, and in some cases to the parts around a feAV teeth. At the commencement there is a red border to the upper margin of the gums; these soon begin to SAvell, and to become dark blue. The pointed processes between the teeth especially swell out, and their attachment to the teeth is loosened. The SAvelling, which depends on oedema and the escape of blood into the parenchyma of the gums, may become so great that the gums press over the teeth and hide them, or that spongy swellings, half an inch or more thick, form on the gums. About the teeth, and at the top of the swelling, the surface subsequently disintegrates to a soft, discolored mass, after the separation of Avhich there is left a loss of substance. This sloughing appears to be caused partly by the excessive tension of the infiltrated portion, partly by the pressure it is subjected to by the teeth. When improA'ement begins, the SAvelling of the gums subsides; they again become attached to the teeth, and finally attain their normal color. In a few cases, a neAV formation of connective tissue seems to occur during the affection; after the swelling has subsided, the gums retain a cica- tricial solidity, are uneven and nodular. Symptoms and Course.—CheAving is very painful, and often im- possible, on account of the swelling of the gums. The secretion of mucus and saliva in the mouth is greatly increased. Haemorrhages occur on attempting to chew, as well as from slight pressure on the gums. The decomposition of the contents of the mouth, which are mingled Avith blood, and subsequently AA'ith dead tissue, causes a very penetrating and disagreeable odor. These symptoms, and the exami- nation of the mouth, in Avhich Ave find the above-described changes, too-ether Avith the observance of the other symptoms of scorbutis, con- firm the diagnosis of a scorbutic affection of the mouth. Treatment.—With proper treatment of the original affection, the affected gums often return to a normal state in a surprisingly short time. Along AA'ith the dietetic and therapeutic remedies for the original 130 DISEASES OF THE MOUTH. disease, Avhich avUI be described hereafter, it is customary to use astrin- gent mouth-washes, such as spiritus cochleariae, tinctura myrrhae, rhata- niae, or decoctions of willow, oak, or Peruvian bark. In an epidemic in Prague, observed and described by Cejka, Avashing the mouth with warm vinegar, containing more or less brandy, Avas found beneficial Avhere there was loosening of the gums. Where the affection of the gums was more severe, a Hnctus, with muriatic acid, Avas prescribed. Subsequent relaxation was treated by astringent decoctions and solu- tions of alum. CHAPTER VII. SOOR — MUGUET — THRUSH. Etiology.—Thrush was considered as a peculiar form of exudative stomatitis until it was discovered that a parasitic plant, growing on the mucous membrane of the mouth, caused the disease, or at least had a great deal to do with it. The thrush-fungus, oidium albicans {Robin), is not found outside of the organism, hence we do not know Iioav its germs reach the mouth. But there is no doubt about certain circum- stances being required for the germs to reach the mouth and the fun- gus to groAV there. In chUdren the affection is only seen during the first days and weeks of life, rarely in the second month; in adults it only occurs in protracted, exhausting diseases a short time before death. Hence it appears probable that the germs become attached most readily, and the fungus grows best, where the acts of chewing and SAvallowing are not very energetically performed, and the fungus can remain quiet and find nourishment in the disintegrating product of the epithelium and remains of food adherent to it. The layer of mucus, lining the mouth, appears to interfere with the implantation of the fungus. In the newly-born or in moribund patients we may often foretell appearance of the thrush fungus, from a certain amount of dry- ness of the mouth. It is not probable, at least for all cases, that the diminished secretion from the mouth is due to the first stage of catarrh, even though the unaccustomed irritation in the delicate oral mucous membrane of a newly-born child may readily cause catarrhal irritation. Neglect of cleansing the mouth greatly favors the development of thrush. In large lying-in and foundling hospitals, where the care, by Avhich thrush can almost ahvays be prevented, is not exercised, the affection often attacks almost all the children. Although thrush has, in some cases, been transferred directly from the oral mucous mem- brane of one person to that of another, still the affection cannot be reckoned among those that spread by contagion. It is not necessary for a patient Avith thrush to be in the vicinity, for another to be affect- THRUSH. 431 ed Avith it; but the germs of thrush, like those of mould, seem to be very plenty and Avidely-spread, and to develop AA'herever they find a suitable place and favorable circumstances. Anatomical Appearances.—Whitish points, or a delicate frosty coating, in severe cases a cheesy, smeary mass, looking much like cur- dled milk, are found on the inner surface of the lips, tongue, and roof of the mouth. At first these may be readily removed, subsequently they are more firmly attached. From the mouth the coating occasion- ally advances to the larynx, more frequently to the oesophagus; in some cases the latter has even been found filled Avith thrush deposit. The disease scarcely ever extends to the stomach. On microscopical examination of the milky deposit it is found to consist of young and old epithelial cells, fat-globules, etc., between which peculiar round granules and filaments may be seen. The first are knoAvn to be spores of fungi by their oval form, sharp outlines, by tfie excavation AA'hich is evident in the larger ones, and by their difference in size, indicating their groAvth. The filaments starting from the spores are of variable thickness ; they have sheaths and constrictions; where the latter occur they have branches, Avhich go off from them at acute angles, and have the same calibre as the trunks. These fungoid filaments form beauti- ful tree-shaped figures, or, when very numerous, form a thick felt. It often looks as if they perforated the epithelial cells, located at their joints. At first the thrush-spores are in the most superficial layers of the epithelium; later they press in between them. They may even, although this rarely occurs, groAV into the mucous membrane itself. Symptoms and Course.—Children suffering from thrush almost ahvays shoAV that nursing pains them. Patients dying of phthisis, car- cinoma, etc., complain of painful burning in the mouth, when they are affected Avith sprue. It is uncertain Avhether these difficulties depend on tfie injuries that the deposit causes to the mucous membrane, or Avhether a coincident sfight inflammation of the oral mucous membrane excites these pains and causes the groAvth of the fungus. In children, suff. ring from thrush, Ave often see diarrhoea, accompanied by pain in the . bdomen, Avith fluid, green, acid stools. At the same time there are not unfrequently redness and excoriations about the anus, inside of the thio-Hs and nates. As this symptom also occurs in nursing infants AAdthout thrush, and as many children having thrush have no diarrhoea, many consider it as an accidental complication, Avhile others, especially French observers ( Voileix), have considered diarrhoea among the symp- toms of thrush. It is difficult to decide Avhich is right. In many cases the diarrhoea may be independent of the thrush. But, as we have to ascribe so many cases of infantile diarrhoea to abnormal decomposition of the ino-esta, and as AA'e knoAV that, AA'here microscopical germs form, 432 DISEASES OF THE MOUTH. there is usually abnormal decomposition, it does not appear very im- probable that part of these diarrhoeas are caused by the presence of thrush-deposit in the mouth and its passage into the stomach and in- testine. Treatment.—Even sensible and attentive mothers rarely use an amount of care in cleaning the baby's mouth sufficient to prevent the development of thrush. It is true the mouth is washed out in the morning AA'hile bathing the baby, and at night Avhen undressing it; but during the day they let it go to sleep on the breast, carefully AA'ith- draw the nipple from the mouth so as not to aAvake it, and lay it in the cradle, while the last portions of milk, not yet SAvalloAved, remain in the mouth and decompose, preparing the mouth for the thrush-fungus. At the same time most nurses, partly from ignorance, partly to excuse their neglect, conceal from the mother the fact that neglect of cleanli- ness is the cause of the development of the fungus. They even desig- nate the sprue as a " healthy affection," which is advantageous for the Avell-being of the child. The physician should most strongly urge his patients to carefully wash the baby's mouth with a linen rag dipped in Avater, or a mixture of water and Avine, after each feeding, Avhether it is to go to sleep or not. If this rule is carefully followed, the children Avill almost certainly remain free from thrush. EAren after the deA'elopment of thrush we may limit ourselves to carefully remoA'ing the creamy deposit and Avashing the mouth. The home remedies, such as sprinkling the mouth AAdth sugar, painting it Avith borax and mel rosae, Avhich are advised by the nurses, are to be avoided; they render the mouth sticky, give new material fox decom- position, and do not at all interfere with the development of the thrush. The accompanying diarrhoea must be treated according to principles hereafter set doAvn. CHAPTER VIII. PARENCHYMATOUS INFLAMMATION OF THE TONGUE—GLOSSITIS. Etiology.—In most cases of glossitis an exudation is deposited between the muscular filaments of the tongue while they themselves are rarely inflamed or destroyed (see pathogenesis of myocarditis). Acute parenchymatous glossitis is a rare affection, it is only induced by severe injuries affecting the tongue; such as burns and injuries from acrid or caustic substances, and especially from bee and Avasp stings. Chronic partial glossitis results most frequently from the pres- sure of sharp edges of the teeth and rough pipe-stems. We do not knoAV the causes of dissecting glossitis. > PARENCHYMATOUS INFLAMMATION OF THE TONGUE. 433 Anatomical Appearances.—In acute glossitis the Avhole tongue is usually affected; very rarely the affection is limited to one side. The tongue often appears doubled in size, dark red, the surface smooth or fissured, and covered Avitfi tough, often bloody exudation. The sub- stance of the tongue is infiltrated, softened, and pale. When resolu- tion occurs, the tongue returns rapidly to its normal size and structure; in other cases it remains for a long while, or permanently, somewhat indurated and enlarged. In severe glossitis, small abscesses, filled with purulent fluid, form in the substance of the tongue; these enlarge, unite, and may perforate the mucous membrane, and be evacuated. The loss of substance thus caused leaves a radiated, depressed cicatrix when it heals. In chronic partial glossitis Ave find, particularly at the edge of the tongue, circumscribed hard spots, Avhich project slightly or not at all, and Avhich often retract the neighboring parts of the tongue just like cicatrices. At these points the muscular substance has disappeared, and is replaced by connective tissue. In the form called glossitis dissecans, the tongue is divided into lobules by deep furroAvs over its surface. Remains of food and epithe- lium collect in these furrows and cause ulceration. Many apparent cracks in the surface of the tongue are simple folds of the mucous membrane, and are analogous to the Avrinkles of the skin, Avhich we so often see in old persons, especially in the face. Symptoms and Course.—In acute glossitis there is not room enough in the mouth for the enlarged tongue, which projects almost an inch beyond the teeth, which are kept apart. The upper surface is AA'hitish, or, if the exudation covering it is mixed with blood, it is dirty broAvn; the under surface is dark red. The deep impressions made by the teeth in the sides soon change to ulcers Avith fatty coatings. The tension of the tongue caused by the great swelling excites severe pain. The movements of the tongue are impaired by the pressure caused by the exudation on the muscular fibres, speech becomes unin- telligible and soon impossible, chewing and swalloAving the same Avay. The saliva constantly runs out of the mouth at both sides of the tongue, Avhile, the mouth being open, evaporation constantly goes on, and the surface of the tongue, not being moistened, becomes dry and incrusted. The submaxillary and the lymphatic glands of the neck enlarge, the circulation in the jugular vein is obstructed; the face appears blue and SAVollen. The entrance to the larynx may be contracted by the SAvelling at the root of the tongue, and respiration be very much im- paired ; hence attacks of suffocation often occur at the height of the affection; these may cause death. Acute glossitis is accompanied by high fever, full pulse, great anxiety and restlessness, and severe con- 28 434 DISEASES OF THE MOUTH. stitutional disturbance; but, when the breathing has been affected for some time, the symptoms change: the pulse becomes small, the patient listless, and the symptoms occur that we have described as caused by carbonic-acid poisoning. When the disease runs an entirely favorable course, these symptoms gradually subside; they are often suddenly arrested by suitable treatment. When abscesses form, all the symp- toms increase; but, Avhen perforation occurs, they subside almost in- stantly. Chronic partial glossitis causes a circumscribed dull pain, which only becomes burning when there is coincident ulceration of the mu- cous membrane. The induration impairs the movement of the tongue. The affection may last for years, and is often mistaken for cancer of the tongue. Glossitis dissecans is A'ery painful as long as there is any excoriation between the divisions of the tongue. When these have healed, abnor- mal divisions of the tongue remain, but do not incommode the patient. Treatment.—The great danger of acute glossitis requires that the treatment should be very energetic. General bleeding, leeches or cups to the neck, are of no use. Leeches applied directly to the tongue increase the eAdl. Blisters to the nape of the neck, determination to the intestines by the use of laxatives or stimulating enemata, are just as useless. It is much better to scarify the whole top of the tongue boldly and deeply; OAving to the swelHng, Ave need not fear Avounding the ranine artery. When the disease is at its height, we may give the patient pieces of ice in the mouth, and not give soothing mouth- Avashes till the symptoms have moderated or the glossitis subsided. If deep incisions are ineffectual and suffocation threatens, tracheotomy may be necessary. In chronic partial glossitis we must first of all remove the sharp edges of teeth, etc. But frequently this is insufficient, and operation is the only effectual treatment. Iodine, water from mineral springs, and systematic purgation, have been recommended on theoretical grounds; experience has not proved their advantage. In glossitis dissecans we may limit ourselves to the treatment of the ulcers by nitrate of silver in substance or solution. CHAPTER IX. NOMA—WATER CANKER—GANGRENOUS SORE MOUTH. Etiology.—Noma is that form of gangrene which results from an asthenic inflammation, that is, from an inflammation occurring in a de- bilitated person. " If a nutritive change of destructive character af- NOMA, WATER CANKER, ETC. 435 fects parts Avhich have been greatly altered by previous changes of their nutrition, entire death of the part may quickly result." ( Virchow.) The disease is almost exclusively encountered among chUdren, especially among those Avho haA'e become cachectic from want of care, insufficient or spoiled food, and bad dAvelfings; or among those who have just recovered from severe illness that has greatly weakened them. Noma is most frequently seen as a result of measles, more rarely after other acute exanthematous affections, or after typhus, pneumonia, etc. Misuse of mercurials in the treatment of the above affections appears to have much to do with the occurrence of noma as a sequel; it often begins simultaneously with mercurial stomatitis. In the north of Germany, and especially in Holland, it is more fre- quent than in the south. It seems never to be epidemic. Anatomical Appearances.—The affection almost ahA-ays begins on the inside of the cheeks. Over a spot hardened by infiltration, the mucous membrane becomes red, then discolored ; a vesicle filled with cloudy serum, often forms on this. The affected part soon blackens, softens, and disintegrates. The gangrene spreads, destroys the gums, the lips, the base and edges of the tongue on the affected side; the maxUlary bones are exposed and exfoliate, the teeth become loose and fall out. Progressing, the gangrene reaches the outer surface of the cheeks, spreads rapidly, and finally changes the entire cheek, part of the nose, the loAver eyelid, often even half the face, into a ragged, pulpy, moist mass, or to a dry, black slough. The blood-vessels resist the destruction longest; on post-mortem examination, they are found still preserved, but filled AA'ith fibrinous coagula. In the few cases that recover, the gangrenous masses are throAvn off and the loss of sub- stance is filled with granulations, so that a firm, fibrous cicatrix finally results from a neAV formation of connective tissue. Adhesions in the mouth and frightful disfigurement ahvays remain. Symptoms and Course.—According to the excellent description of Rill let and Barthez, Avhile the gangrene commences, usually with- out pain, on the inner surface of the oral mucous membrane, a soft, regular, circumscribed oedema occurs in the affected cheek and lip, and gradually spreads. A liard, round nucleus forms in its centre, over which the skin appears shining, pale, or mottled violet. Even Avhen the inside of the cheeks and a great part of the gums have become gangrenous, the child often sits quietly in bed. A sanguineous, or even black saliva, runs out of his mouth; but he plays, demands food, takes it eagerly, and with the food sAvalloAVS the sloughs that fall off from the gangrenous parts. At the same, time the skin is pale and cool, the pulse small and moderately frequent, and there is delirium at night. Occasionally, mostly at the fifth or sixth day of the disease, a 436 DISEASES OF THE MOUTH. circumscribed, dry, black slough forms on the cheeks or under-lip ; this increases daily, till it affects half the face. Occasionally, even at this stage, the child is tolerably strong, demands food, and tears gangre- nous pieces out of the mouth. The appearance becomes more hideous Avhen the slough separates, and tags hang from the cheeks, between Avhich we can see the bare, loosened teeth, and blackened jaAV-bone. Then the smell is excessively disagreeable, the patient very Aveak, and diarrhoea usually comes on; thirst is almost unquenchable; the skin is cool and dry; the pulse small and imperceptible; finally, the child dies of exhaustion. Occasionally, the disease begins to recover from the first stage; but, even after detachment of the external slough, the gangrene may be limited, the swelHng diminish, the general health improve, the surfaces of the wound clean off, and healthy suppuration occur. Treatment.—Quinine, chlorine-Avater, charcoal, and other antisep- tics, have been recommended as internal remedies; but they are of little service ; tfiey are recommended more on theoretical grounds than from experience of their benefit. We should give the patient fresh air, good nourishment, a small amount of Avine, and treat the gangrene locally, according to surgical principles. Almost all caustics have been advised for noma ; the actual cautery has obtained the greatest repu- tation. The object of these applications is to destroy the gangrenous parts, and to excite inflammatory reaction in the surrounding parts. CHAPTER X. PAROTITIS—INFLAMMATION OF THE PAROTID AND ITS VICINITY— MUMPS. Etiology.—Besides the cases caused by wounds of the parotid, by the entrance of foreign bodies into its excretory duct, or by calcareous deposits, which cases belong to the surgeon, we distinguish two forms of parotitis: 1. Idiopathic parotitis, parotitis polymorpha (mumps) ; 2. Symptomatic or metastatic parotitis. In opposition to the generally-received opinion, Virchoio maintains that the affection starts in the gland-ducts of the parotid. He has di- rectly proved this in the case of symptomatic parotitis, and in the idio- pathic form also it appears to us much more probable that the inflam- mation should begin in the gland-ducts than in the interstitial tissue. If, with Virchow, we consider idiopathic parotitis as resulting from a simple catarrh, which has no tendency to suppurate, and the sympto- matic or metastatic form, as caused by catarrhal inflammation of the gland-ducts, that has a tendency to suppurate, the symptoms, course, INFLAMMATION OF THE PAROTID, ETC. 437 and so-called metastases of the affection are less inexpficable than if we follow the old vieAV, which considered the intercellular substance of the gland as the starting-point and peculiar seat of the affection. Idiopathic parotitis is rarely sporadic; it almost always occurs in epidemics ; these usually come in the spring and autumn, that is, in cold, damp weather, rarely in the dry, warm weather of summer. They vary in duration and extent; occasionally they are confined to certain institutions, foundling houses, barracks, etc. Trustworthy observations render it most probable that the disease spreads by contagion. It does not appear to us justifiable (Avith Rilliet) to consider mumps as an in- fectious disease, and the inflammation of the parotid as the local ex- pression of a constitutional disease, and to regard it as analogous to the affections of the skin that accompany the acute infectious diseases. The same objections that we have raised to considering whooping- cough among the infectious diseases, in the ordinary sense of the term, urge us to separate mumps from them also, in spite of its contagious- ness. Infants and old persons usually escape epidemic parotitis; males are more frequently attacked than females. Symptomatic parotitis results from severe diseases, Hke typhus ; in some epidemics of this disease it follows almost all cases. More rarely it is seen in the course of cholera, septicaemia, measles, small- pox, dysentery, or as an accompaniment of pneumonia. We do not exactly knoAV the relation of such cases of parotitis to these diseases. The oral catarrh, which ahvays accompanies abdominal typhus, might excite the suspicion that the parotitis accompanying this disease Avas induced by a propagation of the catarrh of the mucous membrane of the mouth along the excretory ducts of the glands. But, opposed to this A'ieAV is the fact, that the frequency Avith which it occurs in typhus is not proportionate to the intensity of the affection of the oral mucous membrane, as well as the circumstance that parotitis, running the same course, occurs in other affections that are not complicated by oral ca- tarrh. Since symptomatic parotitis is seen not only in infectious dis- eases, but also in pneumonia, Ave cannot say that it is induced by an irritation of the gland from infected blood. The hypothesis, that under some circumstances it has a critical indication, and exercises a favorable influence on the course of the original disease, is disproved by facts ; it ahvays forms an unpleasant and undesirable complication. Anatomical Appearances.—We do not exactly knoAV the ulti- mate anatomical changes of parotitis. As the course of the disease is almost ahvays favorable, there is rarely an opportunity for anatomical examinations. Nevertheless, from the softness of the swelling, and the sfight amount of pain that it causes, and especiaUy from its usually rapid disappearance, Avithout leaving any traces, Ave may beHeve that 438 DISEASES OF THE MOUTH. it is chiefly or solely caused by serous exudation. Although avc have said above that the affection probably proceeds from a catarrh of the gland-duct, still there is no doubt that the swelling chiefly affects the interstitial substance and the connective tissue about the gland. The SAvelling usually extends far beyond tfie borders of the gland. The development of oedema about the inflamed gland-ducts is not at all strange; it corresponds exactly with observations made in analogous conditions. Infiltration, with firm fibrinous exudations and suppura- tion, rarely occur in parotitis. We do not know Avhether the suppura- tion proceeds from the gland itself or the interstitial substance ; but it is most probable that there is just the same state of affairs as in sup- purating symptomatic parotitis. (See beloAV.) Symptomatic parotitis begins, according to the careful observa- tions of Virchow, with decided hyperaemia, AA'hich causes the gland and interstitial substance to appear infiltrated and SAvelled. Changes in the gland-ducts soon begin; a tough, filamentous, whitish, or yellow- ish substance, which soon becomes purulent, collects in them. Even at the second or third day the microscope shows that it contains pus- corpuscles, with numerous salivary corpuscles. If the disease pro- ceeds, the lobules of the gland soften and break doAvn; this process. begins within, so that at one time the lobules represent caAdties filled Avith pus. Finally, the tunica propria is also destroyed, and the inter- stitial tissue begins to suppurate; this suppuration may extend rap- idly, and become a diffuse phlegmonous inflammation. In this case a large parotid abscess forms ; more frequently the gland-tissue only is destroyed, and as the interstitial tissue remains intact, numerous small abscesses are formed. Occasionally also there are extensive destruc- tion and gangrene of the gland-tissue and interstitial substance; the inflammation and suppuration may spread from its original seat in vari- ous directions and cause dangerous results. It most frequently attacks the neighboring connective tissue, and the masticatory muscles lying in it, the periosteum of the maxillary, temporal, and sphenoid bones, or even the bones themselves. Where the disease is very severe, it occasionally passes from the bones to the membranes of the brain, and the brain itself, or to the internal and middle ear. This propagation of inflammation and suppuration to the cerebral membranes and the internal ear may take place along the blood-vessels and nerve-sheaths, as well as through the bones. Finally, in some cases parotitis induces- phlebitis and thrombus of neighboring veins, especially of the anterior and posterior facial and external jugular veins; the disintegration of these thrombi may cause embolism and septicaemia. Symptoms and Course.—In idiopathic parotitis, as in other in- flammations, the 'iocal symptoms are often preceded by slight fever INFLAMMATION OF THE PAROTID, ETC. 43«j The general disturbance, depression, headache, loss of appetite, rest- less sleep, etc., accompanying this as other fevers, are usually called the premonitory symptoms of idiopathic parotitis. After the fever has lasted tAvo or three days, or in some cases simultaneously with its occurrence, a SAvelling forms, which, beginning near the lobe of the ear, rapidly extends over the cheek and to the neck; usually only one side is at first affected. In the middle it is firmer, at the periphery softer; the skin over it is pale or only slightly reddened. This SAvelling is accompanied by a feeling of tension and pressure, but by no severe pain; the motions of the head are impaired, the mouth can only be slightly opened, and chewing and SAvalloAving are difficult. The secre- tion of saliva may be increased, diminished, or unaltered. These annoyances are so slight in proportion to the disfigurement which gives the name to the disease, that the patients excite more laughter than sympathy. The SAvelling almost ahvays soon extends to the other side of the face, and is often greatest there Avhen it has gone from the side first affected and the fever has subsided. About the fifth'or sixth day, occasionally even earlier, rarely later, the fevei ceases, and after eight or ten days the face appears natural. But sometimes a circumscribed, painless, hard swelling remains for a while in the region of the parotid. Far more rarely about the fifth or sixth day the SAvelling becomes very painful, hard, dark red, and abscesses form, Avhich open outAvardly or into the external auditory meatus. Occasionally, in the course of the disease, one of the testicles is affected by an inflammation similar to that of the parotid ; this occurs more frequently in men than in boys; it is usually accompanied by pain in the sacral and inguinal regions and exacerbation of fever. The scrotum also becomes oedematous and forms an inelastic, doughy tumor, Avhich is not often reddened; on careful examination Ave readily find that there is a serous exudation in the tunica vaginalis. Inflam- mation of this part usually runs as favorable a course as that of the parotid does, and after a feAV days terminates in resolution. Occasion- ally the parotitis and orchitis seem to alternate, as it Avere; the for- mer disappears as the latter comes on, and the reverse: hence we speak of parotitis polymorpha being "fugitive," and of its inclination to metastasis to the testicle. In other cases, hoAvever, the tAvo inflam- mations run on together, AA'hich renders it probable that both are due to the same cause, and that the occurrence of the one is not to be regarded as due to the disappearance of the other. As in men the scrotum is sometimes affected, so in women the vulva or breasts are occasionally attacked Avith inflammatory oedema. In other cases, pain in the region of the OA'aries, increased by pressure, shows that an ovary is inflamed, just as the testicles are in men. Cases have also been 440 DISEASES OF THE MOUTH. recorded, AA'here, in the course of idiopathic parotitis, fatal meningitis has been developed. When symptomatic parotitis occurs at the height of typhus or any of the above-mentioned diseases, the apathetic patients do not usually complain of pain or any other symptom. Occasionally slight chiUs or an exacerbation of fever precede the formation of the parotid tumor. This sometimes forms gradually, at others very rapidly, and generally affects only one side. If parotitis comes on during convalescence from typhus, etc., it is accompanied by the same symptoms that Ave have described for idiopathic parotitis. Symptomatic parotitis also may end in resolution. This occurs most readily AA'hen the tumor has formed gradually and attained only a moderate hardness and extent. The diminution in size is sometimes slow, sometimes rapid. When about to suppurate, the SAvelling becomes uneven, nodulated, and very red ; it usually shoAvs fluctuation at several points, and, Avhen opened spontaneously or artificially, benign pus is evacuated. Occasionally the opening occurs simultaneously outward, and into the external auditory meatus, more rarely into the mouth or pharynx. Finally the pus may burroAV along the sterno-cleido-mastoid muscle, or the oesoph- agus and trachea, and form abscesses at the lower part of the neck or even enter the chest {Bruns). While mortifying, the skin cover- ing the tumor becomes dark blue and discolored; the tumor, Avhich Avas previously hard, becomes doughy and sinks in; after a spontaneous or artificial opening, a discolored pus, mixed Avith shreds of tissue, is evacuated. Treatment.—As idiopathic parotitis almost ahvays ends in a cure, if left to itself, we have Httle to do but protect the patient from inju- rious influences, and to regulate the digestion and bowels, Avhile the disease lasts. We keep the patient in his chamber, cover the SAvell- ing with Avadding or a spice-bag, and as long as the fever lasts let him aA'oid eating much meat or other protein substances Avhich would not be readily digested (see diseases of the stomach). In some cases an emetic or laxative may be necessary. If hardness and greater sen- sibility of the swelling, with increase of the fever, excite fears of sup- puration, Ave may attempt to check it by applying leeches. If Ave find fluctuation, we should apply cataplasms, and open the abscess early, to prevent further destruction of the parotid, or perforation of the pus into the external auditory meatus. Irritant applications have been used to prevent metastases, and sinapisms and blisters have even been applied to the parotid region, to induce a return thither of the inflam- mation that had affected the scrotum and testicles. As experience has shoAvn, such treatment can only prove injurious. In symptomatic parotitis even local blood-letting is badly borne, on SALIVATION—PTYAL1SM. 441 account of the severity of the original disease. If the SAveUing be red, and the patient Avinces when Ave press on the tumor, Ave should apply compresses of cold Avater or ice. When there is fluctuation, warm poultices and early opening of the abscess are indicated. CHAPTER XI. SALIVATIO N—P T Y A LIS M. Strictly speaking, Ave have no right to consider salivation as a distinct disease (it forms a symptom of a great variety of affections), but avc folloAv custom in giving a separate chapter to the anomalies of secretion of the salivary glands. The quantity of salh'a secreted in twenty-four hours is usually estimated at ten to tAvelve ounces, but it varies considerably even during health. It is best, Avith WiXnderlich, to consider the increased secretion as disease or salivation, when it ceases to pass into the stomach with the ingesta; but some of it Aoavs out of the mouth, some is spit out, or is swalloAved by itself, because it becomes troublesome. Etiology.—Physiology sufficiently explains the causes of most forms of salivation ; in other cases we do not knoAV them. Salivation is caused—1. By irritation of the mucous membrane of the mouth or pharynx. Introduction of irritating substances into the mouth excites the flow of saliva, Avhich consequently occurs in most of the affections of the mouth described in the preceding chapters, as Avell as in almost all surgical affections of the mouth. According to the beautiful experiments of Ludwig, the flow of saliva is increased by irritation of certain nerves, such as the lingual branch of the tri- facial or the glossopharyngeal; this increase also occurs when these nerves are divided and their central ends irritated. Of course the irritation of the divided nerves must be transferred to the nerve fil- aments governing the secretion of saliva, which is then to be regarded as a reflex symptom. In the same AA'ay Ave may regard the flow of saliva caused by the irritation of the peripheral expansions of the glossopharyngeal and lingual nerves induced by acrid ingesta, by Avounds or ulcers, as a reflex symptom. Probably the salivation ob- served in neuralgias of the trifacial results fromt he same cause. The increase of saliva due to the use of mercurial and iodine preparations appears to depend not on the simple addition of these substances to the secretion, but to the irritation of the mouth, produced by excreting them for a long time. For they must be long taken before the secre- tion of saliva is great!}' increased; salivation does not begin till the mouth becomes diseased from their continued action. Corresponding 442 DISEASES OF THE MOUTH. to this, Lehrnann found that at the commencement of mercurial pty- alism the excretion Avas not saliva but mucus, mingled Avith shreds of epithelium from the oral mucous membrane. The preparations of iodine, Avhich induce stomatitis less frequently, cause salivation far more rarely, although Ave can detect their presence in the saliva quite early. We do not knoAV Avhether the salivation produced by muriate of gold and other metalfic and vegetable substances originates in the same Avay. 2. In many cases, salivation appears to depend on irritation, affect- ing the gastric or intestinal mucous membrane, perhaps also the uterus or other organs. Frerichs has shoAvn, by experiment, that irritation of the gastric mucous membrane increases the secretion of saliva; for, Avhen he introduced food into the stomachs of dogs through fistulous openings, there was profuse salivation; if he used common salt, quan- tities of saliva floAved from the mouth. These experiments appear to prove that irritation of the gastric nerves is also reflected to the nerves governing salivation, and they at least partly explain the increased flow of saliva accompanying many pathological states of the stomach, such as ulcer or cancer of the stomach, and preceding vomit- ing, whether induced by emetics, overloading, or disease of the stom- ach. It seems probable, also, that the same cause induces the saliva- tion so constantly accompanying the pains produced by Avorms in the intestines, that the laity who are aAvare of this symptom have the most Avonderful hypotheses about the Aoav of water into the mouth from the irritation of worms. We have less reason for referring the salivation Avhich not unfrequently occurs during the first montfis of pregnancy, or in hysteria, to an excitement of the genital nerves re- flected to the secretory nerves of the salivary glands. 3. Salivation depends on certain mental influences. We see Iioav the secretion is increased in disgust or desire. As a proof that abnor- mal excitement of the brain may directly increase the secretion of sa- liva, we may note the fact that physiologists have been obfiged to locate the origin of the nerves, governing the secretion of saliva, in the brain. The activity of the salivary glands is increased in the same Avay by irritation of the trigeminus and facial nerves, even at points Avhere no sympathetic filaments are mingled with them, that is, above the ganglia. 4. Occasionally salivation occurs in the course of diseases, such as typhus, intermittent, etc., without other perceptible cause; its occur- rence in these diseases has even been regarded as critical. Finally, some apparently healthy persons suffer from obstinate sali- vation without perceptible cause. In insane and old people, the flow of saliva from the mouth does not appear to depend on its increased SALIVATION—PTYALISM. 443 secretion, but on neglecting to SAvaUoAV that AA'hich is produced in nor- mal amount. Anatomical Appearances.—We do not know the anatomical changes undergone by the salivary glands in increased salivation. In continued and excessive salivation, slight SAvelling of tfie parotid occurs in some rare cases. The fact, that the secretion may stUl be obtained after the heart has ceased to beat, proves that overloading of the ves- sels, or hyperaemia of the salivary glands, which instantly causes their infiltration and SAvelling, is not the sole cause inducing increased secre- tion. Symptoms and Course.—The pains in the mouth, and painful SAA'ellings of the neighboring lymphatics, which occur in salivation, be- long to the various forms of stomatitis exciting it; salivation itself causes no pain, but it greatly inconveniences the patient. The fre- quent collection of fluid in the mouth obliges him to spit constantly ; frequently he cannot speak tAvo Avords AA'ithout interruption. Rest at night is also disturbed, partly by the saliva flowing from the mouth and Averting the pilloAv, partly by that Avhich, floAving backward, passes into the pharynx and larynx. The escaping fluid may reach the amount of six or eight pounds in twenty-four hours. Lehmann and other observers have found it, at first, more mucous, cloudy, of greater specific gravity, and richer in solid constituents (young and old epi- thelial cells), than normal saliva. The fluid is alkafine, contains much fat and little ptyaline, and only rarely perceptible amounts of sulpho- cyanide of potassium. Subsequently, the secretion Avas less cloudy, and, like the saliva that Ludwig obtained, by continued irritation of nerves influencing the secretion, it contained less solid constituents than normal saliva. This fluid Avas also alkafine, rich in fat and so- called mucous corpuscles ; it contained no sulpho-cyanide of potassium. When salivation has continued a long AvhUe, albumen may occasional- ly be found in the fluid. The patients usually emaciate ; the loss of AA'ater and organic constituents has little to do Avith this, but, as the accompanying stomatitis interferes Avith cheAving, the patients take little nourishment, and Avhat they do take is badly assimUated, be- cause the quantity of safiva SAvalloAved interferes Avith digestion. Treatment.—The causal indications require a careful treatment of the original disease Avhen the salivation is caused by affections of the mouth. When resulting from the misuse of mercurials, slight laxa- tives are to be recommended. Cullerier calls constipation " one of the best knoAvn of the exciting causes of safiA'ation," and, indeed, it is more rational to suppose that the mercurials which reach the mouth through the salivary glands, and are SAvalloAved, Avould be more readily removed by purgatives than by remedies directed to the skin or kidneys. Sali- 444 DISEASES OF THE MOUTH. vation caused by affections of the stomach, intestines, uterus, etc., is also most readily improved by proper treatment of the original affec- tion ; in other forms the causal indications cannot be fulfilled. For the indications of the disease, derivatives, " general baths, ap- plication of blisters and mustard to the throat and nape of the neck," astringent mouth-washes of alum, sulphate of zinc, sage, or oak-bark, have been recommended. The use of opium deserves most confidence. It is ahvays satisfactory when, as in this case, theory and practice agree in supporting a therapeutic measure. The use of opium in sali- vation was recommended by the first practitioners of medicine; and, since salivation depends on excitement of the nerves, it appears ra- tional to use for it remedies which, like the narcotics, diminish the ex- citability of the nerves. There are cases of spontaneous safivation that defy all treatment. SECTION II. 1FFECTIONS OF THE PHARYNX. CHAPTER I. CATARRHAL INFLAMMATION OF THE PHARYNGEAL MUCOUS MEM- BRANE--ANGINA CATARRHALIS. Etiology.—The disturbances of function and nutrition, which we haA'e frequently designated as characteristic of catarrhal inflammation, are often observed in the mucous membrane of the pharynx, the soft palate, the uvula, and tonsils, and are usually termed angina catar- rhalis. In this section, the tissues of the soft palate are considered as belonging to the pharynx, since they participate in almost all the dis- eases of the pharynx. The predisposition for catarrhal inflammation of the pharynx varies with the individual. If exposed to the sfightest injurious influences, some persons are immediately attacked AAdth affections of this part, Avhile others, exposed to the same influences, remain Avell, or have dis- ease of some other part. Some persons are troubled several times a year Avith catarrhal angina, Avhile others live for years Avithout having it. The causes of the increased predisposition to catarrhal angina are mostly unknown. It is customary to say that a lymphatic constitu- tion predisposes to the disease, or that it is more apt to occur in scrofu- lous persons. But Ave often see robust individuals, who shoAV no con- stitutional anomalies, affected Avith catarrhal angina at every exposure. In general, avc may say that the disease is more common in children and young persons than in those more advanced in life ; that repeated attacks leave an increased predisposition ; that patients who have had svphilis, or Avho have used mercurials for a long time, are peculiarly liable to acute and chronic pharyngeal catarrh. Among the exciting causes are : 1. Direct irritation; such as hot or corrosive substances, rough, ragged bones, which stick in the fauces, and other injuries to the pharyngeal mucous membrane. Perhaps the 140 AFFECTIONS OF THE PHARYNX. catarrh induced by spirituous liquors depends on their direct action. 2. In other cases, the catarrh undoubtedly depends on catching cold. 3. Not unfrequently it is propagated from neighboring parts to the pharyngeal mucous membrane. In this class belong the catarrhs oc- curring in mercurial stomatitis, and those difficulties of swallowing which accompany the later stages of laryngeal catarrh. Sometimes it accompanies catarrh of the stomach; but every angina is not, as was formerly supposed, of gastric origin. Not unfrequently catarrhal an- gina must be regarded as the result of a blood-disorder. It is not a complication, but a symptom of scarlatina, which is just as constant as the exanthema. More rarely in exanthematous typhus, or measles, Avhich are ahvays accompanied by catarrh of the respiratory organs, there is also pharyngeal catarrh. Among the chronic infectious dis- eases, constitutional syphilis often makes its appearance as pharyngeal catarrh ; but other changes in the tissues of the pharynx usually occur soon, which will be spoken of hereafter. 5. Sometimes catarrhal angi- na is epidemic. A large number of persons are taken sick without our knowing the influences inducing the affection. In many other cases, also, the exciting causes are unknown. Anatomical Appearances.—In acute catarrhal angina, the mu- I cous membrane, especially that of the soft palate, appears dark red. The SAvelling of tfie mucous and sub-mucous tissue is most evident at the uvula, which has plenty of relaxed sub-mucous tissue. The uvula is thicker, but especially longer, and often rests on the root of the tongue ("the palate is doAvn"). The tonsUs also are more or less swollen. At first the mucous membrane is dry; later, it is covered with cloudy secretion, particularly about the tonsils and posterior wall of the pharynx. In chronic catarrh of the fauces, the membrane does not appear regularly reddened; it is traversed by varicose veins, and is darker-col- ored. The swelling is greater and more irregular than in the preced- ing variety. The diseased mucous membrane sometimes appears dry and glistening, sometimes covered with a cloudy secretion. On the soft palate and uvula the swollen and closed glands often appear as small granules, or they form small yellow vesicles, which soon rupture, and leave round (follicular) ulcers. In tfie dilated openings of the tonsUs there are occasionally found cheesy, badly-smelling plugs or stony concretions, wfiich are the putrefied or petrified contents of the follicles. Recently, chronic pharyngeal catarrh has received a great deal of attention in the journals and treatises on baths, but it has not been sufficiently considered in the text-books on pathology. Occasionally it is limited to the pharyngeal mucous membrane ; again, it extends to CATARRHAL INFLAMMATION—ANGINA CATARRHALIS. 447 that of the larynx or nares. The changes consist in an irregular hy- peraemia, so that sometimes we see only a feAV varicose A'essels in the otherAAdse pale membrane; in a thickening, or hypertrophy, AA'hich is either diffuse, or fimited to undefined spots ; and, in a perverted secre- tion of the mucous membrane. From the partial thickening of the mucous membrane, in Avhich the sub-mucous tissue also participates, the posterior Avail of the pharynx acquires a peculiar nodulated appear- ance ; there are numerous round, or oval, sometimes confluent promi- nences, Avhence the disease is called pharyngitis granulosa. Some authors designate it pharyngitis follicularis, because they consider that the partial hypertrophy of the mucous membrane is chiefly limited to the vicinity of diseased mucous glands. This vieAV is probably correct, but has not yet been anatomically proved. In some cases the secre- tion of the mucous glands is very abundant, and then it sometimes sIioavs an inclination to dry into disgusting yelloAV or green crusts ; in other cases it is scanty, and then also shoAVS the inclination to dry, and the posterior Avail of the pharynx looks as if covered AAdth a thin coat of Aarnish. For this form of the affection, Lew in has proposed the very suitable name of pharyngitis sicca. Symptoms and Course.—Acute catarrhal angina is usually ac- companied by a fever, AA'hich has the symptoms of catarrhal feA'er, as previously described; this occasionally precedes the local difficulties, but it is sometimes, tfiough rarely, entirely absent. At first the secre- tion from the mucous membrane is diminished; hence the patients complain of dryness in the throat. From the tension of the mucous membrane, especially at the half arches of the palate, Avhere it is closely attached to the subjacent muscles by a scanty connective tissue, there is great pain, Avhich is so increased at every attempt to SAvaUoAV that the patients make Avry faces whenever they attempt it. When, as frequently happens, the elongated uvula touches the tongue, there is a sensation of a foreign body in the throat and a constant inclina- tion to swallow. In very severe forms of catarrhal angina, Avhich are often called erysipelatous or erythematous angina, the muscles of the palate are often infiltrated AA'ith serum and their functions lim- ited. Under normal circumstances, as is Avell knoAvn, the contrac- tion of the muscles of the anterior half arches of the palate prevents the return of food into the mouth; contraction of the muscles of the posterior half arches closes the passage to the nose, as the uvula fills up the opening that is left. If the function of these muscles be im- paired, fluids Avould be driven through the nose or back into the mouth by the contractions of the pharynx in the attempt to SAvaUoAV. If the mucous membrane of the pharynx be the seat of an intense catarrh, and, as a consequence, the muscles be paralyzed by serous infiltration, / 448 AFFECTIONS OF THE PHARYNX. the patient suffers still more. As soon as a morsel of food, or, still more, any liquid, has passed the anterior half arches, the patient is greatly terrified, as fie cannot pass it either forward or backward. As the substance in the pharynx would pass into the larynx on any at- tempt to breathe, the patients hold their breath and attempt, in every conceivable manner, to evacuate the contents of the pharynx through the mouth; they bend far forward and let the head hang over the side of the bed. Nevertheless, some of the contents of the pharynx often enter the larynx, and are again expelled by spasmodic coughing. The patients at last become timid, and, with terror, Avave back the drink or medicine offered to them, they pass day and night in the most uncom- fortable postures, so that the saliva may flow out of the mouth, and they may not be obliged to swallow it. A " nasal" tone of the voice is a pathognostic symptom of all affections of the pharynx, Avhere the functions of the muscles of the half arches of the palate are affected, and consequently for all the intense forms of catarrhal angina. As is AveU known, it is only in saying Arand Mth&t Ave allow the air to pass through the nose ; while pronouncing other letters, the nasal cavities are closed. When patients are unable to shut off the nose in this Avay, from inability to contract their posterior half arches, the resonance of the nose gives to all sounds a peculiar tone, which is called " nasal," and the person is said to " speak through the nose." Besides this dif- ference of tone, there is a certain difficulty of speech. The patients speak slower and more carefully, because it pains them, especially when saying N, in doing which the root of the tongue is for a moment pressed against the roof of the mouth. A last characteristic is, that the pronunciation of guttural R, in which the uvula is made to vi- brate, becomes difficult or even impossible, if the uvula is much SAVoUen and elongated. As we said in the first chapter of the previous section, the milder as well as the more severe forms of catarrhal angina are almost ahvays accompanied by catarrhal stomatitis. The patients have a coated tongue, bad taste, foul breath, and the mouth is always full of saliva. Not unfrequently acute pharyngeal catarrh extends to the Eustachian tubes and the tympanum; the patients become deaf, have piercing pains in the ears, which may be excessive, until perforation of the drum permits the escape of pus from the middle ear, when a remission suddenly occurs. Catarrhal angina almost ahvays terminates in recovery after a feAV days. While the pain and difficulty in swallowing subside, quantities of mucus are removed from the pharynx by haAvking and spitting; at the same time the symptoms of oral catarrh pass aAvay. t In chronic catarrh of the fauces, the pain and difficulty of SAvaUoAV- CATARRHAL INFLAMMATION—ANGINA CATARRHALIS. 449 mg are usually slight, and only become Avorse occasionally Avhen the chronic catarrh is exacerbated by slight injuries. This is particularly true of the chronic catarrh of the soft palate, which is very frequent in patients who have suffered from syphilis, or Avho have used mercurials for a lqng AA'hile. The slight difficulties that these patients experience in SAvalloAAdng, and the temporary exacerbations AA'hich occur, are a source of unceasing care. They usually soon attain great skill in looking at their OAvn throats in the mirror; the smallest phlyctenula coming on the soft palate does not escape their notice; they constantly run after the doctor, Avho must again look in their mouth, and again assure them that they are not syphilitic. The cheesy plugs Avhich form in the tonsils are occasionally ejected by haAvking. This symptom also troubles the patient a great deal; the yelloAV, round bodies, Avhich smell horribly Avhen squeezed, are to them a sure sign that they have tubercles; and it is as difficult to convince the latter patients that they are not consumptive as to satisfy the former that they are not syphi- litic. Chalky concretions from the tonsils, Avliich are haAvked up, are usually represented as lung-stones. The milder cases of chronic pha- ryngeal catarrh, from AA'hich most habitual drinkers suffer, usually ' trouble the patients only in the morning, Avhen the mucous membrane \ secretes most abundantly a tough mucus, or Avhen it is covered AAdth I ] the mucus secreted during the night. The patients attempt to remove this secretion by continued hawking and spitting, and this straining, Avhich not unfrequently causes nausea and A'omiting, is one of the causes of the notorious morning vomiting of drunkards. The severe forms of chronic pharyngeal catarrh, especially of the follicular or granular 1 varieties, are far more troublesome. They do not render swalloAving actually difficult, but the patients complain of an irritation, a disagree- able sensation of prickfing, also of dryness in the throat, Avhich leads them uhaa illingly to make the motion of SAvalloAving, or, more fre- quenth', to hawk and hack for a long Avhile. It is thought, too, that this repeated hawking is a bad habit. The voice often becomes husky also, as the laryngeal mucous membrane usually participates in the | affection. When the follicular pharyngeal and laryngeal catarrh is 1 exacerbated, the hacking increases to a troublesome spasmodic cough, i and the husky voice becomes actually hoarse. If the affection extends to the nasal mucous membrane, the nose becomes stopped at night; i hence the patients sleep Avith^the mouth open, and by morning the pharynx and back of the tongue have become so dry that moving them causes cracks in the dry coating, or even in the membrane itself, and then there are slight haemorrhages. Many patients are greatly worried by this spitting of blood, Avhose origin can hardly be discovered, unless \A'e see the patient just after he has aAA'akened; and thus follicular 29 450 AFFECTIONS OF THE PHARYNX. catarrh of the pharynx and larynx, Avhich is a very obstinate, although not dangerous disease, has a very depressing effect on most patients. Treatment.—When of moderate intensity, acute catarrhal angina does not require any particular treatment. Often the patients do not apply to a physician, but go to some old woman, who knoAVS how to raise the " fallen palate" by certain hairs at the top of the head. These foolish ideas have a serious as well as a ridiculous side. The apparent success of this and similar senseless procedures must teach us to abstain from energetic treatment in affections Avhere they have a great reputation. This teaching is much opposed in the treatment of catarrhal angina. We might say that more than half the physicians superfluously give an emetic, partly AAdth the idea that it avUI act as a revulsive, partly to combat the gastric disorder, Avhich is diagnosticated from the symptoms of oral catarrh, on Avhich the angina is thought to depend. As the tongue is cleaner the day after the emetic, and the angina has improved, as it would have done at any rate, the remedy receives the credit of it. In catarrhal angina, the use of an emetic is only admissible under certain circumstances, as when there are substances in the stomach that have excited, or are keeping up, a gastric catarrh. In severe cases it is well to let the patient apply moist compresses, well wrung out, and carefully covered with a dry cloth, to the throat, every few minutes. In persons who are afraid of the cold compresses, or AA'here, for any reason, we do not wish to use these, we may employ Avarm poultices. At the same time, Ave may have the mouth frequently washed with cold water, or with a solution of alum, sulphate of zinc, acetate of lead, etc. Occasionally, by covering the inflamed spots Avith powdered alum, or painting them with a solution of nitrate of silver, 3 j to 33, Ave may abort the disease. Chronic catarrh of the fauces is best treated by the above-named astringent mouth-washes, and particularly by painting the inflamed spots with solution of nitrate of silver. Chronic pharyngeal catarrh must be very carefully and continu- ously treated; in many cases it defies medical skiU. In the blennor- rhceal form even, which offers the best prognosis, treatment often faUs, because the patients cannot decide to gh'e up the use of liquor, or to smoke less. The best treatment in these cases is the local application of solutions of nitrate of silver, alum, or tannin, and these seem to be more efficacious when given in a nebuhzed form than when applied Avith a brush. In the forms where there is little secretion, and par- ticularly in the follicular and granular pharyngeal catarrh, it occasion- ally appears as if the application of the above solutions caused a ' toning up " of the affected mucous membrane, and an improvement CROUPOUS INFLAMMATION—PHARYNGEAL CROUP. 454 of the disease, but in the cases that I have seen, this improvement has only been apparent, or, at least, only temporary. Solutions of corro- sive sublimate or sulphuret of lime have not proved more beneficial. Recently, as recommended by Lewin, I have, in some cases, tried a LugoVs solution (I£ iodin. gr. vj ; potass, iodid. gr. xij; aquae § A'j), for painting the pharyngeal mucous membrane, and, although I have not used it in a great many cases, it seems preferable to other remedies in dry catarrh of the pharynx, with or AA'ithout granulations. In this form of chronic pharyngeal catarrh the alkaline muriatic mineral waters have the best reputation, particularly those of Ems and the sulphur springs, especially those of Weilbach, and some Pyrenean springs. CHAPTER II. croupous inflammation of the pharyngeal mucous membrane --pharyngeal croup. Etiology.—In the croupous inflammation of the pharyngeal mu- cous membrane, the croup membrane often adheres so firmly to the inflamed mucous membrane that, on detaching it, a bloody, superficial loss of substance remains. Then the affection sIioavs a change from croupous to diphtheritic inflammation. 1. Pharyngeal croup occurs as an independent disease, from the same, causes as pharyngeal catarrh, and it almost seems as if it were occasionally only a more intense form of catarrh. 2. The croupous deposits on the tonsils, so often seen in parenchymatous angina, are explained by the intense participation of the mucous membrane in the inflammation of the subjacent tissues. 3. Pharyngeal croup, AA'hich appears as a symptom of a sporadic, or, more frequently, epidemic croupous inflammation, affecting the mucous membrane of the palate, pharynx, larjiix, and trachea, is very important. In this form the croup sometimes seems to spread from the larynx to the pharynx (croup as- cendant), sometimes the reverse (croup descendant). 4. Lastly, pha- rvno-eal croup occurs AAdth croupous and diphtheritic inflammations of other mucous membranes in the later stages of typhus, in septicaemia, and similar diseases, a form which Ave shall not consider further at present. Anatomical Appearances.—We see AA'hite or grayish-Avhite mem- branous masses on the reddened mucous membrane of the soft palate, tonsils, and pharynx. They usually form small, irregular, roundish islands; more rarely extensive membranes. Under these there is no loss of substance. # Symptoms and Course.—Idiopathic, uncompficated croupous an- 452 AFFECTIONS OF THE PHARYNX gina causes the same annoyances as severe catarrhal angina; Ave only discover the form of the inflammation by inspecting the pharynx. On careless examination, the gray patches may be mistaken for ulcers, Avith fatty bases. The subjective symptoms of parenchymatous angina are not altered by croup, so that, in this case also, the croup is first recognized on in- specting the pharynx. Croupous angina, Avhich usually occurs epidemically with croupous laryngitis, is easily overlooked, as it causes proportionately little diffi- culty, which, moreover, will probably be misunderstood, as it affects children almost exclusively. If we examine the fauces of children sick AA'ith croup, Ave often find them covered Avith croup membrane, although the parents may not have noticed that the children had any difficulty in SAvalloAving. We have before said how important for diagnosis and prognosis it is to examine the throat of every chUd affected with hoarseness. Treatment.—The treatment of croup occurring idiopathically, after catching cold, etc., is the same as that for the severe forms of pharyn-( geal catarrh. I Pharyngeal croup accompanying croupous laryngitis requires, as we have already said, the prompt removal of the membrane, and energetic ] cauterization of the affected mucous membrane, with a concentrated j solution of nitrate of silver. j CHAPTER III. diphtheritic inflammation of the pharyngeal mucous mem- brane. Diphtheritic inflammation, in which a fibrinous exudation is de- posited in the tissue of the mucous membrane, and presses on its ves- sels so as to cause it to slough, attacks the pharynx very frequently. Diphtheritic pharyngitis, however, does not occur as a primary and in- dependent affection, but in almost all cases depends on infection of the blood from the poison of scarlatina, or of the disease we call epi- demic diphtheria and class among the infectious diseases. (We speak of croupous and diphtheritic inflammations of the different mucous mem- branes ; but when we speak of " croup," or " diphtheria," we ahvays mean croupous inflammation of the laryngeal mucous membrane or diphtheritic inflammation of the pharyngeal mucous membrane.) We sljall hereafter give a detailed account of diphtheria, AA'hen speaking of scarlatina and epidemic diphtheria. PHLEGMONOUS INFLAMMATION OF THE PHARYNX. 453 CHAPTER IV. PHLEGMONOUS INFLAMMATION OF THE PHARYNX. Etiology.—The submucous tissue of the pharynx and the inter- stitial tissue of the tonsils, Avhich are the seat of simple oedema in ca- tarrhal and croupous inflammation, may also suffer from inflammatory disturbances of nutrition. These often consist in infiltration of the tissue Avith fibrinous exudation, and in proliferation of the connective tissue; in other cases pus is formed, the tissues melt aAvay, and ab- scesses result; diffuse mortification and pfiagedaena of the affected parts occur in some rare cases. The same causes, according to their intensity, or the predisposition of the patient, appear capable of exciting the catarrhal and parenchym- atous forms of pharyngeal inflammation; hence Ave refer to the etiol- ogy of the catarrhal form. Parenchymatous pharyngitis also leaves great tendency to relapse; the more frequently it has affected a per- son, the more liable he is to have it again. Many persons have it yearly, or even oftener. Once having ended in suppuration, it seems disposed to take the same course on subsequent occasions, so that, in such cases, in new attacks, there is little hope of causing the disease to end in resolution. Anatomical Appearances.—Acute parenchymatous pharyngitis usually attacks the tonsils; one or both may be inflamed, sometimes the inflammation passes from one to the other. From the exudation, with Avhich they are infiltrated, the tonsils often swell to the size of a Avalnut; their surface appears nodulated, dark red, covered Avith glu- tinous exudation or croupous deposits. As the inflammation passes on to suppuration, some circumscribed spot usually becomes softer and more prominent, and finally tfie pus perforates the thinned AA'alls of the abscess. More rarely the acute parenclrymatous inflammation oc- curs in the submucous tissue of the soft palate; a hard swelling forms here, and fluctuation gradually occurs; finally, in this case also, the pus is evacuated into the mouth or pharynx. Chronic parenchymatous pharyngitis also almost exclusively affects the tonsils; more rarely the uvula, or the soft palate, is permanently thickened by inflammatory hypertrophy of the submucous connective 1 tissue. From this cause the tonsils may become very large and hard; their surface is often uneven and nodulated, and has depressions Avhere there Avas formerly a-loss of substance fiom suppuration. The mu- cous membrane is but slightly reddened, or is even pale. We often find the above-described cheesy plugs in the gaping openings on the surface of the tonsils. 454 AFFECTIONS OF THE PHARYNX. Symptoms and Course.—Acute parenchymatous pharyngitis gen- erally begins with a high fever, which may be preceded by a severe chill. The general condition of the patient is much affected, the pulse full and frequent, the temperature 104°, or over. In this case we have not, as in pharyngeal catarrh, a catarrhal, but Ave have an inflamma- tory fever, such as accompanies pneumonia and other inflammations of important organs. It is only in rare cases, where the disease is not severe and runs a very sluggish course, that the fever is moderate. With the commencement of the fever, or, perhaps, not till next day, the patients complain of a feeling of tension and soreness in the throat, and often of piercing pain, extending toward the ear; it feels to them as if there were a foreign body in the pharynx, hence they make con- stant attempts to swallow, although the motion increases their pain. Sometimes all the painful and terrifying symptoms occur, which we described in the first chapter of this section as accompanying the se- verer forms of catarrhal pharyngitis. Not only does swallowing be- j come Aery painful, so that, when the patient attempts to swallow ai little saliva, he distorts the face; but, from the imbibition and paraly- sis of the muscles of the palate and pharynx, Avhen he attempts to SAvallow, both solids and fluids come back through the mouth and nose, or else Ave have the painful and dangerous condition that we have be- fore described (p. 448) as caused by the impossibUity of getting the morsel out of the pharynx. The secretion of saliva is often enormous- ly increased; if the patient opens the mouth, without spitting, the saliva runs from the corners of the mouth. The tongue is thickly coated, the odor from the mouth very unpleasant; there is also the characteristic modification of the voice; its resonance is changed, the speech has the peculiar nasal twang, from which alone we may often suspect the disease as soon as the patient speaks. Other characteris- tics of parenchymatous angina are the difficulty and pain caused by opening the mouth; frequently the patient cannot separate the teeth more than a few lines; this difficulty is apparently caused by the ex- cessive tension of the bucco-pharyngeal fascia. Respiration is affected far less frequently than speech and the opening of the mouth. Any considerable Avant of breath, added to the symptoms of parenchyma- tous angina, is ahvays a serious symptom, and must arouse the suspicion that there is oedema glottidis. On examining the mouth and pharynx, which is done with difficulty, we often find the tonsUs so swollen as to touch each other or to squeeze the oedematous uvula betAveen them. If only one tonsil be inflamed, we often see the uvula pressed entirely to the opposite side. We find the soft palate pressed forward into the middle of the mouth. At the part of the neck corresponding to the tonsil, that is, behind and beloAV the angle of the lower jaw, we PHLEGMONOUS INFLAMMATION OF THE PHARYNX. 455 find a hard, painful SAvelling. Even more frequently than in catarrhal pharyngitis, the inflammation extends, Avith severe pain, to the Eusta- chian tube and tympanum. While the local symptoms thus increase for three or four days, the fever grows higher, and symptoms of hyper- aemia of the brain occur; the patient has severe headache, is sleepless, tormented by horrible dreams, or even becomes delirious. When the inflammation ends in resolution, the local and general symptoms usu- ally subside toAvard the end of the Aveek, and the patient generally re- covers in eight to fourteen days. When suppuration occurs, and ab- scesses form, there is a sudden remission after the symptoms have reached their highest point. The patients often perceive the opening of the abscess only by the sudden relief they experience, as the pus may be SAvalloAved or overlooked ; in other cases the opening may be instantly recognized by the fetid odor and the yellow color of the sub- stance throAvn out. It is doubtful how the pus, which has been com- pletely enclosed and protected from the air, acquires this very disagree- able smell. After the opening of the abscess convalescence is gener- ally rapid. Acute parenchymatous inflammation of the soft palate gives sub- jective symptoms similar to those of acute tonsillitis, and Ave can only decide on the presence of one or the other by the objective appear- ances. Chronic parenchymatous angina either results from protracted at- tacks of the acute form, or comes on gradually and independently. It generally causes very little trouble; there is little or no pain, the in- creased mucus is due to the accompanying catarrh; but the slightest irritation causes the chronic to relapse into the acute form again. The speech is often changed by the hypertrophy of the tonsUs; in other cases pressure on the Eustachian tubes causes permanent deafness. The enlarged and elongated uvula may irritate the entrance to the glottis, and so excite habitual spasmodic cough. Treatment.—General and local blood-letting are recommended in acute parenchymatous angina. The former, which Bouillaud em- ployed as " saignees coup sur coup," is never required by the disease itself, and but rarely by its complications. Leeches, applied to the neck, give little ease, and even scarification of the tonsils has not done as much good as Avas expected of it. If called the first or second day of the disease, Ave may employ the treatment adAdsed by Velpeau; that is, apply poAvdered alum to the inflamed part tAvo or three times daily, and advise the patient to rinse his mouth frequently with a solution of alum ( 3 iij— 3 ss to 5 vj of barlej'-Avater). Instead of alum, solid nitrate of sUA'er has been recom- mended to cut short the disease. I 156 AFFECTIONS OF THE PHARYNX. If called in later, or if the Velpeau treatment has been unsuccess- ful, the energetic use of cold is a rational treatment, whose benefit is proved by experience. We let tfie patient take ice and cold water in tfie mouth, and cover the throat AA'ith cold compresses, which must be frequently renewed. If fluctuation occurs, we should apply warm poultices to the throat, Wash out the mouth frequently Avith camomile-tea, and open the abscess early Avith the finger nail, or Avith a bistoury, covered to near the point with adhesive plaster. Emetics are not indicated by the disease, and should only be used Avhere the abscess cannot be opened any other Avay. Laxatives are more advisable, especially where there are marked symptoms of cere- bral hyperaemia. Purgatives, mustard-plasters, foot-baths, as well as some remedies called specifics (tincture of pimpinella, borax, guaiac), fiave no effect on the disease. In chronic parenchymatous angina, internal remedies are of no avail. As long as the swelling of the tonsils depends on their infiltra- tion, we may paint solutions of alum, nitrate of silver, or dilute tinc- ture of iodine on them, and apply cold compresses to the throat. Any remaining hypertrophy of the tonsUs can only be removed by oper- ation. CHAPTER V. SYPHILITIC AFFECTIONS OF THE PHARYNX. Etiology.—The disturbances of nutrition in the pharyngeal tissue, caused by syphilis, occasionally consist only in hyperaemia, swelHng, succulence, and perverted secretion of the mucous membrane, that is, in the characteristic symptoms of catarrh. In other cases, as a result of infection Avith syphihtic poison, we find the mucous papules, de- scribed when speaking of syphUitic affections of the mouth, which afterward become superficial ulcers or condylomata. Lastly Ave have, in the fauces and pharynx, gummy tumors, nodular tumors, and, by the breaking doAvn of these, deep and often extensive loss of sub- stance. As syphUitic catarrh of the pharynx and syphilitic mucous papules come soon after the infection, they are classed among the secondary symptoms, while the gummy tumors, which do not appear tfil late, are classed among the tertiary symptoms. Anatomical Appearances.—Syphilitic catarrh of the pharynx particularly affects the soft palate and tonsUs. The generally sharp SYPHILITIC AFFECTIONS OF THE PHARYNX. 457 boundary of the redness, at the line Avhere the soft palate becomes the hard, is as little characteristic of this disease as is a bluish-red (copper) color of the mucous membrane; Ave find both of these appearances in non-syphilitic cases of catarrhal angina. Syphilitic mucous papules also come chiefly on the arches of the palate and the tonsils, Avhich are sometimes extensively covered with them. In such cases, if the epithelial covering be milky, on superficial observation it looks as if the mucous membrane Avere covered with a croup membrane, and, if the Avhite coating be present only in the space betAveen the half arches of the palate, it seems as if there Avere an ulcer covered Avith a fatty base. The ulcers caused by the breaking doAvn of syphilitic papules present losses of substance, reddened or covered Avith gray detritus, and bleeding easily, Avhich gradually spread, by the breaking doAvn of more recent papules that come around the edges, but shoAV no tendency to become deeper. Condylo- mata form, small pedunculated excrescences, particularly on the uvula. Gummy tumors occur in all parts of the pharynx. If they develop on the tonsils, these at first appear decidedly SAVollen, AA'ith smooth red surfaces. The breaking down of the nodules causes deep ulcers, of the size of a pea or a bean, Avith fatty floors. Not unfrequently gummy tumors form on tfie posterior wall of the velum, and then sometimes cause perforation before they are recognized. Gummy nodules, and the ulcers caused by their breaking doAvn, occur most frequently on the uvula and the parts of the soft palate bordering it. At first the uvula looks as if gnaAved, later it only hangs by a small pedicle, finally it and a large part of the soft palate may be destroyed. Under prop- er treatment, gummy tumors may be resolved. In such cases there is proliferation of connective tissue at the former seat of the nodule; this subsequently shrinks, and there is a cicatricial contraction. If ex- tensive ulcers heal, there remain radiated, firm, Avhite cicatrices—occa- sionally also adhesions of the soft palate to neighboring parts, con- strictions and distortions of the pharynx, or closure of the Eustachian tube. Symptoms and Course.—Syphilitic catarrh of the pharynx can- not at first be distinguished from other pharyngeal catarrhs; diagnosis is only possible later in the disease. If a patient has had difficulty of SAvalloAA'ing for Aveeks, if this difficulty lias come on gradually, not sud- denly, and if it obstinately resists all treatment, Ave may strongly suspect that the existing catarrh is of syphilitic nature. If these difficulties are found in a person Avho had a chancre a feAV weeks pre- vious! y, and if they improve rapidly under the use of mercurials, the diagnosis may be considered as certain. Syphilitic mucous papules often develop Avithout pain or other 458 AFFECTIONS OF THE PHARYNX. inconvenience. Sometimes Ave find them accidentally, Avhen examining the throat of a patient Avho has other symptoms of syphilis. If they have changed to ulcers, they cause pain in SAvalloAving. The objective symptoms are given above. Gummy tumors do not cause pain or difficulty of swalloAving tUl they have softened and ulcerated. When patients that Ave suspect of syphilis complain of difficulty in swallowing, Ave should never neglect to examine the posterior surface of the velum Avith the finger or the rhinoscope, AA'hen inspecting the throat. Occasionally our attention is called to ulcerated nodules at the above locality, by a circumscribed dark-red spot on the anterior surface of the velum. The acts of swal- loAAdng and speaking are impaired, as before described, by perforation of the velum; this impairment is the greater the farther forward the perforation has occurred. In eating and drinking, solids and fluids return into the nose ; and as soon as the patient speaks, Ave hear the nasal twang to his voice. For the objective symptoms, Ave may refer to the last paragraph. Treatment.—Syphilitic affections of the throat must be treated according to the rules to be hereafter laid down Avhen speaking of syphilis. In recent cases, the favorable action of mercurials is very striking. When there is danger in delay, I often employ Weinhold's treatment (which is of late very unpopular), with the modification that, for several evenings in succession, I give ten to twenty grains of calo- mel, until the ulceration is arrested, which is usually by the third or fourth day. CHAPTER VI. RETROPHARYNGEAL ABSCESS. Etiology.—Inflammations terminating in suppuration are oc- casionally seen, especially among children, in the connective tissue betAveen the spinal column and the pharynx. This affection is usually caused by caries of the spine, or a " scrofulous" inflammation and suppuration of the lymphatic glands at the back of the pharynx; at other times it develops Avith secondary inflammation of other organs, late in typhus, measles, the septicaemiae, and other infectious diseases; lastly, it appears to occur occasionally as an idiopathic inflammation. Anatomical Appearances.—The posterior wall of the pharynx is often pressed forward by the collection of pus, and the pharynx con- tracted or entirely closed; the pus may subsequently perforate the wall of the pharynx, or even sink into the breast, and there perforate >he oesophagus, trachea, or pleura. Symptoms and Course.—When disease of the cervical vertebrae ANGINA LUDOYICI. 459 accompanies retropharyngeal abscess, the affection is preceded for a time by peculiar stiffness of the neck and other symptoms of the verte- bral disease; in this case avc cannot easily make a mistake, for, as soon as there is difficulty of swallowing, the inside of the throat avUI be carefully examined. It is otherwise, especially in small children, when the affection begins without these preliminary symptoms. The rest- lessness of the child, its refusal to take the breast, its anxiety when compelled to drink, and the attacks of coughing and choking which interrupt the drinking, are occasionally referred to some primary affec- tion of the larynx, as croup, laryngismus, etc. This is particularly liable to be the case Avhen, besides the above symptoms, there is con- tinued dyspnoea, the child is hoarse or voiceless, and the cough has a croupy sound. With the above symptoms it Avould be unpardon- able not to examine the pharynx carefully; this examination quickly certifies the diagnosis: the finger usually encounters, close behind the soft palate, a tense, elastic tumor, which usually fluctuates distinctly and cannot be readily mistaken. Sometimes the abscess breaks spon- taneously into the pharynx, its contents being swallowed or vomited up, and there is immediate relief of the symptoms. More frequently, if aid be not given at the proper time, the patient dies. There may be complete closure of the glottis by the swelling or the occurrence of oedema glottidis, or the opening of the abscess during sleep, and the entrance of its contents into the larynx, may choke the patient. In other cases the abscess sinks into the breast and causes pleuritis, pneu- monia, pericarditis, etc. Treatment.—The abscess is to be opened as early as possible. My old preceptor, Peter Kruckenberg, of Halle, said, in his hu- morous Avay, Avhich always had a substratum of earnest, that every physician should alloAV one of his finger-nails to groAV long, and sharpen it like a lancet, so that it Avould be always ready to open immediately any retropharyngeal abscess that he might run against. Probably none of his pupils ever followed this advice of " old Peter," but doubt- less some of them have to thank him for the symptoms of retropharyn- geal abscess always remaining fresh in their minds, and that no casea of it haA'e escaped them. CHAPTER VII. ANGINA ludovici. The floor of the mouth and the intermuscular and subcutaneous connective tissue of the submaxiUary region are occasionally the seat of a phlegmonous inflammation, which may readily lead to diffuse 460 AFFECTIONS OF THE PHARYNX. gangrene and sloughing, but in other cases ends in formation of abscess or not unfrequently in resolution. This disease (which is often improp- erly called " gangrenous" inflammation of the neck, and which Ave name Angina LudoAdci, after the deceased Ludwig, of Stuttgard, who first fully described it) is said by reliable observers to occur as a pri- mary and idiopathic disease, and sometimes to be epidemic. In the few cases that I have observed, the inflammation of the connective tissue undoubtedly proceeded from periostitis of the lower jaw. Last- ly, there is a form of the disease which comes Avith symptomatic or metastatic parotitis occurring in typhus and other infectious diseases; this probably starts from the submaxillary glands. The disease begins with a more or less painful, very hard swelling in the vicinity of one or other submaxUlary gland. We may feel this SAvelling from the mouth, as well as from the outside; the skin cover- ins: it is of normal color. The swelling1 soon extends over the entire submaxillary region, and upAvard toward the parotid; sometimes also downward, toward the larynx and trachea. The floor of the mouth is pressed far upAvard. Chewing and speaking become very difficult; the movements of the tongue are almost arrested, and the patient cannot open the mouth, because the muscles by which this is done are partly embedded in the infiltrated cellular tissue, and partly participate in the inflammation. The affection is usually accompanied by moderate fever and slight general disturbance; at other times the fever is high, and there is great constitutional sympathy. Even in favorable cases, when resolution has occurred, the hardness disappears very sloAvly. When an abscess forms, the skin becomes red at some points, and fluctuation occurs; finally the pus breaks through the thinned covering. Quite as often the abscess opens into the mouth. When it terminates in gangrene, and there is perforation, instead of healthy pus, we have a fetid, discolored fluid, containing shreds of tissue. Death may result, at the height of the disease, from oedema glottidis and suffocation; at the termination, in gangrene from septi- caemia ; in the metastatic forms death usually results from the original disease. At the commencement of the affection we attempt to secure reso- lution by the application of a large number of leeches near the tumor. Later Ave should continuously apply warm cataplasms. As soon as there is fluctuation Ave evacuate the matter through a large incision. Where there is danger of suffocation, Ave should scarify freely, and, if this does not answer, we should proceed to tracheotomy. If a hard, indolent swelling of the maxUlary region remain for a long while, I find that repeated blisters do more good than rubbing in iodine or mercurial salves, or painting on tincture of iodine or LugoVs solution. SECTION III. AFFECTIONS OF THE OESOPHAGUS. CHAPTER I. INFLAMMATION OF THE CESOPHAGUS--OESOPHAGITIS--DYSPHAGIA INFLAMMATORY. Etiology.—Catarrhal, croupous (diphtheritic), and pustular inflam- mations may affect the mucous membrane of the oesophagus, which may also be the seat of ulcers, or even mortify from the action of strong chemical agents; lastly, there are inflammations and suppurations of the submucous tissue. Catarrhal inflammation is most frequently caused by the action of local irritants, such as acrid or too hot food, awkwardly-introduced oesophageal sounds; in other cases, the catarrh extends from the stomach or pharynx to the oesophagus; in still others, it may depend on venous congestion, Avhich, in diseases of the heart and lungs, often exists throughout the Avhole intestinal canal. Croupous inflammation of the oesophagus is rarely seen, and, AA'hen it does occur, it is almost always in company with similar inflamma- tions of the larynx and pharynx, or in protracted typhus, cholera, and the acute exanthemata. Pustular inflammation comes in some rare cases of variola, or after the use of tartar emetic. Ulcers of the oesophagus are mostly caused by pointed bodies, AA'hich penetrate the mucous membrane, or by angular bodies that have become lodged at some spot in the oesophagus; more rarely, it comes from corrosion of the mucous membrane, or in the course of chronic catarrh. The same causes may excite inflammations and suppurations of the submucous tissue. Lastlv, the mucous membrane is sometimes burned by corrosive 6ubstances, particularly by concentrated acids. Anatomical Appearances.—Acute catarrhal inflammation of the t 4-62 AFFECTION'S OF THE ESOPHAGUS. oesophagus is rarely found on post-mortem examination; AA'hen it is seen, the mucous membrane appears very red, swollen, readily torn, and is covered Avith a mucous secretion. In chronic catarrh, the mu- cous membrane, particularly that of the loAver third of the oesophagus, appears thickened, dirty brown, or slate-gray, and is covered with tough mucus. Chronic catarrh may cause dilatation of the oesophagus by relaxation of its muscles, or stricture, by partial hypertrophy of the muscles and submucous tissue (see Chapter III.). In croupous inflammation of the oesophagus Ave find the mucous membrane dark red, and covered with thick layers of exudation, in spots, or spread out widely. In pustular inflammation slight elevations form, fill with pus, burst, and leave a superficial loss of substance; when caused by tartar emetic, the disease is limited to the lower third of the oesophagus. Ulcers of the oesophagus are mostly superficial excoriations, but they may also destroy the entire thickness of the mucous membrane, and attack the muscles and surrounding connective tissue. When chronic, inflammation of the submucous tissue may lead to thickening of the walls of the oesophagus and stricture; when acute, it may ter- minate in abscess. In inflammation of the oesophagus from corrosive substances, the parts affected are changed to a discolored, brown, or black slough, in whose vicinity injection and extensive serous exudation are quickly de- veloped. The sloughs become detached, the loss of substance may be filled up; if the destruction was extensive, stricture of the oesophagus always remains as a result of the contraction of the cicatricial tissue. Symptoms and Course.—In swallowing a hot mouthful, we may notice how little sensibility the oesophagus has, particularly at the loAver portion. Hence we only have pain in very severe inflammations of the oesophagus, when caused by burns, injuries from pointed or angular bodies, but particularly after corrosion from caustic substances. This pain is felt deep in the breast, and at the back, between the shoulder-blades. In these cases we also find difficulty of swallowing; for, as soon as the muscles of the oesophagus are inflamed or infiltrated with serum, they cannot pass the morsel downAvard. This condition, which was formerly described as dysphagia inflammatoria, is ahvays accompanied by oppression and great anxiety. The higher up the morsel is arrested, the more distinctly the patient feels it. If he makes new attempts to SAvallow, the contractions of the oesophagus may drive upward its contents, which cannot pass downward, so that there will be a regurgitation of the partly-swalloAved substance, bloody mucus, and masses of exudation (see Chapter II.), These symptoms are always accompanied by excessive thirst, and, Avhere the inflamma- * STRICTURES OF THE OESOPHAGUS. 4,33 tion is extensive, there may also be fever. When the cHsease runs a favorable course, the symptoms disappear gradually; after the perfora- tion of a submucous abscess, they may pass away suddenly; in other cases stricture remains; occasionally, even death is caused by perfora- tion or rupture of the oesophagus (see Chapter V.). During life, the slighter cases of acute and chronic catarrh do not have any recognizable symptoms. The same is true of pustular in- flammation. The croupous form also is usually overlooked, unless pseudomembranes are vomited up; if it accompanies croup of the larynx and fauces, the dyspnoea and other symptoms of these affec- tions throAV into the background the pain and difficulty of SAvalloAving; Avhen it conies as a secondary croup in typhus and similar diseases, tfie patients usually lie in a perfectly apathetic state, so that they utter no complaints. Chronic ulcers occasionally cause pain at some circumscribed spot, and permanently interfere with swalloAving; they can only be distin- guished from strictures by introducing an oesophageal bougie, which, in case of ulcers, finds no obstruction, and often brings up mucous, bloody masses. As the ulcers cicatrize, the symptoms of stricture may occur. Treatment.—The question of treatment can only arise in the more severe forms of oesophagitis, as the slighter cases are not recog- nized. Foreign bodies exciting the inflammation are to be removed according to the laAVS of surgery. In corrosion by mineral acids and caustic alkalies, antidotes can only be used in very recent cases. For the rest, in acute catarrh, we may limit ourselves to ghdng the patient ice-Avater to swallow, or let him take pieces of ice in the mouth. Gen- eral and local bleeding are only injurious ; the employment of medi- cines is difficult, and promises little benefit. If the patient can SAval- low, he should take only fluids. If swallowing be totally impossible, the patient may be nourished through the stomach-tube, or by ene- mata. In chronic ulcers of the oesophagus, the numerous remedies recommended remain AAdthout effect, and careful nourishment of the patient is the chief object of treatment. CHAPTER II. STRICTURES OF THE CESOPHAGUS. Etiology.—Contractions of the oesophagus may be due—1, to com- pression ; 2, to the protrusion of neAv groAvths into its canal; 3, to structural changes of its Avails. The latter form are strictures in the exact sense of the word; they result from the inflammations described in the last chapter. 464 AFFECTIONS OF THE CESOPHAGUS. Anatomical Appearances.—Compression of the oesophagus may arise in various Avays. Among the most frequent causes Ave may men- tion : SAvelling of the thyroid bodies or of the lymphatic glands of the neck or mediastinum; dislocation of the hyoid bone ; exostoses of the vertebrae ; abscesses or tumors betAveen the trachea and oesophagus ; carcinoma of the lungs or pleura; aneurism. Not unfrequently the diverticuli, to be described in the next chapter, compress the section of the oesophagus immediately below them. In some cases where, during life, there were signs of compression of the oesophagus, on post-mortem examination, the right subclavian artery has been found morbidly di- lated, arising from behind the left subclavian, and running to the right betAveen the oesophagus and trachea, or oesophagus and vertebrae. The difficulty of SAA'alloAving thus caused has been named dysphagia lusoria. In Chapter IV. we shall speak of the neAV formations on the inner Avail of the oesophagus, Avhich are the most frequent causes of its con- traction. Strictures of the oesophagus, in the exact sense of the word, de pend—1, on cicatricial contractions of the membrane AA'hich have oc- curred after considerable losses of substance; they remain most fre- quently after corrosion or extensive ulceration; 2, on hypertrophy of the muscular and intermuscular connective tissue, induced by chronic catarrh of the oesophagus. On a longitudinal section through the wall of the oesophagus, which, in such cases, is frequently much thickened, there is often a peculiar fan-like appearance, as the hypertrophied mus- cular filaments are grayish red, whfie the hypertrophied connective tissue between them presents white fibrous bands, and the mucous membrane is thickened and irregular. Lastly, strictures may be due i to hypertrophy and subsequent cicatricial shrinkage of the submucous tissue. Sometimes the contraction is almost unnoticeable, at others so de- cided that the oesophagus is completely closed. The most frequent seat of stricture is the lower third, but it may occur in any part. Above the stricture, the walls are almost always hypertrophied, and the canal dilated; beloAV it, the walls are often thinned, and the canal collapsed. Symptoms and Course.—As strictures of the oesophagus from any cause develop gradually, the disease is at first apparently without danger, and does not cause much inconvenience. For a long time the sole symptom is a slight impediment in swallowing large morsels, which is overcome Avhen the patient drinks or makes neAV efforts to swalloAV. Although the patients become more careful, and chew all their food very fine, they gradually find it more and more difficult to STRICTURES OF THE (ESOPHAGUS. 465 BAvalloAV. Even Avhen the stricture is near the cardiac orifice of the stomach, they almost ahvays indicate the region beneath the manu- brium sterni as the place AA'here the food sticks; finally, they cannot even SAvaUoAV liquids. The greater the obstacle, the less the patient succeeds in overcom- ing it by drinking, or by renewed attempts to SAvallow ; and the more frequently the food regurgitates. An antiperistaltic movement, in which the contraction of a lower segment of the oesophagus is folloAved by the contraction of the segment just above it, has not been physiologi- cally observed, it is true ; on the contrary, the contractions Avhich are voluntarily begun in the pharynx always go from above doAvmvard; but these facts do not exclude the possibUity of a morsel of food, which cannot pass doAvmvard, being pressed upAvard by contractions AA'hich have proceeded peristaltically from above down to the point of stric- i ure, or of a regurgitation in the same Avay, into the mouth, of the con- lents of the oesophagus, which has been filled up to a certain point. Occasionally there is no abdominal pressure in this form of vomiting; in other cases there is spasmodic contraction of the muscles of the ab- domen Avithout any influence on the evacuation of the oesophagus. When the contraction has increased still further, after every attempt to eat or drink; often after a feAV mouthfuls, occasionally not tUl a good deal has been swalloAved (Chapter III.), there is a feeling of pressure deep in the breast, accompanied with great unpleasantness and anxiety, AA'hich increases until, with intentional or instinctive at- tempts to SAvaUoAV, the food is sloAvly evacuated from the mouth, little changed, but largely mixed with mucus. The introduction of a bougie affords the best diagnostic sign, as it shoAVS not only the existence of the stricture, but also its grade, locality, and even its form. Besides the appearances described, and the other symptoms that a carcinoma or other tumor causes, the impaired nutrition induces grad- ual emaciation, and the belly sinks in; there may be no passage from the boAvels for Aveeks, the patient starves, and, as Boerhaave aptly says, " tandem post Tantali pcenas diu toleratas lento marasmo conta- bescunt." Treatment.—The treatment of stricture of the oesophagus belongs to surgery. By skill, patience, and persistence, surprising results are sometimes attained. In the surgical clinic at GriefsAvald there Avas a patient AA'ho, Avithout perceptible cause, had a stricture of the oesopha- o-us; at first only a common elastic catheter could be passed through it, but after four Aveeks it Avas so dilated that not only could the largest oesophageal sounds be passed, but ordinary morsels of food could be SAvalloAved Avith ease. 30 466 AFFECTIONS OF THE OESOPHAGUS CHAPTER III. DILATATION OF THE 03S0PHAGUS. Etiology.—The dilatation of the oesophagus is sometimes total, af- fecting the entire organ, sometimes partial, limited to a short section. In partial dilatation sometimes only one Avail is affected, then enlargements form Avhich often develop to large sacs, communicating AAdth the oesoph- agus ; they are called diverticuli; their walls are sometimes formed of the mucous membrane, which protrudes hernia-fike betAveen the mus- cular filaments, and of the external connecth'e tissue layer. Besides the diverticuli, dilatations of the oesophagus are most fre- quently found:—1. Above a constricted portion; in stricture of the cardiac orifice there is total, Avhen the stricture is higher up there is partial dilatation. 2. In other cases the total dilatation appears to de- pend on a chronic catarrh and on the muscular paralysis induced by it. 3. In many cases the causes are unknoAvn. Rokitansky*s hypothesis, that concussions of the body, and Oppolzer's, that the treatment of gout Avith large quantities of warm water, may cause enormous dilata- tion of the whole oesophagus, appear to me very problematical. The diverticuli are formed—1. By foreign bodies which have stuck in the walls of the oesophagus, and are constantly driven farther in by the food Avhich passes down. 2. They are sometimes formed by the shrinkage of bronchial glands, which have become adherent to the mu- cous membrane, while they were swollen, and which on contracting draw the mucous membrane after them. 3. In other cases Ave can dis- cover no cause. Anatomical Appearances.—In total dUatation of the oesopha- gus, the entire canal has been found dilated to the size of a man's arm; the walls are usually hypertrophied, more rarely thinned. In partial dilatation, the portion immediately abo\Te the constriction is usually largest. The dilatation gradually decreases as Ave go up- ward, so that an elongated sac is formed, at Avhose fundus there is a second, narroAV exit. Diverticuli usually form near the bifurcation of the trachea, or at the point where the pharynx becomes the oesophagus; they are at first roundish, but later they form cylindrical or conical appendages to the oesophagus, lying between it and the spine. Such diverticuli sometimes only communicate Avith the oesophagus by a narroAV fissure; in other cases, they seem to be prolongations of the oesophagus itself, with a blind end, which the food enters, Avhile alongside of it the lower part of the oesophagus lies empty, constricted, collapsed. Symptoms and Course.—Total dilatation exists Avithout the MORBID GROWTHS IN THE ffiSOPHACUS. 4^7 presence of any symptoms by AA'hich the affection may be recognized. The partial dilatation that forms above a contracted part modifies the symptoms, so that the food remains in the oesophagus for a longer time and in greater quantities before regurgitating. When the food is finally vomited, it is softened, mixed with mucus, sometimes decom- posed, but it is undigested and almost ahvays of alkaline reaction. This circumstance may be useful in deciding AA'hether the food comes from the stomach or oesophagus. When the diverticuli are so large that food goes into them instead of into the stomach, they excite the same symptoms as stricture Avith partial dilatation. The food that has been SAvalloAved sometimes re- gurgitates hours afterward, and may then be much decomposed, so that there aa'UI be a A'ery bad smell from the mouth of the patient. Occasionally introducing the bougie renders the diagnosis certain, since Ave may at one time meet an insurmountable obstacle to its passage, Avhile at another it may readUy pass the diverticulum, and enter the stomach. If the diA'erticulum be at the commencement of the oesoph- agus, a soft tumor may be found in the neck behind the larynx, Avhich increases in size after eating and drinking, and diminishes AA'hen the food and drink have been evacuated; if it be farther doAvn, by pressure on the trachea and great vessels, it may cause dyspnoea, and disturbance of the circulation. In these cases, also, the patient may finally die of starvation. Treatment is of no use in dilatation of the oesophagus. If Ave can pass a stomach tube through the diverticulum into the stomach, Ave may attempt to feed the patient in this Avay for a while, with a very slight hope that, if the food no longer enter the diverticulum, it may decrease in size. CHAPTER IV. MORBID GROWTHS IN THE 03SOPHAGUS. Etiology.—Fibroid tumors are rarely, and tubercles almost never, seen in the oesophagus; but carcinomata occur quite often. They' are usually primary, more rarely carcinomatous groAvths spread from the mediastinum to the oesophagus. The cause of cancerous degeneration of the oesophagus is just as unknoAvn as that of cancer elseAvhere. It has been claimed that brandy- drinkers are particularly liable to the disease. Anatomical Appearances.—The fibroid tumors form movable, bluish-Avhite concretions of the size of a lentil or bean, in the submu- cous tissue, or they appear as pedunculated polypi, often lobulated at 468 AFFECTIONS OF THE ESOPHAGUS. the free end, AA'hich usually originate from the cricoid cartilage {Roki- temsky). Of the carcinomatous growths, scirrhus and medullary cancer, and very rarely epithelioma, occur in the oesophagus. They generally affect the upper or lower third, more rarely the middle third; the AA'hole circumference is usually comprised in the degeneration forming a can- cerous stricture. The degeneration ahvays begins in the submucous tissue, but soon attacks the mucous membrane. If the cancer softens and disintegrates, uneven ulcers form, surrounded by a medullary in- filtrated Avail, and covered with sanies, and bleeding fungous groAvths, or black ragged masses. From the external connective tissue mem- brane of the oesophagus, the cancer may extend to the neighboring structures, and, when breaking doAvn, cause perforation of the trachea, bronchi, or even of the aorta and pulmonary arteries. Symptoms and Course.—The small movable fibroids of the oesophagus cause no symptoms; pedunculated fibrous polypi cause the symptoms of stricture of the oesophagus, and may induce haemor- rhage ; the oesophageal sound may be passed around them, and, Avhen they are high enough up, they may be reached with the finger. Cancer of tfie oesophagus is not easUy mistaken. If, in a person of advanced age, particularly in one who has been in the habit of drinking strong liquor, difficulty of swallowing gradually occurs, with- out any other known cause, and increases sloAvly till it produces the very painful symptoms described in the second chapter, Ave may very strongly suspect carcinoma, for Ave knoAV that this is by far the most frequent cause of stricture of the oesophagus, and that all other forms are proportionately very rare. The presumption that the disease is cancerous increases in probability when there are lancinating pains at various places, particularly betAveen the shoulder-blades, when the patient emaciates rapidly, and the dirty-yellow, cachectic appearance of the face, common to cancer-patients, occurs. The diagnosis be- comes absolutely certain when we find fragments of cancer in the mu- cous, sanious, or bloody masses, that are vomited or brought up with the oesophageal sound. Subsequently, when the cancer sloughs, the symptoms of stricture subside ; nevertheless, the emaciation continues, the feet swell, coagula often form in the femoral A'eins, and, finally, the patient dies from exhaustion, or from perforation of one of the aboA'e-named organs. Treatment.—Dilatation of the cancerous stricture by bougies is dangerous, and should never be tried Avhen the diagnosis is certain. In the earlier stages it may fiasten the sloughing of the cancer, and later it may cause perforation of the oesophagus. The treatment must be symptomatic. If there is great pain, we may give opium; when PERFORATION AND RUPTURE OF THE (ESOPHAGUS. 469 there is inability to SAvaUoAV, Ave may make the almost hopeless at- tempt to nourish the patient by enemata. CHAPTER V. perforation and rupture of the oesophagus. Perforation of the oesophagus may take place from Avithin out- Avard, or the reverse. The first form most frequently results from the breaking doAA'n of cancer, more rarely from ulcers caused by splinters of bone, or from deep sloughs, excited by corrosion AA'ith caustic sub- stances. So-called perforating ulcers, such as are found in the stomach and duodenum, are never seen in the oesophagus. The oesophagus may be perforated from Avithout imvard by aneurisms of the aorta, by the breaking down of tuberculous bronchial glands, espe- cially of those located at the bifurcation of the trachea, by abscesses on the anterior surface of the spine, by caries of the A'ertebrae, even by tuberculous cavities in the lungs, etc. Rupture of the oesophagus Avithout precedent disease has only been observed in a very feAV cases {Boerhaave, Oppolzer). It more fre- quently happens that the Avail of the oesophagus, Avhich has been almost destroyed by carcinoma, corrosion, or ulcers, and nearly per- forated, is suddenly ruptured by severe retching and vomiting. If the Avail of the oesophagus is opened in any way, its contents pass into the surrounding connective tissue, or communication is opened Avith the trachea, pleural or pericardial sacs, or Avith the great vessels. Before perforation or rupture of the oesophagus occurs, the advan- cing destruction may cause adhesive inflammation of the adjacent or- gans, the symptoms of Avhich precede the perforation. I have seen double pleurisy and pericarditis gradually develop in a man with car- cinoma of the oesophagus; on post-mortem examination I found the parts of the pleura and pericardium lying next the cancer discolored and mortified, but no escape of the contents of the oesophagus into those caAdties. Sudden, severe pain, deep in the breast, usually indi- cates the moment of perforation ; besides this there are chill, paleness, and coolness of the extremities, fainting, and sometimes, depending on the seat of the perforation, attacks of suffocation, or symptoms of se- vere pleurisy, or profuse vomiting of blood. Death sometimes occurs immediately. There can be no treatment. 470 AFFECTIONS OF THE ESOPHAGUS. CHAPTER VI. NERVOUS AFFECTIONS OF THE 03S0PHAGUS. Globus hystericus, or the feeling of a ball rising to a certain point in the oesophagus and remaining there, has been called hyperesthesia, i. e., increased excitabUity of the sensory nerves, of the oesophagus. We have already mentioned globus hystericus when speaking of the nervous affections of the larynx. Some cases that are described as spasm of the oesophagus should also be reckoned among the hyperaes- thesiae; such as those where the patient feels as if the oesophagus Avere ligated, and thinks he cannot SAvallow. This state not unfre- quently occurs in persons that have been bitten by dogs. Andral re- lates a case Avhere Boyer was obliged to stay with a patient at meal- times for a whole month, because she thought she would suffocate as soon as she attempted to swalloAV. There can hardly be anesthesia, that is, diminished or lost excita- bility of the sensory nerves of the oesophagus, because the normal sen- sitiveness is so very slight. Hyperkinesis, increased excitability of the motor nerves, cesopha- gismus, or dysphagia spastica, occurs more frequently, although, doubt- less, many cases, classed under this head, have been misinterpreted. Spasm of the oesophagus is most frequently of reflex origin; it is often excited by irritation of the uterus, hence is most frequently met in hysterical Avomen; occasionally it is of central origin and forms one symptom of disease of the brain or upper part of the spinal marrow; it may also be induced by poisoning with narcotic substances or alco- hol. Like most neuroses, spasm of the oesophagus runs its course with paroxysms and free intervals. The attacks most frequently occur during eating; the patient suddenly becomes unable to swallow, and feels as if there Avere a foreign body in the oesophagus. If the spasm be at the upper end of the organ, the food returns as soon as intro- duced ; if at the lower end, it does not regurgitate for a short time. There are, usually, at the same time, attacks of oppression and suffo- cation, and sometimes spasmodic contractions of the muscles of the neck. After lasting for a while, the attack usually passes off; in other cases, a slight amount of spasm remains for weeks or months as a per- manent affection, called " spastic stricture." During the interval, if Ave examine Avith the bougie, we find no obstacle; if Ave examine dur- ing the attack, the stricture occasionally disappears during the probing. Besides a proper treatment of the original disease, it is advisable to use narcotics, particularly belladonna, or the so-called antispasmodics, NERVOUS AFFECTIONS OF THE (ESOPHAGUS. 471 such as A'alerian, asafcetida, musk, etc. If the patient cannot SAvalloAV, these remedies should be used by enema. Repeated careful introduc- tion of the oesophageal bougie promises the best results. Akinesis, diminished excitability of the motor nerves of the oesoph- agus, is not unfrequently seen along with the signs of general paral- ysis shortly before death. In other cases, the paralysis is of central origin, and accompanies diseases of the brain, or of the cervical por- tion of the spinal marroAv. In complete paralysis of the oesophagus, SAvalloAving is impossible; often, when the bystanders wish to refresh the dying patient, they are horrified that he cannot swalloAV, and be- cause the food or drink they offer returns out of the mouth, or passes into the larynx, and excites attacks of suffocation. When the paraly- sis is incomplete, food does not return, but large morsels and firm sub- stances are most easily swallowed. SAvalloAving is facilitated by the upright position and by drinking. In this dysphagia the patient does not usually complain of pain, and the probe meets no obstacle. Treat- ment is almost always hopeless, on account of the severity of the origi- nal disease. The repeated use of the probe, the employment of strych- nia and electricity, have been recommended, and it has been claimed that they have sometimes proved serviceable. SECTION IV. DISEASES OF THE STOMACH. CHAPTER I. ACUTE CATARRHAL INFLAMMATION OF THE MUCOUS MEMBRANE OF THE STOMACH--ACUTE GASTRIC CATARRH. Etiology.—During normal digestion changes occur in the gastric mucous membrane, which, if found in other mucous membranes, Avould be called catarrh. The secretion of the gastric juice is always accom- panied by considerable hyperaemia of the mucous membrane, AA'hieh is regularly followed by an abundant Aoav of mucus, and a considerable detachment of epithelium. This physiological process, like the analo- gous pathological one, is accompanied by a slight general disturbance, the so-called digestive fever. Hence, the definition, that Ave have given for catarrh of mucous membranes generally, does not answer for gas- tric catarrh; what in them is pathological is here normal, and we can only speak of gastric catarrh when the physiological process increases beyond normal bounds. It will be readUy understood that, as the act of digestion is repeated several times during the day, and our food is complicated and sometimes of improper character, the process may readily become abnormal; hence, as may easily be conceived, acute gastric catarrh is one of the most frequent of diseases. On the other hand, it is just as eAddent that a morbid augmentation of normal pro- cesses may subside more readUy and quickly than other more material deviations from the normal state. Hence, under favorable circum- stances, gastric catarrh usually lasts a shorter time than that of other mucous membranes. The predisposition to this affection varies AA'ith the individual; in some persons it is induced by exciting causes, Avhich would have no effect on others. In many cases increased predisposition to gastric catarrh depends on too scanty a secretion of gastric juice, as this favors abnormal decomposition in the stomach, Avhich is the most frequent ACUTE GASTRIC CATARRH. 473 cause ot the disease. On this diminution of the gastric juice depends the great inclination to gastric catarrh observed: 1. In all fever patients. It is going too far to say that every fever is accompanied by catarrh of the stomach; neither the coated tongue nor the loss of appetite of fever patients justifies this vieAA'. But, as in every fever, in consequence of the increased temperature, the amount of Avater lost through the skin and lungs is excessively increased, it may be concluded a priori that less gastric juice vAdll be secreted; this supposition is confirmed not only by the analogous condition of other secretions, but by actual observations {Beaumont). (It is possi- ble that in feA'er the composition of the gastric juice is also changed; but this hypothesis is not necessary to explain the results of slight errors of diet on the part of the fever patients.) If the patients do not bear this in mind, and adapt their diet to the diminished secretion of the stomach, very distressing gastric catarrh avUI result. A large portion of the gastric complications in pneumonia and other inflam- matory affections result from neglect of this simple dietetic rule. 2. The increased predisposition to acute gastric catarrh, Avhich Ave see in debilitated and badly-nourished persons, appears also to depend on diminished quantity or inferior quality of gastric juice, Avhich faA'ors the decomposition of the ingesta. If the amount of blood be decreased, it is probable that the quantity of gastric juice as Avell as of the other secretions is diminished. As, in hydraemia, there is a diminution of the albuminates of the blood, which Ave must regard as the material of Avhich pepsin, the organic constituent of the gastric juice, is formed, the supposition is Avarranted that a juice, deficient in pepsin, is formed in such cases. From the diminished action of the gastric juice, part of the ingesta remain undissolved and decomposed; hence many con- A'alesccnts have gastric catarrh from eating Avhat Avould not have harmed them at another time. In the same AA'ay puny children haA'e this disease Avhen they take the same amount of mother's milk, or the same quantity of coav's milk diluted to the same extent, as healthy children of the same age can take Avithout harm. 3. Although Ave have many analogous facts in other organs, it is not easy to explain the increased predisposition to gastric catarrh in persons Avho are very careful about their stomach, and carefully protect it from irritation. Catarrh of the stomach is more readily induced by a slight excess in drinking, in persons unaccustomed to the use of liquor, than in those Avho take a moderate amount daily; and by a slight error of diet in children Avhose diet is usually carefuUy Avatched, than in those accustomed to complicated and indigestible food. 4. Lastlv, Ave find an increased predisposition to gastric catarrh in persons Avho have suffered from it repeatedly. £74 DISEASES OF THE STOMACH. 1. Among its exciting causes is the use of very large quantities of food, even of that AA'hich is very easily digested. We have already pointed out that in these cases acute gastric catarrh is not induced so much by the overfilling of the stomach as by the action of the products of decomposition, formed when the gastric juice does not suffice for the sub- stances to be digested. Hence, after overloading the stomach, the symp- toms of acute catarrh do not occur immediately, but come on next day. In groAvn-up and sensible people it does not often happen that they have simply eaten too much / this is far more frequently seen in children, especially among such as have their diet very much restricted, and hence are never satisfied, but seize every opportunity to overload the stomach. Children at the breast hardly have any feeling of satiety; AA'hen nourishment is plenty, they usually drink till the stomach is overfilled. If they vomit easUy, the overloading is soon removed, and only so much nourishment remains as they can readily digest; if they do not A'omit easily, the stomach remains overfilled, and they are affected AAdth gastric catarrh, although they have taken the most suit- able nourishment. Nurses know very Avell that children which vomit often and easily (" spei-kinder") sicken less readUy and thrive better than others. 2. Gastric catarrh may be excited by moderate use of food difficult ofr digestion. In this case, also, it is not the food itself, but the prod- ucts of its decomposition, when partly undigested, that cause the dif- ficulty. The indigestibility of food often depends on its shape. Per- sons AA'ho eat with avidity, or who have no teeth, often introduce perfectly digestible food into their stomachs in a state Avhich offers little surface to the gastric juice, which is consequently sloAvly absorbed and digestion is retarded. It is well known that the yolk of a hard- boUed egg is far more easily digested than the Avhite; this is simply because the former is far more readily broken into fine morsels in the mouth than the latter is. The use of fat meat, or greasy sauces mixed Avith the meat, often causes gastric catarrh, not, as the laity suppose, because fat is indigestible, but because, when mixed AAdth the meat, it hinders its imbibition and so diminishes its digestibility. It Avould lead us too far if we Avere to mention all the substances that are indi- gestible, and may cause gastric catarrh, even AA'hen used in moderate. quantities. 3. Gastric catarrh is often caused by the use of substances that haA'e begun to decompose before entering the stomach. It may be thus caused in adults by spoiled meat, or by neAV beer; but it most frequently occurs in children from the use of mUk that has begun to sour. This is Avhat renders the artificial nourishment of infants so dif- ficult in hot Aveather, when milk begins to spoil very soon. If children ACUTE GASTRIC CATARRH. 475 | do not have their mouths regularly cleaned, or if a sugar-teat be given them to preA'ent their crying, the decomposition of good fresh cow's milk, or even of the mother's milk, may be commenced in the mouth itself. (It is AveU knoAvn hoAv carefully milk-cans must be cleansed and purified of all decomposing substances in order to prevent the milk from spoiling.) If decomposition has once begun in the mUk in the stomach, the best milk taken subsequently wUl act as a poison, as it also soon begins to decompose. We shall hereafter see that ferment- ing substances in the stomach, after death, may destroy and dissolve its Avails. Even if such an action on the AA'alls of the stomach be pre- vented during life by the chculation and the rapid change of tissue in them, it is nevertheless not improbable that the epithelium, where nu- trition is less active, may be destroyed, even during life, by tfie fer- menting substance; and that the deprivation of the mucous membrane of its protection may cause extensive transudations. It appears not to be the lactic acid, the product of the souring of the mUk, but the process of fermentation itself, AA'hich excites the symptoms of cholera infantum, and after death causes the softening of the stomach. We come to this conclusion because milk, AA'hich has already curdled, and Avhose sugar has been transformed into lactic acid, may be eaten even in large quantities by older children and by adults, without dele- terious influence; and because the so-called softening of the stom- ach may be more readily induced in that organ, when cut out of an animal, by filling it Avith fresh mUk and exposing it to a moderate tem- perature, than by filling it Avith dilute acid. 4. Acute catarrh of the stomach may also be caused by irritation, from taking into it A'ery hot or cold articles, some medicines, alcohol, or spices. Alcohol acts most injuriously when it is but slightly dUuted. Spices and similar substances, in small quantities, excite the normal processes, and hence may improve digestion; in larger quantities, hoAvever, they increase these processes beyond the normal limits, and lead to gastric catarrh. 5. Acute gastric catarrh is excited by the introduction of sub- stances that weaken the digestive poAver of the gastric juice, or retard the movements of the stomach. It is evident that, in either case, there may be abnormal decomposition of the contents of the stomach. Apart from the direct irritation of the gastric mucous membrane, the misuse of alcoholic stimulants acts injuriously in this Avay. In the matter vomited the day after a debauch, much to the astonishment of the patient, he often finds some of the food eaten the previous day, Avhich is hardly changed. The narcotics, particularly opium, seem to cause the gas- tric catarrh, Avhich is so often seen after large doses of them, by impair- ing the movements of the stomach and thus preventing the food from 470 DISEASES OF THE STOMACH. being sufficiently mixed AAdth gastric juice, and keeping it too long in the organ. 6. Catching cold also leads to gastric catarrh, though less fre- quently than to catarrh of the respiratory organs. 7. Lastly, at certain times, Avithout knoAvn cause, from a " genius epidemicus gastricus," gastric catarrh occurs surprisingly often; and at such times other affections are complicated Avith it, Avithout there having been any error of diet. In this class belong the feverish, gas- tric, and intestinal catarrhs and cholera morbus, Avhich are occasionally epidemic. When speaking of infectious diseases, Ave shall treat of those cases of gastric catarrh AA'hich, like other catarrhs, are symptomatic of an in- fection. Anatomical Appearances.—We seldom have the opportunity of seeing the remains of acute gastric catarrh on post-mortem examina- tion ; AA'here Ave do, the gastric mucous membrane is found reddened in spots by a fine injection, its tissue is relaxed, and its surface covered with a layer of tough mucus. But more frequently, especially among chUdren Avho die Avith the symptoms of cholera infantum, the autopsy gives negative results, except as to appearances that avUI be described hereafter. This does not appear strange, when Ave remember that the capUlary hyperaemias of other mucous membranes, Avhich Ave have been able to observe directly during life, leave no trace after death ; and that a relaxation and partial loss of epithelium, Avhich we have re- garded as the most probable cause of the extensive transudation in cholera infantum, may be very readily overlooked in the dead body, and can very rarely be observed Avith certainty. Hence, the observa- tions that Beaumont made on his Canadian St. Martin, when he had catarrh of the stomach after overloading that organ Avith indigestible substances, or after the excessive use of liquor, are very important. At the commencement of the affection the gastric mucous membrane appeared intensely reddened, had aphthous (?) spots on it, and was covered with tough mucus, here and there mixed with traces of blood. Later, the mucous covering Avas thicker, and the secretion of gastric juice Avas suppressed. The fluid taken out through the fistula con- sisted mostly of mucus and muco-pus, Avhich showed an alkaline reac- tion. In a few days the mucous secretion and the alkaline reaction of the contents of the stomach ceased; and, at the same time, the mucous membrane regained its normal appearance. The gastromalacia, or softening of the Avails of the stomach, found on autopsy of children, was often diagnosticated during Hfe, so that it appeared as if the diagnosis were confirmed by the post mortem. An exhaustive description of the symptoms of gastromalacia has also been ACUTE GASTRIC CATARRH. 477 given {Jaeger), and AA'e often meet AA'ith cases ansAvering the descrip- tion. XeA'crtheless, there can be no doubt {Elsaesser) that gastroma- lacia is ahvays a post-mortem appearance. The description of soften- ing of the stomach is precisely that of cholera infantum, and thus there is a simple explanation of the apparent confirmation of the diagnosis by the autopsy. For, if a child dies avIio has had A'omiting and purging from abnormal fermentation in the stomach, and if there are still fermenting substances left there, the fermentation AA'ill not be arrested by the gradual cooling of the body. When the circulation ceases, the stomach can no longer resist the decomposition, AA'hich then extends to it also, just as the stomach, that has been cut out of an ani- mal and filled AA'ith milk, softens if left only for a short time in a Avarm place. Hence physicians, avIio consider softening of the stomach as a post-mortem appearance, may also predict it Avith certainty, AA'hen a child that has died of cholera infantum had eaten milk, or any other easily-decomposed substance, shortly before death. Roklteinsky, AA'ho does not consider softening of the stomach as a post-mortem appearance in all cases, distinguishes tAvo forms, the gelatinous and the black. According to his description, the former almost ahvays begins at the fundus of the stomach, and gradually ex- tends along the greater curvature ; the mucous membrane is first soft- ened, but the softening soon extends to the muscular coat, and finally to the peritonaeum. The membranes altogether change to a grayish or yelloAvish-red translucent gelatin, Avliich occasionally has some blackish-broAvn striae through it; these are the blood-vessels that are also softened. When the softened inner la}-er is detached, the fundus consists of a thin, easily-torn peritonaeum. The softened stomach tears on the slightest touch, and comes to pieces between the fingers, or else avc find that rupture has already occurred, and the contents have escaped into the abdomen. The process is not ahvays limited to the stomach, but may attack the neighboring organs, especially the dia- phragm ; this may even be perforated, and the contents of the stomach may pass into the left side of the thorax. In the black softening of the stomach, the Avails are not changed to a translucent gelatin, but to a blackish broAvn or black pulp. This modification occurs if tfie cap- illaries of the stomach are OA'erfilled when the softening begins. The blackish-broAvn stria1 in the gelatinous softening represent the same changes of the large A'essels and of the blood contained in them, AA'hich, 111 this case, affect the capillaries and their contents. The theory that gastromalacia does not occur till after death, or, at least, till a short time before it, when the circulation and the change of tissue in the AA'alls of the stomach have almost ceased, is supported— 1, bv the fact that the softening is almost ahvays found in the fundus 178 DISEASES OF THE STOMACH. of the stomach, Avhere the acid contents are collected together, and it only attacks the pyloric portion, when, from the position of the body on the right side, the contents have settled to that portion ; 2, by the circumstance that it is also found in the bodies of children who showed no signs of gastric disturbance during Hfe, but Avho had taken mUk, sugar-Avater, or other easily-fermenting substances, during the last hours of fife ; 3, because, even in cases where the Avails of the stomach are found torn, and its contents have entered the abdominal caA'ity, there haA'e been no symptoms of peritonitis during life, nor have any remains of it been found on autopsy; finally, 4, another proof is the above-mentioned experiments, where artificial softening Avas induced in stomachs that had been removed from animals. (The cases AA'here softening of the stomach has been found, Avhile that organ was empty, do not belong here. It has been attempted to explain this by citing the digestive power of the gastric juice, and asserting that there Avas a self-digestion of the stomach, and that the gastric juice secreted shortly before death had digested the stomach just as it would digest any other membranous tissue. It is, hoAvever, improbable that gastric juice would be secreted into an empty stomach, and it is possible that a decomposition of mucus (Avhich also sets free lactic acid) would have the same effect on the walls of the stomach as fermenting ingesta do.) Symptoms and Course.—We shall first speak of the symptoms of acute gastric catarrh when it is accompanied by moderate fever, and often constitutes only an ephemeral affection. This form, the most frequent result of errors of diet, is usually called status gastricus, gas- tricismus, gastrosis, " disordered stomach." EA'en the physiological process of digestion is accompanied by a certain depression, sluggishness, and disinclination to bodily or mental exertion ; and the hyperaemia and production of mucus, when increased to acute catarrh, are accompanied by a general malaise and sick feel- ing that seem out of proportion to the slight and evanescent disease. The patients feel dull, are fretful, complain alternately of heat and cold; have a hot head, cold extremities, but particularly a pressing, tormenting pain in the forehead, Avhich extends toward the occiput; on stooping, they have flashes before their eyes, and feel as if their heads would burst. The affection of the mucous membrane of the stomach causes a feeling of pressure and fulness, even AA'hen that organ is empty ; the " pit of the stomach " is sensitive to pressure ; there is loss of appetite, but increased thirst; there is usually distaste for food, and qualmishness. Besides these, there are symptoms caused by ab- normal decomposition of the contents of the stomach ; gastric catarrh is often the result of abnormal decomposition of the ingesta, and, on ACUTE GASTRIC CATARRH. 479 ihe other hand, it is sometimes the cause. Bidder and Schmidt have shoAvn that Avhen the gastric juice is rendered alkafine by admixture of mucus, it loses its poAver of dissolving protein substances, which then undergo spontaneous decomposition, and give out a putrid odor. Daily experience in practice confirms this experiment. But those sub- stances also, that are not digested by the gastric juice, undergo abnor- mal decomposition in gastric catarrh. The amylaceous substances, Avhose change had already begun in the mouth from the admixture of saliva, under normal circumstances, are not converted into sugar until they enter the stomach. But, in gastric catarrh, the mucus secreted acts as a ferment, and induces a change of a large portion of the sugar into lactic acid, and often also into butyric acid. If, during gastric catarrh, fermented substances, such as beer or Avine, be taken, or if ex- cessive use of these has induced the affection, acetic fermentation takes place ; if fatty substances be SAvallowed, fatty acids appear to be de- veloped from them. In all of these decompositions of the contents of the stomach, except the lactic acid fermentation, gases are set free. In the breaking up of albuminous substances, stinking, sulphuretted, hydrogen gases are freed; hydrogen and carbonic acid are formed in butyric-acid fermentation; in acetic fermentation, carbonic acid is freed. This explains why the epigastrium is slightly prominent in pa- tients Avith acute catarrh, and why, from time to time, they belch up gases Avhich sometimes smell disagreeably, at others are odorless, ac- cording to the quality of the food that has been taken. At the same time, sour or rancid substances often rise into the mouth. Since gastric catarrh, as before mentioned, is usually complicated Avitfi oral catarrh, the tongue is generally coated, the taste stale and slimy, and there is a bad breath. If the patients fast, and do not expose themselves to any neAV sources of injury until the stomach is able to fulfil its normal functions, the above symptoms usually disappear quickly. The abnormally-de- composed contents of the stomach pass through the pylorus into the intestine; there further decomposition seems to be arrested sometimes by the admixture of bile, but more frequently, although moderated, it still continues; the secretion of the irritated intestinal mucous mem- brane increases, the movements of the intestines are hastened, flatu- lence, rumbling, etc., Avith griping pains in the belly, occur, and are relieved by the passage of badlj'-smelling gas; finally, one or more pulpy stools occur, and the trouble ends. If the patient sleeps the followino" night, his general health is usually improved, or fully restored. We may also mention that, during the affection, the urine usually con- tains quantities of pigment and urates, and that herpetic A'esicles not unfrequently come on the Hps. 480 DISEASES OF THE STOMACH. When the injuries that excite the acute gastric catarrh are more intense, or the patient more sensitive, there is greater nausea, Avhich finally increases to retching and vomiting. By the latter the contents of the stomach are evacuated, more or less changed, Avith a A'ery acid smell and taste, and usually mixed AA'ith quantities of mucus. The vomiting may be repeated at varying intervals; the longer it lasts, the more the matter A'omited is mixed Avith bile, Avhich gh'es it a bitter taste and green color. These seA'ere forms of the status gastricus are almost ahvays accompanied by great irritation of the intestinal mucous membrane. Then there is severe diarrhoea, by Avhich green masses are passed, Avith or without pain. After the vomiting and purging, the patient is almost always relieved, and, although perhaps a little feeble, is usually Avell otherAvise in a couple of days. In other cases, the vomiting and diarrhoea are very bad, and present the symptoms of cholera morbus. By cholera morbus we mean that form of acute gastric catarrh AA'hich extends to the intestinal mucous membrane, and is characterized by profuse transudation of a fluid, containing little albumen, into the stomach and intestines. These Avatery transudations occur so fre- quently in the first stage of acute catarrhs of other mucous membrane,. especially of the nasal, that Ave cannot hesitate to designate as a ca- tarrh the gastric and intestinal affection, on which depend the symp- toms of cholera morbus, and mostly, also, those of Asiatic cholera, AA'hich avUI be hereafter described, and Avhich only leads to symptoms that other catarrhs do not haA'e, on account of its extent. The disease prevails most during the hot Aveather of summer, and then often attacks a number of persons simultaneously; it is more rarely excited, at other times, by errors of diet. The cholera attacks are rarely preceded by premonitory symptoms; on the contrary, the patient is usually attacked suddenly, often during the night, Avith a disagreeable feeling of pressure at the pit of the stomach, Avhich is soon folloAved by nausea and vomiting. At first the food last eaten is A'omited, little changed, but the A'omiting is soon repeated, and quan- tities of a pale-yellow or greenish bitter fluid are thrown up. After this, or, in some cases, even previously, there are borbyrigmi, followed by pulpy stools, Avhich soon become thin and liquid. In a short time enormous quantities of fluid are evacuated; the greater the amount, the less color it has, as the bile, even if of normal amount, no longer suffices to color all the transudation. The loss of water from the blood excites intense thirst, AA'hich is only temporarily quenched by large quantities of drink. The fluid taken into the stomach is rapidly evacu- ated, upAvard or doAvmvard, being voided every quarter of an hour, or oftener, as long as the diarrhoea and vomiting continue. The blood CHOLERA MORBUS. 481 constantly becomes thicker; the secretions, particularly that of urine, are diminished, or cease entirely, for Avant of fluid to maintain them; the interstitial liquid is absorbed from all the tissues; hence the skin appears dry and shrivelled, the patient looks collapsed and disfigured, the nose is pointed, the eyes are sunken, because the connective tissue m the orbit has become dry, and has hence actually lost in volume. While there is rarely pain in the abdomen, there are very painful con- tractions of the muscles, especially of the calf of the leg. If these' occur, and the evacuations of the patient consist only of colorless fluid, containing shreds of intestinal epithelium, so that they resemble rice, water, or oat-meal gruel, the cholera morbus will very much resemble Asiatic cholera; nevertheless, it rarely goes on to the complete disap- pearance of the heart-beat and the pulse, to the cyanotic hue, and rep- tile temperature of the skin, which is seen in the so-called asphyxiated stage of the Asiatic cholera. No matter hoAV threatening the symp- toms, hoAV great the collapse and depression of the patient, how dis- pirited he and his attendants may appear, the physician must not feel discouraged if he is sure that epidemic cholera is not raging, for he must knoAV that a previously healthy adult very seldom dies of cholera «morbus. Usually, after a feAV hours, rarely not tUl the next day, the j vomiting and purging subside; the skin becomes warm, and acquires its fulness again, the exhausted patient falls asleep, and only suffers from great depression. More rarely, the symptoms of gastric fever join on to the cholera morbus. In the rarest cases, and only in sickly and weak persons, or in children or old persons, do Ave see a fatal ter- mination ; then the boAvels are paralyzed, the vomiting and ^nro-ino- cease, Avlfile the transudation continues; the pulse disappears, the move- ments of the heart become Aveaker, the intellect cloudy, and the patient dies of exhaustion. The acute gastric catarrh of chUdren, during the first years of life presents certain peculiarities, Avliich are due to the fact of such children being almost exclusively nourished AA'ith mother's or cow's milk. Bed ■uur considers the fermentation of the ingesta as the sole cause of this disturbance of digestion, and denies either a primary or secondarj' par- ticipation of the Avails of the stomach in the affection; he designates the milder forms of the affection as dyspepsia; according to the classic description of this author, the appearance of the child is little changed, at most it only looks a little pale and lias a slight ring around the eyes. Almost ahvays, shortly after nursing, there is vomiting, and the milk evacuated is no longer curdled. This sort of vomiting is an im- portant symptom; even the nurses recognize it as such, and readUy distinguish it from the healthy eA'acuations of an overfilled stomach. The curdling of the milk in the so-called " puking of children " does 31 482 DISEASES OF THE STOMACH. not sIioav that the milk has become sour, but that the -gastric juice has acted normally on it, and curdled the casein; when the A'omited milk is not curdled, it shows that there is an abnormal secretion in the stom- ach, and this must excite the suspicion of gastric catarrh. Soon after the vomiting, or even at the same time, the passages from the boAvels become abnormal, or there may be no vomiting, and the appearance of the passages may form the sole symptom of gastric catarrh. The evacuations consist of a very acid, green or greenish-yelloAV fluid, con- taining more or less firm lumps; they remind us of the changes that the milk undergoes after standing for some time out of the body, and shoAv that the gastric juice has not even digested it enough to cause its sudden coagulation. The vomiting and purging, AAdiich are usually preceded by restlessness of the child, by crying and draAving the legs up toAvard the belly, occur more or less frequently; the evacuations often change their color and consistence. In many cases, the vomiting ceases after a feAV days, the undigested milk disappears from the evac- uations, the children improve and pick up; but in other cases, from time to time, quantities of acid milk, partly unchanged, partly curdled and mixed Avith mucus, are vomited; the purging increases, the evacuations become thin, liquid, and very free; at first they are bright yellow or green, but at last almost white. Some yellow or greenish flocculi swim in the colorless fluid; these remain on the diaper, Avhile the fluid partly filters through, partly leaves large, damp, discolored spots in it. Even now both the smell and reaction of the evacuations are acid. Occasion- ally the appearance of the dejections changes suddenly, without our being able to say Avhy; they become dark brown or clayey, and softer masses of disagreeable smell are evacuated in large quantities. These severer forms of acute gastric and intestinal catarrh reduce the chUd rap- idly ; its face falls and is contracted with pain, it may even become wrin- kled in a feAV days, the eyes are usually half opened and deep set, the lips as well as the hands and feet are often bluish, the rest of the body, es- pecially the back, is mottled. The temperature is uneven, the trunk, especially the belly, is burning hot, while the face and limbs are cool. From the diminution of cerebral pressure the fontanelles become de- pressed, occasionally even the frontal and occipital bones sink slightly beloAV the parietal bones, the movements of the children become sluggish, even nursing troubles them; they let go of the breast, but eagerly drink water when it is offered to them. The cries of pain Avhich usually pre- cede the evacuations gradually change to Aveak whimpering; in the interval the child lies fialf asleep. As the exhaustion increases, many die; occasionally, shortly before death, convulsions (hydrocephaloid) and other symptoms of anaemia of the brain appear. When the disease runs a favorable course, the evacuations gradually become feAver and CHOLERA INFANTUM. 483 more normal, the collapse disappears, the temperature becomes more even, the child improves and convalesces, but a great tendency to re- lapse remains. If the symptoms above described appear very rapidly, and the evac- uations come one right after the other, if decided collapse occurs in a feAV hours, AA'ith great depression of the bodily temperature, and signs of thickening of the blood, before emaciation has resulted, Ave call it cholera infantum. The thickening of the blood is shoAvn by the un- quenchable thirst; older chUdren folloAV the glass of water AA'ith eager eyes, and AA'hen it is offered to them seize it with both hands and hold it tightly till it is emptied; it further betrays itself by the increasing cyanosis, and by a peculiar dyspnoea, in AA'hich the thorax and dia- phragm make extensive movements, Avithout there being any apparent obstruction to the breathing, except the difficulty of the thickened blood passing through the capillaries of the lungs. The patients may die in a feAV hours of cholera infantum, AA'ith the above symptoms; in other cases, the cholera proper passes off, and a milder form of the disease remains; and finally, in other cases, rapid and complete re- covery take place from conditions which are apparently utterly hope- less. j i Diagnosis.—In Chapter X. of this section Ave shall speak of the | listinction betAveen gastric catarrhs, occurring as the status gastricus, ^nd other disturbances of digestion. During an epidemic of Asiatic cholera it is impossible to distinguish cases of cholera morbus from those caused by the cholera miasm, for the symptoms are not only similar, but are absolutely the same as those of the milder cases of Asiatic cholera. The chief difference is, that of those attacked Avith Asiatic cholera about half the patients die, while /almost all recoA'er from cholera morbus. The disease may much more readily be mistaken for poisoning; but cholera morbus is rarely accom- panied by such severe pain as poisoning with acids and metallic salts induce, and they seldom cause such copious evacuations as characterize cholera morbus. If the disease lasts unusually long, or if its course sIioavs any other peculiarity, Ave should carefully examine every circum- stance that could indicate the presence of poison. Acute gastric catarrh of children in the first years of life and the diarrhoea of chUdren cannot easily be mistaken for other dis- eases. Prognosis.—The prognosis is evident from the description we have just given of the course. Previously healthy adults rarely die of this disease ; but chrome catarrh may result from repeated attacks, weakly and decrepit persons may die of gastric fever, or still more readily of 'catarrhal fever (see this disease). In children, acute gastric catarrh, / i84 DISEASES OF THE STOMACH. Avith its results, is a very dangerous disease, which may end fatally even under the most careful treatment. Treatment.—To speak Avith only moderate exactness of acute gastric catarrh, Avould lead too far, as Ave should have to mention all the rules for diet. From the remarks on etiology, Ave may see that, in order to avoid gastric catarrh, the diet of some persons, as of fever patients and convalescents, but particularly of infants, must be carefully Avatched. In the latter case, where it is impossible to give the child the breast of the mother, or a healthy nurse, certain precautions must be exercised in the choice of cow's milk; these Avere mentioned under etiolo- gy : 1. The milk must be fresh; even in the city it should be brought twice daily. If it shows the least indication of acidity, it should be boiled immediately, to prevent further transformation of the sugar into lactic acid; carbonates of the alkalies may also be advantageously added to such milk, till it becomes neutral or sligfitly alkaline [small quantities of sulphite of soda are very good for this purpose]. 2. Milk from coavs fed on oil-cake or distillery savUI should not be used. In large cities, the best milk is that from breAvery coavs Avhich are fed on grains. 3. The milk should be sufficiently diluted, the first three months, with about two parts of water, the second quarter AA'ith- onaj part. 4. It should be given at regular, and not too short, intervals. During the first weeks, the bottle may be given every two hours, latei every three or four hours. The shorter the intervals, the less milh should be given at each time. 5. The vessels from Avhich the child drinks, as well as its mouth, should be carefully cleansed. Neglect of any of these rules may lead to gastric catarrh, while their observance may prove, at least, some protection for the child, against the disease. The causal indications may require the administration of an emetic, AA'here injurious or decomposing food in the stomach keeps up the ca- tarrh. Some carry the use of emetics in gastric catarrh too far, Avhilei others neglect them too much. If Ave accede to the request of the patient, or, from the feeling of pressure and fulness in the epigastrium, the coated tongue and the odor from the mouth, conclude that the stom- ach is coated also, and, in all such cases, give an emetic of ipecacu- anha or tartrate of antimony, Ave shall often protract the disease by letting a neAV injury act unnecessarily on the already diseased mucous membrane of the stomach. But just as much harm is done by the ex- cessive fear of the injurious effects of emetics, induced by their acting also as purgatives, and by the pustular inflammation of the stomach, occasionally caused by the continued use of tartrate of antimony, but particularly by a false theory of their action. It is forgotten that the irritation of the gastric mucous membrane by the emetic, as is proved by daily experience, is not very malignant or injurious, and that ACUTE GASTRIC CATARRH. 485 the beautiful experiments of Magendie and Budge have proved that the emetic influence of ipecac, and tartrate of antimony do not result from initation of the gastric mucous membrane, but from absorption into the blood. By injecting tartar emetic into the veins, Magendie proved that vomiting could be excited eA'en Avhere a bladder had been substituted for the stomach. If the prominence of the epigastrium, percussion over the stomach, eructations of gases and fluids whose smell and taste are like those of the food that has been eaten, render it certain that there are decom- posing substances in the stomach, and if the sufferings of the patient justify such active treatment, it avUI be best to give a sure emetic, such as ipecacuanha 3j Avith tartrate of antimony gr. j. In the para- graph on symptoms avc have shown that, even in such cases, Avithout the use of an emetic, the undigested and decomposed ingesta may be occasionally passed from the body quickly and uninjuriously; but this is not by any means an absolute rule. The injurious substances often remain a long Avhile in the stomach, and when they pass into the intes- tines cause seA'ere and lasting disturbance. If Ave can rid the stomach of the substance causing a continued irritation and protect the boAvels from its action, Ave should not dread the temporary irritation of the gastric mucous membrane by the emetic. If, in such a case, Ave do nothing, or, instead of an emetic, prescribe the popular mixture of magnesia usta, we may just as readily cause a prolongation of the at- tack as if Ave gave an emetic at the Avrong time, or Avithout sufficient cause. Moderate fever, accompanying the gastric catarrh, does not contraindicate an emetic; but if the fever is more severe, and Ave have the faintest suspicion of a commencing typhus, it should not be used, for typhus almost ahvays runs a severe course, Avhen emetics or laxa- tives have been used at its commencement. The causal indications never require the use of laxatives in the treatment of simple acute gastric catarrh. It is different Avhen the injurious ingesta have passed into the bowels and caused flatulence, colicky pains, escape of flatus, and other symptoms Avhich are called the passage of the gastric turgescence doAvnward. In such cases mUd laxatives, such as rhubarb or compound infusion of senna, may be prescribed; if there is excess of acid, we may use a mixture of mag- nesia usta ( § ss to 3 Adij Avater, a tablespoonful every fiour or tAvo), which, in these cases, acts as a mild and efficient laxative; the purga- tive neutral salts are less suitable. If there be an excessive formation of acid in the stomach that seems to keep up the catarrh, Avhether it be caused by the transforma- tion of the amylacea into lactic or butyric acids, or if acetic fermenta- tion has been induced by the use of beer or Avine, and if the very 486 DISEASES OF THE STOMACH. moderate sufferings of the patient do not justify the use of an emetic, we should give a carbonate of one of the alkalies. The most used is the bicarbonate of soda, in doses of gr. v-x, in poAvder or solution; if Ave Avish to employ it in the popular form of mineral water, Ave should first assure ourselves that the water furnished actually contains bicar- bonate of soda, and does not simply consist of carbonic acid and Avater. In spite of numerous evacuations upAvard and doAvnAyard, small amounts of the decomposing substances not unfrequently remain in the stomach. The alkalies prescribed can neutralize the acids already formed, it is true, but they cannot entirely arrest the process of decom- position and the formation of new acid products. The substances re- maining in the stomach and undergoing decomposition transfer their chemical action to the fresh and unspoiled food, and render the most harmless food injurious and even dangerous for the gastric mucous membrane of children, in AA'hom this state most frequently occurs. In such cases it is necessary to arrest the decomposition of the contents of the stomach remaining after the vomiting and purging. It is diffi- cult to fulfil this indication, and all the skill of the physician often fails in the attempt. If we recognize the abnormal decomposition of the contents of the stomach and intestines as the most frequent cause of infantile diarrhoea, we can at least understand the unfortunate results of its treatment, Avhich we cannot do if Ave regard the gastric and in- testinal catarrh as the sole disease. Even outside of the body, as is Avell known, it is often difficult to arrest a fermentation or other de- composition that has once begun. But the means that answer for this, outside of the body, cannot always be used in it. We cannot perfectly dry the contents of the stomach or keep them at so high or so low a temperature as to arrest decomposition; and certain substances that prevent fermentation are poisonous to the organism. But, if we regard | the numerous remedies (often exactly opposite in their other qualities) Avliich physicians employ in the diarrhaea and vomiting of chUdren, with or Avithout clear ideas of the reasons for so doing, and which are somg- thnes unmistakably serviceable, Ave find that they are such substances as are used outside of the organism for arresting fermentation and other decompositions. The remedies most frequently given in infantile diarrhoea are carbonates of the alkalies; mineral acids, particularly muriatic; metallic salts, especially calomel and nitrate of silver; also tannin, creasote, and nux vomica. Possibly part of these, such as the nitrate of silver and tannin, have, at the same time, a favorable effect on the irritated mucous membrane of the stomach and intestines, by their astringent action on the hyperaemia. But the greater part of these remedies, especially the one most used, calomel, cannot be said ACUTE GASTRIC CATARRH. 487 to act in this Avay, and their effect is only to be explained by then poAver of arresting decomposition. If a child is suffering from a slight gastric catarrh, Avhich only shows itself by the characteristic vomiting and the presence of undigested milk in the acid dejections, besides strict diet (of AA'hich Ave avUI hereafter speak), Ave should use the nfildest of the above remedies, such as the carbonates of the alkalies, AA'ith small doses of rhubarb; a Avell-knoAATi and popular form of these is the pulv. rhei comp.; if the diarrhoea is more severe, we may give the tine, rhei aquosa. An old and extensively used mode of giving the latter is in a mixture of tinctura rhei aquosa 3 ij, with liq. potassii carbonic! gtt. xij, aqua fceniculi 3 ij, and syrupus simplex 3 ij, of AA'hich a teaspoonful is to be taken several times daily. If this treatment is inefficacious, if the decomposition in the stomach continues, and the passages become more frequent, Ave may give small doses of calomel, a plan that has long been justly popular in the treatment of infantile diarrhoea. I usually give •£ to 4; gr. tAvo or three times daUy. Bednar, avIio pre- fers calomel to all other remedies in this disease, gives it combined with jalap, in larger and more frequent doses. His prescription is: " I}, calomel, gr. iv; pub', jalap, gr. ij; sacchar. alb. 3 ss; TH,. ft. pulv. no. A'iij. S. Take one poAvder in Avater every tAvo hours." Even this treatment is not ahvays successful. The evacuations often persist in spite of the most rigid diet and the free employment of calomel, untU Ave fear to use any more mercury, although, from the continuance of the A'omiting and purging, but little of it seems to be absorbed, and hence mercurial stomatitis rarely occurs. In such cases, every prac- tising physician sometimes finds fiimself in a position AA'here he is obliged to give up the remedy from which he has seen the best effects and AA'hich he usually trusts most, and try one in Avhich he has less confidence. He may even feel around from one remedy to another. There are no definite and certain indications for the cases Avhere nitrate of silver, tannin, muriatic acid, tincture of nux vomica, etc., are re- spectively advantageous. Usually the remedy that Avas efficacious in tfie last attack is given ; if it faUs, others are tried. Without laying particular stress on it, I Avould recommend very small doses of nitrate of silver (IJ argent, nitrat. gr. \; aquae distillat. 3 ij. Tl. S. Take a teaspoonful every half hour or hour), and frequent potions of ice- water, in those cases AA'here there are excessive vomiting, great thirst, and copious Avatery eA'acuations. If there be no vomiting, but great purging, and calomel does not ansAver the purpose, I usually give tan- nin (I£ tannin, 3ss; aquae distUlat. 3 iij. x\. S. A teaspoonful eA'ery tAvo hours). In mild but prolonged cases I give muriatic acid in mucilage. I have not much experience in the use of tincture of nux vomica, creasote, or tincture of muriate of iron. 4SS DISEASES OF THE STOMACH. In gastric catarrh, caused by catching cold, the causal indications demand diaphoretic treatment. When induced by unknoAvn epidemic influences, there are no causal indications to fulfil. For the fulfilment of the indications of the disease, it is just as ne- cessary to folloAV out the strictest dietetic rules, as it is unnecessary to give medicine. Experience teaches that the abnormal hyperaemia, mu- cous secretion, etc., of the gastric mucous membrane readily and speedi- ly disappear on the remoA'al of the causes Avhich had induced or kept it up. But, as there is no doubt that even the mildest ingesta may main- tain catarrhal hyperaemia, it is safest to keep patients Avith acute gastric catarrh without food for a while—to let them fast entirely. This is particularly advisable in the form called status gastricus. This order is often objected to; anxious mothers can hardly make up their minds to refuse their children all nourishment, even for a short time; adults with acute gastric catarrh do not feel hungry, it is true; but they have a longing for salty, piquant food. The more Ave insist on the fasting, the better results we shall have. If the disease is protracted, if it is accompanied by fever, or if, on account of the consumption of tissue, caused by the fever, Ave fear continuing the starvation, we should give nourishment in the fluid form, as that causes least irrita- tion. In choosing this nourishment, we must remember that the gas- tric secretion is rendered alkaline from the admixture of mucus, and its digestive power greatly impaired. Hence Ave should usually forbid milk, eggs, and meats, which require acid gastric juice for their assimi- lation, and, as long as there are no signs of abnormal formation of acid, Ave should only permit amylaceous food. The so-called water- soups are very suitable nourishment for persons with protracted gas- tric catarrh. It is exceedingly difficult to manage the diet of children AA'ith acute gastric catarrh, which has been caused, and is kept up, by decomposi- tion of the contents of the stomach, that it is difficult to arrest. Milk, AA'hich is the most suitable and natural food for chUdren, is injurious to them in these cases, because it quickly decomposes; then arises the difficult question : Wfiat shall we give them instead of milk ? Under these circumstances, what nutriment AAdll not be decomposed and trans- formed into injurious substances ? We may easily satisfy ourselves that oat and barley gruel, as well as arrow-root and panada, are changed, and become sour as quickly as milk. For the successful treatment of the disease in question, we should carefully remember that the chUdren do not suffer from hunger, even if Ave AvithdraAV all nourishment for a day or two, and feed them on fresh water alone, avoiding even the addition of sugar. If, under tliis ACUTE GASTRIC CATARRH. 4S9 treatment, the vomiting and purging cease, if the Avater be restored to the thickened blood, the collapse often disappears quickly, and it looks as if the fasting child Avere recovering, then we commence gradually AA-ith small quantities of diluted milk. If this be rejected again and again, and it appears dangerous to subject the children to a longer ab- stinence, I can recommend teaspoonful doses of beef-essence, AA'hich is prepared by cutting the flesh into small cubes, placing these in a bot- tle (Avithout adding Avater), closing tfiis securely, and leaving it in a vessel of boiling Avater for several hours. The indicatio morbi very rarely calls for the so-called antiphlo- gistic remedies. Abstraction of blood, general as Avell as local, may be dispensed Avith. In severe cases, characterized by excessive vomit- ing and thirst, cold is serviceable. Both in cholera morbus and cholera infantum the use of ice-Avater and small pieces of ice is beneficial, as is also the application of cold compresses to the abdomen; these should be frequently reneAved. We can speak even more decidedly against the use of muriate of ammonia in the treatment of acute gastric catarrh than Ave did of its use in bronchial catarrh. We cannot depend on its anticatarrhal action, and its employment can only increase the difficulty. Carbonic acid is A'ery popular in the treatment of this disease; it is given as effervescing poAvder, or effervescing mixture, or as carbonic- acid Avater. It usually causes eructation very soon, and this appears to bring up other gases from the stomach, so that there is almost ahvays momentary relief. It is not claimed, howeA'er, tfiat carbonic acid, Avhich everyAvhere acts as an irritant, moderates the hyperaemia of the stomach, and has any direct influence on the rapid cure of the disease. It is different Avith the use of the carbonates of the alkalies; tfiey lessen tfie toughness of the secreted mucus, and facilitate its evacua- tion ; lience, independent of their use for fulfilling the causal indica- tions (see above), they deserve full consideration in the later stages of acute gastric catarrh. Moreover, the alkaline carbonates appear to assist the secretion of the gastric juice; at least Blondlot and Fre- richs observed that, after giving carbonates of the alkalies, enough acid gastric juice Avas formed, not only to neutralize the alkali, but to give the contents of the stomach an acid reaction. In the status gas- tricus they are usually given in the form of soda-water, or tinctura rhei aquosa. Further rides are rarely required for the treatment of symptoms. Among the symptoms that most frequently call for treatment is vom- iting, and, Avhere the boAvels are affected at the same time, diarrhoea. If moderaf e, these may be regarded as favorable symptoms, and re 490 DISEASES OF THE STOMACH. quire no special treatment; but sometimes, as in cholera morbus, or cholera infantum, they may be so severe that the blood will be much thickened by the loss of Avater, and life be endangered. Opium is the most usual prescription for the excessive vomiting and purging. We do not know exactly how opium arrests these symptoms. If it only paralyzed the intestines, and so diminished the number of the stools Avithout decreasing the secretion of the mucous membrane, it Avould be of little real benefit; but it really seems as if, besides the influence it has on the movements of the intestines, and perhaps as a direct result of this, it also limited the secretion of the intestinal mucous membrane. Hence, if, in cholera morbus, ice-water do not arrest vomiting, and the passages become more numerous, we should give gr. ss of opium in poAvder, or its equh'alent of laudanum, alone or Avith analeptics. In spite of our dislike to give opium to children, and in spite of our be- lief that it ansAvers neither the indicatio morbi, nor the causal indica- tions, Ave may be obliged to give small doses of it in cholera infantum. In cholera morbus, or cholera infantum, the greater the collapse, the weaker the pulse, and the loAver the temperature, the more necessary it becomes to use stimulants; inAvardly we may give small doses of wine, ether, coffee ; outwardly we may use sinapisms. On the other hand, in the course of acute gastric catarrh, in spite of the alkalies that have been exhibited, a quantity of mucus may col- lect as a product of the disease, and by its decomposition cause an obstinate continuance of the affection, or, after this has run its course, may retard convalescence and disturb digestion. If, in the later stages of gastric catarrh, the painful attacks of vomitingj Avhich, from time to time, throw out quantities of mucus, the loss of appetite, or the sIoav recovery, render it probable that such a state of affairs exists in the stomach, it may be necessary to give an emetic. CHAPTER II. CHRONIC GASTRIC CATARRH. Etiology.—Chronic gastric catarrh sometimes occurs as a result of the acute affection; Avhen this is protracted or relapses frequently, sometimes it originates as a chronic disease. Hence the etiology is mostly the same as that of acute gastric catarrh. It may be caused: 1. By all injurious influences that excite the above disease, Avhen they act continuously or repeatedly. But the habitual mis- use of spirituous liquors deserves particular mention, as it is by far the most frequent cause of chronic gastric catarrh. We also ob- CHRONIC GASTRIC CATARRH. 491 serve that alcohol acts the more injuriously the more undiluted it is taken; hence brandy-drinkers are most liable to the affection. 2. In many cases chronic gastric catarrh depends on congestion of the gastric mucous membrane. The obstruction of the circulation in- ducing this congestion may be located in the portal vein; hence we find that all affections of the liver, by Avhich the portal vein or its branches are compressed, are always accompanied by chronic gastric catarrh. But more frequently the obstruction lies beyond the liver; all affections of the heart, lungs, or pleura, that cause an overfilling of the heart and obstruction of the vena cava, also obstruct the escape of blood from the liver, and hence from the stomach; consequently, in emphysema, cirrhosis of the lungs, valvular disease of the heart, etc., Ave meet chronic gastric catarrh just as often as Ave do cyanosis of the skin, and both affections must be induced in the same way. 3. Chronic gastric catarrh often accompanies phthisis and other chronic diseases. In part I., Ave shoAved that patients Avith incipient phthisis often complain more of their gastric catarrh than of the lung trouble, and that is what first induces them to apply for aid. 4. It ahvays accompanies cancerous or other degeneration of the stomach. Anatomical Appearances.—In chronic gastric catarrh, the mu- cous membrane is often reddish broAvn or slate gray, just as it is else- Avhere when it is the seat of chronic catarrh. This is caused by smaU capillary haemorrhages in the tissue of the mucous membrane, and the transformation of the haematin into pigment. Instead of the fine injection seen in acute catarrh, Ave usually find a coarse anastomosis, and in some places dilatations of tfie vessels. Moreover, the mucous membrane has become hypertrophied, it is thicker and firmer, and, even Avhen the muscles are not contracted by rigor mortis, Ave find the mucous membrane forming numerous folds, and some parts of it are occasionally elevated to soft spongy nodules by a velvety hypertrophy. We often find innumerable small prominences, separated by super- ficial furroAVS, a state described as the etat mamelonne. The mam- millated appearance most frequently depends on partial hypertrophy of the gastric mucous membrane, by AA'hich some of the glands and their insterstitial connective tissue have been enlarged. Frerichs asserts that it is also caused by roundish collections of fat in the sub- mucous tissue, or by the development of closely-croAvded closed fol- licles ; according to Budd, they result in some cases from overfilling of the gastric glands Avith retained secretion. These changes are found most frequently and farthest advanced in the pyloric end of the stomach. The inner surface of the stomach is covered with a grayish- white, tough mucus, AA'hich cfings firmly to it. 492 DISEASES OF THE STOMACH. The thickening is not ahvays limited to the mucous membrane; sometimes the submucous and muscular tissues are changed to a fatty mass, several lines or even half an inch thick. This thickening of the wall of the stomach also depends on simple hypertrophy, in AA'hich there is both a neAV formation of muscular cells, and an increase of the submucous and intermuscular connective tissue. On the cut surface the thickened musciUar tissue shows a pale grayish-red, soft, fleshy mass, traversed by parallel connective-tissue striae, running from Avith- out imvard, and having a peculiar fan-like appearance. Occasionally the Avhole pyloric end of the stomach, and especially the pylorus itself, is changed in this way; in other cases the thickening of the Avails of the stomach is more circumscribed, and forms certain prominent nod- ules {Foerster). The pylorus may be greatly constricted by thicken- ing of the walls of the stomach from simple hypertrophy, and this con- striction may cause great dilatation of the part of the stomach above the stricture. Symptoms and Course.—In chronic gastric catarrh, the patients complain most of a disagreeable feeling of pressure and fulness in the stomach, Avhich is increased by eating, but rarely amounts to severe pain. Where the latter occurs after eating, and the epigastrium is sensitive to pressure, Ave must always suspect that there is not simply chronic gastric catarrh, but that it is complicated by some more serious disease. With the feeling of fulness there is almost always a promi- nence of the epigastrium, caused by the filling of the stomach with gas, and by the ingesta remaining in it for a long while. The gases in the stomach are formed in chronic catarrh also by the decomposition that the ingesta undergo when the gastric juice, AA'hich has become alkaline, no longer causes normal digestion, and the mucus in the stomach acts as a ferment on its contents. The abnormal decomposi- tion is assisted, however, by the fact that, although the muscular coat of the stomach has increased in thickness, its functions are paralyzed by serous infiltration. When the movements of the stomach are retarded, food remains in it a great while, and undergoes abnormal decomposition. From time to time there is eructation of gases having the same composition as those formed in acute gastric catarrh. With the eructation, Avhich is a constant symptom of chronic gastric catarrh, besides the gases, small quantities of sour or rancid fluid often rise into the mouth, and are either spit out or swallowed again. The for- mation of lactic and butyric acids from the transformation of the amy- lacea is often very extensive, and the sour and acrid fluids, rising into the oesophagus and pharynx on belching, cause the burning feeling called heartburn. Occasionally, beside the above symptoms there is vomiting • this, CHRONIC GASTRIC CATARRH. 493 however, is not constant; on the contrary, it is rather rare. According to the observations of Frerichs, to whom Ave owe most of what we knoAV concerning the anomalies of digestion, the hydrocarbons are occasionally changed into a tough filamentous mass resembling gum, and AAdiich is not unfrequently formed by lactic-acid fermentation out- side of the body. The vomited substances not unfrequently consist of large quantities of this non-nitrogenous material, AA'hich is throAvn up in mucous filamentous masses after painful retching. In other cases, pure mucus with an insipid fluid is thrown up; this form of A'omiting occurs chiefly in the chronic catarrh of drunkards, and con- stitutes the celebrated vomitus matutinus (water-brash). Frerichs, Avho has carefully examined these masses, found that they were usually alkaline, had a Ioav specific gravity, ahvays contained sulphurets, and that alcohol added in excess threw doAvn a Avhite flocculent precipitate Avhich rapidly converted starch into sugar. This peculiarity of tfie fluid shoAved that it Avas not formed in the stomach but in the sahvary glands. We have before said that irritations and diseases of the stomach increased the salivary secretion; hence it appears that in drunkard's chronic gastric catarrh, the saliva SAvalloAved during the night is throAvn off in the morning as vomitus matutinus. In simple, non-complicated chronic gastric catarrh, unaltered food is very rarely vomited. If this does occur, it is usually mixed Avith a quantity of mucus, and from admixture of butyric acid has a disagreeable, acrid smell and taste, and occasionally contains a peculiar microscopic for- mation, the so-called sarcina ventriculi. It can scarcely be doubted that the sarcina, which, when it occurs in the stomach, is ahA'ays found in great numbers, is an algoid groAvth. It presents cells of the -^^ to 3-4/0- of a line in diameter, Avith square surfaces divided into four regular parts; usually several, sometimes very many of these, are united into smaller or larger squares. It is not to be supposed that it is this par- asitic plant AA'hich, acting as a ferment, causes an abnormal decomposi- tion of the contents of the stomach, for, in healthy stomachs (though it rarely occurs there, it is true), its presence does not induce this ab- normal decomposition. The sensation of hunger is almost lost, even Avhen the patient is much emaciated, and the body is A'ery much in need of support; fre- quently the patients can hardly be persuaded to take nourishment. In other cases there is a feeling of hunger, but even a few mouthfuls satisfy it. Finally, in some cases, particularly Avhere much acid is formed, there is occasionally pain in the stomach, accompanied by faint- ness. As this is generally relieved by eating, it is commonly called " AA'olfish appetite " (heiss-hunger). As there is no fever, the thirst is not increased; it is often less, like the appetite. 194 DISEASES OF THE STOMACH. If the chronic catarrh extends from the stomach to the mouth, we have, at the same time, the symptoms of chronic oral catarrh: the tongue is coated, shows the impression of the teeth along its sides; there is a stale, slimy taste, and a more or less fetid smell from the mouth. But a clean tongue and absence of the other symptoms of oral catarrh do not at all prove that the stomach is healthy. Not unfrequently the chronic gastric catarrh extends to the intes- tines, and, besides the symptoms above described, we have those of chronic intestinal catarrh. We must, however, bear in mind that every intestinal catarrh does not cause diarrhoea, because it is not ahvays accompanied by fluid secretions, or large quantities of mucus. There is more apt to be somewhat obstinate constipation, because the move- ments of the intestines, like those of the stomach in chronic gastric catarrh, are greatly impeded. Decomposition of the contents, which thus remain a long time in the intestines, continues; there is flatu- lence, which renders the belly tense, and the patients, who feel reheved by the escape of flatus, usually ascribe their difficulty to the " move- ments of the flatus." Occasionally, also, the catarrh extends from the duodenum to the ductus choledochus, and there are retention and absorption of bile. We"'' 1 shall find that the jaundice caused by gastro-duodenal catarrh is the most frequent form of icterus. In regard to the general state of the patient, the severe headache, * pain and Aveakness of the limbs, and other general symptoms Avhich accompany acute gastric catarrh, are usually absent in the chronic form; but, on the other hand, there is usually some mental depression. If tliis state be designated as hypochondria, because the abnormal excite- ment of the brain depends on abnormal conditions of the abdominal viscera, there can be no objection to it; but the mental disturbance accompanying gastro-intestinal catarrh should not be distinguished from other forms of melanchofia by the fact that the bodily state is ■the sole object of the gloomy thoughts. I have seen a general dis- couragement, an under-valuation of mental power, despair as to busi- ness, etc., induced by chronic gastric catarrh, and have seen these symptoms disappear on the cure of the disease. Only a feAV years since I treated a very wealthy man for chronic gastric and intestinal catarrh, Avho, during the disease, thought he Avas near bankruptcy, and left unfinished a building that he had begun, because he thought he had not sufficient money to continue it. After spending four Aveeks at Carlsbad, his old strength and feelings returned, he finished his house with great splendor, and has been Avell ever since. When the disease lasts a long Avhile, the nutrition of the patient suffers from the disturbance of chymification, as well as from the in- \ CHRONIC GASTRIC CATARRH. 495 tcrference AAdth resorption, caused by the tough mucus on the gastric and intestinal mucous membrane; the fat disappears, the muscles be come relaxed, and the skin dry. Not unfrequently, scorbutic affeo tions, loosening of the gums, bleeding from them, and even ecchymoses on the extremities, are seen. Excessive emaciation is suspicious; AA'hen it occurs, Ave may fear that the gastric catarrh is a secondary or symp- tomatic affection, AA'hich is caused or maintained by carcinoma. The frequent change observed in the urine in this disease is pecu- liar, and difficult to understand. Even taking into consideration the fact that disturbed absorption must excite a change in the excretions, Ave cannot explain the high color, the sediments of urates, or the frequent appearance of quantities of oxalate of lime in the urine of patients Avho have chronic gastric catarrh (see chapter on dys- pepsia). As to the course and results of chronic gastric catarrh, the symp- toms above described may run on for months, or even years, AA'ith more or less severity, and often AAdth frequent Aariations of intensity. When the causes can be removed by proper treatment, the disease is often cured; in other, not very frequent, cases, it induces severer lesions of the stomach, particularly chronic ulcer of the stomach (?), and, AA'hen induced by mechanical disturbances, it may cause hcanorrhage from the stomach. Not counting the secondary affections, this disease is rarely fatal; although cases do occur Avhere the patients finally die of marasmus and drops}', but they more frequently die of the diseases comphcating or causing the gastric catarrh. Hypertrophy of the membranes of the stomach cannot be recog- nized during life, unless the calibre of the pylorus is diminished. This may result from the vUlous hypertrophy of the gastric mucous mem- brane which Ave described among the anatomical appearances. Stricture of the pylorus, from hypertrophy of the mucous mem- brane, impedes the exit of the contents of the stomach ; a neAV cause of abnormal decomposition is thus added to those resulting from the catarrh. This explains AA'hy, in stricture of the pylorus, the symptoms that avc deduced from abnormal decomposition of the contents of the stomach (such as eructation of gases and badly-tasting fluids, heart- burn, etc.) reach even a higher grade, and are more distressing than in simple chronic gastric catarrh. Besides this, Ave have vomiting, Avhich does not occur, or comes only occasionally, in many, or even in most cases of simple chronic gastric catarrh, as one of the most con- stant symptoms of pyloric obstruction ; it usually comes quite regu- .arly tAvo or three hours after eathig. This is occasionally different when the stomach is much distended, and hence can hold a large quantity ; then there may be no vomiting for tAA'O or three days; aftei 490 DISEASES OF THE STOMACH. such pauses, enormous quantities are evacuated at one time. In such cases there may be a certain regularity. In stricture of the pylorus, the vomited masses almost always con- sist of more or less digested food embedded in mucus, Avhich smell dis- agreeably sour and rancid; they usually contain quantities of lactic and butyric acids, and frequently sarcina. If there be decided acidity Avhich cannot be checked, Avith frequent and regular vomiting, there is very probably pyloric obstruction; the diagnosis becomes more certain 1 Ave can make out a consecutive dilatation of the stomach (Avhich may become large enough to fill the greater part of the abdomen) ; this may sometimes be done by inspection of the abdomen, Avhen the distended stomach may be seen as a convex prominence, extending doAvn to the navel, or even below it. Bamberger calls attention to the fact that Avhere the stomach is very low down, not only the greater, but also the lesser curvature, may be made out as a prominence extend- ing from the cartilages of the false ribs on one side to those on the other, just beloAV the so-called " pit of the stomach," Avhich is sunk in. On moving the skin in the epigastrium, we occasionally observe the region of the stomach to SAvell up and form a tense tumor. This ap- pearance, along Avith Avhich the contours of the stomach may be felt, is doubtless due to the tension of the organ over its fluid and gas- eous contents Avhich cannot escape, and to its consequent change from its usual relaxed state to a more spherical shape. The most elevated segments of this sphere become visible on the abdomen, while those lying deeper are perceived only by the touch. This change of the stomach from a relaxed, loose bag, to an elastic, tense, spherical blad- der, is usually accompanied by a disagreeable and more or less painful sensation. Apart from the transitory symptom just described, we notice the slight resistance of the epigastric region, which Bamberger has so well described as feeling like an air-cusfiion. The prominence of the epigastrium decreases or disappears when the patient has A'om- ited freely. In one case, treated at the GreifsAvalder clinic, on giving the patient an effervescing poAvder, the region over the stomach, and as far down as the navel, swelled considerably, and the contours of the stomach were clearly marked. Then, if part of the carbonic acid were belched up, the SAvelling subsided. When the stomach is fuU of food, the percussion dulness is very extensive ; but if, as is usually the case, it contains a quantity of gas at the same time, the percussion- sound is particularly full and tympanitic at the prominent places. If the patient changes his position, the solid substances always go to the lower parts of the stomach, and the bounds of the dull and clear per- cussion change. The above symptoms render the existence of pyloric constriction CHRONIC GASTRIC CATARRH. 497 very probable, but Ave can only ascribe this to simple hypertrophy of the Avails of the stomach, AA'hen we can exclude the other and more frequent forms of stricture, particularly the cancerous and the cica- tricial stricture, not unfrequently left after the heafing of a chronic I ulcer. The prognosis of chronic gastric catarrh agrees with what Ave have said of its course. Stricture of the pylorus must be classed among the frequently fatal diseases, for patients with this disease ahvays die, sooner or later, of marasmus or dropsy. Treatment.—Of all serious chronic diseases, chronic gastric catarrh probably gives the best result from rational treatment. As avc have described, in the first part of this chapter, the injuries Avhich, according to the duration of their action, induce acute or chronic gastric catarrh, Ave may, in speaking of the causal indications for treat- ment, refer to that description, and we have little to add to it. These in- dications are rarely fulfilled by the use of an emetic, as there are rarely any injurious substances in the stomach that can be considered as keeping up the disease. On this point Ave often meet opposition. It , is difficult to convince the patients that the pressure they feel is not excited by " something heavy on the stomach," and that an emetic would bring no relief, but rather Avould make matters Avorse. The causal indications urgently require the forbidding of all spirituous liquors, if their continued use has caused, and is keeping up, the affec- tion. This command will rarely be obeyed; nevertheless, Ave must not Aveary of repeating it. Temperance lecturers, Avho also demon- strate the terrifying results of brandy-drinking on the stomachs of topers, usually preach to deaf ears, it is true, but they attain some un- deniable results, and these should encourage the physician to persist in his adA'ice. In the chronic catarrh caused by repeatedly catching cold, or by the action of a moist, cold climate, the indication is to ex- cite the acthdty of the skin by warm clothes, warm baths, and similar means. Such cases are not at all rare; and, even at Greifswald, pa- tients avIio have come here without preparing for the damp, windy climate, by dressing more Avarmly, are often affected with chronic gas- tric catarrh, Avhich is better in summer, Avorse in Avinter, and is not cured till the causal indications are properly attended to. When the disease results from congestion, the causal indications can rarely be fulfilled. Dietetic rules are also of the greatest importance in fulfilling the indications of the disease. It is not possible to keep the patients fastino- throughout this tedious complaint, but Ave should most care- fullv select their food, and urgently insist on its exclusive use. The more precise the rules, the more carefully they will be folloAved, and,., 32 498 DISEASES OF THE STOMACH. if the prescribed diet be considered as a regular treatment, it is usually observed by the patient Avith painful conscientiousness. Since the use of meat, and other animal food, particularly requires activity of the stomach, one might suppose that the indication Avas to alloAV only vege- table diet to a patient Avith chronic catarrh of the stomach, the diges- tive poAver of whose gastric juice has become weakened, but experi- ence teaches the contrary. The poAver of the gastric juice to convert the protein substances into peptone {Lehman), or albuminose {Mialhe), is diminished in chronic catarrh, it is true, but it is not entirely lost. If they be given judiciously and in proper form, the patients improve more than if fed only on amylacea, from which quantities of lactic and butyric acids are formed in the stomach. From AA'hat has been said above, it folloAvs, of course, that fat meat and sauces are to be for- bidden ; that the food is to be carefully cheAved, and only small por- tions of it swalloAved at a time. Some patients get along very well Avhen they only eat concentrated, unskimmed meat broth; others do so Avhen they only eat cold meat, and but little Avhite bread. The latter prescription is especially useful in patients avIio suffer from ex- cessive acidity, and, in very obstinate cases of this kind, instead of the " cold-meat treatment," Ave may recommend the use of salt or smoked- meat. If it be considered curious that some patients bear meat betterjr when in this indigestible form than otherAvise, it is because the fact isi o.A'erlooked that smoked and salt meat, even if indigestible, has this* advantage over freeh meat, that it is not so readily decomposed as| fresh meat. In one case that I treated, the patient, avHo had chronic j gastric catarrh, AA'ith great inclination to acidity, kneAV exactly when he must abandon all other food (because it increased the gastric juice),! and limit fiimself to the use of lean smoked ham, sea-biscuit, and a j little Hungarian wine. The exclusive use of milk, the so-called milk- cure, agrees AvonderfuUy with some patients, while others cannot stand it at all, and we cannot certainly tell beforehand Avhich AviU be the ease. Butter-mUk suits many patients better than fresh milk. In Krukenburg's clinic I have seen very brUliant results from the pre- scription, " when the patient is hungry, let him eat butter-mUk; when ne is thirsty, let him drink butter-milk." Perhaps fresh milk is not so i well borne, because it readily curdles in the stomach, and forms large, I firm lumps, while in the butter-milk the casein is already cuudled, but! finely divided. Dietetic treatment does not succeed so often in chronic as in acute gastric catarrh, but we have some very efficient remedies for the former i disease. The chief among these are the alkaline carbonates. We ' have already recommended bicarbonate of soda, in divided doses, and tinctura rhei aquosa, in prolonged attacks of acute gastric catarrh. CHRONIC GASTRIC CATARRH. 499 Where chronic gastric catarrh is obstinate, we should try soda Avater, or the natural soda Avaters of Ems, Salzbrun, Selters, and Bilin, as Avell as the waters which, besides carbonate of soda, contain sulphates of the alkalies and earths or chloride of sodium. The use of the waters of Karlsbad and Mai ienbad has the most wonderful results. The highest recommendation that could be given for them is the fact that they are recommended by parties whom no one can accuse of being easily de- ceived by therapeutic results: the learned professors of the Vienna and Prague schools prize the use of the warm springs of Karlsbad as the best remedy for chronic gastric catarrh, and even for chronic ulcer of the stomach. Moreover, the numerous cases where obstinate jaun- dice Avas cured by the use of the waters of Karlsbad Avere almost ahvays those where it Avas due to gastro-duodenal catarrh. There is no reason to delay this treatment until the catarrh of the stomach and duodenum has caused jaundice, or to suppose that it will be less effi- cacious if this complication be Avanting. If the circumstances of the patient permit, the treatment may be folloAved out at Karlsbad or Marienbad; at these places the anecdotes of the frightful results from errors of diet during the use of the Avaters so terrify the patients that the diet required by chronic gastric catarrh will be certainly adhered to AvhUe there. Even after returning home, the patients subject them- selves to the strictest regimen for months, fearing that the waters may revenge themselves even yet for the slightest errors of diet. If obliged to use the waters at home, it makes little difference from Avhich of the Karlsbad springs they come, as they vary little except in their temperature, and they may be warmed to any desired extent. In Karlsbad the springs of loAver temperature, as the Schlossbrunnen and Theresienbrunnen, are most frequently used in chronic gastric catarrh. If there be no coincident obstinate constipation, soda water will often succeed quite as well, provided it be properly used, i. e., if the patient diets the same as at Karlsbad. After eating but little, and not very late, the night previous, he must drink the soda water in the morning AA'hile fasting, and must not breakfast for an hour after the last glass of water, so that the medicament may not be mixed with the ingesta, but may act undiluted on the gastric mucous membrane, and on the mucus covering it. The results from this treatment are the most bril- liant that are ever attained in medicine. The ter-nitrate of bismuth and the nitrate of sUver have a great reputation in the treatment of chronic gastric catarrh. These metallic salts may be beneficial, both by arresting decomposition in the stomach and by their great astringent action on the hyperaemic and relaxed mucous membrane. I have used these remedies in my clinic in very laro-e doses (bismuth nitrat. gr. x, argenti nitrat. gr. j—ij, at once), 500 DISEASES OF THE STOMACH. given like tfie alkafine carbonates, on an empty stomach, before break- fast. Most patients bore these doses very Avell; severe pain, nausea, or vomiting never occurred, and there was diarrhoea in only a feAV cases. But the results were very varied; Avhile in some cases there Avas very rapid improvement, in others there was none, and I Avas unable to find any cause for difference between them. In chronic gastric catarrh we sometimes dare not continue the mild diet; on the contrary, slightly-seasoned and salty food is much better borne than unseasoned and unirritating. When this state of " atony of the gastric mucous membrane " occurs, Ave should carefuUy prescribe preparations of iron and mild stimulants. The Eger Franzbrunnen, and even the chalybeate waters of Pyrmont, Driburg, or Cudowa, are better borne, and do more good than those of Karlsbad and Marienbad. When the mucous membrane is in this state, the best remedy is, ipe- cacuanha, gr. ss—j, pulv. rhei, gr. iij—iv, in pill, to be taken before meals, as recommended by Budd. The tinctura rhei vinosa, Hoff- mann's visceral elixir, ginger, calamus, etc., do good in these cases; but Ave must beAvare of going too far in the use of these remedies, or of giAdng them in improper cases, or too large doses. The symptoms rarely require the application of leeches or cups tojgg the epigastrium; they are only to be used Avhen there is great pain..H Difficult as it is to understand, the pain is almost always relieved byfwj the abstraction of blood. In those cases where the hyperaemia and I] catarrh of the stomach are symptomatic of great abdominal plethora,;! depending on compression of the portal vein, or obstruction to the j; B flow of blood from the hepatic veins, surprising results are often ob-|| tained by an abstraction of blood from the anastomoses of the portal I vein by applying leeches at the anus. Narcotics, which are almost in-} I dispensable in treating ulcers of the stomach, are rarely required in \ chronic gastric catarrh. Emetics may be employed under the circum- , stances in which they were advised in acute gastric catarrh, but we | must be more careful with them, as AA'e do not know that ulceration j may not have occurred already. The constipation which almost always ?■ exists is to be treated by enemata or laxatives; the medicines most ij used are rhubarb and aloes, and, in obstinate cases, extract of colo- '' cynth. Several of these articles are usually combined; the officinal (in Germany) and much-used compound extract of rhubarb contains aloes, rhubarb, and jalap. Budel says, also, that aloes and colocynth ' act chiefly on the rectum, and irritate the stomach but little, so that they are the best purgatives in chronic gastric catarrh; he warns \ against the use of senna and castor-oil. INFLAMMATION OF THE CONNECTIVE TISSUE, ETC. 5Q1 CHAPTER III. CROUPOUS AND diphtheritic inflammation of the gastric MUCOUS MEMBRANE. Croupous and diphtheritic inflammation of the gastric mucous membrane is rarely observed, unless poisonous substances have acted on it (see Chapter V.). In some cases, in infants, the catarrhal form of inflammation increases to the croupous; in others, croupous and diphtheritic gastritis belongs to the secondary inflammations occurring in the acute infectious diseases, especially in typhus, septicaemia, and small-pox. Croup membranes rarely spread over a great extent of the gastric mucous membrane; they are usually limited to small circumscribed spots. The diphtheritic sloughs also form isolated patches; on falling off, they leave losses of substance with discolored ragged bases. Unless pseudomembranes are vomited up, the disease is rarely, if ever, recognized during life. The difficulties the disease causes in children can never be rightly interpreted, and the severe symptoms of septicaemia, typhus, etc., are so little modified by an intercurrent croup- ous or diphtheritic gastritis, that in such cases also diagnosis is impos- sible. CHAPTER IV. 2NFLAMMATI0N OF THE SUBMUCOUS CONNECTIVE TISSUE--GASTRITIS PHLEGMONOSA. Inflammation of the submucous connective tissue, Avhich Roki- tansky compares to pseudoerysipelas, is also rare. It occurs either as a primary affection, AAdthout perceptible cause in previously healthy persons, or, like the above, it is a so-called secondary or metastatic in- flammation, and, as such, accompanies typhus, septicaemia, and similar diseases. The submucous tissue of the stomach is diffusely infiltrated Avith pus, AA'hich collects in its distended meshes ; more rarely there are cir- cumscribed abscesses in the submucous connective tissue. The under- mined mucous membrane is thinned, and subsequently it has numerous small openings, from which the pus trickles out as through a sieve. The inflammation soon extends to the muscular layer, the submucous tissue, and peritonaeum. If the patient recovers, cicatricial tissue may form in the meshes of the submucous, and strictures may thus result, as is shoAvn by specimens in the Erlangen Museum. 502 DISEASES OF THE STOMACH. The most important symptoms of the disease are severe pain in the epigastrium, vomiting, great anxiety, high fever; later, there are svmptoms of peritonitis, the patient collapses, and usually dies in a feAV days. Of course, a diagnosis can only be certainly made in a feAV cases, Avhere, AA'ith the above symptoms and vomiting of pus, we are able to exclude other forms of gastritis, particularly those caused by poisons. The treatment can only be symptomatic. CHAPTER V. inflammations and other changes in the stomach from caus- tics AND POISONS. Etiology.—The changes in the stomach caused by the action of concentrated acids, caustic alkalies, and some metallic salts, depend on the fact that these substances unite chemically with the tissue of the Avails of the stomach, whose organic structure is consequently de- stroyed. The changes that vegetable or animal poisons excite in the gastric mucous membrane, on the contrary, cannot be traced to chem- ical processes. Poisoning by carelessness is most frequently induced by copper-y salts, sulphuric acid, or vegetable poisons being taken into the stom-i ach ; while intentional poisoning occurs most frequently from arsenic I or sulphuric acid. I Anatomical Appearances.—If (filute mineral acids have acted I on the mucous membrane, only the epithelial and superficial mucous I layers are changed to a soft, brownish or black slough. If a quantity I of concentrated acid has reached the stomach, all the layers of the mucous membrane are converted into a soft black mass, which may | become several lines thick from imbibition with bloody Avatery fluid.1 The muscular tissue becomes softened or gelatinous, and very friable ; j more rarely both it and the serous membrane are entirely decomposed, and the stomach perforated. These changes are usually limited to a feAV longitudinal folds of the mucous membrane, running from the car- diac end toward the pylorus, Avhile the rest of the membrane is red- dened by hyperaemia and ecchymosis, and swollen by serous infiltra- tion ; the blood in the vessels of the stomach, and often even in the j neighboring large vascular trunks, is transformed into a black, smeary, \ tar-like substance. Only the nfilder cases recover, for the parts de- stroyed slough off, and the loss of tissue is replaced by callous cicatri- Ij cial substance. The caustic alkahes change the epithelium and the Ij superficial, or even the deeper layers of the mucous membrane, into a j1 pulpy, discolored mass. In these cases, more frequently than in cases j EFFECTS OF POISONS ON THE STOMACH. 503 of poisoning from acids, the destruction extends to the muscular and serous tissues, and so leads to perforation. When .the destruction is superficial, cure may result even in such cases, after the sloughing of the necrosed parts. BroAvn or black sloughs are formed by the action of corrosive sub- limate, copper, or other metallic salts ; these are surrounded by active injection and serous SAvelling of the mucous membrane. Phosphorus excites similar changes. If gastritis occurs after poisoning from arsenic, Ave find one or more spots of the mucous membrane coA'ered with a powdered, Avhite sub- stance, swollen, reddened, and softened to a pulp, or transformed to a yelloAvish or greenish-broAvn slough. From these sloughs extend red- dened folds of mucous membrane, between Avhich the Avails of the stomach are often unaltered. After the action of ethereal oils, or acrid vegetable or animal poi- sons, the remains of severe catarrhal, croupous, or diphtheritic inflam- mation are seen. Symptoms and Course.—Gastritis from poisoning is peculiar, be- cause, eA'en Avhere the poison used has no directly paralyzing effect on the nervous system, besides the local symptoms, there is a general de- | pression, and particularly an almost complete arrest of the circulation. These paralytic symptoms are also seen in other severe injuries of the stomach or other abdominal viscera, but especially in perforation of the I stomach from idceration. . If a previously healthy person be suddenly attacked AA'ith severe pain, AA'hich spreads from the epigastrium over the abdomen; if this be accompanied by vomiting of mucus or bloody mucus; if there be also purging of mucus and blood, preceded by severe colicky pains and tenesmus, and the patient be at the same time coUapsed, and his fea- tures distorted, his extremities cool, pulse smaU, and skin covered Avith cold, clammy SAveat; there is strong ground for suspecting the action of a corrosiA'e substance or some other poison on the gastric mucous membrane. If concentrated acids or strong alkalies have been taken, there are almost ahvays characteristic sloughs about the mouth ; the oral mucous membrane is destroyed in some places; there are severe pains in the mouth and throat; SAvalloAving is very difficult, or impos sible. After taking the metallic salts or arsenic in a diluted form, the signs of corrosion of the mouth and throat do not appear, and the symptoms of gastritis do not occur for some time. The symptoms ob- served in the different organs, but particularly the examination of the evacuations, sIioav AA'hat kind of poison has been taken. In the most severe cases there is nausea, but the paralyzed stomach cannot evac- uate its contents; an icy coldness spreads over the body, the paralysis 504 DISEASES OF THE STOMACH. becomes total, and the patient may die in a feAV hours. In milder cases death does not occur tUl later, and, Avhen a quantity of the poison has been vomited, the symptoms of paralysis may gradually disappear, and the circulation may be reestablished; but convalescence is usually A'ery slow, and the patient often suffers for life from strictures in tfie oesoph- agus or stomach, or else because the poison taken has undermined the constitution in some other Avay. Treatment.—The antidotes given in books on toxicology can only be given in recent cases, that is, within a feAV hours after acids, caus- tic alkalies, or metalfic salts have been taken. If these substances have already been vomited, or have already united Avith the elements of the gastric mucous membrane, antidotes can do no possible good, and may prove injurious by exciting new irritation in the inflamed gas- tric mucous membrane. It is different Avith arsenic and the acrid vege- table and animal poisons, whose action continues longer, and for Avhich the customary antidotes may be used for a longer time after they have been taken. If there be no vomiting, or if this do not suffice to rid the stomach of the poison, we may give an emetic of ipecacuanha. Besides these rules for fulfilling the causal indication, the indications from the disease itself are to use cold, as blood-letting does little or no good. We may cover the abdomen with cold compresses, which are to be frequently changed, and give smaU quantities of ice-water; or, if the patient can swallow, let him have small pieces of ice. For fur- ther treatment, we refer the reader to works on toxicology. CHAPTER VI. chronic (round, perforating) ulcer of the STOMACH—ULCUS VENTRICULI CHRONICUM (ROTUNDUM, PERFORANS). Etiology.—Perforating ulcer of the stomach is probably always acute; even its extension appears to be due to an acute process of destruction at its periphery and base. However, as the ulcer in ques- tion often gives the patient great trouble for years, it may rightly keep its name of " chronic ulcer." The sharp borders of the round ulcer, the absence of signs of inflammation or suppuration at its periphery, the direct observation of very recent cases, as well as the strik- ing results of a series of experiments on animals, prove, beyond doubt, that the destruction of the wall of the stomach is not due to a gradual breaking down from suppuration, but to the formation of a slough, to a partial necrosis, and that this usually, if not ahvays, de- pends on an obstruction of the blood-vessels running in the Avails of the stomach and nourishing it. The death of a circumscribed portion CHRONIC ULCER OF THE STOMACH. 505 of the Avail of the stomach from cutting off its nourishment is analo- gous to the locaHzed softening of the brain, infarction of the lungs, spontaneous gangrene of the toes, caused by cutting off the circula- tion. In the above-mentioned experiments on animals, the obstruc- tion of the gastric vessels was induced by introduction of emboH. This mode of development of the round ulcer is rare in man, but there are some cases Avhere certainly it has been observed. (I myself have seen a most exquisite example of it Avithin a few years.) The ob- structing clots usually form at the very site of the ulcer, and their formation seems to depend on disease of the Avails of the vessel. The gastric juice quickly causes softening and entire dissolution of the dead portion of the Avail of the stomach, Avhich cannot Avithstand its action, so that Ave rarely have the opportunity of seeing the first stage of the process on post-mortem examination. The predisposition to chronic ulcer of the stomach is very extended. Jaksch and others have given us statistics of its frequency at different ages, in different sexes, and in different employments, etc. In the accounts of two thou- sand three hundred and thirty post-mortem examinations, Jaksch found round ulcers mentioned fifty-seven times, and cicatrices fifty-six times; so that, to about every twenty bodies, there was either an ulcer or a cicatrix. Willigan, Brinton, and others came to simUar conclusions. Round ulcer is rarely found in children, but, on the other hand, it is quite frequent about puberty. Females are much more dis- posed to it than males. I think there is no doubt that poverty of the blood and chlorosis, those frequent results of sexual disturbances, have great influence in causing the round ulcer, and that they do so because abnormal states of the blood induce diseases of the AA'alls of the ves- sels, and hence favor the formation of thrombi. In other cases acute or chronic catarrh of the gastric mucous membrane appears to cause disease of the Avails of the vessels, and consequently thrombosis. The exciting causes of round ulcer are entirely unknoAvn. We can- not deny the possibility of its being induced by the injuries usually named; such as the use of very hot or very cold food and drink, the misuse of liquor, and other errors of diet. But it is very remarkable that, in spite of the frequency of chronic gastric catarrh in topers, they rarely have the round ulcer. Anatomical Appearances.—The ulcer which Ave are considering occurs almost exclusively in the stomach or upper part of the duodenum, while it is only rarely seen in other parts of the intestinal canal. It is most frequently situated in the pyloric portion of the stomach, oftener in the posterior than in the anterior wall; and almost ahvays at the small curvature or its vicinity; it is rarely seen at the fundus. Usual- ly these is only one ulcer, occasionally two or more, and not unfre- 506 DISEASES OF THE STOMACH. quently a recent ulcer near the cicatrices of some that have healed. In typical cases, according to Rokitansky's classical description, there is a circular hole Avith sharp borders in the serous coat of the stomach, as if a piece had been cut out Avith a punch. Regarded from AA'ithin, the loss of substance is greater in the mucous membrane than in the muscular coat, and greater in this than in the serous coat, so that the ulcer is in terraces and looks like a shallow funnel. The ulcers vary from \—\ inch in diameter; old ulcers attain the size of a thaler or the palm of the hand. At first they are round, after they have existed some time they become elliptical, or bulge out in some places, and so become irregular. They spread transversely in the course of the ves- sels, so that the stomach is occasionally surrounded by a girdle as it Avere. Sometimes the ulcer heals before it has perforated all the coats of the stomach. If the loss of substance has been fimited to the mucous and submucous tissue it is replaced by granulations; these are trans- formed to shrinking cicatricial tissue; they draAV the edges of the ulcer together, and a stellate cicatrix of variable size forms on the inner sur- face of the stomach. If the ulcer has penetrated deeper and destroyed the muscular coat also, when it heals up, the cicatricial contraction of the neoplastic connective tissue will contract the peritonaeum also into a stellate figure; its inner surface may even be retracted into the form of a fold in the stomach. If the ulcer were very large, its healing may cause a stricture, as the diameter of the stomach will be much dimin- ished by the cicatricial contraction; this will remain as an incurable obstacle to the passage of the contents of the stomach into the bowels. If the ulcer be located in the small curvature, as is usually the case, even if all the walls of the stomach be destroyed, escape of the contents into the peritoneal cavity may be temporarily or permanently prevent- ed. For, Avhile the ulceration progresses outwardly, local peritonitis occurs at the affected part; the threatened portion of serous membrane becomes attached to the neighboring organs; if it then be destroyed, these organs (most frequently the pancreas, the left lobe of the liver or the omentum), which are firmly attached to the edges of the ulcer, fill up the resulting opening in the walls of the stomach. The destruc- tion sometimes extends to the organ which covers the ulcer, but more frequently a thick layer of connective tissue develops on the surface of this organ, and forms the floor of the ulcer. The covering organ never lies in the same plane with the inner waU or projects into the stomach. But, after the muscular coat has retracted, the mucous coat becomes everted at the edge of the ulcer, and comes in contact Avith the organ in question. If, in such cases, the ulcer heal, the connective-tissue layer on the organ contracts, the edges approach each other, and, A CHRONIC ULCER OF THE STOMACH. 507 if the opening be not too large, may finally unite so as to form a firm, hard cicatrix. When the ulcer first forms, and stUl more frequently Avhile an ulcer already formed is spreading, the vessels of the stomach, or of the neighboring organ into which the ulcer has perforated, are destroyed, and there is considerable haemorrhage into the stomach. Perforations of the coronary, pyloric, gastro-epiploic sinistra, gastro-duodenal arte- ries and their branches, of the splenic artery, but most frequently of its branches going to the pancreas, and of the pancreatico-duodenalis, have been observed. The gastric mucous membrane also exhibits the changes character- istic of chronic gastric catarrh, which were described above. Sometimes these are absent or very slight. Symptoms and Course.—Sometimes, by perforating all the coats, and thus permitting the escape of the contents of the stomach into the peritonaeum, ulcer of the stomach may cause fatal peritonitis; or, by erosion of a large vessel, may cause abundant haematemesis before the disease has been recognized, or before its recognition Avas possible. It is going too far, hoAvever, to say that in such cases the signs of the suddenly occurring peritonitis, or the haematemesis, Avere the first symp- toms of the ulcer of the stomach. On more careful inquiry, Ave almost ahvays find that slight disturbances of digestion, and some oppres- sion in the epigastrium, increased by eating, have gone before, and that the patient had been troubled by wearing any thing tight about the Avaist. Between the first appearances of tfiese insignificant difficulties and the fatal termination, there is sometimes only an interval of a feAV days or Aveeks, so there can be no doubt that, in this short time, all the coats of the stomach have been perforated. (I have had a very sorroAV- ful opportunity of satisfying myself of the rapid course of a perforating ulcer; in Magdeburg, Dr. Brunnemann, a very distinguished and prom- ising young physician, died of such an ulcer. When the perforation occurred, he was not for an instant in doubt about the diagnosis, and most decidedly said that he had not suffered over eight days from shght trouble, Avhich he thought proceeded from a slight gastric catarrh.)^ It even seems as if perforation, Avith escape of the contents of the stom- ach into the abdomen, occurred most frequently in the cases beginning in this concealed manner, and running a rapid course; that, on the other hand, in the cases Avhich begin AAdth severe and pathognomonic symptoms, and run on for months or years, the stomach has time, as it Avere, to unite to the neighboring organs, and so prevent the escape of its contents into the abdomen. I Avould remind my readers that the cheesy infiltrations of the lungs, AA'hich run a rapid course, lead to per- foration of the pleura and pneumothorax far more frequently than 508 DISEASES OF THE STOMACH. mUiary tuberculosis, which has a slow course, and Avhere the folds of the pleura almost always become adherent, if the destruction goes as far as the pleura. The cases Avhere the inconvenience is so slight that a certain diagnosis of ulcer of the stomach is impossible, or Avhere the patient is so little troubled that he does not seek medical aid before the occurrence of the perforation, or the haematemesis, are, hoAvever, rare when compared to those where the disease is readUy recognized, and where it excites very annoying symptoms. Among the most frequent and troublesome symptoms of chronic ulcer of the stomach are pains in the epigastrium. The patients complain partly of a steady pain in the pit of the stomach, Avhich is increased by pressure, and is generally par- ticularly severe at some circumscribed spot; partly of paroxysms of se- vere pain, AA'hich, starting from the epigastrium, extend toward the back, and are designated as attacks of cardialgia. The sensitiveness to pressure in the epigastrium, Avhen the ulcer is extending in breadth or depth, is sometimes so great that the patient can hardly bear even the pressure of light bed-clothes; this is because there is slight peritonitis over the affected part. The cardialgic attacks generally occur soon after meal-times, and are severe in proportion to the coarseness and roughness of the food that has been taken. The patients sigh, groan, double themselves up, and often do not find ease till the stomach has been emptied by vomiting; if there be no emesis, the attacks of pain may last for hours. The seat of the ulcer may be determined with some certainty from the length of time at AA'hich the pains follow the meal; if they come immediately after eating, we may suppose that the ulcer is near the cardiac orifice; if they come an hour or tAvo later, it Avill probably be in the pyloric portion. Although, as a general rule, the attacks of pain occur after eating, and are the more severe the more indigestible and the rougher the food, there are some exceptions, and it is important that Ave should know these even if we cannot ex- plain them. In these exceptional cases, whUe the stomach is empty there is pain, Avhich is relieved by taking food; or after eating indiges- tible food tfie patient remains free from pain, whUe it becomes very severe if he eat easily-digested articles. The attacks of pain are usually attributed to the irritation of the surface of the ulcer by the motion of the contents of the stomach; while in an empty stomach such causes are absent. Another explanation is that the gastric juice secreted on the introduction of food irritates the ulcer and excites the pain, whUe there are intermissions, because, while the stomach is empty, a mucus which is but slightly irritating covers the ulcer. But when we consider that perforation of all the coats of the stomach may occur without ex- citing these attacks of pain, and that, on the other hand, the most se- vere pain often continues Avhen the ulcer has healed, but the stomach CHRONIC ULCER OF THE STOMACH. 509 has become adherent to other organs, there seems no doubt that the chief if not the only cause of pain is the obstruction to the peristaltic movements of the stomach, due to cicatricial contraction, or the adhe- sion of its Avail to neighboring organs. The larger and rougher the in- gesta, the more energetic and continued are the movements of the stomach they excite; hence the severity and long duration of the paroxysms of pain after eating large pieces of bread, potatoes, and other vegetables, and the comparative ease of the patient after eating soup, milk, and other fluid and mild nutriment. Vomiting is almost as constant a symptom as the sensitiveness of the epigastrium and the cardialgic attacks. It is caused by the same circumstances as the attacks of pain, and often terminates these, as it Avere. Vomiting also occurs a longer or shorter time after meals, ac- cording as the ulcer is near the cardiac or pyloric orifice. It is the more apt to occur, the nearer the ulcer is to the orifice of the stomach. Henoch calls attention to the fact that the same holds good in other IioUoav organs ; that is, reflex movements are particularly liable to be excited in them by affections near their openings; he reminds us that severe spasm of the bladder is most apt to occur from inflammatory irritation about its neck; that tenesmus,depending on affections of the rectum, is more distressing the nearer the disease is to the anus. Patients usually vomit their food more or less changed, and mixed Avith mucus and sour fluids. The state of the substances vomited, in Avhich there are often sarcina, depends principally on the intensity and extent of the coexistent gastric catarrh. Sometimes only quantities of mucus and acid fluids are vomited, AA'hile the food remains in the stomach. Severe cardialgia and vomiting, occurring regularly after meals, render it very probable that there is a chronic ulcer of the stomach ; the diagnosis is rendered certain, if there be also vomiting of blood. The haematemesis may have various sources: sometimes it is due to capillary haemorrhage, induced by the spreading of the ulcer; more frequently it is caused by the erosion of a large vessel, and this form is pathognomonic of ulcer of the stomach. We shall speak more in detail of haemorrhage from the stomach in Chapter VIII. The symptoms of the chronic gastric catarrh Avhich accompanies ul- cer of the stomach unite Avith the characteristic symptoms of the latter, it is true, but they are more or less decided according to the grade and extent of the catarrh, sometimes being just apparent. Some patients have decided SAvelHng in the epigastrium, frequent eructation, severe heartburn, complete loss of appetite; others feel very well during the intervals of their pain ; even their appetite is scarcely impaired. The sio-ns of oral catarrh, which also complicates ulcers of the stom- 510 DISEASES OF THE STOMACH. ach, are someAvhat different from the usual state of the mouth in chronic oral catarrh. The acid fluids tfiat rise into the mouth appear to dissolve the epithelium and the vomiting to clear it away; at least, instead of the thicldy-coated tongue, which is rarely absent in simple chronic catarrh of the stomach, we usually find the tongue red and fur- rowed, and this state is almost always accompanied by increased thirst. Finally, as in most cases of chronic gastric catarrh, there is habitual constipation. Regarding the general health of the patient, chronic ulcer of the stomach may soon impair the nutrition, so that the patient is rapidly debUitated, and has a pale, cachectic look-; in other* cases, the nutrition is very little deranged. This difference unmistakably depends on the varied grade and extent of the accompanying gastric catarrh. Except in the first-mentioned cases, where the round ulcer proves fatal in a feAV days or weeks, the course of the disease is usually A'ery tedious; it may run on for years. During this time the symptoms may vary greatly. At one time the patient lives comfortably; at another, AAdthout apparent cause, he suffers severely. Not unfre- quently, in the midst of an apparent convalescence or complete cure, vomiting of blood suddenly occurs; or the affection returns Avith its former severity years after it had disappeared. Recovery is the most frequent termination of chronic ulcer of the stomach. The sufferings of the patient gradually subside, the nutri- tion is fully restored, all disturbance ceases, and when the patient has died of some other disease, we find the characteristic cicatrix as the sole remains of the ulcer. Secondly, the result in incomplete cure is not infrequent. The symptoms of chronic gastric catarrh disappear, it is true; often also the periodical vomiting; the patient may become fresh and healthy- looking ; but every meal is followed by cardialgia, which occasionaUy becomes more severe than usual. In such cases the ulcer has healed, and the gastric mucous membrane has become relatively healthy; but there is a cicatrix or more frequently an adhesion of the stomach to some neighboring organ, which limits its movements at some point, and keeps up the cardialgic attacks. In other cases, ulcer of the stomach causes death. This may occur (a), from perforation of the walls of the stomach, and escape of its contents into the abdominal cavity. In such cases patients sometimes die before the occurrence -of peritonitis, or before this has developed sufficiently to be regarded as the cause of death. Along Avith the sud- den occurrence of fearful pain in the abdomen, the skin becomes cool, the pulse small, the countenance sunken ; and the patient collapses and dies in this state. If the heart's action becomes weaker, the filling of CHRONIC ULCER OF THE STOMACH. 511 the arteries less complete, typical cyanosis may result from the collec- tion of blood in the veins, and the patient looks like one in the col- lapsed stage of cholera. In these cases the perforation appears to cause a paralysis in the sympathetic nervous system, analogous to Avhat oc- curs in other seA'ere injuries. Although such cases are not rare, it is more common for the patient not to die during the first day or two, but for the symptoms of a fatal peritonitis to combine with the above. {b.) In rare instances death results from haemorrhage from the stomach. Even Avhen the patient appears quite bloodless and AA'axy-looking, Avhere every attempt to raise the head induces fainting, Avhere oppres- sion, palpitation, dizziness, tinnitus, and other symptoms of loss of blood, are present, the patient often recovers, contrary to all expecta- tion. Death may result very quickly, hoAvever, from erosion of large arteries. I saAV one case where the splenic artery was perforated, and the patient suddenly fell and died before there Avas any vomiting of blood, (c.) Death may result from gradual exhaustion, and this may take place even Avhere the ulcer has healed, but there is a stricture of the stomach from cicatricial contraction. In such cases not only is there the seA'erest cardialgia, but every thing that the patient eats is vomited; he may have no passage from his bowels for weeks, the belly sinks in, he Avastes aAvay to a skeleton, and dies from inanition. Diagnosis.—In the rare cases of ulcer of the stomach, AA'here it runs its course AAdthout any pathognomonic symptoms, it cannot be distinguished from chronic gastric catarrh; but in most cases the dif- ferential diagnosis between the tAvo affections presents no difficulty. Great sensitiveness of the stomach at a circumscribed spot, severe cardialgic attacks, but particularly A'omiting of blood, exclude simple catarrh Avith great certainty. A far less certain sign is the appearance of the tongue, Avhich is red and smooth in cases of round ulcer, and almost ahvays coated in cases of simple catarrh. It may be difficult to distinguish it from stricture of the pylorus due to hypertrophy of the membranes of the stomach. The slightness of the cardialgic attacks, Avhich are not in proportion to the frequency of the vomiting, the reg- ular occurrence of the latter, and the presence of consecutive dUatation of the stomach, aid someAvhat in the diagnosis, as they indicate stric- ture rather than ulcer. Where, Avith great severity of the cardialgic attacks, there are no dyspeptic symptoms, and, in spite of the long continuance of their dis- ease, the patients preserve a blooming appearance, Ave may suspect a cicatrix, AA'hich impairs the motions of the stomach. The probability of this is still greater if there have formerly been for a long time sure sio-ns of an ulcer of the stomach, Avhich, except the cardialgia, have subsequently entirely disappeared. Where the symptoms of stricture 512 DISEASES OF THE STOMACH. have developed and sloAvly increased after there has been chronic ulcer of the stomach, we must suspect that a cicatricial stricture has formed. We AA'ill speak in the folloAving chapter of the diagnosis of chronic ulcer of the stomach, from cancer and nervous cardialgia. Prognosis.—In accordance with what we have said of the course and results, the prognosis of chronic ulcer of the stomach is, on the AA'hole, favorable; Ave must not forget, however, that the disease often has remissions followed by exacerbations, that in the midst of apparent improvement haemorrhages avUI occur, and that, even after recovery has begun, relapses are always imminent. Treatment.—The disease of the blood-vessels, Avhich, as Ave have said, gives rise to the partial necrosis of the walls of the stomach Avhich results in round ulcer, can rarely be referred to chronic gastric catarrh; for topers, Avho have the most obstinate forms of this disease, rarely have ulcer of the stomach. As we do not know the causes of these affections of the blood-vessels, Ave have no hesitation in saying that, in the treatment of chronic ulcer of the stomach, Ave cannot fulfil the causal indications. Dietetic rules best ansAver the indications from the disease. The result of the treatment mostly depends on their being strictly followed out. It is true, we cannot protect the affected portion of the Avail of the stomach from injury, as Ave would an ulcer of the skin ; the intro- duction of even the mUdest food excites a hyperaemia of the gastric mucous membrane and irritates the affected part; hoAvever, the coarser and rougher the ingesta, the greater the irritation they excite. From this fact, proved by experiment and confirmed by practice, we deduce the rule that the patients should have the mildest possible, and, pref- erably, a liquid diet. We should then try if an exclusively milk diet Avill be borne; unfortunately, this, is not always the case. If fresh milk curdles in the stomach to hard, tough lumps, we should ahvays give it with white bread, as advised by Budd. Some patients, who cannot use fresh mUk, have no difficulty with buttermilk, or sour milk. If the patient has a great distaste for milk-diet, or if he cannot take sour or buttermUk, we may give rich unskimmed soups, Avith an addi- tion of Liebig's meat-extract. The nutrition in the small quantities of these extracts that the patient takes is not great, it is true, but they are strong analeptics. Trommer's malt-extract, Avhich has been before described, contains the nutritious constituents of malt in a state of solution, and is to be recommended because several spoonfuls of it may be taken daily without difficulty; hence it must be regarded as a valuable remedy. I knoAV patients who have taken one or tAvo ounces of Trommer's malt-extract daily for years. Vegetables, bread from CHRONIC ULCER OF THE STOMACH. 513 unbolted flour, roast potatoes, potato salad, etc., are particularly to be avoided, while puree of potatoes does well. The therapeutic use of the alkaline carbonates has a Avonderful effect in chronic ulcer of the stomach. Among the mineral Avaters con- taining alkaline carbonates and purgative salts, the Avarm springs are preferable to the cold. Patients whose circumstances alloAV it may be sent to Karlsbad. If there be insuperable obstacles to a trip to the springs, Karlsbad, Marienbad, Tarasper, and similar Avaters may be prescribed at home; they should be properly warmed before drinking. In some cases I have seen patients Avonderfully improA'ed by the treat- ment at AVildbad, and other Akrato-therma, after they had taken the Avaters of Karlsbad and Marienbad Avithout benefit; but am not con- vinced that the use of Avater from warm springs can replace the treat- ment at Karlsbad, as Professor Bock claims in the " Gartenlaube." I am sorry that so clear and shreAvd a person as Bock should permit himself to spread a dangerous half-knowledge among the laity; I have more than once found that people, under the impression that they had learned enough from Bock's Avritings to judge of their cases and treat themselves, have done themselves great injury. The rules of the ■ water-cures contain some superfluous and finikin regulations, but it is \ not Avell to shake faith in these, or else eA'en the rational rules may be ' less carefully folloAved. Among the latter I place in the first rank, that patients should not eat later than seven o'clock, and then only soups, that they should not breakfast for at least half an hour or an hour after their last glass of Avater. It is certain that very much depends on the Avarm mineral Avater going into an empty stomach. If under the treatment just described, contrary to our expectations, there be no improvement, Ave may give nitrate of silver, or subnitrate of bismuth. From the effect that these remedies, particularly the for- mer, are seen to have on ulcers of the skin, or of other mucous mem- branes, their use appears perfectly rational, and in some cases the results attained Avith them are surprising. In other cases, on the con- trary, they do no good. For the mode of administering these rem- edies and their dose, Ave refer to what was said in the treatment of chronic gastric catarrh. The treatment of symptoms, first of all, requires the relief of the cardialgic attacks. There are but feAV cases of chronic ulcer of the stomach Avhere Ave can dispense Avith the use of narcotics; these usually ' haA'e an instantaneous and brilliant effect on tfie attacks of pain. Even a feAV minutes after the administration of a small dose of mor- phia, there is relief or even complete freedom from pain. This seems to shoAV that the pain is chiefly induced by tension of the stomach. If it depended on irritation of the Avails of the stomach by the ingesta, or 33 / 514 DISEASES OF THE STOMACH. the gastric juice, Ave could not explain the action of the narcotics, AA'hich Jaksch says is often magical; but, if it depends on tension of the walls of the stomach, Ave can readily understand the effect of nar- cotics, Avhich, besides their anaesthetic effect, retard the movements of the stomach. Stokes declares that morphia is the only trustAvorthy remedy in the treatment of chronic ulcer of the stomach, and thinks that all the other remedies Avhich are highly spoken of are only effect- ual Avhen combined Avith a narcotic, as is generally done in using sub- nitrate of bismuth. Very small doses (^—i gr.) of morphia usually suffice, and it is not necessary to increase these. Jaksch saAV a Avoman take the same sized dose of morphia more than a hundred times with- out its efficacy diminishing. Morphia is preferable to extract of hyoscy- amus or belladonna, which are also recommended. When the epigas- trium is A'ery sensitive to pressure, a feAV leeches or Avet cups fulfil tfie indications. If these do not answer the purpose, blisters or pustulat- ing plasters left for some time on the pit of the stomach may be of use. Among the symptoms deserving particular attention, Ave may haA'e obstinate vomiting. The narcotics, particularly morphia, seem to be of aid in this symptom also. If they do no good, small pieces of ice or mouthfuls of ice-water are sometimes beneficial, and occasion^ ally AA'here all else fails we may give creasote (gtt. jv. to 3 A'j. of Avater, in tablespoonful doses), or tincture of iodine (gtt. ii.—in. in SAveetened water). Finally, in the course of chronic ulcer of the stom- ach, haematemesis or peritonitis may require special treatment; but Ave will speak of this in the chapters devoted to these subjects. CHAPTER VII. CARCINOMA OF THE STOMACH. Etiology.—Among the internal organs, the stomach is the one most frequently affected with carcinoma; it is usually affected pri- marily ; more rarely it is secondary to cancerous degeneration of other organs, or is propagated from them to the stomach. The cause of cancer of the stomach is just as obscure as that of cancer elsewhere. In some families it seems to be hereditary: the father of Napoleon I., his sister, and himself, died of this disease. In regard to the influence of sex, age, and employment, Ave may say that men are more frequently affected than women; that it is most frequent between the ages of forty and sixty years, AvhUe before forty it is rare, and before thirty it very exceptionally occurs ; finally, that no class of people escape it entirely. If cancer of the stomach be more frequent in the. inferior classes than in the higher, it is because the former are CARCINOMA OF THE STOMACH. 515 more numerous. There is no proof of Avhat has been said of the in- fluence of strong liquors, mental depression, the suppression of erup- tions, or the cure of ulcers {J. Frank). Anatomical Appearances.—Cancer of the stomach most fre- quently attacks the pyloric portion of the stomach, less often the cardiac portion or the small curvature, and most rarely the fundus and greater curvature. It ahvays shoAVS a tendency to spread trans- versely, so that cancer of the small curvature extends toAvard the greater, and that of the pyloric or cardiac portions readily causes annu- lar stricture. Cancerous stricture of the pyloric portion is usually sharply limited by the pylorus, whUe that of the cardiac almost always affects more or less of the oesophagus. Of the various forms of carcinoma of the stomach, the most fre- quent is scirrhus, medullary next, and the least frequent are alveolar or colloid; the various forms often combine—the union of scirrhus and medullary is most common. Scirrhus almost ahvays begins in the submucous tissue; it occasion- ally forms small nodules, sometimes diffuse thickening, which, groAV- ing irregularly, gives an uneven appearance. The groAvth has the char- acteristics of hard cancer, and presents a dull, Avhitish, dense mass of ' cartilaginous hardness. The mucous membrane soon unites AA'ith the , subjacent neoplasia; it subsequently softens to a black pulp, sloughs off, and the bare surface of the cancer is left. The muscular coat usu- ally becomes hypertrophied, and shows the previously-described fan- like appearance; it may subsequently atrophy under the pressure of the groAvth, or may be destroyed by the latter. The serous coat be- comes thickened and clouded by local peritonitis, often unites Avith adjacent parts, and is frequently covered Avith milky, laminated de- posits. After the destruction of the mucous membrane, the exposed cancer begins to ulcerate; at first shalloAV, later deep excavations are formed, and Ave have an irregular cancerous ulcer, AA'ith hard, callous edges, like those occurring on the skin. In other cases niedullary masses spring from the floor and borders of the scirrhous ulcer. If the affection of the stomach commence as medullary cancer, the nodules and diffuse thickening of the submucous tissue are softer from the first; they look like brain-substance, and, after a section through them, Ave may press out a quantity of the so-called " cancer-juice." | Medullary cancer spreads much more rapidly than scirrhous, and soon projects from the inner surface of the stomach as soft, easily-bleeding, spongy excrescences. The middle of the growth usually breaks doAAm into black, soft, ragged masses, Avhile the proliferation continues at the periphery. If the dead masses be throAvn off, there is left an ex- caA'ated ulcer, surrounded by elevated, eA'erted, cauliflower edges. 516 DISEASES OF THE STOMACH. Such a cancerous ulcer may attain tAvice the size of the hand, and the proliferations be sufficient to encroach considerably upon the space in the stomach. Alveolar or colloid cancer rarely appears as scattered nodules; it j more frequently occurs as diffuse degeneration. It also usually com- J mences in the submucous tissue, but soon induces degeneration of all | the coats of the stomach; in the Avail, AA'hich has become several lines, or even half an inch thick, no trace of the original structure can be j found; it consists almost entirely of innumerable small cavities (al- veoli), AA'hich contain a gelatinous fluid. Microscopic examination of J the latter shows the cellular formation characteristic of gelatinous can- \ cer. In alveolar cancer, also, the mucous membrane is destroyed, the J alveoli are evacuated, the free surface appears ragged and discolored; 1 but the loss of substance never becomes A'ery deep, for, while the | destruction goes on above, there is new production beloAV. The cancerous degeneration often extends to other organs, particu- larly to the lymphatic glands, the pancreas, liA'er, transverse colon, or omentum. The breaking down of the growth may also extend beyond the stomach to these organs, and give rise to communication betAveen the stomach and the intestines, or, after adhesion of the stomach to the anterior Avail of the abdomen, perforation outAvardly may occur. Al- veolar cancer alone rarely affects the organs above mentioned; but it frequently induces diffuse degeneration of the peritonaeum and conse- quent ascites. If the breaking down of the cancer advances to the peritonaeum be- fore the stomach has become adherent to the neighboring parts, its contents may escape into the abdomen, and fatal peritonitis result. If the cancerous degeneration leads to stricture of the pylorus, AA'hich, by nodular prominences and angular curvature of the contracted portion may stUl more increase the difficulty of the escape of the con- tents of the stomach, dilatation of the stomach avUI result. If, on the other hand, the cancer be located at the cardiac portion, or, if there be degeneration of a large portion of the wall of the stomach, as happens particularly in alveolar cancer, the stomach may become smaller. In many cases the diseased pylorus remains at its normal locality, being attached by adhesions; but in many others it moves freely, and, from its Aveight, sinks doAvn in the abdomen even as Ioav as the sym- physis pubis. Symptoms and Course.—Cases occur Avhere it is impossible to recognize cancer of the stomach Avith certainty during life. In elee- mosynary and hospital practice, patients not unfrequently come under treatment AA'ho are emaciated to skeletons, indifferent, and so apathetic, j that they make no complaints, and cannot give any history of theii CARCINOMA OF THE STOMACH. 517 case. At the same time they have no pain on pressure in the epigas- trium ; they have little appetite, but the food taken is not vomited, and examination of the abdomen reveals no tumor. It is necessary to knoAV that cancer of the stomach may occur Avithout the last-mentioned symptoms, and remember the possibility of its being the cause of the excessive marasmus ; but an absolute diagnosis is impossible. If such a patient die and at the autopsy a large cancerous ulcer of the stom- ach be found, inexperienced physicians are usually greatly astonished, and cannot understand hoAV a disease so severe and so far advanced could be mistaken. In other cases Ave can make an approximative diagnosis of cancer of the stomach. A patient, far advanced in fife, complains of loss of appetite, of a feeling of pressure and fulness in the epigastrium, of eructation and other dyspeptic symptoms; but, along AA'ith these mild symptoms, the patient rapidly loses his strength, acquires a dirty-yel- Ioav cachectic color of the face, and finally oedema of the ankles occurs. If, in such a case, avc can exclude other diseases, Avhich might explain the cachexia and marasmus, Ave haA'e cause to suspect that there is not a chronic catarrh, but a malignant disease of the stomach, even if there be no actual pain, vomiting, or characteristic tumor. In most cases the symptoms of cancer of the stomach are much more decided, and can scarcely be mistaken. Besides the dyspepsia and symptoms of cachexia and marasmus, there is tenderness in the region of the stomach. This is increased by pressure, and also after eating; but does not usually attain the severity of cardialgic attacks. Almost as often there is vomiting. When the cancer is in the smaller curvature, the vomiting only occurs noAv and then, but comes after every meal, when it constricts the pyloric or cardiac orifices. In stric- ture of the pylorus the vomiting does not usually come on till several hours after eating; in stricture of the cardiac orifice it occurs imme- diately after or during eating. Occasionally it happens that, after the vomiting has recurred regularly for a time, it gradually becomes less frequent, ceases altogether, or is replaced by a sort of cheAving the cud. This occurrence is explained Avhen the autopsy shoAVS that by breaking doAATi of the cancer the contracted part has become larger, or that the stomach, being enormously dilated or structurally changed, is eAddently not in condition to contract and perform its part in the act of vomiting. In other cases the autopsy gives no explanation of the cessation of A'omiting. The vomited masses consist sometimes of the food, enveloped in a thick coat of mucus, which is little changed, if the cancer be at the cardiac extremity, but is often greatly altered Avhen the pA'lorus is affected; sometimes they consist only of quantities of mucus and A'ariously-colored sour and bitter liquid. The presence of 51S DISEASES OF THE STOMACH. lactic, butyric, or acetic acids in the vomited matters depends on the causes that Ave investigated Avhen speaking of simple stricture of the pylorus. Sarcina ventriculi very often occur in the vomited matters, Avhile portions of the cancerous groAvth are rarely found. This is be- cause, Avhile the cancer ulcerates and breaks doAvn, the characteristic form of its elements is destroyed. Capillary haemorrhage readily re- sults from the breaking doAvn of the vascular growth. The blood poured into the stomach is quickly altered by its acid contents and converted into^ a black, grumous mass. Hence the presence of " cof fee-ground" masses in the vomited matters is a frequent and impor- tant symptom in cancer of the stomach; but its diagnostic significance has been much overestimated. The erosion of large vessels, causing copious haemorrhage, is much more rare; in doubtful cases this symp- tom indicates chronic ulcer of the stomach (see Chapter VIII.) rather than cancerous disease. The most important symptom of cancer of the stomach is the pres- ence of a tumor in the epigastrium. It is necessary to know that this symptom may be Avholly absent; this may be readily understood when we remember the relation of the stomach to the liver and ribs. Can- cer of the cardiac portion never causes a perceptible tumor, even when it attains a great size; that of the small curvature is not felt till it has advanced to the greater curvature. Most of the tumors that can be felt are located at or near the pylorus, the pyloric part of the stomach; and it is only because cancer affects this portion most frequently, that we almost always find a tumor in this disease of the stomach. Hyrtl's description of the position of the stomach is not true; this is particu- larly the case in the assertion that, on expiration, the point of the ster- num corresponds to the middle of the anterior Avail of the stomach. Luschka says, in his classical Avork (on every page of which the prac- titioner will find valuable information), that an incision made through the median line of the body will divide the stomach, so that five-sixths will lie on the left side, and at most one-sixth on the right. When the itomach is in a normal position, even cancer of the pylorus wUl give a tumor of the left side. When the diseased pylorus sinks down from its weight, the tumor may be near the naA'el, usually somewhat above and rather to the right than to the left of this. If it be still farther down, it may be mistaken for ovarian tumor. The size of the tumor varies from that of a pigeon's egg to that of the fist; if it be very large, it may form a visible prominence in the abdomen; the surface is usually uneven and nodular. In many cases the tumor is moA'able, and it changes position according as the stomach is full or empty; in other cases, Avhere there are adhesions, it is immovable. In the same way the sensitiveness of the tumor A-aries greatly. Sometimes, instead oi CARCINOMA OF THE STOMACH. 519 a circumscribed, nodular tumor, Ave find a regular, more or less exten- sive prominence and resistance of the epigastrium. Percussion of the tumor, caused by cancer of the stomach, almost ahvays gives a not quite clear and decidedly tympanitic sound. In cancerous stricture of the pylorus, besides shoAving the presence of a tumor, physical examination may prove a dilatation of the stomach, Avhose symptoms Ave described Avhile speaking of simple stricture of the pylorus; if, on the other hand, the stomach be contracted, and, as often happens, the boAvels be empty, the lower margin of the ribs be- comes very prominent, while the belly is sunken, so that we can dis- tinctly feel the A'ertebral column and the pulsating aorta. The symp- toms of cancer of the stomach are modified by the deA'elopment of cancer in other organs, particularly in the liver. Occasionally, also, cancer of the lymphatic glands of the stomach spreads to the retro- peritoneal glands, to those of the mediastinum, thence to those of the neck, so that a hard swelling of tfie supra-clavicular glands may be of diagnostic importance in cases of cancer of the stomach (I have seen such cases). The symptoms of alveolar cancer are often modified by the occurrence of ascites. During the course of cancer of the stomach the symptoms gener- ally increase regularly; more rarely, the patient improves for a time, pain and vomiting cease for a Avhile, and even the appetite returns. These remissions do not usually continue long; the difficulties increase again, the appetite is entirely lost; constipation, AA'hich has existed from the first, can fiardly be overcome; emaciation makes giant strides. If the cancer be medullary, the disease usually runs its course in a few months, Avhile scirrhus, and particularly alveolar cancer, may run on for years. The only termination of cancer of the stomach is in death. In those cases AA'here cure of cancer has been claimed from the clinical course of a disease of the stomach, there may have been a mistake in diagnosis. Those observations, Avhere autopsy is said to have revealed the cicatrix of a cancerous ulcer, also are not perfectly trustworthy; for if fresh cancerous growths are found in the vicinity of the cicatrix, the disease has not truly disappeared; but if this support be Avanting, the cicatrix from a cancer cannot be certainly distinguished from that of a simple ulcer. In most cases, death occurs with the symptoms of exhaustion. As there is no accompanying fever, the last stage of the disease is usually much protracted, and patients may live for days, Avhile Ave hourly expect their death. In these cases the tongue usually becomes red, inclined to dryness, and covered Avith aphthous deposits. Besides this painful affection, there is not unfrequently a painful tense oedema of one of the legs shortly before death. This symptom de- 520 DISEASES OF THE STOMACH. pends on obstruction of the femoral vein, and shoAVS that, in conse- quence of the retarded circulation, a clot has formed in it. More rarely death occurs from a rapid peritonitis, after perforation of the stomach. StUl more rarely, copious haemorrhage from the stomach hastens the exhaustion, or, by its extent, causes sudden death. Finally, death may be caused or hastened by complications and secondary diseases. Diagnosis.—In cases where the epigastrium is painful, where there is frequent vomiting, occasionally of substance looking like coffee- grounds, Avhere there is a tumor in the epigastrium, the diagnosis of cancer of the stomach from chronic catarrh is easy. If these symp- toms he absent, particularly the tumor, which Andral maintains is the only certain sign of cancer of the stomach, the differential diagnosis of these tAvo diseases may be very difficult. In forming an opinion, the age of the patient is important; besides this, Ave often can only judge from the general condition. The diagnosis from chronic rdcer of the stomach, also, is sometimes easy, again A'ery difficult. In one Avell-knoAvn case, tAvo medical celeb- rities, Oppolzer and Schoenlein, could not agree whether there was cancer or ulcer of the stomach. In the differential diagnosis, the factors chiefly to be regarded are the folloAving: 1. The age of the patient; in young persons, cancer may be excluded almost Avith certainty. 2/ The duration of the disease; if it has existed more than a year, the probabilities are against cancer. 3. The strength and condition of the patient; in ulcer, these are often affected but Httle, and not tUl late in the disease, Avhile in cancer they are greatly impaired very early. 4. The character of the pain; cardialgic attacks indicate ulcer rather than cancer. 5. The condition of the blood vomited; in ulcer of the stomach, it is in large quantities, and hence slightly changed, Avhile in cancer the amount is usually scanty, it is black, and looks like coffee-grounds; still, in some cases of cancer, there is abundant vomiting of blood, and Avith an ulcer of the stomach there may be ejection of black, grumous masses. 6. The presence or absence of a tumor; the former proves almost certainly that there is cancer, for the cases Avhere thickenino- of the walls of the stomach and connective-tissue groAvths, in the vicinity of an ulcer, cause a tumor, are exceedingly rare. But, on the other hand, we must not forget that absence of a tumor does not prove that there is no cancer. The variety of the cancer can rarely be determined Avith any cer- tainty during life. Alveolar cancer, being the rarest A'ariety, is only to be suspected Avhere the disease runs a very sIoav course, and when there is ascites. The diagnosis becomes more certain if, after tapping, nodular masses can be felt in the omentum. If these symptoms are absent, Ave must suspect scirrhus or medullary cancer. The more acute ILEMORRHAGE FROM THE STOMACH. 521 the course, the larger the tumor becomes and the more rapidly it groAvs, the more probable it is that the neAV formation is medullary cahccr. Treatment.—As the indications from the cause and from the dis- ease cannot be fulfilled, Ave must restrict ourselves to the treatment of symptoms. The diet must be regulated according to the rules pre- scribed in the treatment of chronic gastric catarrh; if milk be Avell borne, it is the most suitable nourishment; if milk cannot be used, con- centrated broths, yolk of egg, and other nutritious substances may be ordered, but ahvays in small quantities, and Avhere there is stricture they should be given in fluid form or finely dhdded. Wine also, par- ticularly red wine, may be given, and it is usually AveU borne. For the excessive acidity, the alkaline carbonates do Avell, especially in tfie form of soda-Avater; they often fail, hoAvever, and sometimes, as in stricture of the pylorus, Ave cannot in any Avay prevent the acidity. In such cases it is AveU at each meal to give pills containing gtt. 1—1^- of creasote, as recommended by Budd. Pills of aloes and colocynth may be given for the obstinate constipation. For the severe pain and the sleeplessness, narcotics, particularly morphia, must be given. CHAPTER VIII. HEMORRHAGE FROM THE STOMACH. Etiology.—1. Haemorrhage from the stomach results from rupture of the over-filled blood-vessels Avithout preA'ious change of texture. Arterial fluxion is rarely so decided as to cause rupture; besides the slight haemorrhage seen in inflammation of the stomach, this occasion- ally occurs in anomalies of menstruation. It cannot be denied that ripening and detachment of an ovum are sometimes accompanied by fluxions and haemorrhages in other organs and not in the uterus, although Ave can give no explanation of the fact. Venous congestion of the gastric mucous membrane is a much more frequent cause of haemorrhage. The most decided congestions result from impediments to the circulation in the liver. Haemorrhage from the stomach may be caused by obstructions of the portal vein by blood-clots ; by pressure on its branches due to cirrhosis of the liver, or to the enlargement of the gaU-ducts, caused by closure of the ductus hepaticus or choledochus; by plugging of the capUlary vessels of the fiver AA'ith clumps of pig- ment in pernicious fever {Frerichs); finally, by destruction of the capillaries, in the so-called yelloAV atrophy of the fiver. The hyper- emia of the gastric mucous membrane, due to obstruction of the cir- culation in the chest by diseases of the lungs, pleura, heart, or pericar- 522 DISEASES OF THE STOMACH. dium, is rarely sufficient to cause a rupture of the vessels; but haemorrhage from the stomach is sometimes seen from these causes. The haemorrhages AA'hich sometimes occur in new-born infants most likely belong in this class. It is most probable that these depend on imperfect expansion of the lungs, and the obstruction thus induced to the Aoav of blood from the stomach. 2. Haemorrhage from the stomach may result from the rupture of diseased vessels. In rare cases varices burst or aneurisms open into the stomach. More frequently disease of the walls of the vessels must be suspected, Avithout our being able to prove it either AA'ith or without the microscope. Under this head come the haemorrhages occurring in the so-called haemorrhagic diathesis; those coming after exhausting dis- eases, in the course of yellow fever and other severe diseases; finally, those arising from improper living, especially abstinence from fresh meat and vegetables, Avhich form one of the symptoms of scorbutis. In these cases it is insufficient to ascribe the bleeding immediately to an abnormal quality of the blood; this can only act by disturbing the nutrition of the walls of the vessels. 3. Finally, haemorrhage from the stomach may arise from erosion and other injuries of the Avails of the vessels. In this class belong the cases AA'here chronic ulcer or ulcerating carcinoma leads to haemorrhage. from the capillaries or larger vessels; those Avhere corrosive substances and sharp, foreign bodies open vessels of the stomach; lastly, those AA'here a Woav over the stomach has caused rupture of one of the vessels. Anatomical Appearances.—Even after decided haemorrhages from the gastric mucous membrane, we often seek in A'ain, on post- mortem examination, for its source; when the patient has died from loss of blood, after Avashing off the stomach, Ave find it just as pale and bloodless as the rest of the body. In other cases there has been coin- cident capUlary haemorrhage in the mucous membrane, in Avliich Ave find bluish-red or blackish-red spots, from which blood oozes out on slight pressure. This haemorrhagic infiltration of circumscribed por- tions of mucous membrane generally leads to superficial softening and throwing off of the softened portion; superficial excavations tfius oc- cur, which are not discovered tUl the dirty-brown blood particles cling- ing to them are Avashed off. The superficial bleeding fossae, called haemorrhagic erosions, are usually numerous, small, of round or elon- gated form, and are chiefly found at the summit of the longitudinal folds formed by the mucous membrane. If large vessels have been eroded by ulcer or cancer of the stomach, or if ruptured varices or aneurisms have caused the haemorrhage, we may in many cases find the gaping mouth of the vessel. HAEMORRHAGE FROM THE STOMACH. 523 When the patient dies soon after the haemorrhage, and if this has been very copious and occurred rapidly, the blood contained in the stomach forms red, clotted masses. If it has escaped sloAvly, and has been retained in the stomach a long AvhUe, so that the gastric juice and the acid contents of the stomach have had a chance to act on it, it ap- pears broAA'n or black. Where the haemorrhage has been A'ery sfight. Ave find only a feAV black striae and flocculi, or masses like coffee-grounds, in the stomach. Symptoms and Course.—If the haemorrhage from the stomach be not abundant and the blood be not vomited, the haemorrhage is not usually recognized during life. According to Beaumont's observations, small haemorrhages usually occur in the stomach during acute gastric catarrh; but blood mixed Avith mucus is very rarely A'omited. The haemorrhagic erosions also, which, as proved by autopsies, quite fre- quently accompany chronic catarrh, cancer, and ulcer, rarely cause haematemesis and consequently are rarely recognized during life. In other cases, it is true, the mixture of small quantities of blood with the vomited matters leaves no doubt that there has been a haem- orrhage from the stomach, Avhen it is certain that the blood has not been preA'iously swallowed; but frequently haematemesis is the only symptom of the bleeding. This is daily observed dn patients Avith cancer of the stomach, who are neither better nor Avorse AA'hen they A'omit the " coffee-ground " masses. If there has been a quantity of blood poured into the stomach, there are usually some symptoms preceding the haematemesis. These depend partly on the stomach being full of blood, partly on the empti- ness of the blood-vessels of the body. The patients have a feeling of pressure about the stomach, a desire to loosen the clothes, feel con- stricted and nauseated; they become pale, the pulse is smaU, the skin cool, they see sparks before the eyes, haA'e noises in the ears, become dizzy, or they even faint. I kneAV one case where a surgeon opened a vein for his mother, AA'hile she was in such a state, thinking that she Avas apoplectic. In robust, strong persons the faint feelings do not occur, and the premonitory symptoms are limited to the feeling of pressure and fulness in the epigastrium. After there has been nausea for a time, accompanied by the feeling of a Avarm fluid rising in the oesophagus, and a SAveetish, stale taste, there is \dolent A'omiting, and, to the great terror of the patient, blood, partly fluid, partly clotted, and usually dark broAvn, is evacuated through the mouth and nose. Small portions of blood often enter the larynx and induce coughing, and, as blood is brought up by this also, the patients relate that they ha\Te " broken a blood-vessel," but they cannot say whether they A'om- ited or coughed up the blood. Sooner or later, after the haematemesis, I 524 DISEASES OF THE STOMACH. there is a passage of blood from the boAvels. If the haemorrhage were very copious, blood is passed at stool very soon afterward, and it appears in black, clotted masses; if it be not passed for tAvo or three days after the haematemesis, it is usually changed to a black, tar-like mass. In exceptional cases the blood poured into the stomach is evacuated by stool alone, and there is no vomiting. If patients, suffer- ing from chronic ulcer of the stomach, become very pale in a shorl time, and shoAV other symptoms that may depend on internal haemor- rhage, Ave should not neglect to examine the passages repeatedly. Many pounds of blood may be AvithdraAvn from the circulation in a short time by haemorrhage of the stomach; and even the strongest persons avUI then become pale, cool, and faint. In severe cases, every attempt of the patient to sit up, or even to raise the head, causes nausea, blackness before the eyes, and dizziness; every attempt to rise brings on fainting. Terrifying as it usually is to the patient and those around him, the fainting undoubtedly has a beneficial effect on the attack, for it momentarily arrests the haemorrhage and favors the formation of coagula. It appears entirely due to this fact that the affection usually terminates more favorably than Ave should expect from the appearance of the patient. Indeed, proportionately feAV patients die of haemorrhage from the stomach, that is, by bleeding to death, or suffocating from the blood entering the larynx. Much more frequently, after the patients have become deathly pale and exces- sively exhausted, and have lain for days in an apparently hopeless state, the vomiting ceases, blood gradually disappears from the stools, and a very sIoav convalescence begins. The patients long remain with- out appetite, complain of foul eructations and an unpleasant taste. As the great loss of blood is replaced by Avater, the patients become A'ery hydraemic, and often dropsical; but these symptoms may also disap- pear, although, perhaps, someAvhat slowly, and the patients recover. Finally, we must mention those cases where the haemorrhage is so profuse that the patient dies before the blood is evacuated either up- ward or downward. We must remember this when a patient, AA'ho has had the symptoms of chronic ulcer or cancer of the stomach, suddenly sinks Avith the symptoms of internal haemorrhage and dies in a feAV minutes. Diagnosis.—Since patients Avith haemoptysis often vomit at the same time, and those with haematemesis frequently nave a coincident cough, it is not ahvays easy to distinguish haemorrhage of the stomach from that coming from the lungs or bronchi, particularly if we are not present at the time, or if it is a question of a " haemorrhage " that has occurred some years before. The following points are important in the differential diagnosis. HAEMORRHAGE FROM THE STOMACH. 525 1. The appearance of the blood ejected. Vomited blood is usually dark, blackish, clotted, mixed Avith food; the coagula, containing no air, are heaAder; sometimes it has an acid reaction from the gastric juice. On the other hand, blood coming from the lungs and bronchi is usually bright-red, frothy, mixed Avith mucus, not coagulated at first, and if a coagulum does form, it contains air-bubbles and is light"; its reaction is ahvays alkaline. But Ave must knoAV that blood, Avhich has been but a short time in the stomach, and has been little affected by the gastric juice, may be bright red, and, on subsequent haematemesis, small portions of black blood may be throAvn off 2. Vomiting of blood is, in most cases, preceded by cardialgic at- tacks and other symptoms of ulcer or cancer of the stomach; in the much rarer cases caused by congestions and fluxions, there are symp- toms of hyperaemia of all the organs in the abdomen ; haemoptysis, on the other hand, is usually preceded by disturbance of the respiration, and of the circulation in the thoracic viscera. 3. Intelligent patients can generally tell AA'hether vomiting occurred first and Avas followed by coughing, or whether, on the other hand, nausea, retching, and vomiting have been excited by the coughing. 4. In haematemesis percussion generally sIioavs fulness of the stomach, Avhile physical examination of the chest sIioavs no changes there. In haemoptysis there is no epigastric dulness on percussion, and in the thorax Ave almost always hear moist rdles, if there be no other sounds present. 5. After vomiting of blood, there are almost ahvays bloody stools for a few days; after coughing of blood, instead of these, there is just as often a bloody mucous expectoration. We cannot tell, from the A'omited matters or from the stools, Avhether the blood A'omited really comes from the stomach or Avhether it has been SAvalloAved. In doubtful cases Ave should carefully exam- ine the nose and pharynx, and ask the patient if he noticed any signs of nose-bleed before going to bed the previous night. A careful inquiry about premonitory symptoms may clear up the matter here also, particularly when Ave suspect intentional decej^tion. In the description of the symptoms preceding the A'omiting, malingerers usu- ally OA'erdraAv the picture, and this fact, with the contradictory state- ments they make, often assists to expose them. It is generally easy to decide whether the A'omited matters be really blood or not, although there are cases AA'here the physician has lost his presence of mind, and mistaken steAA'ed cherries for blood. Even in the black coffee-ground masses some shrunken and misshapen blood-corpuscles can almost always be recognized Avith the microscope, and a chemical examination to prove the presence of iron in the black 526 DISEASES OF THE STOMACH. masses, avUI very rarely be necessary to determine that it is really altered blood. It is usually easy to decide whether the bleeding depends on the erosion of large vessels or the rupture of capillaries. Besides the fact that in the first case the bleeding is usually more abundant than in the 'Tatter, a reAdeAV of the premonitory symptoms almost ahvays gives a certain means of diagnosis. If there have been cardialgic attacks, chronic vomiting, and other symptoms of ulcer of the stomach, there is probably erosion of a large vessel, which is by far the most frequent cause of haemorrhage from the stomach. If, on the contrary, there haA'e been ascites, enlargement of the spleen, or other signs of obstruction to the portal circulation, the haemorrhage is most probably from the smaller vessels, and Avas caused by venous congestion. If the hemor- rhages occur regularly every four weeks Avhile there is amenorrhoea, Ave must suspect extensive fluxion to the stomach; if it come during yel- Ioav fever, or scorbutis, or after exhausting diseases, Ave must suspect disturbance of nutrition of the walls of the vessels. Prognosis.—We have already mentioned that only a small pro- portion of patients die from hematemesis, and that in spite of the Avaxy color of the skin, and even of the long-continued faintness, Ave may give a favorable prognosis. It is doubtful whether haemorrhage from the stomach has under any circumstances a beneficial influence on chronic ulcer of the stomach; if the patients are occasionally better for a long time after it, it is probably because the severe attack has frightened them, and they haA'e become more careful in their diet. The haemorrhages caused by congestion may temporarily have a good effect on the other symptoms of abdominal plethora. On the other hand, in scorbutis and other exhausting diseases, haemorrhage from the stomach always renders the prognosis more grave. Treatment.—The prophylactic and causal indications are fulfilled by the treatment of the original disease. If patients, with cirrhosis or other disturbance of the circulation of the liver, shoAV premonitory symptoms of haemorrhage from the stomach, we may with advantage apply a few leeches to the anus; in women, who with amenorrhoea have periodical vomiting of blood, we may from time to time apply a feAV leeches to the os uteri. The indications from the disease require a less energetic treatment in haemorrhage from the capillaries, than in that depending on erosion of a large vessel. At the commencement of the latter, Jaksch recom- mends a venesection; but this is rarely beneficial, and AA'hen not so, increases the danger. The employment of Junod's cupping-boot Avould be much more advisable, but never after faintness has come on; tor, after this, the use of haemospastics, Avhich may cause even robust STASM OF THE STOMACH—NERVOUS CARDIALGIA. 527 patients to faint, is very dangerous. Cold must be regarded as the most efficacious remedy in haemorrhage from the stomach; we may let the patients swallow small quantities of ice-water or small pieces of ice, from time to time, and we may cover the epigastrium with cold Avater or ice-compresses, and renew them frequently. Styptic medi- cines are not always Avell borne, but are often vomited up; the best of these are mistura sulphurica acida or alum, particularly in the form of serum lactis aluminatum. We should ahvays give these remedies in small quantities and keep them on ice. Acetate of lead, sulphate of iron, and ergotin, may be dispensed Avith. The indications from the symptoms, first of all, require attention to the syncope. The patient must lie flat in bed; must not rise to stool, but use a bed-pan. If syncope occur, Ave may hold eau de cologne or hartshorn to the nose, and sprinkle the face AA'ith Avater, but be A'ery careful about the internal administration of restoratives. Among these cold champagne is best, as it is less apt to cause vomiting than the analeptic medicines. The unceasing inclination to vomit, Avhich is partly due to the attacks of syncope, partly to the blood in the stom- ach, is the most annoying symptom that the patient has. In trying to arrest it, Ave should be careful about the use of narcotics, and should preferably apply a sinapism to the pit of the stomach occasionally, and give a pinch of effervescing poAvder. Since P. Frank has an- nounced that it is necessary to purge patients AA'ith haemorrhage from the stomach, to prevent the blood from exciting Ioav and putrid fever, clysters and slight coofing laxatives are almost universally prescribed. My observations correspond Avith those of Bamberger, according to Avhom even enemata are injurious for the first feAV days after a haemor- rhage. CHAPTER IX. SPASM OF THE STOMACH—NERVOUS CARDIALGIA. Etiology.—By nervous cardialgia, we mean painful affections of the stomach, not dependent on perceptible changes of structure. Rom- berg distinguishes tAvo forms of this disease, one of Avhich, he says, de- pends on a hyperaesthesia of the pneumogastric, the other on hyperaes- thesia of the solar plexus. The former he calls gastrodynia neuralgica, the latter neuralgia cceliaca. But it can probably never be determined in any given case Avhether the pains be located in the filaments of the pneumogastric or in those of the sympathetic; and Henoch says, Avith truth, that this distinction is practically Avorthless, though it may be theoretically correct. 528 DISEASES OF THE STOMACH. 1. Like other nervous diseases, this affection is often observed in | anaemic persons. If in chlorotic females, Avho have more or less se- vere attacks of spasm of the stomach as a constant symptom, the blood be enriched by preparations of iron, the cardialgia disappears, even in those cases Avhere the amenorrhoea continues, and the quick recurrence of the chlorosis proves that the original disease has not been removed. , It folloAVS, from these observations, that the cardialgia of chlorotic pa- tients depends solely on the poverty of the blood; not, as in hysterical women, on affections of the sexual organs. The cardialgia not unfre- quently observed in tuberculous persons, convalescents, and onanists, probably, also, depends on poverty of the blood. 2. Diseases of the uterus, such as dislocations, flexions, or chronic inflammation, and follicular ulcers of the os uteri, as Avell as affections of the ovaries, induce cardialgia. It is among the most frequent symp- toms of hysteria. The dependence of spasm of the stomach on affec- tions of the female sexual organs is most evident when the attacks occur exclusively, or are most severe, at the menstrual periods. I treated one woman for amenorrhoea Avith retroflexion of the uterus and catarrhal erosions of the os uteri, AA'hose cardialgic attacks recurred regularly every four Aveeks and lasted three days; but during the in- tervals they only appeared AA'hen leeches Avere applied to the cervix uteri, and they only lasted during the time of the application. 3. In other cases, nervous cardialgia depends on diseases of the spinal marroAV or brain; and from analogy Avith other neuroses, it is probable, although it has not been proved by observations, that it may be caused by organic changes in the pneumogastric, or sympathetic nerves, SAvelling of their neurilemma, or tumors pressing on them. 4. Cardialgia may depend on dyscrasia. Infection of the blood, Avith malarial poison, occasionally seems to excite spasm of the stomach in- stead of the paroxysm of intermittent fever. Romberg attaches par- I ticular importance to arthritis as a cause, and in his own first attack of gout he suffered severely from spasm of the stomach. 5. Finally, Ave frequently cannot find, either during life, or on au- topsy, any cause for cardialgia that has existed for years. From the description above given, the attacks of pain caused by certain contents of the stomach, without any structural change, must be considered as nervous cardialgia. Among these are the cases of spasm of the stomach induced by excessive acidity, by the presence of Avorms in the stomach, by the exhibition of certain medicines, and oc- casionally after a cold drink and similar causes. Symptoms and Course.—Like most neuroses, nervous cardialgia is distinguished from other diseases by its typical course, i. e., after in- tervals of freedom, follow paroxysms of the severest pain. Occasion- SPASM OF THE STOMACH—NERVOUS CARDIALGIA. 529 ally there is a regular type, so that the attacks recur at the same hour daily, or every second or third day. * It is impossible to describe a cardialgic attack more strikingly, or II briefly, than has been done by Romberg. | " Suddenly, or after a precedent feeling of pressure, there is severe, griping pain in the pit of the stomach, usually extending to the back, Avith a feeling of faintness, shrunken countenance, cold hands and feet, and small intermittent pulse. The pain becomes so excessive that the patient cries out. The epigastrium is either puffed out, Hke a ball, or, as is more frequently the case, retracted, with tension of the abdominal Avails. There is often pulsation in the epigastrium. External pres- sure is Avell borne, and not unfrequently the patient presses the pit of the stomach against some firm substance, or compresses it Avith his hands. Sympathetic pains often occur in the thorax under the ster- num, in the oesophageal branches of the pneumogastric, Avhile they are rare in the exterior of the body." " The attack lasts from a feAV minutes to half an hour; then the I pain gradually subsides, leaving the patient much exhausted; or else J it ceases suddenly with eructation of gas or Avatery fluid, AAdth vomit- [ ing, Avith a gentle soft perspiration, or with the passage of reddish urine.'" Besides these severe attacks, we often see painful sensations, of various varieties and degrees of intensity, in the stomach, Avhich also alternate Avith intervals of rest and freedom from pain, Avhich are less- ened, not increased, by external pressure, or by the introduction of food; these also are accompanied by sympathetic pain in the breast and back, reflex motions of the abdominal muscles, etc. It is these mild attacks, Avithout " the feeling of faintness and impending death," that Romberg styles neuralgia of the pneumogastric, in contradistinc- tion to neuralgia coeliaca." Diagnosis.—The character of the pain gives no aid in distinguish- ing cardialgic attacks, accompanying an ulcer of the stomach, from those due to neuralgia of the gastric nerves. In the former we also see the extension of the pain to the back and breast, and see them subside Avith vomiting and eructation, and the depressing effect of the pain on the patient. The foUoAAdng factors are important in judging betAveen the tAA'O states: 1. In most cases, pains induced by ulcer of the stomach are increased by external pressure by introduction of food (" pressure from Avithin ") ; while, on the other hand, nervous cardialgia is usually reheved by pressure over the stomach, and by eating. 2. In chronic ulcer of the stomach, dyspepsia and other symptoms of dis- turbance of the functions of the stomach are present during the in- tervals ; these do not appear in nervous cardialgia. In accordance with 34 530 DISEASES OF THE STOMACH. this, nutrition is little impaired in the latter disease, and, Avhen the neuralgia is not due to anaemia, the patient may look strong and healthy. 3. Dysmenorrhoea, metrorrhagia, sterility, and other symp- toms which betray affection of the sexual organs, as well as decided chlorosis, render it probable that the affection is nervous in character; but too much Aveight must not be attached to these symptoms, for it is in just such cases that ulcer of the stomach is apt to occur. 4. The simultaneous occurrence of other neuralgic affections speaks for a similar nature in these attacks of pain. 5. Finally, genuine neuralgia of the stomach is excited by unknoAvn causes, and often occurs while the stomach is empty; the attacks of pain in ulcer of the stomach almost always come after eating. Prognosis.—The prognosis is favorable in cardialgia dependent on poverty of the blood, which is not due to cancer, tuberculosis, or some other incurable disease. Those cases, also, that are caused by uterine complaints disappear Avith the cure of the original disease, if this be amenable to treatment. The prognosis is generally favorable, also, in those cases resulting from the influence of malaria or arthritis. On the other hand, treatment is almost always unavailing in the cases depending on affections of the brain Or spinal marroAV, and in those arising from unknown causes. Treatment.—The indications from the cause require the energetic and early employment of the preparations of iron in chlorotic and anaemic cases. It is a great error to delay the use of iron in the treat- ment of chlorosis until the stomach is prepared for it, and the cardialgic attacks have passed away. The dyspepsia and cardialgia of chlorotic patients do not yield sooner to any remedies than to those which improve the state of the blood. The springs of Pyrmont, Driburg, and CudoAva are Avonderfully beneficial in this affection. Among the officinal preparations of iron, the best is the ferri carbonas saccharata (Br.). Blaud's pills are also an excellent prescription (see treatment of chlorosis). In hysterical cardialgia, applications of leeches to the os uteri, touching ulcers on it with nitrate of silver, and other treat- ment, Avhich we shall learn when speaking of uterine diseases, may be indicated, and may have a striking effect. In cardialgia excited by malaria or arthritis, the fulfilment of the causal indications answers for the treatment of the original disease. The indications from the disease are best ansAvered by the narcotics, and, among these, acetate of morphia is preferable to the extracts of hyoscyamus, belladonna, etc., Avhich have also been recommended. This remedy is usually given in combination with the so-called anti- spasmodics, particularly Avith valerian, asafoetida, and castoreum. Re- cently, a mixture of equal parts of tincture of nux vomica and tincture DYSPEPSIA. 531 | of castor (dose, 12 drops during the attack) has been much used, and | apparently Avith good effect. MetalHc remedies also, particularly i nitrate of bismuth, nitrate of silver, cyanide of zinc, have been recom mended in spasm of the stomach; hoAvever, as they are scarcely ever gh'en alone, but are used in combination Avith narcotics, their efficacy is problematical. Finally, Romberg recommends aiding the treatment by applying belladonna or galbanum plasters over the stomach, or rub- bing in a mixture of mixtura oleosa-balsamicae (§ j) Avith tinctura opii ( 3 ij). CHAPTER X. DYSPEPSIA. In the preceding chapters we have often spoken of dyspeptic symp- toms, i. e., of signs of impaired digestion. Hence, AvhUe giving a sepa- rate chapter to dyspepsia, Ave shall only speak of those disturbances of digestion which arise Avithout perceptible change of structure of the ] stomach. The different forms of this dyspepsia may be included under j tAvo heads: the digestion is impaired either because the gastric juice secreted is of abnormal quality, or because the moA'ements of the stomach are diminished, and, consequently, the ingesta are not suffi- ciently mixed Avith the gastric juice. Digestion, Avhich is a purely chemical process, can only be influenced by the nerves Avhen they modify the secretions, or the moA'ements of the stomach, and only in this sense is it proper to speak of nervous dyspepsia. The change in the gastric juice may be either qualitative or quan- titative. We knoAV very Httle about the qualitative changes. They may consist in alteration of the proportion of the normal constituents to each other; thus we knoAV that too shght an amount of free acid Aveakens the solvent poAver of the gastric juice; or in the fact that for- eign substances are mixed AAdth the gastric juice, such as urea in cases of retention of urine; or because, under certain circumstances, the con- stitution of the gastric juice is totally changed, some constituents being added and others disappearing. The symptoms caused by quali- tative changes of the gastric juice are entirely unknoAvn, and still less do avc knoAV the remedies for treating the state in question. As to the quantitative changes of the gastric juice, the A'ery un- suitable name of " atonic indigestion" has been given to the symp- toms induced, Avhere the gastric juice is insufficient, or Avhere it is not sufficiently concentrated. In the etiology of gastric catarrh Ave men- tioned that too scanty a secretion, or too poor a quality of the gastric juice, existed in anaemic and chlorotic persons. We there explained 532 DISEASES OF TOE STOMACH that this anomaly increased the inclination to chronic catarrh of the stomach, because, as the ingesta readily decomposed, their products j excited intense irritation of the mucous membrane. To Avhat has been j said, Ave must add that the gastric mucous membrane is not affected in all the cases AA'here the contents are abnormally decomposed, and that the cases where this membrane remains healthy should be carefully distinguished from those Avhere it becomes diseased. The symptoms induced by restricted secretion of gastric juice are, it is true, frequently similar to those occurring in chronic catarrh, and even to those of chronic ulcer of the stomach. In this form of dyspepsia, also, the ap- petite is less, or is satisfied after eating very little. After eating, the epigastrium SAvells, and there is eructation of gases, or sour and rancid liquids; the patients suffer from flatulence, and are disturbed and anxious about their condition. Besides the nervous cardialgia occur- ring in anaemic and chlorotic patients, the excessive formation of acid may cause griping pain in the stomach (in the substances vomited by chlorotic patients, Frerichs found acetic acid and quantities of yeast fungus), and these cases may very readily be mistaken for chronic ulcer of the stomach. The diagnosis of this form of dyspepsia depends chiefly on the etiology. If the symptoms occur in chlorotic girls, about * the age of puberty, or in persons Aveakened by venereal excesses, par- ticularly onanism, or in those exhausted by care and anxiety, by con- tinued work, or night Avatching, or if they come during convalescence, from protracted and exhausting diseases, and particularly if Ave can find that the nutrition was impaired before the appearance of the digestive difficulties, the chances are in favor of its being the so-called atonic dyspepsia, and against the existence of structural change of the stomach. The condition of the tongue gives another point in diagnosis. While in chronic gastric catarrh there is a coated tongue and other signs of oral catarrh, in the dyspepsia of anaemic patients the tongue is usually clean, the taste unchanged, and there is no fetor from the mouth. In many cases the diagnosis is decided by the effect of fast- ing and of eating. Spiced and irritating substances, which increase the difficulty in chronic catarrh and chronic ulcer of the stomach, are weU borne in atonic dyspepsia, and ease the painful symptoms which accompany it. Above all, a mode of life that improves nutrition, the administra- tion of iron, and sea-bathing, Avhich have but little effect on chronic gastric catarrh, or chronic ulcer of the stomach, produce most brilliant results in dyspepsia dependent on anaemia or hydraemia. In some of these cases, particularly where the dyspepsia is accompanied by irrita- oUity or sensitiveness of the stomach, the pure bitters, such as quassia DYSPEPSIA. 533 or hops, are very sendceable. We cannot explain the unmistakably favorable influence of these remedies on the gastric mucous mem- brane ; for, while they are very irritant to the gustatory nerves, they have no effect when applied to the other mucous membranes, or to the skin. Quassia is generally ordered as a cold infusion. In the evening Ave may pour a cupful of cold Avater over about a teaspoonful of quassia-chips ; by the next morning a bitter infusion will have formed, which is to be drunk fasting, or else Avater may be left for a while in a cup, turned from quassia-Avood, and then drunk. Hop-bitter is gen- erally used in the form of Bavarian beer, which is noAv breAved all OA'er Germany; but avc must take care that it comes from a trustworthy brewery, where, instead of hops, some injurious substitute is not used. The strong malt-extract, of which Ave previously spoke (page 246), has proved very efficient, in my hands, in several cases of dyspepsia, char- acterized by irritable indigestion. Occasionally it Avas almost the only nourishment the patients bore. It is not improbable that the prepara- tions of nux vomica, which have a great reputation as stomachics, act like the above remedies, by their bitterness. The preparations most used in dyspepsia are the aqueous extract (gr. £—1), alcoholic extract (Sr- i—k), and the tincture (gtt. x—xii). Too scanty a secretion of gastric juice, and the symptoms depend- ent on it, occur also in persons accustomed to great irritation of the stomach, as soon as they change their mode of life, and take their food Avithout the addition of any stimulants. Unable as we are to explain hoAV an organ becomes accustomed to irritation, there is no doubt of the fact. We may aptly compare the gastric mucous membrane of persons who daUy use quantities of pepper, mustard, and other spices, to the nasal mucous membrane of habitual snuff-takers. In most per- sons small quantities of snuff excite great reflex symptoms, when taken into the nose, Avhile the habitual snuff-taker can fill the nose with snuff Avithout sneezing. Moreover, the secretion of gastric juice must be regarded as a reflex symptom, excited by the irritation of the ingesta on the mucous membrane. In the persons in question, the irritation from ordinary food is insufficient to produce a sufficient sup- ply of gastric juice. Part of the ingesta remain undigested; it is de- composed, and Ave have the symptoms above described. If, on the other hand, the food be taken Avith a strong addition of spices, the patients do quite avcII, their nutrition goes on all right, and there is nothing to induce us to think that they have chronic gastric catarrh, or other organic change of the stomach, tUl finally symptoms occur AA'hich prove that the stomach has not borne these insults Avithout injury. We must go A'ery carefully to work in the treatment of these patients we cannot alloAV them to retain then- bad habits, but Ave should only 534 DISEASES OF THE STOMACH. break them off gradually. If Ave break either of these precepts, Ave may readily induce gastric catarrh or some other disease of the stomach. Among the stomachics, Avhich are indicated in the last-described form of dyspepsia (well called "torpid indigestion"), rhubarb is the | best; it is given as powder or pills, or as the aqueous tincture ( 3 j), but best as the A'inous tincture (gtt. xx—xxx). In torpid dyspepsia, ipecac, (gr. %—%) has also a good reputation, particularly with EngHsh physicians. Finally, the bitter medicines containing an ethereal oil are good in torpid indigestion; among the most popular remedies of this class is elixir aurantiorum comp. (gtt. xxx—xl). The dyspepsia of old persons also appears to be caused by too vcanty a secretion of gastric juice, which partly depends on a lack of lie materials necessary to its formation, and partly on diminished excitability of the gastric nerves. It is difficult to decide how far the disturbance of digestion in this, as well as in the first-mentioned form of dyspepsia, depends on bad nutrition of the muscles of the stomach; and it is sufficient to call attention to the fact that the retarded move- ments of the stomach consequent on this deficient nutrition may lead to incomplete mixture of the ingesta with the gastric juice, and hence -"j to dyspepsia. Abnormally-increased secretion of gastric juice does not cause dys- pepsia, it is true; nevertheless, we avUI here relate the symptoms that it appears to excite, particularly AA'hen the stomach is empty. Vomit- ing is seen to result from irritations which do not affect the walls of the stomach itself, but neighboring organs, particularly the ureters or the ductus choledochus, or even distant organs, as the uterus. This is usually considered as depending simply on reflex movements. Budd, hoAvever, in a spirited and striking manner, calls attention to the fact that in such cases the nerves causing secretion of the gastric juice have become more active from the reflex irritation. When Spallanzani induced vomiting in himself before breakfast, by tickling the fauces, he threw up an acid fluid, Avhich dissolved meat; this shoAVS that mechanical irritation of the fauces may excite secretion of gastric juice, even when the stomach is empty. Budd further says that, AA'here there is impaction of bUiary or urinary calculi, the vomited masses are often very acid, even when the stomach was previously quite empty of food, and that the acid they contained Avas found by Prout to be muriatic. This circumstance and the decided and rapid ■ removal of these gastric difficulties by alkafine remedies render it probable to him that part of the pain, and perhaps also the vomiting, depended on the irritation of the gastric mucous membrane by the | juice poured into the empty stomach. At all events, the urgent ! DYSPEPSIA. 535 adAdce of Budd and Prout, to give large doses of bicarbonate of soda ( 3 ij in a pint of Avarm Avater), is Avorthy of attention. A number of renoAvned physicians, particularly in England and France, maintain the opinion that the occurrence of oxalic acid in the blood, along Avith some other symptoms of disease, results in a peculiar form of dyspepsia, Avhich can only be cured by removing the oxalic diathesis. As the doctrine of the oxalic diathesis, and of the dys- pepsia caused by it, has lately found many supporters as AveU as many opponents in Germany also, I avUI briefly state my position in regard to this still debatable question. Traces of oxalate of Hme are so often found in the urine of healthy persons, that it forms, as it Avere, a transition from the normal to the abnormal constituents of urine. Quantities of this salt are found in the urine when the affected persons have eaten substances containing oxalates, such as certain vegetables, sorrel, sheep-sorrel, or rhubarb-stalks; they also occur temporarily after the free use of carbonated drinks, such as cham- pagne, seltzer-Avater, soda-water, etc. In all of these cases no disturb- ance of digestion or of the general health is observed. It is different in those cases Avhere large quantities of oxalate of lime occur for a length of time in the urine; here there are almost al- ways other morbid symptoms. Sometimes, along Avith the oxalate of lime, Ave find spermatozoa and quantities of mucus in the urine, Avhich render it probable that, in these cases, the oxalate of lime is not ex- creted by the kidneys, but forms in the urine during its stay in the urinary passages. Since Gallois and Hoppe-Seyler have shoAvn that the characteristic crystals of oxalate of lime (octohedrons, so-called envelope-shaped) increase in size after the urine stands awhile, we cannot doubt that this salt probably also forms in secreted urine from the decomposition of mucus. We must dismiss the idea that the insoluble salt formed in the urinary passages can have an injurious influence on the stomach and the rest of the organism; then the symptoms of this form of oxaluria, disturbance of the general health, melancholia, paleness, etc., Avillbe naturally explained by the coincident spermatorrhoea and the catarrh of the urinary passages. But, finally, there are a greater number of cases where the oxaluria cannot be de- duced from a decomposition of the secreted urine, but we are obliged to refer the presence of the oxalates in the urine to an increased formation of oxalic acid in the blood, that is, to an oxalic diathesis. Noav, what causes the proportionately rich formation of this substance in the blood and its proportionate abundance in the excrements of the body, where, normally, only traces of it can be found ? At present, this question cannot be satisfactorily ansAvered. HoAvever, there is no doubt that 536 DISEASES OF THE STOMACH. oxaluria is more frequent in England, Avhere the people cat and drink more and better food and liquor than in Germany, and that in the latter country it is almost only seen among people of the better classes, aa-Iio enjoy the pleasures of the table. Little inclination as I have for chemico-physiological hypotheses, I stiU believe that, from these facts, we may consider it as probable that the oxalic diathesis and oxaluria are to some extent caused by the supply of nutriment to the body exceeding the reqinrements. At the same time, I will not dwell on the question as to whether, AvhUe this misproportion exists, the consumed products can only be brought to a low degree of oxida- tion ; or Avhether the abnormal increase of substances at a low grade of oxidation in the excrements of the body, such as oxahc acid, uric acid, etc., depends upon other complicated and still wholly unknown causes. I think I can support the observation that, in general, persons who become fat AA'ith good living remain healthier than those Avho pro- duce but little fat under like circumstances, and particularly more so than those Avho, continuing their mode of life, lose fat. While, as a rule, the former only suffer from certain inconveniences dependent on their corpulence, the latter often complain of all kinds of distresses, Avhich physicians usually associate Avith portal obstructions or haemorrhoids, or deduce from gouty, rheumatic, or catarrhal diseases. This renders it probable that, in many cases where there is the above-mentioned dis- proportion between the supply and demand, and this is not at once removed by increased production of fat, the products of the change of tissue are modified, and that the above-described difficulties depend on an abnormal nutrition of the different organs by the blood, which is overloaded with quantitatively or qualitatively abnormal excremental material. After a long continuance of the hypochondriasis, the dis- turbance of digestion, the pharyngeal and bronchial catarrh, pain in the joints, especially the smaller ones (of AA'hich groups of symptoms, first one, then another becomes prominent, or is even exclusively pres- ent), such persons usually become feeble, pale, and thin, so that they appear to have a severe and grave affection. The urine, Avhich is usually concentrated and acid, does not always show characteristic changes. But, in most cases, abundant sediments of uric-acid salts are occasionally de- posited. According to my experience, tonic treatment, and the use of wine, and preparations of quinine and iron, to Avhich Ave may be tempted by the weakness, pallidity, and emaciation of the patient, are ahnost al- ways injurious; whUe the use of alkaline-saline mineral waters has the happiest results, particularly Avhen combined with cold Avashing, or cold douches (as is often done by Dr. Mutter, in Homburg), or if sea- bathing be tried after the Avater-treatment. I haA'e no great experi- ence in oxaluria and the oxalic diathesis, but those cases that I have DYSPEPSIA. 537 met resembled most closely those I have just described, although I Avill not consider them as exactly identical; they had the same etiol- ogy? the same varied complaints (not exactly corresponding to any of the usually-described forms of disease), the same sleepiness, paleness, and emaciation, only the urine, which is usually acid, contained no sediment of urates, but had crystals of oxalate of lime. Hence I deem it most proper to regard the dyspepsia, Avhich occurs as one of the many symptoms of oxaluria, as the result of a constitutional derange- ment, and that this derangement is developed in persons predisposed to it, by the manner of living above described. At present Ave have no idea Avhich link in the long chain of processes betAveen assimilation of nourishment and the excretion of the used-up constituents of the body, is first cfianged by this injurious influence, Avhich induces the formation of quantitatively or qualitatively abnormal products. In this affection Ave should employ the treatment Avhich I above recommended for the diseases allied to, if not identical Avith, the oxalic diathesis. (The occurrence of oxalate of lime, as a final product of tfie change of tissue in the oxalic diathesis alone, is opposed to their com- plete identity.) The administration of nitric acid (twenty drops of the dilute acid tAvo or three times daily), recommended by English physi- cians for the oxalic diathesis, and the forbidding of all saccharine arti- cles of food, appear to depend more on theory than on the results of practical experience. Before closing the consideration of dyspepsia, I wish to speak of a peculiar form of dizziness AA'hich is a very frequent but inexplicable symptom. Trousseau, Avho considered that it arose from the dyspepsia, called it vertige stomacale. Almost any practitioner can refer to some case among his patients that will correspond Avith the true and life-like description given by Trousseau of the vertige stomacale, the A'ertigo a stomacho laeso, or, as our people call it, abdominal dizziness (bauch- schwindels). The disease, AA'hich subsequently becomes very obstinate and tedious, usually begins acutely Avithout any premonition. The patient, Avho just preAdously felt perfectly well, complains of great diz- ziness ; it seems to him as if every thing around him, or as if he him- self, Avere whirling or rolling about. Besides this hallucination, there are usually abnormal sensations in the head, Avhich, the patient says, he cannot call pain, but AA'hich he in vain attempts to describe. Some- times patients say their heads feel " empty," or " light;" others speak of a " numbness," of a " sensation of undefined pressure," of a " cloud arising in tfie fiead;" besides this, there are usually sparks before the eyes, noises in the ears; the patients are afraid of falling, seek sup- port, Avant to sit doAvn or lie down. These attacks, during Avhich the color is either unchanged or becomes pale, usually pass off after a few 538 DISEASES OF THE STOMACH. I minutes; but, while they last, they greatly terrify the patients and | those around them. They often, but not always, terminate with gap- : ing and eructations. Sometimes there is only one such attack, but more frequently there is a recurrence, sooner or later. It is, at the same time, very re- markable that the new attacks are excited by apparently insignificant causes, such as Avalking on a polished floor, or a smooth sidewalk, or by passing a grating ; also, that on such occasions the patient does not become dizzy if he holds the hand of even a smaU chUd, or rests on a slender cane; lastly, that there is no dizziness if he is engaged in something that occupies his Avhole attention, or if he be mentally ex- cited. I knew one patient who could on no consideration Avalk alone through a hall, or across an open square, Avhile he could dance Avithout trouble in the same hall, and unconcernedly rode a spirited horse across the same square. The longer the affection lasts, the more the thoughts of the patient are directed to his enigmatical and curious state. He becomes greatly depressed by the idea that he has disease of the , brain, and particularly Avhen he hears that dizziness Avas one symptom j in some other patient Avho actually had cerebral disease, Avho perhaps r died of softening of the brain, that most terrible bugbear of the laity, t Physicians also are often mistaken, and order bleeding, derivatives, \ preparations of iodine, saline springs, and forbid wine and beer, and restrict the diet as much as possible. If this treatment be ineffec- tual, and under it the patient becomes pale and thin, the physician often changes his opinion: he suspects that the dizziness is caused by anaemia of the brain; then he prescribes iron, advises the use of AAdne and beer, and places the patient on a nutritious animal diet. HoAvever, this treatment also proves unavailing, and the patient re- turns unimproved from the Alps, from the cold-Avater cures, and from the sea-shore. As above mentioned, Trousseau believes that these attacks of dizziness depend on dyspepsia; at the same time he ac- knowledges that in many cases the signs of dyspepsia are so slight as to be readily overlooked. He relates cases of the successful treatment of " vertige stomacale " by the alternate administration of infusion of quassia and a composition of carbonates of the alkalies. Even from this prescription I have never seen any benefit; and while I must ac- knowledge that the first attacks of dizziness, affecting the patients that I have seen, usually occurred after an indigestion, and were accompa- nied by dyspeptic symptoms, still, in none of them were there evident signs of indigestion during the subsequent attacks, which often con- tinued for years. I believe the repetition of the attacks of dizziness to be due to psychical causes. As there are persons who become dizzy AA'hen they stand on the edge of a precipice, or on a high toAver; and DYSPEPSIA. 539 as one Avho has once become dizzy on such an occasion, is almost cer- tain to become so again in a similar position; so, a person, AA'ho has once become dizzy in his chamber, or whUe walking over an open square, is in the greatest danger of becoming so again on a similar oc- casion. The fear of the dizziness is a strong predisposing cause for it in this form, just as it is in that Avhere people have it from standing on a high place. On the other hand, concentrated attention on any point, mental emotion, or even a slight noise, may, to a certain extent, prevent attacks from either cause. As a proof of the correctness of this vieAV, I may mention the case of a clergyman, who, while going to the pulpit in his church, had a severe attack of dizziness, and fell to the floor. For years, as long as I had a chance to observe him, this patient never had another attack of severe dizziness; but he never en- tered his pulpit after the first attack. On tAvo or three attempts, he thought he noticed premonitions of the dizziness, AA'hich induced him to give up further attempts ; he had to give up his employment, just as a toAver-keeper or a roofer Avould have to abandon his, if, while engaged in his avocation, he had one or two severe attacks of dizzi- ness. SECTION \. AFFECTIONS OF THE INTESTINAL CANAL. CHAPTER I. CATARRHAL INFLAMMATION OF THE INTESTINAL MUCOUS MEMBRANE—■ ENTERITIS CATARRHALIS, CATARRHUS INTESTINALIS. Etiology.—In the mucous membrane of the intestines also catarrh is the constant result of every hyperaemia, Avhether the vascular fulness depend on purely mechanical causes, or on other injurious influences. At the commencement of the disease, and in acute cases, the hyperae- mia induces more particularly extensive transudations of a salty fluid, deficient in albumen; subsequently, and in chronic cases, on the other hand, it generally leads to abnormal production of mucus and cells. Intestinal catarrh, and particularly the chronic variety, is one of the most frequent of diseases : 1. It constantly accompanies obstruction of the circulation of the liver. The impeded escape of the blood from the portal vein must necessarily cause overfilling of the intestinal veins, and so produce catarrh of the intestines. 2. It frequently, but less constantly, accompanies the diseases of the respiratory and circulatory organs, which cause obstruction to the evacuation of the vena cava. As in these affections there is venous congestion throughout the circulation, it also occurs in the intestinal mucous membrane; in these cases the hyperaemia and catarrh of the intestine represent, as it were, the cyanosis of the skin. ' 3. More rarely, disturbance of the external circulation appears to cause active hyperaemia and catarrh of the intestines. In this class appear to belong the excessive hyperaemia of the intestines, which ac- company severe inflammation of the skin, caused by burns, as well as the evanescent hyperaemia Avith copious serous exudation induced by sudden exposure of the skin to low temperature, as by travelling in the mountains {Bidder and Schmidt). We will not attempt to say INTESTINAL CATARRH. 541 whether cases of catarrh caused by coldness of the feet and of the lower part of the body, which depends on the continued action of cold, and the chronic cases induced by damp, cold cfimates, belong in this class. 4, The severe intestinal catarrh frequently occurring in peritonitis, particularly puerperal peritonitis, must also be considered as due to excessive active hyperaemia. In these cases the intense inflammation , leads to oedema of the subserous tissue, of the muscular coat, and of the intestinal mucous membrane. We see simUar oedema occur in the Adcinity of all inflammatory disturbances of circulation, and Ave have repeatedly described it as collateral oedema, or oedema from collateral fluxion. It readily explains the watery passages, Avhich often accom- pany peritonitis, in spite of the paralysis of the muscular coat of the intestines. 5. Fluxion to the intestinal capillaries AAdth consecutive serous transudation appears also to be the cause of diarrhoea induced by men- tal excitement. In these cases Ave must suppose that the afferent ves- sels are dilated by nervous influence, and this hypothesis has at least received some support, since Budge showed that there is constant diarrhoea after extirpation of the cceliac ganglion in rabbits. G. In most cases hyperaemia and catarrh of the intestinal mucous membrane are the results of local irritation. Most purgatives act in this Avay, for very few of them purge, by acting as concentrated solu- tions of salt, i. e., by endosmotically inducing a copious flow of liquid from the intestinal vessels into the intestines, Avithout exciting hyper- aemia. Catarrh of the intestines is caused much less frequently than Avas formerly supposed by large quantities of bile, and not very often by the presence of parasites. In this class belong the cases of intesti- nal catarrh occurring after the use of certain non-medicinal substances, such as some kinds of vegetables, but particularly those cases due to the passage of undigested and decomposing substances from the stomach into the intestines (see etiology of gastric catarrh). It is very frequently caused by the retention of fecal masses; if these remain for a length of time at any part of the intestines, they decom- pose, and form products Avhich have a very injurious and irritant influ- ence on the intestinal mucous membrane. To Virchow is due the credit of calling attention to the frequent occurrence of local peritonitis and the change of position, constriction, and twisting of the intestines dependent on it. Indeed, these are in many cases the causes of habit- ual constipation; and some chronic ailments, which in general terms are called " chronic abdominal difficulty," depend solely on distortion and constriction of the intestinal canal, on the development of gases from the decomposed faeces, or on consecutive intestinal catarrh. 542 AFFECTIONS OF THE INTESTINAL CANAL. 7. At certain times intestinal catarrhs prevail from unknoAvn causes, Avhich, Avithout our exactly understanding, are usually called genius epidemicus gastricus. Finally, it is frequently only a symptom of a general disease. In the lower animals it may always be excited by the injection of putrid substances into the veins {Stich), it always accompanies typhoid fever, and is the severest symptom in Asiatic cholera. We shall hereafter speak of these symptomatic forms, as well as of those accompanying ulceration and degeneration of the intestinal canal. Anatomical Appearances.—Catarrh rarely affects the entire intestinal canal. It is most frequent in the large intestine, less so in the ileum, and rarest in the jejunum and duodenum. . The anatomical changes left in the cadaver by acute catarrh are sometimes pale, at others dark, redness, SAvelling, relaxation, and friability of the mucous membrane, Avhich is sometimes diffuse, at others limited to the vicin- ity of the solitary glands, and of Peyer's patches, and a serous infil- tration of the submucous tissue. Occasionally, after death, the injec- tion has entirely disappeared, and the mucous membrane appears pale and bloodless. Swelling of the solitary glands and glands of Peyer is an almost constant appearance; they distinctly project above the surface of the mucous membrane. The mesenteric glands also are usually found hyperaemic and someAvhat enlarged. The contents of the intestines consist at first of plentiful serous fluid, mixed with detached epithelial and young cells, subsequently of a cloudy mucus, AA'hich is adherent to the Avail of the intestine, and contains epithelial structures. In chronic intestinal catarrh the mucous membrane looks more broAvnish-red or slate-gray; it appears puffed up, and, particularly in the rectum, forms polypoid protrusions. The enlarged follicles usually project even more distinctly than in acute catarrh, as white nodules above the surface, covered with tough, gray, or puriform mucus. Some- times, though more rarely than in chronic gastric catarrh, there is hypertrophy of the muscular coat, which may cause a constriction of the intestinal canal analogous to simple stricture of the pylorus. In some cases catarrhal inflammation has a diphtheritic character. Then superficial sloughs form on the very red mucous membrane, so that it looks as if sprinkled with bran. After the sloughs have been thrown off, shalloAV erosions, Avhich bleed readUy, are left. This anatomical appearance, Avhich is almost exclusively found at the lower part of the large intestine and in the rectum, and occurs there from a collection of hardened faeces at that place, ansAvers to the clinical pic- ture of a mild catarrhal dysentery. The severe forms of intestinal catarrh may lead to ulceration; Ave \ INTESTINAL CATARRH. 543 may have either diffuse catarrhal or follicular ulcers in the intestine. Diffuse catarrhal ulcers result from acute or still more frequently from chronic inflammation, to which an acute attack supervenes. The most frequent cause is foreign bodies in the intestine or retained faeces. Hence they most frequently occur where the contents of the intestines are most readily arrested; in the ccecum, ascending colon (typhlitis stercoralis), processus vermiformis, then in the rectum and colon, above constricted or distorted places. The dark-red and SAvollen mucous membrane softens, and is destroyed by suppuration in its tissue; the result is a loss of substance which exposes the submucous or muscular tissue. If the ulcer heal at this stage, the loss of substance is filled AAdth granulations, and a firm cicatrix remains, which almost ahvays constricts the intestine. In other cases the muscular and serous coats are also destroyed and the intestine perforated. While the destruc- tion proceeds from within outward, a partial peritonitis may occur, and cause a union Avith neighboring portions of intestine, thus preventing the escape of the contents of the bowels into -the abdomen. This course is most frequently seen in perforation of the A'ermiform append- age. Perityphlitis (a phlegmonous inflammation of the loose connec- tive tissue attaching the ccecum and ascending colon to tfie iliac fascia) occurs as frequently as peritonitis in inflammation and ulcera- tion of the ccecum, Avhich is called typhlitis stercoralis. As this may also occur independently of disease of the intestines, Ave avUI speak of it in a separate chapter. The second form of catarrhal ulceration, the follicular idcer, occurs almost exclusively in the large intestine, particularly at its loAver part. It causes great destruction, and is characterized by the slight reaction shoAvn by the mucous membrane, in the vicinity of the ulcer. Accord- ing to Rokitansky's masterly description, it comes in this way: At first the follicles are greatly swollen, surrounded by a dark-red vascu- lar ring; subsequently they ulcerate from within; the pus breaks through; there is a small, follicular abscess, AA'hich has red, spongy Avails, and a small, ulcerated, finely-fringed opening. WhUe the ulcer- ation gradually destroys the whole follicle, the hyperaemia of the adja- cent mucous membrane gradually disappears; the ulcer is then about the size of a lentil-seed, round or OA-al. The ulceration soon extends to the surrounding mucous membrane ; the round form of the ulcer is lost; large, irregular ulcerations occur, or, for a considerable distance of the intestine only, some islands and irregular projections of the membrane are preserved, Avhile elseAvhere the submucous or the mus- cular tissue is exposed. In the intestine Ave usually find a grayish- red, half-fluid, floccular substance, mixed with undigested ingesta. Symptoms and Course.—In acute intestinal catarrh, besides the 5U AFFECTIONS OF THE INTESTINAL CANAL. serous transudation, there is acceleration of the movements of the in- testines, so that the passages are not only more fluid, but they become more frequent. Diarrhoea, Avhich is often preceded by rumbfing in the intestines, is the most constant, and occasionally the only symptom of acute intestinal catarrh. Pain and other symptoms may be absent, the strength and nutrition of the patient may remain normal, if the evacuations be not too copious and long continued. In such cases the laity usually regard the diarrhoea as a favorable symptom, from Avhich they anticipate a cleansing of the body and all sorts of benefit. At first the evacuations consist of thin fecal matters (diarrhoea stercoralis). If the serous transudation and the accelerated peristaltic movement continue after all the faeces present in the bowels have been evacuated, the dejections gradually lose the peculiar fecal odor, and consist of salty transudations mixed with epithelial masses (cylindrical epithe- lium), young cells, and more or less undigested and slightly-changed ingesta (diarrhoea serosa). The color of fluid stools is usually some shade of green; this does not depend on an abnormal quantity of bile being poured into the intestines, but on the bile being evacuated Avith the fluid and the intestinal secretions, before it has undergone the normal changes. The more copious the transudations, the paler they become, because the bile, mixed with them, is insufficient to color the Avhole. There is scarcely a trace of albumen in these catarrhal evacua- tions ; but there are not unfrequently crystals of phosphate of mag- nesia and ammonia, Avhose presence Avas long considered as character- istic of typhous passages, and there is usually plenty of chloride of sodium. Generally, after the diarrfioea has lasted a day or two, or even longer, the normal transformations of the ingesta begin again; the evacuations become less frequent, and again acquire their feculent appearance and smell. A more or less obstinate constipation gener- ally folloAvs the diarrhoea. In other cases, besides the diarrhoea, there are pains in the abdomen. These are chiefly periodical attacks of griping pain or colic, during which, if the pain be severe, the patient becomes very pale and cool. These colicky pains usually subside when a discharge from the bowels has just taken place, or is about to occur. A continued feeling of pressure or soreness, and of sensitiveness to pressure, in the abdomen, is seen far more rarely than the above-mentioned attacks of pain. It is only in the rare cases, Avhere acute intestinal catarrh accompanies extensive burns of the skin, that the latter pains become very severe. This peculiarity and the presence of blood in the evacuations distin- guish this form from all others. In acute intestinal catarrh the abdomen is often someAvhat promi- nent, and quantities of badly-smelling gases escape with the passages. INTESTINAL CATARRH. 5d5 The development of gas in the intestines cannot be regarded as a symp- tom, or as the result of acute intestinal catarrh, as long as this is in the stage of moderate transudation and increased peristaltic motion; it more frequently depends on the same causes as the catarrh itself, particularly on the passage of undigested and decomposing food from the stomach into the intestines. Finally, acute intestinal catarrh is not unfrequently accompanied by fever. If it Avas caused by catching cold, it generally shoAVS the pecu- liarities of so-called catarrhal fever; in other cases the fever is more severe, and, if the stomach be affected at the same time, Ave have the symptoms of a gastric, bilious, or catarrhal fever, AA'hich Ave shall here- after describe. Acute intestinal catarrh runs the aboA'e course Avhen it affects a large portion of the intestines, or if, as is usually the case, it be located in the loAver part of the ileum and colon. Catarrh of the duodenum often accompanies catarrh of the stomach; but it can only be recog- nized Avhen it extends to the ductus choledochus, and so causes obstruc- tion of the gall-ducts and jaundice; in all other cases it modifies the symptoms of gastric catarrh too little to be recognized. Catarrh of the small intestines may run its course Avithout diar- rhoea, if the fluid contents of the small intestine remain for some time in the large intestine, and become thickened by resorption of the Avatery portions. If, Avith the symptoms of gastric catarrh, Ave have loud gurgling and rumbling in the abdomen, shoAving that there are gases and liquids moving about in the boAvels, but if the anticipated discharge do not occur, Ave are justified in supposing that the gastric catarrh has extended to the small intestines, but not to the large. There is often catarrh of the loAver part of the large intestine and of the rectum Avithout coincident disease of the other parts of the intestinal canal. When the inflammation is very seA'ere, and sIioavs a diange from the catarrhal to the diphtheritic form, the symptoms are I eculiar. Just as in dysentery, the passages are preceded by severe cuttino- pains, AA'hich spread from the navel toAvard the sacrum. Then there are spasmodic contractions of the sphincter, burning sensations at the anus, and, AA'ith severe pressure and straining, more or less Avhite and glassy mucus, often mixed AA'ith blood, is evacuated. After this there is generally relief for a while, AA'hen the pains begin again, and the scene is repeated. Occasionally masses of hard faeces are passed, and the patient is left at rest for some time. Under proper treatment, i. c., if Ave immediately remove the hardened faeces, AA'hich excite and maintain the disease, catarrhal dysentery (as this disease is propcrlv called) may be quickly cured. Improperly treated, it may be protracted, and lead to follicular ulcerations. 35 546 AFFECTIONS OF THE INTESTINAL CANAL. Finally, if the acute catarrh be confined to the rectum, there ia also a constant desire to go to stool; the passages are mucous, or bloody mucus AA'ithout any faeces; but there are none of the char- acteristic pains in the belly that precede the stools in catarrhal dys- entery. In adults, chronic intestinal catarrh rarely leads to extensive serous transudations into the bowels; in most cases the secretion from the mucous membrane is scanty and mucous. Hence, in adults, this dis- ease is rarely or only temporarily accompanied by diarrhoea; on the contrary, the patients are usually constipated. The tough mucous coating OA'er the Avail of the intestine hinders resorption, and inter- feres Avith the nutrition; patients become debilitated and emaciated, and their complexion assumes a pale or dirty-gray color. Moreover, the mucus in the intestines acts as a ferment on the other contents, in- ducing decomposition, thus setting free quantities of gas, AA'hich inflate the bowels, and cause great annoyance ; the belly becomes tense, the diaphragm is pressed upAvard, the respiration impaired; compression of the arteries causes congestion of other organs, particularly of the brain. Under such circumstances the passage of flatus is a great event for the patient, and it affords him much gratification. Besides the habitual constipation, the disturbance of the nutrition, and the flatu- lence Avith its results, there is almost ahvays great mental disturbance, like that which we have already described among the symptoms of chronic gastric catarrh. The patients either occupy themselves entire- ly with their physical state, and have no brains or time for any thing else, or they are subject to a total indifference and despair. In this connection it is Avell worth attention, that, on autopsy of lunatics and suicides, Ave often find flexions and abnormal positions of the intestines, i Avhich are the most frequent causes of chronic intestinal catarah. Oc- casionally the habitual constipation is temporarily interrupted by severe colicky pain and a diarrhoea, by which quantities of mucus and badly-smelling faeces are evacuated. As this interlude often occurs AA'ithout perceptible cause, it appears as if the decomposition of the contents of the intestines occasionally formed products Avhich Avere particularly injurious and irritating to the mucous membrane of the bowels, and increased the chronic to an acute catarrh. Chronic ca- tarrhs, running the above course, are among the most frequent, trouble- some, and obstinate of diseases. From the in efficacy of the remedies prescribed, many patients despair of medical aid, and fall into the hands of charlatans, or use Jlorrison's pUls, Leroi's herbs, StrahFs pills, or other domestic remedies. We shall hereafter shoAV that these remedies, being laxative, undoubtedly haA'e a favorable influence on the difficulties that accompany chronic intestinal catarrh, and that they INTESTINAL CATARRH. 547 OAve their reputation as universal remedies to the great frequency of this affection. Occasionally, hoAvever, chronic intestinal catarrh is accompanied by increased secretion from the mucous membrane and accelerated peri- staltic movement of the bowels, and then runs its course as chronic diarrhoea. But in adults these cases are very rare; hence, diarrhoea, lasting a Aveek or a month, must always excite the suspicion that there are more severe lesions of the intestines, and we should not consider simple catarrh as the cause of such cases till Ave have excluded other lesions. In such cases the dejections consist of quantities of glairy or puriform mucus, mixed sometimes with softened faeces, or sometimes Avith undigested food, if the catarrh be very extensive (diarrhoea lien- terica). If colorless masses of mucus or puriform fluids be passed at some times, while at others hard scybola are evacuated, Ave may decide that the loAver part of the large intestine is the seat of the disease, and that there is danger of the catarrh passing into follicular ulcera- tion. Occasionally tfie diarrhoea ceases for a feAV days, giving place to ] obstruction, and then begins again more severely. Sometimes patients i die of exhaustion from the chronic diarrhoea; bur then Ave usually find some further disease or change in the intestines. The case is quite different in the chronic intestinal catarrh of chil- dren. This almost always runs its course as an obstinate and exhaust- ing diarrhoea, and we must be careful not too hastily to diagnosticate tuberculosis of the intestines, or mesentery, or a catarrhal ulcer, from this symptom. In the intestines of most children AA'ho die of chronic diarrhoea, usually AAdth the imperfect diagnosis of "marasmus," on post-mortem examination, Ave find only the traces of a chronic catarrh, Avhich may readily escape notice. This disease most frequently occurs toAvard the end of the first year, shortly after Aveaning (diarrhoea ab- lactatorum). At first the eA'acuations are more mucous and less copious than natural, HaA'e an acid reaction, and either immediately after being passed, or after being exposed to the air for a AA'hile, they have a greenish color. This depends on the admixture of unchanged bile, and on higher oxidation of the still retained coloring matter of the (bile. Subsequently the dejections are A'ery copious, Avatery, occasion- all v clay-colored, fetid, and mixed Avith undigested food. The previ- ously healthy, Avell-nourished child is at first but little affected by this idiarrhoea, but some fatal judgment often asserts it to be a safety-valve ^hat protects the child from convulsions during teething, and that Viust not be stopped. Hence it often happens that the doctor is not 'filled tUl the chUd has become flabby and relaxed, and then it is fre- uently difficult to master tfie disease; the diarrhoea continues, the I hilcl emaciates more and more; and a large number of children die 54S AFFECTIONS OF THE INTESTINAL CANAL. durino- their second year from chronic catarrh of the intestines. In babies put out to board, chronic intestinal catarrh usually appears earlier and runs its course quicker. The mother of such a chUd, Avhich has preAdously been healthy and plump, and whose appearance was the best recommendation for the fitness of the mother as a nurse, often takes a position as wet nurse even six or eight weeks after her confine- ment. The child is given over to some old Avoman, Avho feeds him AA-ith bad milk and spoiled pap, and, to prevent his crying too much, gives him a sugar teat or crust of bread during the intervals betAveen meals. Diarrhoea soon occurs, emaciation goes on rapidly, and soon becomes extreme; fat and muscles disappear, the chUd becomes wrinkled, and looks like a little old Avoman; his flabby skin flaps about him like a loose pair of trousers ; there are excoriations about the anus, and the oral mucous membrane is covered AA'ith thrush depos- it. While the child which the nurse suckles flourishes, her OAvn child usually Avastes aAvay and dies in the third or fourth month. In large cities, Avomen AA'ho gain a living by taking children to board bury three or four, or even more, every year. Even in these cases, on autopsy, nothing is usually found but the signs of excessive wasting, and the slight remains of chronic intestinal catarrh. The latter may be consid- ered, in the diarrhoea ablactatorum, as a series of daUy returning acute catarrhs, which are daily excited by the passage of undigested and decomposed ingesta into the intestines. We shall next speak of the most frequent form of the severe ca- tarrhal inflammations that lead to ulceration of the mucous membrane, and not unfrequently of the entire wall of the intestine, viz., typhlitis, or, as it is usually called, typhlitis stercoralis. Sometimes there are premonitory symptoms, before attaining the stage of severe inflam- mation, that we call typhlitis; collections of faeces in the ccecum and as- cending colon cause repeated attacks of colic and catarrh; so that from time to time the patient complains of stomach-ache, and has alternate constipation and diarrhoea. In other cases there are no premonitions, and even the first retention of faeces in the ccecum or ascending colon leads to se\'ere inflammation and ulceration of the Avail of the intestine, When this occurs, the muscular coat loses its poAver of contraction, and there is almost as great obstruction to the advance of the contents of the intestines as there is in constriction or adhesions of the boAvels. Mucous or bloody mucous masses, the result of catarrh in the loAver portion of the rectum, are passed, but there is no proper defecation, The contents of the small intestine cannot pass doAvnward, hence arf| driven upAvard by the contractions of the intestinal muscles; there ar so-called anti-peristaltic movements. The contents of the small inte: tines entering the stomach cause severe irritation • nausea and vomitin INTESTINAL CATARRH. 549 occur; at first the food in the stomach is vomited, then green, bitter, bilious masses, and in rare cases a brownish fluid of disagreeable taste and feculent odor {Mens, miserere). From these symptoms, we may be certain that an obstruction to the progress of the contents of the intestines has occurred at some point; in the few cases Avhere the pains in the right iliac fossa are sligfit, and Avhen no tumor can be found there. Ave may be unable to determine the nature of this obstruc- tion ; but, in most cases, besides the constipation, there are se v'ere pain and a characteristic tumor, AA'hich put an end to all doubt. The pains spread over the right loAver part of the abdomen are marked by seA-ere exacerbations, Avith intervals of comparatiA'e ease, and are increased by the slightest pressure in this region, as avcII as by every motion. On palpation, Avhich the patients usually fear greatly, Ave feel a tumor, AA'hich has a sausage-like shape, and extends from the right iliac fossa toward, the loAver margin of the ribs. This tumor corresponds so exactly to the shape and position of the ccecum and ascending colon that it may be readily distinguished. Improvement begins in the above stage in favorable cases; the patient has several passages, with severe griping pains in the boAvels, large masses of badly-smelling faeces are evacuated; A'omiting subsides, the tumor decreases and dis- appears gradually, as only part of it is due to the contents of the in- testine, the rest depending on the SAvelling of the Avail of the intestine. But the disease does not ahvays take this favorable course; on the contrary, in most cases, the inflammation extends from the serous cov- ering of the ccecum and ascending colon to the peritonaeum of the neighboring intestine and abdominal Avail, and to the connective tissue uniting the ascending colon to the iliac fascia. From the extension of the peritonitis, the abdominal tenderness becomes more diffuse, the SAvelling loses its peculiar sausage shape and groAvs broader; from the perityphlitis (inflammation of the connective tissue behind the colon), there are pains in the right thigh, or a feeling of numbness; the psoas and iliacus muscles are infiltrated and cannot contract, so that the pa- tient cannot raise his thigh. In these cases, the patient usually lies on the right side Avith the body bent forward, and dreads every move- ment, for in this position the abdominal muscles are less tense, and the psoas and iliacus are most relaxed. With the above symptoms the disease has not unfrequently attained its acme, and noAv gradually im- proves. As the typhlitis disappears, the secondary inflammations cease and the exudation is gradually absorbed. In such cases, the pain in the abdomen subsides; the tumor, Avhich had been regularly advancing toAvard the median line of tfie body, again becomes smaller, and finally disappears altogether. In the same Avay the pain and feel- in"- of numbness in the right thigh pass off, the psoas and iliacus may 550 AFFECTIONS OF THE INTESTINAL CANAL. again be contracted, and the thigh again raised. In unfavorable cases, . the inflammation gradually affects the Avhole peritonaeum or the incap- sulated exudation is not absorbed, but keeps up a chronic peritonitis, and the patient succumbs to the protracted fever accompanying this I disease. Finally, the walls of incapsulated exudation may gradually ulcerate, and there may be perforation outAvardly, into neighboring parts of the intestines, or into other organs; Ave shall enter into this , more particularly when speaking of peritonitis. Bad termination of the peritonitis, particularly its rapid spread over the entire peritonaeum, should excite the suspicion that the ulceration of the ccecum has led to perforation; however, perforation is quite rare in this form, and there are very few cases where it can be certainly recognized during life. When perityphlitis results in formation of abscess and burroAving of the pus, its terminations are very varied (see Chapter VI.). Ulceration of the processus vermiformis is usually accompanied by pain in the right iliac region ; but this is usually so undecided that it is almost ahvays impossible to interpret it correctly. It is not till the j ulceration has reached the peritonaeum, or when this has been destroyed J and the above-described symptoms of partial peritonitis or those of I perityphlitis occur, that the disease can be recognized. We could not H at all determine whether the vermiform process or the caecum was the starting-point of the consecutive inflammations, Avere it not for the ab- sence of premonitory symptoms and of the obstruction and vomiting, but particularly of the characteristic tumor. If we are called to a case in a patient where there is already extensive peritonitis or formation of pus as a result of advanced perityphlitis, and Avho can give only a very incomplete history of his disease, the two affections cannot be distinguished. Although the peritonitis and perityphlitis in ulceration of the processus vermiformis are in most cases caused by its perfora- tion and escape of its contents, these diseases may nevertheless run the above-described favorable course. This is most frequently the case Avhen the perforation takes place gradually, so that the intestine be- romes attached to the surrounding parts and the rest of the peritonaeum is thus protected from injury by the escaping contents. Finally, firm | adhesions may form; the pus and escaped masses may be incapsulated ' in a dense tissue, or they may perforate outAvardly, Avhile the point of perforation in the processus vermiformis is closed by a dense cicatricial tissue, so that no further escape takes place. Severe inflammations and ulcerations of the intestines at other points than those above mentioned are much more rare ; their most frequent seats, however, are in the transverse colon and sigmoid flexure. The symptoms are similar to those of typhlitis, and consist in obstinate constipation, pain in a circumscribed spot in the abdomen, and the oc- INTESTINAL CATARRH. 551 surrence of the characteristic tumor. They A'ery rarely induce genera. peritonitis, as it is much easier to remove the collections of faeces at these points and thus arrest the inflammation. Follicular ulcers of the intestines are most frequently met in cachec- tic individuals. At first the symptoms are those of protracted catarrh of the large intestine; but Ave soon find peculiar translucent lumps, resembling sAvelled sago, in the mucous, white, and transparent masses, \A'hose passage is preceded by slight tormina, and accompanied by mod- erate tenesmus. Occasionally there are passages of faeces aa ith whitish or bloody mucus and the sago-like lumps. The mucous masses noAv become more opaque, fluid, yellowish AA'hite, and purulent, and we have the form of diarrhoea that Avas formerly called fluxus cceliacus, or diar- rhoea chylosa. In this stage, also, the passages may sometimes be of normal color and consistence. If the follicular ulcers heal, strictures almost ahvays result, and hence there are obstinate constipation, great inclination to flatulence, and the above-described symptoms of chronic catarrh. Diagnosis.—Acute intestinal catarrh, unaccompanied by fever, is not readily mistaken for other diseases. We shall hereafter speak of the diagnosis of idiopathic gastric and intestinal catarrh, occurring in the commencing stage of typhoid fever. Those cases of chronic intestinal catarrh, Avhere constipation, flatu- lence, and mental disturbance are the prominent symptoms, are often mistaken. Not long since it Avas almost universally believed that these symptoms depended mostly on disease of the large abdominal glands, particularly of the liver. The patients Avere sent to Karlsbad to be cured of their " biliousness," and, Avhen they returned improved, it Avas considered as an eAddence that the diagnosis had been correct. After accurate and unprejudiced autopsies had shoAvn that chronic abdominal derangements, as the above symptoms AA'ere characterized, Avere rarely caused by perceptible changes of the liver, spleen, or pancreas, and, on the other hand, that great degeneration of these organs, as found on autopsy, had not always been accompanied during life by severe indigestion, a neAV error crept in. Many physicians, AAdth Rademacher, considered it as proved that there are numerous diseases of the liver, spleen, and pancreas, Avhich leave no perceptible changes of structure. It is unnecessary to enter into an argument against such a hypothesis, and AA'e shall only call attention to the unheard-of method by which these diseases of the liA'er, spleen, pancreas, etc., are diagnosticated. If an affection, aa liich, according to our physiological knoAvledge, has not the most remote connection Avith any organic or functional derange- ment of these organs, is improA'ed by the use of St. Mary's thistle, nux 552 AFFECTIONS OF THE INTESTINAL CANAL. vomica, or nut-galls, Rademacher and his folloAvers consider it as a proof of the dependence of the disease on a primary affection of the or- gans in question, in spite of the fact that none of these remedies have been proved to have any specific action on these organs Avhose diseases they are said to cure. The recognition of chronic catarrh Avith obstruc- tion is facilitated, if there be at the same time a chronic gastric catarrh ; but there are cases where the gastric digestion is intact. In the latter cases, the good appetite, the comfort of the patient after eating, and the clean tongue, readily mislead us into seeking the cause of the trouble in other anomalies than in disturbances of digestion. If there be also pain in one or more circumscribed spots in the right hypochondrium, it is often difficult for the physician to make his patient believe that there is chronic intestinal disease. Just at the first flexure of the colon are most frequently found adhesions AA'ith the fiver, Avhich induce distor- tions and constrictions, and hence sensitiveness to pressure in this region rather confirms than opposes the diagnosis of chronic intestinal catarrh. The diagnosis of this form of chronic catarrh is materially assisted by the symptoms groAving worse if the patient remain consti- pated for some time. We shall hereafter ha\'e frequent occasion to speak of the diagnosis of chronic intestinal catarrh from other abdom- inal diseases,'and Avill therefore simply again call attention to the fact that it is a A'ery frequent disease, and that in making a diagnosis avc should accustom ourselves to first think of ordinary every-day diseases. If this were more commonly done, there would be feAver of those pa- tients Avho now say that no physician could aid them, and that they did not improve till they began to take Morrison's pills. Prognosis.—The prognosis of intestinal catarrh may be deduced, for the most part, from AA'hat we have said of its course. An acute case, causing copious transudation and accelerated movements of the intestines, is usually of not much importance or danger ; the diarrhoea may even prove advantageous, by removing irritant substances that have reached the intestines. Moderate intestinal catarrh may also prove beneficial at the period of dentition, in children inclined to hy- peraemia of the brain and lungs; but Ave should disabuse our patients of the belief that all patients must have diarrhoea while cutting the teeth, and that at this time Ave should never try to arrest a diarrhoea. This superstition is Avidely prevalent and very dangerous ; this is why the physician is often not sent for till the child is debilitated and emaciated, and in a very dangerous condition. Under Avell-timed and suitable treatment even the chronic diarrhoeas of children usually offer a favorable prognosis. In accordance Avith what Ave have said of its course, eA'en typhlitis and its sequelae do not often endanger life. The prognosis is Avorst in the follicular ulcers of the large intestine, par- INTESTINAL CATARRH. 553 ticularly Avhen they occur in a person already cachectic, as is usually the case. Treatment.—The causal indications can rarely be fulfilled in in- testinal catarrhs depending on congestion, as Ave can rarely succeed in remo-ving the obstruction to the flow of blood from the intestinal veins. But Ave can frequently give palliative aid in these cases by attention to the exciting causes; Avhen patients suffer from chronic intestinal ca- tarrh as a result of congestion, Ave may occasionally, particularly during exacerbations, apply a feAV leeches at the anus. Sometimes, after repeat- ing this abstraction of blood, at regular interA'als, perhaps every four Aveeks, there may subsequently be periodical loss of blood from the haemorrhoidal veins, Avhich avUI greatly relieve the patient. If acute intestinal catarrh has resulted from catching cold, the patient should be put to bed, he should drink a few cups of Avarm peppermint or camo- mile-tea, and haA'e the abdomen covered Avith Avarm cloths. Patients avIio suffer from chronic intestinal catarrh, caused by a damp, cold climate, should wear woollen stockings, and change these whenever they have cold feet. Abdominal bandages of flannel, also, are very good in such cases; where women suffer from this disease, they should Avear drawers, and in Avinter these should be made of Canton flannel or some other thick material. (In GreifsAvald, even the neediest women Avear drawers, an article of clothing AA'hich elseAA'here is only customary among women of the upper classes.) If Ave neglect this precaution, or if Ave have too much false modesty, Ave shall neglect a remedy that is often more important for the welfare of the patient than all other dietetic or medicinal prescriptions. When chronic intestinal catarrh in children is due to improper nour- ishment, the causal indications require the regulation of the diet, and attention to this will often be croAvned by brilliant success. While the diarrhoea lasts, as has already been explained, the child will rarely stand a milk diet; meat broths suit him best, but still better, finel v- shaA'ed raw beef, taken with a little white bread, and a small quantity of good Avine, such as pure Tokay or Malaga. Under this treatment, the diarrhoea, Avhich had previously Avithstood all remedies, often ceases in a short time, and the emaciated child soon recovers its appearance. Concerning the use of calomel, and other customary remedies in gas- tric and intestinal catarrh, see treatment of gastric catarrh. If the retention of hardened faeces in the colon, or any other part of the in- testines, be the cause of the catarrh, the treatment should be com- menced AA'ith a purgative. If Ave Avould treat intestinal catarrh success- fully, Ave should ourseh'es examine the passages, to see Avhether there are no hard scybola along AAdth the Hquid discharges. The rule of commencing the treatment AA'ith a laxative is particularly apphcable to 554 AFFECTIONS OF THE INTESTINAL CANAL. the catarrhal inflammation of the colon, which Ave have designated as catarrhal dysentery. In such cases, one rather large dose of oil often suffices to entirely remove, in a feAV hours, the abdominal pain, tenes- mus, and even the mucous and bloody appearance of the passages. This result is the more striking AA'hen the patient has been for days taking mucUaginous soups and opiates, and Avhen, under this treatment, the disease has gradually been groAving worse. We can only partly fulfil the causal indications in those cases, also, where tAvisting and distortion of the intestines, or constrictions, Avhich will be spoken of in the next chapter, lead to habitual constipation, and this again to intestinal catarrh; for, although Ave can remove the constipation, AA'e cannot get rid of its cause. Such patients only feel well, and can only feel well, while constantly using purgatives, and we have to exercise great care in the choice and composition of the laxatives prescribed. The rule of giving as simple a prescription as possible does not answer in those cases AA'here Ave wish to prescribe a purgative that avUI act Avell for months. Compositions of rhubarb, jalap, aloes, and colocynth answer better than either of these remedies alone; but, as patients often have copious stools, which are, at most, pulpy, not Avatery, Ave are often obliged to try for a long while before we find the proper remedy and the suitable dose. Practitioners can obtain at Berlin seA-eral packages of Strahl's domestic pUls, No. H. and III.; then the patient can try for himself how many of each he must take to produce the desired result. By careful attention to keeping the bowels regular, wonderful results are sometimes attained in this disease. Enemata alone, particularly of cold water, rarely answer the purpose, at least for a length of time, but they may be used as adjuvants. The action of laxatives is greatly facilitated by certain dietetic rules, which, how- ever, are not always expficable. Some patients find it advantageous to drink a few glasses of water, or to smoke before breakfast; others to eat bread and butter with their coffee, and most persons are bene- fited by stewed vegetables, particularly stewed prunes, Avith their dinner. Regular exercise, on foot or horseback, and other bodily move* ments, aid the treatment, but Ave should not over-estimate their value. Finally, Ave should constantly urge the patient to at least attempt to have a stool at a regular hour every day. Bretonneau and Trousseau praise belladonna as the most efficient remedy in habitual constipation, and " dyspepsia accompanied by slug- gishness of the large intestine." They give belladonna alone (pulv. belladonnae, extract belladonnae, each gr. \—gr. £), not, as some phy- sicians do, in combination Avith drastic purges. Although I cannot agree Avith all the laudations AA'hich Trousseau expends on belladonna, not having Avitnessed its " efficacite merveilleuse " in all patients with INTESTINAL CATARRH. 555 habitual constipation, I haA'e, nevertheless, been agreeably surprised by its decided effect in many cases of this affection. Some patients have assured me that, from the time they began to take the belladonna pills, they had felt like neAV beings, and, particularly Avith the last pre- scription, they had less disagreeable sensations than with the former ones. Unfortunately, I cannot at present distinguish the cases of habitual constipation Avhere belladonna is indicated from those where it is not. It is to be hoped that future observations wiU determine the cases proper for the use of this remedy, which is so excellent in some forms of habitual constipation. In typhlitis stercorafis, the causal indications also require the re- moval of the masses collected in the ccecum and ascending colon, it is true, but this is to be done with care. If the case be recent, and un- accompanied by A'omiting, Ave may give a full dose of castor-oU ( § ss— 3 j), but if vomiting has begun, and the oil administered be rejected, avc should cease the attempt of giving internal remedies to cause a passage, and, above all, Ave should not be led into the error of giving drastic purges. As long as there is an insuperable obstacle to the passage doAvnward of the contents of the intestines, all remedies that increase the movements of the bowels cause their contents to move upward, and induce vomiting. In the latter cases, the clysopompe [Davidson's (syringe] is an invaluable remedy; it cannot be replaced by a simple syringe, even if Ave give several injections in succession. We may inject as much as four pints of liquid; as pure Avater is readily absorbed in the large intestine, Ave should add to it salt, oil, mUk, or honey. Vomiting usually ceases after a moderate evacuation, or even Avhen the passage of a feAV badly-smelling, crumbly masses shoAvs that the fluid has reached the fecal collections, and has softened and set them in motion. But if there has been a free evacuation, Ave must not be misled, by the SAvelling in the coecal region, into continuing the cvacuant treatment. If the intestinal wall or the peritonaeum be ex- tensively inflamed, Ave shaU increase the pain and inflammation by con- tinuing to excite the movements of the intestines. The indications from the disease never require bleeding in acute intestinal catarrh, and even leeching may be dispensed with, except in the treatment of typhhtis. But, in the latter disease, the apphcation of 10—20 leeches in the right Iliac region, and the employment of cataplasms, to keep up the bleeding, are usually very beneficial, and the operation should be repeated if the pains recur. As Ave mentioned AA'hen speaking of cholera morbus, cold suits those cases Avhere the hyperaemia is excessive, and is accompanied by moderate transudation into the intestine, as well as in the severe forms of catarrhal enteritis, Avhich occur after extensive burns, and are accompanied by great pain. 55G AFFECTIONS OF THE INTESTINAL CANAL. The best mode of using cold is by applying cloths, Avrung out of cold Avater, to the abdomen. In the chronic forms of intestinal catarrh, par- ticularly those combined AA'ith obstruction, irritating and Avarming com- presses are suitable; among these, Preissnitz's compress is extensively used. We let the patient Avear a Avet towel, covered Avith a dry one, during the night only, or renew it several times daily. In those cases of chronic intestinal catarrh accompanied by the production of tough mucus, the same mineral Avaters are indicated as in the analogous form of gastric catarrh. The astringents, also, particularly nitrate of silver and tannin, may, by their astringent action, moderate the relaxation of the mucous membrane, decrease the hyperaemia, and so answer the indications from the disease. Besides these remedies, of AA'hich nitrate of silver, in small doses, particularly deserves trial in the chronic ca- tarrh of young children, Ave may use catechu, kino, Colombo, casca- rilla, etc.; but the circumstances AA'here any particular one of these remedies deserves the preference are still obscure, and Ave employ one Avhen we find another unserviceable. Employment of astringents, in the form of enemata, is only advisable when the catarrh affects the large intestine, as eA'en large enemata avUI not pass the ileo-ccecal valve and enter the small intestine. In follicular ulcers, Avhich par- ticularly occur in the lower part of the large intestine, enemata of nitrate of silver (gr. ij—vj to § vj), sulphate of zinc, or tannin ( 3 ss to § vj), are very useful, and are preferable to all other remedies, but, unfortunately, they are not Avell borne in all cases. In cases Avhere the diarrhoea is to be regarded as an injurious, rather than as a favorable symptom, the indications are to arrest it. It is easy to tell, in each case, when the time has come for arresting the discharges. No general rules for this can be given. We usually first attempt to attain our end by dietetic rules, by prescribing mucila- ginous drinks, oat-meal, rice, or barley-water, or give soups made of parched meal; and these prescriptions are Avorth trying. I Avill not dis- cuss the question as to whether mutton-broth, particularly Avhen fat, avUI cure diarrhoea, as is popularly believed. Besides mucilaginous drinks, slightly astringent liquids, Avhich are not exactly medicines, are usually prescribed; red wine, infusions of dried whortleberries, roasted acorns, etc. These also may prove serviceable, and are Avorthy of trial in slight cases. The astringents mentioned above, Avhen speaking of the indi- cations from the disease, may also be named among diarrhoea remedies. As we have already said, nitrate of silver is particularly serviceable in the chronic diarrhoea of children, Avhile catechu in large doses ( 3 ij to | vj of mucilage, a tablespoonful every hour or two) is often surprising- ly efficacious in the diarrhoea of adults. In proportion to the advantage from its use, acetate of lead is too dangerous a remedy to merit exten- PERFORATING DUODENAL ULCER. 557 sive employment. By far the most certain and useful remedy is opium, little as Ave positively knoAV of its manner of action. If a diarrhoea seem dangerous, and Ave Avish to check it quickly and certainly, Ave may use laudanum (3j— 3 ss to f vj of mucilage, or Aveak infusion, of ipecac. Give a tablespoonful every hour). Opium given by enema is not less sendceable than Avhen given by the mouth. Intestinal disease is only one symptom, and is not eA'en a constant symptom, in typhus fever [Professor N. divides typhus fever into exan- thematous or typhus, and abdominal or typhoid fever. This explains Avhy he does not consider the boAvel affection as by any means a con- stant symptom]; hence it is impossible to fully describe the typhous disease of the intestine Avithout depicting typhus fever. Moreover, typhous boAvel affections are the result of the specific infection, AA'hich Ave are compelled to admit in typhus. On this account, Avhen considering the infectious diseases, Ave shall speak both of typhus and the accompanying intestinal affection. The case is someAA'hat different Avith the intestinal affections in Asi- atic cholera and dysentery, induced by miasma; for, in these affections, disease of the intestines is very rarely absent, and all the symptoms of cholera and dysentery may be deduced from the bowel lesions. Hence, Ave have spoken of cholera morbus and catarrhal dysentery in the present section, and avUI treat of epidemic cholera and epidemic dys- entery in a future one, because Ave believe that, from a proper inter- pretation of the etiological causes, the latter must be regarded as infectious diseases. CHAPTER II. PERFORATING DUODENAL ULCER. The cases of perforating ulcer of the duodenum, scattered through the journals, hand-books of practice, and monographs, on the diseases of the duodenum, or of the intestine, Avere first collected by the indus- trious and meritorious labor of Erauss, and Avere so carefully analyzed that it is noAV possible to state something positive about this disease Avhich is probably not A'ery rare. Etiology.—From the great resemblance, as AveU of the anatom- ical appearances as of the symptoms, course, and results, it is more than probable that perforating duodenal ulcer is due to the same processes that cause perforating ulcer of the stomach; hence, that it is not a proper ulceration, but a necrosis, and a solution of the necrosed part of intestine by the gastric juice. It is difficult to give any thing definite concerning the frequency of duodenal ulcer, for doubtless some cases that haA'e not led to perfo- 55S AFFECTIONS OF TnE INTESTINAL CANAL. ration, and still more, some cicatrices of healed duodenal ulcers, have been overlooked at the autopsy. In one thousand post-mortem ex- aminations made at the Prague institute for pathological anatomy, Willigk found perforating duodenal ulcer only twice, whUe in seventy four cases he found either ulcers or their cicatrices. Perforating duo- denal ulcers appear to be more frequent in men than in Avomen; just the opposite of what occurs in ulcer of the stomach. It is hardly ever seen during childhood; most of the cases collected by Krauss occurred during middle age. It does not appear, from the analysis of the cases knoAvn, Avhether certain causes, particularly burns of the skin, induce this disease. Anatomical Appearances.—The most frequent seat of the ulcer is the upper horizontal portion of the duodenum; in some feAV cases it has been observed in the descending portion, and in one case in the lower horizontal portion {Krauss). Lebert says that perforating ulcers may occur in any portion of the intestinal canal. I myself haA'e seen an ulcer, with all the characteristics of simple perforating ulcer, in the upper third of the small intestine, in a public officer, aged fifty- six years. In recent cases the edges of the ulcer are sharp and not SAvollen, the loss of substance in the mucous membrane is more exten- sive than in the muscular coat, and greater in this than in the serous. Ulcers that have existed some time are surrounded by thickened edges, indurated by newly-formed connective tissue. In some cases the floor of the ulcer is formed by neighboring organs to Avhich the duodenum has become adherent before its complete perforation. The liver, pan- creas, gall-bladder, and posterior wall of the abdomen, have been ob- served as coverings of duodenal ulcers. The progress of the destruc- tion from the duodenum to the adherent gall-bladder occasionally causes a fistulous communication between the tAvo. A continuation of the destruction to the adherent abdominal Avail may lead to perfo- ration outAvardly. Occasionally this, like the perforating ulcer of the stomach, heals, Avith great retraction of the cicatricial tissue. It may thus lead to stricture of the duodenum. Finally, obfiteration of the ductus choledochus has been observed as a result of cicatricial contraction of a healing duodenal ulcer. Symptoms and Course.—When speaking of round ulcers of the stomach, Ave mentioned cases Avhere peritonitis which Avas rapidly fatal, or severe A'omiting of blood, Avas the first symptom from Avhich that seA'ere and dangerous disease could be diagnosticated. Perforating ulcer of the duodenum appears to remain latent until the fatal ter- mination, more frequently than similar ulcers of the stomach. At the same time it should not be said that the patients have been perfectly Avell until the appearance of these fatal symptoms; on the contrary, it PERFORATING DUODENAL ULCER. 550 seems that slight dyspepsia, a feefing of fulness after eating, and sen- sitiveness to pressure in the upper part of the abdomen, have preceded the perforation or the vomiting of blood for a few days; but these symptoms have remained unnoticed, or have not led to the diagnosis. In another series of cases, the symptoms were as nearly as possible those common to perforating ulcers of the stomach. The cases that have been published do not by any means prove that cardialgia and vomiting occur later in perforating ulcer of the duodenum than in the same disease of the stomach, and only in a feAV cases did it appear that the pains Avere seated rather farther to the right side. In the same Avay the analysis of published cases sIioavs that duodenal ulcer does not induce icterus more frequently, so that this symptom does not aid in the diagnosis between gastric and duodenal ulcers. The rare occurrence of icterus appears to prove that perforating ulcer of the duodenum is not accompanied by extensive catarrh any more fre- quently than ulcer of the stomach is. If the catarrh did occur, nutri- tion Avould be sooner affected from ulcer of the stomach, and obstruc- tion of the gall-ducts with resorption of bile (icterus), from ulcer of the duodenum. The sudden occurrence of peritonitis after sfight dis- turbance of digestion gh'es us no more certainty, in the diagnosis be- tween a perforating ulcer of the duodenum and one of the stomach, than does the folloAving group of symptoms, viz., feeling of pressure and fulness after eating, sensitiveness in the epigastrium^ cardialgia and A'omiting. Perforating ulcer of the stomach being far the more fre- quent, the probabilities are in its favor. Finally, a number of cases are reported, Avhere duodenal ulcers ran their course Avith periodical attacks of pain, and where, from the pain being in the right hypochondrium, from their occurrence several hours after meals, and the accompanying symptoms of dyspepsia and acidity, and occasionally from decided enlargement of the stomach, the diagnosis of duodenal ulcer could be made Avith great probability. But even in such cases Ave cannot ahvays be certain there is not a cancerous or a simple stricture of the pylorus. At the present time, I am treating tAvo patients avIio, besides having a dull pressure in the right hypochondrium, complain of an in- sufferable feeling of fulness after eating, also of a belching sometimes of pases Avithout smell or taste, sometimes of sour and rancid substances. One of these patients never vomits, the other rarely; but both appear convinced that there must be an obstruction to the exit of food from the stomach, both insist that the food escapes from the stomach more readily Avhen they remain upright for a feAV hours after eating; and, in spite of their emaciation and debility, they persist in sitting up for several hours after their meals. No tumor can be found in the hypo- chondrium ; the prominence in the epigastrium can be perceived after 560 AFFECTIONS OF THE INTESTINAL CANAL. a large meal. In both patients the disease has lasted several years. I consider it as not improbable that these patients have an ulcer or a cicatrix in the duodenum. Absence of vomiting speaks against stricture of the pylorus, but I cannot Avith certainty exclude a constriction of the duodenum or com- mencement of the jejunum caused by chronic partial peritonitis (see Chapter III.). If it be difficult to diagnosticate an open ulcer of the stomach from one that has healed and left a contracting cicatrix, it is impossible to distinguish betAveen an open duodenal ulcer and a cicatrix. The peri- tonitis caused by the perforation of a duodenal ulcer runs the same course as one depending on perforation of an ulcer of the stomach, only it appears to run its course more rapidly, perhaps from the mix- ture of bile with the contents that escape into the abdomen. For the symptoms resulting from perforation into the gall-bladder, or exter- nally, I refer to the monograph of Krauss. Treatment.—Perforating ulcers of the duodenum are to be treated in the same way as perforating ulcers of the stomach; by strict regula- tion of the diet, the use of alkaline and alkaline-saline mineral waters, particularly the Avarm springs of Karlsbad and Ems, and under some circumstances by nitrate of bismuth, and nitrate of silver. If there be severe cardialgia, narcotics are indispensable. CHAPTER III. CONTRACTIONS AND CLOSURES OE THE INTESTINAL CANAL. The varied processes which induce constriction or closure of the intestine are best treated of in the same chapter, as the greater part of the symptoms excited by them are common to all. Etiology.—1. Contraction or closure of the intestine may result from compression. The rectum is most frequently compressed either by a retroverted uterus or a pelvic tumor, such as fibroid of the uterus, ovarian cysts having an unusual location, or by tumors and abscesses starting from the pelvic bones or other tissue. Occasionally an over- filled or cancerous portion of intestine compresses the portions of in- testine lying under it; or a piece of mesentery, draAvn down by the intestine belonging to it, being in a large hernial sac, compresses por- tions of intestine lying betAveen it and the spinal column. 2. Constriction of the intestine may be caused by structural changes of the Avail of the intestine. The different forms of stricture of the boAvel come under this head. Those resulting from cicatrization of intestinal ulcers, particularly the catarrhal, follicular, or dysenteric, CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 561 are the most frequent. Cicatrization of tuberculous (scrofulous) ulcers rarely, and of typhoid ulcers never, leads to stricture of the intestine. Cicatricial strictures occur in the rectum also, after the healing of syphilitic ulcers or of Avounds. Simple stricture due to hypertrophy of the walls of the intestine is more rare than that which occurs in the oesophagus and pylorus from the same cause. Lastly, Ave must men- tion those strictures induced by neoplasia, particularly carcinoma, of which Ave shall hereafter speak. 3. The intestine may be closed by rotation on its axis; even half a rotation closes its calibre. The closure may result either from a por- tion of intestine rotating on its own axis, or from the mesentery, or part of it Avith the intestine attached to it, being twisted on itself, or from a portion of mesentery Avith its intestine being wound around another loop of intestine. A long and relaxed mesentery predisposes to the occurrence of rotation on the axis; the mechanism of this is obscure. 4. Closure of the intestine may result from internal strangulation, or incarceration. This occurs Avhen a portion of intestine enters any fissure in the abdomen, or gets behind a ligament stretched there, and thus becomes constricted. A portion of intestine may be thus stran- gulated in the foramen of WinsloAV, or in a congenital or developed fissure in the omentum or mesentery. The bands Avhich most fre- quently cause strangulation are those resulting from peritonitis; they occur betAveen the most different organs, but particularly betAveen the uterus and its surroundings. A portion of intestine may be throAvn v \ around the omentum which is drawn doAvnAvard strongly, or around the vermiform process Avhich has become adherent at its point, and may thus be constricted. 5. The intestine may be closed by one portion of intestine entering another portion; this almost always takes place from above doAvnward. This is called invagination, or intussuscep>tlon, as it consists of an in- version of the intestine into itself. When this occurs, there are three layers of intestine, one over the other; the outer one is called the sheath, or intussuscipiens; the middle and inner one are called the in- tussusceptum. The mucous surface of the external and middle layers and the serous coat of the middle and internal layers are brought in apposition. The mesentery lies betAveen the middle and internal lay- ers. As this is attached at its root, it is rendered tense by this inver- sion and hence exercises traction AA'here it is inserted into tfie intes- tine. In consequence of this one-sided traction, the invaginated portion of intestine is distorted; its opening is draAvn from the middle toward the side of the sheath, and it is elongated to a narroAV fissure. If there be quantities of intestinal contents pressing doAViiAA-ard, the invaginated 3G 562 AFFECTIONS OF THE INTESTINAL CANAL. portion is constantly driven deeper in, and the inversion becomes more complete. Intussusception is found in both the small and large intes- tine. The loAver end of the small intestine not unfrequently enters the large intestine ; and cases have been observed where the Ueo-caecal valve Avas close to, or even projected out of, the anus. Intussuscep- tions mostly occur in the course of chronic diarrhoeas ; it is most prob- able that they are caused by a portion of intestine contracting strongly, and, by elongating and moving forward at the same time, entering the non-contracted portion just below; part of the latter is drawn along and inverted with the contracted portion. New peristaltic movements force the invaginated portion of intestine farther and farther into the outer portion, until the resistance from the mesentery, or the adhesion of the parts pushed into one another, arrests the progress of the inner portion. Occasionally, particularly in the bodies of chUdren who have died of hydrocephalus, we often find one or more intussusceptions, Avhich are usually short; these have occurred during the death-agony, as is shoAvn by the absence of all signs of inflammation. They also appear to be caused by increased and unequal contraction of the intes- tines, by Avhich the contracted portions are forced into the larger. It is worthy of remark that increased movements of the intestines, which may even be perceived through the abdominal.walls, are seen just be- fore death in animals, even after paralysis of the cerebro-spinal system has occurred. 6. Finally, the intestines may be closed by extensive accumulations of hard and dry faeces, or by stony concretions consisting of hardened faeces, or precipitates of the triple phosphates and lime-salts. This form of closure may be just as complete, and the symptoms durinig lfe may be just as threatening, as in those caused by rotation of the intestine on its axis, by internal strangulation, or by invagination. Cases where fecal j vomiting and obstinate constipation were overcome by large doses of metallic mercury and similar remedies are not to be blindly taken as examples of cures of internal strangulated hernia, etc., but rather prove that retained faeces may excite the combination of symptoms, which is usually designated as ileus or miserere. Complete closure of the in- testines by masses of faeces occurs most readily at those. places where mechanical obstructions constantly oppose and retard the progress of the contents of the intestines ; hence it is more Hkely to take place abo\'e the bent portions and the adhesions, of Avhich we spoke in a previous chapter, above compressed portions, or above the various forms of stricture of the intestine. In other cases a sub-paralytic state of the intestinal muscles, or a diminution of the secretion from the in- testinal mucous membrane, appears to faA'or the collection of the ob- structing faeces. Lastly, the use of food AA'hich forms a great quantity CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 563 of hard faeces, such as vegetables, or bread containing much bran, 01 even of badly-prepared asparagus, may induce this form of obstruction of the intestines. Anatomical Appearances.—It Avould take too long to speak in detail of the different tumors that may compress the intestine. The pathological anatomy of strictures of the intestine is entered into AA'hen speaking of the different diseases that cause them. The change of position of the intestines that causes closure of the intestines has been preAdously described. Above contracted places we usually find the intestine dilated, and, as it is at the same time elongated, it is abnormally curved. The walls of these portions of intestine are usually hypertrophied, or at least thickened; the cavities are filled with gases and faeces. BeloAv the contraction the boAvel appears empty and collapsed. Where gas and faeces have rested for a time, the mucous membrane is usually in a state of chronic catarrh, Avhich, from time to time, becomes acute (see previous chapter). In closure of the intestine, its vessels, and in some cases those of the mesentery also, are compressed; in consequence of AA'hich there is great capUlary congestion, AA'hich induces decided SAvelling of the wall of the intestine, seA'ere catarrh of the intestinal mucous membrane, transudations and small haemorrhages in the serous coat. More or less extensive peritonitis usually accompanies these changes. If the pres- sure and tension of the vessels be not removed, absolute stasis occurs in the capillaries, and, in consequence of this, mortification of the wall of the intestine. In the latter case there may be a perforation, which almost ahA'ays causes death from peritonitis. In some few cases the intestine becomes adherent to the abdominal Avail before perforation, and a fecal fistula or so-called artificial anus results; these diseases belong to the domain of surgery. In intussusception the mortification of the invaginated part, and its passage through the anus, may effect a relative cure, if a firm adhesion betAveen the external and middle layers of the intussusception have previously taken place; but this place usually remains permanently constricted. This is still more apt to be the case if only the lower part of the invaginated intestine slough off AA'hile the upper part becomes firmly adherent to the sheath, so that at this point the intestinal Avail shall permanently consist of several superimposed layers. Symptoms and Course.—The most important symptom of con- striction of the intestine is difficult and tedious defecation. But, as many persons suffer from sluggish boAvels Avithout any mechanical ob- stacle impeding the progress of the contents of their bowels, it does not appear improper to insert here some remarks on " habitual con- stipation." 564 AFFECTIONS OF THE INTESTINAL CANAL. Henoch, AA'ho, in his clinic of abdominal diseases, treats very ex- haustively of habitual constipation, and gives a very lifelike and accu- rate account of the inconvenience to AA'hich it leads, says very truly that " suffering from constipation " is a very relative term. Some persons habitually only have a passage every second or third day, and still feel very well, or feel Avorse Avhen they have more; on the other hand, others feel sick if they do not have one or tAvo stools daily. The cause of this difference depends partly on the fact that the former form but little faeces, as they eat food containing but little indigestible ma- terial, and as they perfectly assimilate the digestible part of the food; Avhile the latter haA'e a quantity of faeces, because their food contains much indigestible material, or because their power of digestion is im- paired. But even persons eating similar food and digesting equally Avell show the same difference in the number of evacuations required to keep them feeling well. It is difficult to give a satisfactory explana- tion of these symptoms, but in most cases they seem to depend on the fact that in some persons the irritation of the mucous membrane, by the retained faeces and the products of decomposition, leads to intestinal catarrh, while in other less susceptible persons the intestine remains healthy. In the latter cases only small amounts of gases form from the faeces contained in the intestines, the abdomen does not become tense, and the diaphragm is not pressed upward, even AA'hen the person has no passage for tAvo or three days or more. In the former cases the mucus covering the walls of the intestine acts on the contents of the boAvels as a ferment, and by their rapid decomposition quan- tities of gas are formed; the abdomen is puffed up, and, even after a short retention of faeces, we have the inconvenience described in a pre- vious chapter. To this description Ave have to add a few symptoms that depend more directly on collection of faeces in the loAver portions of the bowels, particularly in the flexure of the colon and in the rectum. Occasionally patients have an "unsatisfactory feeling," as Henoch aptly calls it, after stool; they feel as if there were still masses in the intestines, Avliich should have been passed. This feeling alone gives them great discomfort, and puts them in a disagreeable frame of mind. But, besides this, there are often symptoms resulting from the pressure of the full intestines on the neighboring blood-vessels and nerves. Pressure on the iliac veins rarely causes oedema of the feet; but patients with habitual constipation usually suffer from cold feet, a very annoying symptom, Avhich is most readily explained by the impeded returti of the blood from the feet. Dilatation of tne vessels in the walls of the rectum most frequently result from pressure on the hypo- gastric, veins, and occasionally there are ruptures of these dilated ves- sels. The significance of these A-aricose vessels and the haemorrhages CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 565 (blind and bleeding piles) is oveivalued by the laity, who usually regard them as the cause and not as the result of their trouble. In the same Avay the escape of blood from the pudic veins, or, in women, from the uterine veins, may be impeded. In consequence of this, in most Avomen avIio are habitually constipated, there is hyperaemia of the uterus, which shoAvs itself by very abundant menstruation and uterine catarrh, and which subsequently often leads to important disorders of nutrition of the uterus. Thus Ave see that the notorious Morrison's pUls may not incorrectly be said to benefit menstrual difficulties and fluor albus. Men Avith habitual constipation may have frequent erec- tions and seminal emissions, induced by the impeded escape of blood from the pudic veins ; if they Avere previously Avorried about their feel- ings, they are absolutely frightened by this symptom. Lastly, the pressure of the loaded intestines on the sacral plexus may cause neu- ralgic pains in the legs, or, Avhat is more frequent, a feeling of numbness. The causes of habitual constipation, which does not depend on curva- tures and adhesions of the intestines, or on the various forms of con- striction, are rather obscure. The disease occurs more frequently in women than in men, and not unfrequently develops in groAving chil- dren. A sIoav movement of the intestine appears most frequently to induce it; but there is scarcely any explanation of this sluggishness of the intestinal muscles. The bad habit, of repeatedly restraining the fasces forcibly, induces habitual constipation in some cases. " Sedentary habits," also, such as are common to students and persons of certain occupations, are HkeAvise properly classed among the exciting causes of this affection. Still it is remarkable that perseveringly Avalking does not, by any means, render defecation as easy as might be ex- pected. Patients with habitual constipation usually become indefat- igable Avalkers, Avithout thereby attaining the goal Avhich is often the object of their whole desire and endeavor {Henoch). In some cases, the habitual constipation is due to chronic intestinal catarrh, Avhich, like chronic gastric catarrh, as Ave have shoAvn, induces a sub-paralytic state of the intestinal muscles, in spite of the thickening of the Avails of the intestines that it causes. Hence people Avho have led a luxu- rious life often suffer from habitual constipation. We often meet per- sons who, at the university, Avere great beer-drinkers, and were most jovial and popular felloAvs, Avho, a feAV years later, have become ill- tempered and peevish, and haA'e no thoughts beyond whether they " avUI have the longed-for passage to-day." Recently, inactivity of the abdominal muscles has been classed among the causes of habitual con- stipation, and cases have been described Avhere the patients accustomed the abdominal muscles to exercise, and Avere thus cured of their consti- pation. The excessiAC stretching and relaxation of the abdomen re- 566 AFFECTIONS OF THE INTESTINAL CANAL. tnaining after frequent pregnancies, particularly after tAvins, appear to me much more injurious than the diminished activity of the abdominal muscles. Such women, upon whose abdomen it seems cruel to press, from a feeling that Ave should break through the walls, almost always suffer from habitual constipation, and they cannot strain much; and in these same women there is always abdominal plethora and chronic intestinal catarrh, Avhich alone would sufficiently explain the retarded defecation. (We may readily understand that, under these circum- stances, a dilatation of the blood-vessels in the abdomen can easUy occur; when we consider that, normally, they are subjected not only to the pressure of the atmosphere, but to that caused by the tension of the abdominal Avails, and consequently, when the latter are relaxed, they are deprived of one important aid to the preservation of their normal condition.) As habitual constipation, then, has so many causes, that its presence alone does not justify the diagnosis of stricture of the intestine, the question arises, Hoav shall we recognize such a cause of constipation ? The observation of the faeces may aid us here. In the ordinary forms of constipation, sausage-shaped faeces, of extraordinary size, are often passed; in stricture of the intestine, on the contrary, particularly when seated at the lower part of the intestine, they often have a very small calibre, and consist of small rolls, scarcely as thick as the finger, or of small round masses, like sheep's dung. Important as this symptom is for the diagnosis of stricture of the intestine, Ave must still remember that it may also occur after long starvation, particularly after long-con tinued disease. The empty intestine, AA'hich is tightly contracted at such times, appears to expand only gradually to its former cafibre. Even spasmodic contractions of the sphincter occasionally cause this form of faeces. Hence, before we can diagnosticate stricture of the in- testines from this symptom, the above states must be excluded. The history may give another aid in diagnosis. We have already explained that cicatricial contraction is the most frequent cause of stricture. Hence, if habitual constipation and a peculiar form of the faeces occur after a long attack of dysentery, or after diarrhoeas which seemed to depend on ulcers of the intestine, the presumption is in favOr of stric- ture. In the same Avay, in other cases, AA'e may suspect, from the his- tory, that there is a retroversion of the uterus, or some kind of tumor in the pelvis, which is compressing the intestine. In forming a diag- nosis, we should also avail ourselves of physical examination. Promi- nence of the abdomen at any part, and a remarkably full percussion- sound at this point, if found at repeated examinations, show that part of the intestine, above a constricted portion, is dilated. Finally, when we suspect stricture of the intestine, Ave should never neglect to ex- CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 507 inline the rectum Avith the finger. If we can reach no stricture with the finger, we should use an elastic catheter. We may be deceived by the catheter striking against the promontory of the sacrum, or by a fold in the Avail of the intestine, preA'enting the further entrance of the instrument. Spasmodic contractions of the rectum may also deceive unaccustomed observers. In Avomen it is just as important to make a vaginal examination, to satisfy ourselves about the position, size, and form of the uterus, and find if there be any tumors in the pel Ads. The symptoms of closure of the intestines, which subsequently be- come terrible, and A'ery dangerous, are often slight, and apparently free from danger at the outset. The patients feel puffed up, have colic, periodically appearing and disappearing, think they have made some error in diet, and take some camomile-tea, or a slight laxative. The physician is not usually called till these remedies fail, and, in spite of them, the pains increase, and the bowels do not move, or AA'hen nausea and vomiting occur. A careful and experienced physician ahvays con- siders this combination of symptoms as disagreeable and threatening. The first thing to do is carefully, wdthout over-modesty or forbearance, to examine those parts of the body where hernia may occur. Woe to him Avho trusts that the patient avUI, unquestioned, tell him he has a rupture, or Avho rests contented aa ith his simple denial of the question! The rectum and vagina should be explored just as carefully as the in- guinal regions, to find if there be any obstructions to the eA'acuation of the boAAels. In spite of the anxiety that the case causes him, the physician, of course, hopes, at this time, that the symptoms are excited by a retention of faeces, someAA'hat obstinate, perhaps, but one which may, nevertheless, be overcome. He prescribes enemata, and large doses of castor-oil, Avith the addition of a little croton-oil. After a feAV hours he returns, uncalled for, to the bedside of the patient, for the purpose of satisfying his oaati anxiety. Meanwhile, the enemata have occasionally brought aAvay a little faeces from the loAver part of the in- testine, but, in most cases, they have had no effect, or it has been im- possible to give the patient an enema. In spite of the addition of croton-oil, the castor-oil has remained ineffectual; after taking it, the patient has had great pain, and frequently vomited green masses. At the same time, his appearance has changed; his face is distorted and pale, the skin, particularly on the hands, is cool, the pulse small. Noav the sorroAvful conclusion becomes more and more certain, that the in- testine is closed, and, perhaps, is so obstructed that medical aid can give no relief. The abdomen gradually becomes more prominent; there are severe, straining, bearing-doAvn pains, Avhich the patient calls cramps. These paroxysms of pain are usually folloAved by nausea, and, to the terror of the patient and those around him, the vomited masses 568 AFFECTIONS OF THE INTESTINAL CANAL. constantly become broAvner and more discolored, and the smell more distinctly feculent. There has been much dispute as to Avhether ster- coraceous vomiting could result from obstruction of the small intestine, or if it could only occur in closure of the large intestine, Avhere the formation of the faeces proper begins. We should bear in mind that even the contents of the ileum, particularly if they haA'e been there long, may have a feculent odor, and that in so-called fecal vomiting actual faeces are rarely, if ever, vomited. I consider it improbable that the contents of the large intestine should pass the ileo-ccecal valve, and enter the small intestine and stomach. There are various vieAvs, even, concerning the origin of retrograde movements of the contents of the intestine. Betz not only denies all influence of the contractions of the intestines on the backAvard movement of the contents, but he even believes that they rather impede than aid the normal progress of the contents from the stomach toward the rectum. In the act of vomiting, abdominal pressure unmistakably plays the chief part; it is this, aided by Jhe above-mentioned contraction of the pyloric portion of the stomach, Avhich evacuates its contents. The contents of the in- testines appear to enter the stomach, because, during the contraction of the intestines, the masses cannot pass downward, and are driven upAvard. We will not discuss the question as to whether this occurs regularly, or Avhether the contraction of one portion of intestine imme- diately follows the contraction of the portion just below it—that is, whether there be an actual antiperistaltic motion. At all events, it is evident that, as long as the obstruction exists, all drastics, by increasing the contraction of the intestines, must induce vomiting. In some cases the disease runs along for eight to fourteen days, or longer, with these symptoms, which may even temporarily remit. During the attacks of pain Avhich usually precede the vomiting, according to Watson's graphic description, Ave may feel or see in the abdomen " immense coils of in- testine, as big, perhaps, as one's arm, rise and roll OA'er, like some huge snake, with loud roarings and flatulence. The distended bowel strives with all its power, but strives in vain, to overcome the opposing bar- rier." The patient, now fearfully disfigured, has a ghostly look, a dirty color, his face is covered with cold SAveat, his hands cool, his pulse im- perceptible, Avhile the mind remains long unclouded; finally, he dies exhausted, Avith the symptoms of general paralysis. The picture is someAvhat different when extensive peritonitis occurs early in the obstruction. Then the abdomen is puffed up much sooner; it becomes excessively tense, and so painful that even the slightest pressure is not borne. As the exudation occurs almost exclusively be- tAveen the inflated intestines, it can rarely be recognized by the dull percussion-sound at the dependent parts of the abdomen. The patients CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 569 do not toss around on the bed, like those above described, but lie still on their back, carefully avoiding all movement, because it increases their pain. The pulse is very frequent, the temperature very high; the diaphragm, pressed upAvard, compresses the lungs, and the respira- tion is hastened; the obstructed Aoav of blood from the right side of the heart gives the patient a cyanotic look. In comparison Avith the symptoms above mentioned, Avhich even iioav continue, those of peri- tonitis are so prominent that the former are not sufficiently noticed, and, Avhile the peritonitis is recognized, the internal strangulation, or other obstruction of the intestine causing it, escapes observation. We should make it a rule to consider " rheumatic peritonitis " a very rare disease, and, Avhen peritonitis occurs in a non-puerperal patient, to think of perforation, particularly of perforation of the stomach by an ulcer, or of acute obstruction of the intestine. If the disease has occurred quite suddenly, and is not accompanied by vomiting, the chances are in favor of perforation. If it has come on gradually, and there Avas vomiting at the very first, Avhich continues obstinately, or if fecal vomiting occurs, there is, most probably, obstruction of the intestine. In the latter case, the course is usually much more rapid; even after a feAV days, there is usually great collapse, general paralysis, and almost ahvays a fatal termination. During life it can hardly be said, in any case, Avhether the group of symptoms that Ave have described depends on a rotation, internal strangulation, intussusception, or an obstruction of the intestine by hardened faeces or stony concretions. We have the least certainty in diagnosticating rotation of the intestine on its axis. The suspicion of internal strangulation is someAvhat supported, if the patient has had a previous attack of peritonitis, as the bands, which are the most fre- quent cause of the strangulation, are almost ahvays remains of former peritonitis. Intussusception occasionally sIioavs peculiarities of symp- toms by Avhich it may readily be distinguished from other forms of ob- struction of the intestine. Among these is a sausage-shaped tumor, usually of only moderate resistance, Avhich may sometimes be felt in the abdomen, particularly Avhen the Avails are not very tense. This tumor cannot be moved much; it is painful, and, on percussion, gives a sound not quite dull. In intussusception, moreover, the calibre of the intestine is often not closed so completely as in other forms, so that, occasionally, small quantities of faeces, or intestinal gases, are evacu- ated. Moreover, from the compression of the veins of the mesentery, Avhich is likeAvise invaginated, there is great congestion of the invagi- nated portion of intestine, Avhich may readily induce rupture of vessels in the mucous membrane, and bloody or bloody-mucous passages. This symptom is peculiarly important in the diagnosis of intussusception in 570 AFFECTIONS OF THE INTESTINAL CANAL. small children, in Avhom the disease occurs, proportionately, very often. (In these cases the ccecum and ascending colon are almost ahvays in- verted into the lower part of the large intestine, and into the rectum; the constipation is not ahvays absolute; vomiting rarely becomes fecal, and the puffing up of the abdomen is usually moderate as peritonitis is rare. On the other hand, the bloody or bloody-mucous dejections are rarely absent.) The diagnosis of intussusception is beyond doubt, Avhen, from the rectum, Ave can feel the sfit-shaped mouth of the in- vaginated portion of intestine, AA'hich is usually turned toward the wall of the rectum, or, if this sloughs off, and is evacuated, somewhat mor- tified, but still recognizable. Obstruction of the bowels by hard fecal masses is readily recognized when these can be felt in the rectum. In other cases, a hard movable tumor in the abdomen leaves little doubt that it is formed of hard fecal masses or stony concretions, and that these obstruct the intestines. If the patient has previously suffered from the symptoms of constriction of the intestines, and if these have suddenly increased to those of absolute obstruction, according to what was above said, it is probable that the sudden obstruction has been in- duced by hard masses of faeces. Above all, the favorable course of the disease, the sudden disappearance of the symptoms after the passages of a quantity of faeces, speaks in favor of the latter variety of ob- struction. The diagnosis and prognosis of obstruction of the intestine are evident from Avhat Ave have said of the symptoms and course of the disease. Treatment.—The treatment of habitual constipation has been as fully discussed as the plan of this Avork alloAvs, AA'hen speaking of the causal indications, in the previous chapter; a discussion of the advan- tages of and objections to individual laxatives does not come Avithin its scope. I have no personal experience of the result of the SAvedish movement-cure in habitual constipation. Electricity, which has also been recommended, comes under the head of gymnastics; contractions of the abdominal muscles may be caused by applying the electrodes to the skin of the; abdomen, and they may be strengthened by repeated appfications. Application of the electrodes to the abdomen has no effect on the movements of the intestines themselves. The proposal to place one electrode in the mouth, the other in the anus, must be regarded as very naive. If stricture of the intestine be located in the rectum, the treatment consists in the removal of tumors, or dilatation of strictures, and, where these procedures AAdll not answer, in the formation of an artificial anus; hence it belongs to surgery. Contractions of the intestine higher up can never be radically cured. We haA'e to limit ourselves to placing CONTRACTIONS AND CLOSURES OF THE INTESTINAL CANAL. 571 the patient on a diet AA'hich avUI leave as Httle faeces as possible. The more threatening the symptoms of the constriction, the more necessary it becomes that the patient should live on eggs, strong broths, and pure muscular meat, Avith delicate fibre. At the same time, Ave must secure regular evacuations by enemata and laxatives. Those cases of obstruction of the intestine that are caused by hard- ened faeces and stony concretions are far more amenable to treatment than those caused by changed position of the intestines. This is par- ticularly true of the obstructions of the rectum by faeces, which are often collected in astonishing masses above the sphincter. A prudish physician, avIio does not venture to ask for a local examination, aauII prescribe laxative after laxative for days, in such cases, Avithout any benefit; while a physician who has no false modesty, and takes no refusal AA'hen it is a question of knowing the disease more thoroughly, obtains Avonderful results. It often requires great pains and untiring patience to make a passage Avith the finger, the handle of a spoon, or corn-tongs, for enemata which, at first, Avould not enter, and to pass an elastic tube through these masses, and give softening enemata. The task becomes more difficult if the hardened faeces be higher up. We may here refer to Avhat Ave said of the removal of impacted faeces Avhen speaking of the treatment of typhlitis stercoralis. At first we attempt to induce a passage by a feAV spoonfuls of castor-oU, or by large doses of calomel; to each dose of the former Ave may add half a drop of croton-oil. If these remedies prove ineffectual, and increase the vomit- ing, Ave should confine ourseh'es to the use of the clysopompe [Davi- son's syringe], which certainly offers the most chance of softening the hard masses AA'hich are usually in the large intestine. We must not be discouraged if the first injection does not produce an effect, but must repeat it tAvo or three times daily. In one case that I have seen, it Avas not till after four days' assiduous use of the pump that small, friable, greatly-discolored masses of faeces, Avhich had a horrible odor, were mixed AA'ith the fluid injected. And not till the folloAving day were there large quantities of similar appearance. In desperate cases we may use pure quicksilver; from a few ounces to a pound or more of this article may be swallowed. It cannot be denied that, in some cases, AA'here all other remedies failed, the Aveight of the mercury broke through the obstruction. Rotations and internal strangulations can rarely be diagnosticated Avith sufficient certainty to justify gastrotomy, Avhich, to be successful, should be performed as early as possible. It is not impossible that quicksUver may, by its Aveight, remove a rota- tion of the mtestine, or cause the reposition of a strangulated part by the traction that it exercises on it before reaching it; hoAvever, there is some doubt about the diagnosis of the cases Avhere this result is said 572 AFFECTIONS OF THE INTESTINAL CANAL. to have been attained. Since, in intussusception, the inversion of the intestine almost invariably takes place from above doAvnAvard, there is a contraindication to tfie exhibition of laxatives, AA'hich Avould force the invaginated portion still deeper into the sheath. This is still more true of quicksilver. When the intussusception has been recognized early, avc may perform gastrotomy, as has been successfully done in some cases. If Ave can reach the invaginated intestine through the rectum, Ave should attempt to replace it by carefully introducing an oesophageal bougie that has a sponge fastened to its end. This pro- cedure has been particularly successful in some cases in children. If we cannot reach the invaginated part, we may inject large quantities of liquid, or bloAV air into the rectum with an air-bag, so as to press back the invaginated portion, if possible. As soon as seA'ere perito- nitis has occurred, these procedures can be of no use, but may do harm, as the portions of intestine have become glued together. Then Ave should confine ourselves to large doses of opium, and to covering the abdomen AA'ith cold compresses. The same treatment should be fol- loAved AA'here the symptoms of extensive peritonitis occur Avith other forms of obstruction of the intestine. CHAPTER IV. SCROFULOUS AND TUBERCULOUS DISEASES OF THE INTESTINES AND MESENTERIC GLANDS. Etiology.—Tuberculosis of the intestine and mesenteric glands is not, by any means, so frequent as is taught; many so-called tubercu- lous diseases of these parts are not at all due to the formation of mili- ary tubercle, the only form of tubercle that Ave recognize, but to a cheesy degeneration of the intestinal follicles and mesenteric glands. The solitary glands, and glands of Peyer of the mtestine, which are known not to be secretory organs, but elementary lymphatics, are sympathetically affected in the different diseases of the intestinal mu- cous membrane. In acute and chronic catarrhs of the intestine they are ahvays found more or less SAvelled, and projecting above the surround- ing parts. This swelHng of the follicle, Avhich depends partly on the increase of cellular elements, and still more on increased absorption of fluid, usually disappears Avithout leaving a trace, on the subsidence of the catarrh. But, under some circumstances, it becomes more decided and obstinate; the cellular hyperplasia particularly attains a high grade, and then, as occurs elseAvhere, when there is an extensive collec- tion of cellular elements, atrophy, or an incomplete metamorphosis into fat (cheesy degeneration), readily occurs. The mesenteric glands that SCROFULOUS DISEASE OF THE MESENTERIC GLANDS. 573 derive their lymph from the intestinal mucous membrane usually par- ticipate in its diseases, just as the small lymphatics located in the walls of the intestine itself do. In acute and chronic catarrh of the intestine and cellular hyperplasia, the increased absorption of fluid causes them also to SAvell, but this SAvelling is usually slight and temporary; but, under some circumstances, it becomes more decided and obstinate, and as, in such cases, there is also a large collection of cellular elements in the mesenteric glands, they readily undergo cheesy degeneration. The caseously degenerated intestinal follicles deliquesce after a time, and form small abscesses, filled AA'ith cheesy pus, in the walls of the intestine ; when the coA'ering of these is perforated small ulcers are left, which may subsequently enlarge by the continuation of the cell-production and the disintegration. In the caseously degenerated mesenteric glands, deliquescence and perforation of the capsule of the gland and of the peritonaeum are more rare ; but, on the other hand, condensation and final transformation of tfie cheesy mass to a chalky pulp, or to a hard chalky concrement, are A'ery frequent. If avc more attentively regard the persons in Avhom decided and obstinate SAvelling and cheesy degeneration of the intestinal follicles and mesenteric glands particularly occur, Ave find that the larger part of them are children, and especially those children in Avhom the periph- eral lymphatic glands and the bronchial glands incline to SAvell and undergo cheesy degeneration during the course of moist exanthe- mata, otorrhoea, bronchial catarrh, etc., and which are usually called scrofulous. This circumstance and the entire correspondence of the pathological changes render it consistent to designate this SAvelling and degeneration of tfie intestinal follicles and mesenteric glands and intestinal ulcers, consequent upon the former, as scrofulous diseases of the Intestines and mesenteric glands. The Avide-spread error, that scrofulous ulcers of the intestines are due to tuberculosis, is easily explained : firstly, the caseously infiltrated solitary glands have the greatest similarity to cheesy miliary tubercles; and, secondly, on post-mortem examinations, Ave often find miliary tu- bercles in the portion of peritonaeum corresponding to the ulcers of the intestine. But, if Ave examine these free from prejudice, and then ask ourselves AA'hen the ulcers and Avhen the tubercles probably occurred, Ave shall often come to the conclusion that the ulcers have existed for a long AA'hile, perhaps for years, AA'hile the tubercles have been depos- ited shortly before death. Hence it is just the same in the intestines as in the lungs, Avhere tubercles are finally added to cheesy infiltra- tions and caAdties. As avc haA'e preA'iously explained at length, in some persons the 571: AFFECTIONS OF THE INTESTINAL CANAL. excessive susceptibility and the tendency of the tissues to become the seat of extensive production of indifferent cells, on inflammatory irrita- tion, last beyond the age of childhood. But, as in groAvn persons dif- ferent organs are apt to be diseased from those affected in children, the peculiar forms of the disease vary Avith advancing age. EA-en at the commencement of puberty, the intestinal catarrhs which Avere previously so frequent give way to affections of the lungs, etc. Hence, in many autopsies we find calcareous mesenteric glands and cicatrizing intestinal ulcers, Avhile in the lungs there are fresh cheesy masses and progressing destruction. But, very remarkably and inexplicably, ex- perience shows that adults, AA'ho are rarely affected by these diseases of the intestinal follicles and mesenteric glands, are often afflicted by them when analogous diseases attack or have already affected their lungs. We may express this bit of experience in another Avay, by saying: caseous degeneration of the intestinal follicles and mesenteric glands is rare as a primary and idiopathic disease in adults, but occurs quite frequently secondarily, and as a complication of consumption of the lungs. Except as a secondary tuberculous eruption in the vicinity of scrof- ulous ulcers of the intestines, tuberculosis of the intestines and mesen- teric glands is rare. This is still more true of tuberculosis of the in- testines, in the strict sense. It appears in many cases as if the sec- ondary tuberculosis of the intestines occurred simultaneously Avith sec- ondary tuberculosis of the lungs, and as if the proper tuberculous con- sumption of the intestine affected particularly those Avho had also the tuberculous form of consumption of the lungs. Anatomical Appearances.—Caseously infiltrated intestinal folli- cles and the ulcers resulting from their breaking down are most fre- quently found in the ileum. Not unfrequently the disease extends thence to the colon, and remarkably often to the processus vermiformis. In some cases the colon alone is affected, Avhile the ileum remains free. These appearances are rarely found in the jejunum, and very seldom in the duodenum or stomach. The number of follicles affected varies. Occasionally a considerable extent of intestine is regularly covered Avith them; far more frequently the disease is Hmited to several small spots at some distance apart. In the earliest stage the swollen fol- licles form slightly-prominent, rather hard gray nodules, about the size of a millet-seed. These become yellow and less hard as the cheesy metamorphosis commences. If the mucous covering have been perforated by the pus, we find round " crater-shaped" ulcers {Roki- tansky's primitive tuberculous ulcer). In advanced stages the mucous membrane and submucous tissue in the vicinity of the primitive ulcer are the seat of a gray and subsequently of a yellow infiltration. Ex- SCROFULOUS DISEASE OF THE MESENTERIC GLANDS. 575 tensive losses of substance result from the breaking doAvn of the cheesy infiltration and of the infiltrated tissue itself, and the union of several primitive ulcers {Roklteinsky's secondary tuberculous ulcer). The ulcer extends particularly in the circumference of the intestine, so that finally the ulcers form bands of various Avidth around the interior of the boAvel. Infiltration and destruction sometimes go on in the floor of the ulcer, so that it extends in depth also, and may finally perforate the Avail of the intestine. As the destruction advances toAvard the serous coat, a circumscribed peritonitis occurs at the part about to be attacked. Even on external examination of the intestine Ave can usually tell the points Avhere the ulcers are located, as the serous coat is there cloudy and thickened, and occasionally covered Avith scanty fibrinous exudations, or attached by these to neighboring loops of intestines. These adhesions of portions of intestine to each other not unfrequently prevent the escape of the contents of the intes- tine into the abdominal caAdty Avhen perforation of the intestine takes place. In such cases the contents do not gush out through the perfo- ration till avc break up the adhesions at the autopsy. If capillary haemorrhage have occurred from the extension of the ulcer, Ave find the edges and base of the ulcer suffused Avith blood and covered Avith dark clots. Complete cure of these ulcers of the intestine is rarely seen. On the other hand, we often find undoubted signs of incomplete cica- trization as a callous, darkly-pigmented or non-pigmented connectiA'e tissue forms the floor of the ulcer, and by its retraction appears to have approximated the edges. If the edges of the ulcer approach each other so nearly as to come in contact, they unite together. In such cases a ridge-shaped resistant SAvelling ahvays remains on the inner surface, Avhile there is a cicatricial retraction on the outer surface of the intestine. The SAvelling of the mesenteric glands may be so decided that the indhddual glands will attain the size of a pigeon's egg, and a collec- tion of them may form a tumor as large as the fist. As long as the increase in size depends on simple cellular hyperplasia, a section will shoAV the glands to be succulent and of a grayish-red color. We often find only a feAV points of the SAVoUen glands changed to a yelloAV cheesy mass ; in other cases, one or more glands are caseously degen- erated throughout. On post-mortem examination Ave frequently find chalky, irregular, sometimes branched, concretions, surrounded by nor- mal or atrophied parenchyma in these mesenteric glands, as a result of cheesy degeneration Avhich may have run its course years before. In genuine tuberculosis of the intestinal mucous membrane, small gray nodules, either discrete or united into groups, appear in the early stao-cs. If Ave find such groups of miliary bodies at parts AA'here there 576 AFFECTIONS OF THE INTESTINAL CANAL. are no Peyer's glands, it gives the best means of making the very difficult diagnosis between miliary tubercles and SAvelled follicles. Tuberculous ulcers result from the cheesy degeneration, softening, and breaking doAvn of miliary tubercle; these never become so extensive as the ulcerations dependent on caseous degeneration of the follicles, and in their vicinity Ave find fresh tuberculous granulations, instead of cheesy infiltration of the tissue. In the numerous cases of secondary tuberculosis of the peritonaeum, we find those portions corresponding to the intestinal ulcer thickened by proliferation of connective tissue, and covered AA'ith numerous small nodules. The eruption of tubercles has often spread from these points along the lymphatics to the mesentery. Symptoms and Course.—It is generally difficult to decide AA'hether a scrofulous child has simple intestinal catarrh, or if there be cheesy degeneration of the intestinal follicles and ulceration of the intestine. The case is suspicious Avhen the passages are preceded by pain, when the abdomen is sensitive to pressure, and particularly when these symp- toms are accompanied by a lingering fever. Not unfrequently the diarrhoea disappears for a time, although the intestinal ulcers may remain; the child appears to improve; but some slight error in diet, catching cold, or some other undiscoverable cause, again induces fre- quent, copious, fluid evacuations. If these renewals of the intestinal affection be accompanied by an increase of the fever, the child soon loses again AA'hat strength and flesh he had gained during the interval. Occasionally this variation from good to bad continues for years, and, eA'en Avhen the diarrhoea has ceased for months, Ave are not at aU cer- tain that the ulcers have healed. On autopsy Ave often find the mu- cous membrane of the small and even of the large intestine covered AA'ith numerous ulcers, Avhen, perhaps, there has been constipation instead of diarrhoea. This is not strange, when we remember that the thinness of the dejections depends solely on the catarrh accompanying the intestinal ulcers, and that the severity of the catarrh varies just as much as the hyperaemia and oedema in the Adcinity of a cutaneous ulcer. When the large intestine is free from ulcers and consequently from catarrh, the fluid contents of the intestines entering them become of normal consistence, so that consistent stools are passed during life, and on autopsy Ave find the loAver part of the intestine filled Avith firm faeces. The longer the disease lasts, the more nutrition is affected by it. The patients are often considered much younger than they really are. Young men of tAventy look like boys; girls attain the age of nineteen or tAventy Avithout the breasts developing or the menses appearing. Frequently, Ave do not discover the cause of this retarded development, till, on careful examination, Ave find that for years they SCROFULOUS DISEASE OF THE MESENTERIC GLANDS. 577 have had repeated attacks of diarrhoea accompanied by fever. Death as a result of scrofulous ulcers of the intestine is far rarer than we might suppose. It most frequently depends on a subsequent consump- tion of the lungs, or a secondary tuberculosis. If obstinate diarrhoea join itself to the symptoms of consumption of the lungs, or if it occur as the chest symptoms begk:, it is very probable that the intestinal follicles are caseously degenerated, and that ulcers have developed. Even in such cases the diagnosis is not certain, for so-called colliquative diarrhoea occurs during disease of the kidney and consumption of the lungs, without our being able to find any evident structural changes of the intestine on autopsy. Perhaps these diarrhoeas are the analogues of the abundant sweatings of the phthisis patient, and of the oedema of the subcutaneous connective tis- sue ; and it is not improbable that thinning of the serum of the blood, a so-called " dropsical crasis," favors the occurrence of serous transu- dations into the intestines. If the diarrhoea cease, and be replaced by constipation, and great sensith'eness of the abdomen to pressure, there is still greater probability that the previous diarrhoea Avas caused by intestinal ulcers, for from the above symptoms we may decide that there is peritonitis, and Ave know that this very frequently accompanies ulcers, which are advancing toAvard the serous coat. Caseous degeneration limited to the mesenteric glands, AA'hose remains are often found on autopsy, can hardly be recognized with certainty during life. The intestinal catarrh may long since have dis- appeared, Avhile the swelling and change of the mesenteric glands con- tinue, just as the SAvelling of the peripheral glands in many cases out- lasts the exanthemata that have caused it. It is very rare for con- volutions of glands, even Avhen considerably SAVollen, to become evident to the touch. We may ahvays suspect this disease when Ave find a person aa'Iio has had obstinate diarrhoea, and scrofulous swelling of the peripheral lymphatic glands, Avith a protuberant belly. In scrofulous catarrh, as Ave designate intestinal catarrh, AA'hich is accom- panied by cheesv degeneration and SAvelling of the mesenteric glands, the nutrition and development of the patient are also affected; the so- called tabes mesenterica does not appear to be due to the impermeabil- ity of the mesenteric glands, but solely to the intestinal catarrh. If this be removed, the patients may recover perfectly, and on autopsies we often find chalky masses embedded in the mesenteric glands of robust indhdduals avIio have died of acute disease. We should suspect proper tuberculous ulcers Avhen diarrhoea occurs during decided tuberculosis of the lungs. The secondary erup- tion of tubercles on the covering of the intestines has no symptoms, except the partial peritonitis Avhich usually accompanies it. 37 578 AFFECTIONS OF THE INTESTINAL CANAL. Treatment.—In the treatment of scrofulous diseases of the intes« tinal follicles and mesenteric glands, Ave should first of all combat the morbid predisposition Avhich excites and maintains them. On this point Ave may refer to what Ave have said concerning the prophylaxis and causal treatment of pulmonary consumption, and will only call attention to the important rule, so often neglected, that the patient should be kept in the fresh air as much as possible. When speaking of the treatment of scrofula, we shall treat particularly of the indica- tions for cod-liver oil, acorn-coffee, Avalnut-leaf-tea, as Avell as of tfie use of alkaline springs. Cod-liver oil does not by any means increase the diarrhoea in all cases, so that, AA'hen its use is indicated, we may try if it avUI be borne. In other respects the treatment of scrofulous and intestinal ulcers corresponds with that of chronic intestinal catarrh. If the diarrhoea become exhausting, opium avUI be indispensable, but, before employing this remedy, Ave should try the astringents and bit- ters recommended for the treatment of catarrhal diarrhoea. If the abdomen become sensitive to pressure, we may use Avarm poultices. If the pains increase greatly, Ave may apply a few leeches to the pain- ful part. CHAPTER V. CARCINOMA OF THE INTESTINES. Etiology.—Cancer of the intestines is far rarer than that of the stomach; it is almost always primary, and is even generally isolated; it is only in solitary cases that the cancer advances from neighboring organs to the intestine. The etiology is perfectly obscure. Anatomical Appearances.—Cancer of the intestines affects the large intestines almost exclusively, and particularly the sigmoid flexure and the rectum. Only in rare cases do Ave find numerous cancerous nodules affecting botfi the large and small intestine ; in the latter case they correspond to Peyer's glands. As in the stomach, so in the intestine, Ave have scirrhus, medullary and alveolar or colloid cancer. We also find tfie same combinations of different forms of cancer; the degeneration often begins in the submu- cous connective tissue as scirrhus, and, after it has perforated the mu- cous membrane, medullary masses arise from the scirrhus base. Cancer of the intestine has a great inclination to spread in the transverse di- rection, and so form ring-like strictures. The diseased portion of in- testine often sinks down in the abdomen from its weight; at first it remains movable, but subsequently usually becomes fixed by adhesions between it and neighboring organs, caused by partial peritonitis, or I* CARCINOMA OF THE INTESTINES. 579 by the cancer spreading from the intestine to neighboring organs. The development of the tumor may contract the calibre of the intes- tine to the size of a quill; the stricture is not usually over a feAV inches in length. Above the stricture the intestine is often enormously dilated and filled Avith faeces and gas, its walls are hypertrophied, and the mu- cous membrane is inflamed in various degrees ; below the stricture the intestine is empty and collapsed. As we have stated, AA'hen speaking of cancer of the oesophagus and pylorus, the stricture may be enlarged by the breaking doAvn of the cancer. Occasionally the destruction of the cancer extends to the peritonaeum; when this has been destroyed, the contents of the intestine enter the abdomen, or, if there have been previous adhesions, the destruction attacks neighboring organs. In the latter case, there may be abnormal communications betAveen differ- ent portions of intestine, or, if the affected portion of intestine have be- come adherent to the abdominal wall, there may be a fecal fistula; perforation of the vagina or bladder may be caused by the breaking doAvn of cancer of the rectum. Ulceration of the inflamed part of in- testine above the stricture may also cause perforation, and permit the escape of the contents into the abdomen, or lead to abnormal commu- nications. Symptoms and Course.—In many cases it is impossible to recog- nize cancer of the intestines with certainty. Patients in Avhom it de- velops complain of dull pain, sometimes continuous, sometimes occur- ring at intervals at a circumscribed part of the abdomen. Besides this, there is habitual constipation, Avhich usually begins before the stricture exists, and is then due to the degeneration of the muscular coat and the interruption of the movements of the intestines at that part. From time to time the constipation becomes peculiarly obstinate; the pain increases, the belly is puffed up, and nausea, A'omiting, and other symp- toms of obstruction of the intestines occur. If constipation be relieved, the patient feels pretty Avell again. These attacks recur at shorter in- tervals, increase in severity, and threaten fife more and more. Finally, tfie constipation cannot be relieved, and the patient dies Avith the svniptoms of ileus. If, up to that time, the appearance and nutrition of the patient had not suffered, if there were no tumor to be felt in the abdomen, and the form of the faeces gave no cleAv for diagnosis, the disease Avould be very obscure. It might be knoAvn that there Avas a gradually increasing obstacle to the progress of the contents of the intestines, but the nature of this obstruction Avould not be certainly knoAvn till reA-ealed by autopsy. In other cases the patients do not die so soon from an acute attack of obstruction of the boAvels, but, besides the gradually increasing con- stipation and the dull pain in the abdomen, the signs of a severe ca- 580 AFFECTIONS OF THE INTESTINAL CANAL. chexia appear ; there are a rapid loss of strength, great emaciation, and a dirty complexion. These symptoms give a presumption for the can- cerous nature of the obstruction. If the emaciation increases, and an uneven, nodular, hard, painful tumor, which is at first movable, can be felt deep in tfie abdomen, through the thin abdominal Avails, there will no longer be any doubt about the diagnosis. If, as is frequently the case, the cancer be in the rectum, or even a few inches above it, the patients complain of seA'ere pain about the sacrum, extending to the back and thighs. The significance of these sacral and spinal pains is often undervalued for a long Avhile, and they are regarded as symptoms of a disease free from danger, particularly Avhen there is at the same time varicose dilatation of the haemorrhoidal veins, and a passage of bloody mucus from the intestine. But, grad- ually, the increasing constipation and the peculiar appearance of the faeces become suspicious. The latter have a very small diameter, are sometimes round, again flat and ribbon-like, or are small balls, Hke sheep's dung. These passages are at first mucous and glairy, subse- quently they are covered with blood and pus, and they are evacuated Avith constantly-increasing pain, AA'hich finally becomes excessive. Oc- casionally the passages occur more readily, after the cancer breaks down, or, instead of constipation, there may be diarrhoea, which can- not be checked. At the same time there are often abundant haemor- rhages, and during the intervals between defecation a discolored, stink- ing fluid Aoavs from the rectum, corroding the anus and its Adcinity. If the Avail of the rectum be perforated, and the ulceration advance to the vagina and bladder, there is a most fearful destruction and a most miserable condition. The description of this and the directions for ex- amining the rectum with the finger and the speculum, which give the most reliable information, we leave to Avorks on surgery. With few exceptions, of which we have already spoken, the course of cancer of the intestine is rather tedious; it always terminates in death. The latter sometimes occurs Avith the symptoms of ileus, AA'hich appear gradually or suddenly; sometimes with the symptoms of ex- cessive marasmus, Avhich is occasionally accompanied, at the last, by dropsy and thrombus of the veins ; sometimes death is hastened by peritonitis, which may occur with or Avithout perforation of the intes- tine. Treatment.—The treatment of cancer of the intestine can only be palliative. We must try to regulate the diet, so that as little faeces as possible shall be formed; it is best to nourish the patient with con- centrated broths, soft-boiled eggs, and milk. We should most stren- uously insist on a daily evacuation of the boAvels, and, for this purpose, should prescribe laxatives which act certainly, and Avith as little irri- PERITYPHLITIS AND PERIPROCTITIS. 531 fation as possible. Castor-oil seems to suit best, and, according to IL.noch's observation, after it has been used a long time, the disgust which most patients have for it subsides. For other points we refer to the treatment of stricture of the intestine as described in Chapter II.; and for operative procedures, to works on surgery. CHAPTER VI. INFLAMMATION OF THE CONNECTIVE TISSUE IN THE VICINITY OF THE INTESTINES ; PERITYPHLITIS AND PERIPROCTITIS. By perityphlitis Ave understand the inflammation of the connective tissue AA'hich attaches the ascending colon to the iliac fascia. In far the greater number of cases this inflammation is propagated from the ccecum and ascending colon; in other cases it is an independent dis- ease ; it is then usually called rheumatic perityphlitis ; lastly, it occurs late in typhus, septicaemia, puerperal fevers, etc., and then belongs to the so-called metastatic inflammations. The exudation deposited may be absorbed, and the disease end in recovery ; but more frequent- ly the inflammation leads to diffuse necrosis of the inflamed connective tissue, and large abscesses form AA'hich may extend upAvard to the kid- neys, and doAvmvard even below Poupart's ligament, to the inner part of the thigh. Lastly, the posterior Avail of the ccecum and of the as- cending colon, the anterior Avail of the abdomen or the skin of the thigh, may be perforated; or the contents of the abscess may escape into the abdomen and cause peritonitis. If the disease deA'elops from a typhlitis, after the superficial tumor due to the inflamed coecum has disappeared, there remains a painful tumor lying farther back. This is covered by the inflated ccecum, and hence gives a clear percussion-sound. Frem the pressure of the tumor on the nerve-trunks, there is often pain, or a duU feeHng in the corre- sponding leg, and from the pressure on the Aeins there is oedema. If there be resolution of the inflammation, the tumor becomes smaller, the pain less, and the patient qruckly recovers. If it leads to suppura- tion and formation of abscesses, the tumor increases; in favorable cases, fluctuation appears sooner or later in the abdomen or thigh ; AA'hen the abscess opens, purulent masses, mixed Avith mortified connective tissue, are evacuated, and if the strength of the patient hold out, cure may result in these cases also; in other cases death results from exhaus- tion. If the contents of the abscess escape into the ascending colon after perforation of its posterior Avail, the result is usually favorable ; but if on the contrary, they break through into the abdominal caAdty, 5S2 AFFECTIONS OF THE INTESTINAL CANAL. the resulting peritonitis soon causes death. The course of rheumatic peritj'phfitis is perfectly similar, while in the metastatic form death usually results from the constitutional disease before suppuration and perforation take place. At the commencement of the disease, as in typhlitis, we apply leeches ; this application may be repeated several times ; subsequently Avarm poultices may be used. The abscess should be opened as soon as there is fluctuation. Periproctitis is an inflammation of the connective tissue surround- ing the rectum; sometimes it develops in the course of acute and chronic inflammations and degenerations of the rectum; again it ac- companies affections of the pelvis, or of the organs situated in the pel- Ads ; at other times, like perityphlitis, it is one symptom of extensive metastatic inflammations. We also see periproctitis develop very often in patients who have consumption of the lungs and intestines. The cause of this complication is obscure, for the dependence of the inflam- mation of the connective tissue on a suppuration of caseously degener- ated lymphatic glands has not been proved. Acute periproctitis may end in resolution, but more frequently leads to abscesses which may subsequently perforate outwardly or into the intestine. Chronic periproctitis leads to decided thickening and induration of the inflamed connective tissue, but it also almost always ends in partial suppuration, and fistulous ulcers form and are difficult to heal. . At the commencement of acute periproctitis Ave find a hard, pain- ful tumor in the perinaeum, or in the vicinity of the coccyx. On intro- ducing the finger into the rectum, we often recognize infiltration of the connective tissue by the feeling. The patient cannot sit up, and has the severest pain on defecation ; if the inflammation terminates in sup- puration, and the abscess perforates inwardly, the pain at stool in- creases, there is severe tenesmus, and, finally, purulent, stinking masses are evacuated per anum. This is the way that internal incomplete rectal fistulas are formed. If the abscess perforates externally, fluc- tuation occurs in the middle of the hard SAvelling in the perinaeum, or near the coccyx, and, after the covering has been pierced, the above- described masses are evacuated. This process may cause an external incomplete rectal fistula. Tfie symptoms of chronic periproctitis are usually obscure till the disease induces stricture of the rectum, and are hidden by the symptoms of disease of the mucous membrane, or other original disease. If abscesses form, there is severe pain along with the symptoms above described. At first, Ave should attempt to bring the imflammation to resolution, particularly by the use of cold; later, we should apply cataplasms and HEMORRHAGES FROM THE INTESTINES. 533 fomentations, and open the abscess early to prevent perforation of the rectum or bladder. CHAPTER YII. HAEMORRHAGES AND A'ASCULAR DILATATIONS OF THE INTESTINE. Etiology.—Haemorrhages from the upper part of the intestinal canal occur from the same causes as haemorrhages of the stomach. They most frequently result from excessive congestion of the portal circulation, such as occurs particularly in cirrhosis of the fiver. In other cases, vessels of the intestinal mucous membrane are eroded by ulceration ; such haemorrhages occur during typhoid feA'er, dysentery, and in some few cases of consumption of the intestines. Lastly, there are haemorrhages in the intestinal canal which must be referred to dis- ease of the Avails of the vessels, although the microscope shows no change of structure; among these are to be classed the intestinal haemorrhages in yelloAV fever (?), scorbutus, etc. Varicose dilatations of the haemorrhoidal veins (blind piles, haemor- rhoids) and bleeding from the vessels of the rectum (bleeding piles) are among the most frequent of affections. It is not long since these Avere regarded as symptoms of a specific constitutional disease, haemor- rhoidal disease, and, according to the former opinion, they were the most faA'orable shape that the disease could assume ; the case was fai more serious if the disease Avere " misplaced," that is, affected the head, breast, or abdomen. This view has been generally given up, since it has been found how much the occurrence of venous dilatation and bleeding in the rectum is due to mechanical causes, and hoAV little tenable is the idea of " misplaced haemorrhoids." Nevertheless, the pathogeny and etiology are still someAvhat obscure. Obstruction of the circulation, Avhich is the most frequent cause of congestion everywhere, must be regarded as the most common cause of haemorrhoids, with AA'hich general name Ave shall designate the ve- nous dilatations and haemorrhages occurring in the rectum. The escape of blood from the haemorrhoidal A'eins may be -eaused: \ 1. By collections of faeces in the rectum, by tumors in the pelvis or the gravid uterus ; and these are the most frequent causes of haemor- rhoids. 2. The escape of blood may be impeded by obstruction of the por- tal vein. Hence Ave shall mention haemorrhoids as one of the most frequent symptoms due to the congestion in cirrhosis of the liver. OA'erfillino- of the portal veins appears to have a similar effect, and perhaps this best explains the frequent occurrence of haemorrhoids in drunkards. During digestion there is an increased Aoav of fluids from 5Sd AFFECTIONS OF THE INTESTINAL CANAL. the intestines into the intestinal veins; Ave knoAV that the increased fulness of the portal vein, from this cause, obstructs the escape of blood from the splenic vein, and that consequently the spleen is enlarged every time that digestion goes on. But it readily folloAVS that from excess in eating and drinking the fulness of the portal veins is in- creased, and is more permanent, and that consequently other veins AA'hich open into the portal veins may dilate, and from repeated ex- cesses may remain dilated. This explanation is hypothetical, it is true, but it is not more so than other explanations that have been offered for the occurrence of haemorrhoids from excess in eating and drinking. 3. The obstruction AA'hich impedes the escape of blood from the haemorrhoidal plexus may lie beyond the liver, in the chest. Thus Ave often see haemorrhoids develop in lung-diseases Avhere the capilla- ries are compressed or atrophied; the patients considering them as the cause, not as the result, of their chest-disease. In the same way , haemorrhoids develop from heart-affections, along Avith other results of overfilling of the veins. The above-mentioned obstructions to the circulation do not usually j suffice to cause haemorrhoids; their frequency is not proportionate to I ' the amount of the obstruction; they are often absent Avhen the escape of blood from the haemorrhoidal plexus is greatly interfered with, AA'hile in other cases, where there is no perceptible obstruction except a \ temporary constipation, they become excessive. There is an analo- gous condition in the A'aricose veins of the legs of Avomen during pregnancy; in some Avomen the varicose^ veins appear during the first months, in others they do not occur even during the latter months, in spite of large amounts of liquor amnii, large children, or the most un- favorable position of the child. This goes to prove that the walls of the veins are less resistant in some persons than in others, and that this diminished tonicity of the walls of the vessels is most important for the occurrence of phlebectasias anyAvhere, and of haemorrhoids in particular. This abnormal lack of resistance in the Avails of the veins is in many cases congenital. The fact, that in certain families all the members for several generations suffer from haemorrhoids, cannot be denied, and can only be explained by the supposition that a peculiar state of the vessels is hereditary. In other cases the want of resist- ance is undoubtedly acquired, and is probably induced by the disturb- ance of nutrition in the Avails of the vessels from the chronic catarrh | of the rectum. We have learned that dilatation of the veins is one of the anatomical appearances of chronic catarrh in all the mucous mem- branes, and hence can understand that the veins of the rectum, which from their position are peculiarly disposed to dilatation, should in a similar Avay become varicose from catarrh of the mucous membrane of HAEMORRHAGE FROM THE INTESTINES. 585 » the rectum. The variety of injuries that the rectum has to bear, the frequency of acute and chronic diseases of neighboring organs, in AA'hich the rectum is implicated, abundantly explain the frequency of chronic catarrh, and at the same time the frequency of relaxation of the haemor- rhoidal veins. It is usually supposed that general plethora induces haemorrhoids, and that bleeding piles are of critical significance in plethoric condi- tions. It cannot be denied that persons, avIio, particularly after they have attained their groAvth, consume more than is required for the support of the body, are often affected Avith haemorrhoids; and also that gout, chronic catarrh, and other diseases, Avhich are also frequent in such persons, are usually better after haemorrhoidal haemorrhage. Nevertheless, Ave should hesitate about referring either the haemor- rhoids or the other diseases, in these cases, to a general plethora, to an absolute increase of the contents of the vessels, as the permanent occurrence of such a state has not been fully proved; and there is good reason to suppose that the overfilling of the vessels leads to increased excretion till the disproportion has been removed. The changes that the blood undergoes from too great a supply of nourish- ment (abnormal concentration?) are not thoroughly understood, and hence the pathogeny of the diseases developing under such circum- stances is quite obscure. Haemorrhoids are rarer in children than in adults; this is explained by the greater rarity of the above-mentioned obstructions to the cir- culation, and of chronic gastric catarrh, during chUdhood. On the other hand, it is evident Iioav a sedentary life, the use of irritating food, the misuse of drastic purges, the frequent and clumsy use of enemata, may rank among the exciting causes of haemorrhoids. If it be true, as is said, that piles are less frequent in Avomen than in men, and in tem- perate climates than in hot ones, and that they are induced by exces- sive vencry, Ave cannot so readily explain the fact by the causes above giA'Cll. Anatomical Appearances.—As the haemorrhages from the upper part of the intestine are almost always capillary, their source can rarely be recognized on autopsy. Occasionally, after capillary haemorrhages, a considerable extent of the mucous membrane is found suffused Avith blood, Avhich is a sign that the haemorrhage has taken place into the tissue of the membrane and not on its free surface. After haemor- rhages caused by ulcers in the intestine, coagula generally adhere to the°ulcers which have bled, and the edges and base of the ulcer are suffused with blood. The blood is sometimes fluid, sometimes sfightly coagulated, rarely red, but usually chocolate-brown, or transformed to an adhesive, black, tarry mass. 536 AFFECTIONS OF THE INTESTINAL CANAL. The varicosities of the rectum, which are termed blind piles, usually occur at the end of the rectum, above the sphincter and at the edge of the anus. The former are called internal, the latter external piles. At first the venous dilatation is diffuse and forms a thick blue net, afterAvard single varices appear, and not unfrequently the anus is sur- rounded by a Avreath of the latter. At first the varices are small and have a broad base, they appear and disappear at intervals; later they may attain the size of a cherry or even become larger. As the inter- nal varices are pressed through the anus, when the boAvels are evacu- ated, and draAV the mucous membrane after them, the latter often forms a pedicle for them and they remain outside of the anus; even then they sometimes appear tense, at others relaxed; but the sacs once formed never disappear. The appearance and structure of the haemorrhoidal tumors change in the course of time. At first they are bluish and their walls are thin and delicate; if repeated cfironic inflam- mations subsequently cause them to adhere to the mucous membrane, they lose their bluish look, and become hard and thick-walled. Not unfrequently neighboring varices coalesce, only rudiments of their par- titions remain, and thus large, sinuous sacs are formed, into which several veins open. Occasionally a thrombus forms in the varices, filling them up and causing their obliteration and ulceration. Large varices which are extruded during defecation may inflame and even mortify from the pressure; in other cases there is inflammation and ulceration of the mucous membrane at the root of the haemorrhoidal tumor and haemorrhoidal ulcers result; in still other cases the inflam- mation attacks the surrounding connective tissue, and we have peri- proctitis, and, as a result of this, may have rectal fistula. Bleeding piles result sometimes from the rupture of varices, but small haemorrhages are mostly caused by overfilled capUlaries. According to Virchoio's description, on anatomical examination of the rectal mucous membrane, we find it " relaxed, often in puffs and folds, slightly thickened, grayish-Avhite; the submucous tissue is in- creased and relaxed; both are very vascular. It is usually covered Avith tough, whitish mucus, which chiefly consists of detached epithe- lium, with a mixture of mucus." Symptoms and Course.—Haemorrhages in the upper part of the intestine are, as above stated, symptoms of severe diseases, and must be described Avhen speaking of these. The description of haemorrhoids given in the old text-books, and Avhich still corresponds to the popular idea, distinguishes three groups of symptoms: 1. The local difficulties which are caused by the catarrh, the varices, and the haemorrhages, "mucous or blind and bleeding piles;" 2. Periodical difficulties, both local and general, which precede HEMORRHAGE FROM THE INTESTINES. 537 the SAA'elHng of the varices and the haemorrhage from the rectum, and are reheved by the latter, " moHmina haemorrhoidalia;" 3. Permanent difficulties, Avhich indicate constitutional disease, or disease of some dis- tant organ, but Avhich are also relieved by the haemorrhoidal bleeding, " misplaced haemorrhoids," or, if haemorrhages occur elseAvhere, " Adca- rious haemorrhoids." We should strike the latter from the list of haemorrhoids. If a venous abdominal plethora, dependent on cirrhosis of the fiver, is im- proved by haemorrhoidal bleeding, and the dyspepsia, flatulence, and hypochondria disappear for a time, this does not justify us in regarding these symptoms as signs of a haemorrhoidal disease. We have just as little rigfit to regard bronchial catarrh, or attacks of gout occurring in a plethoric person, as anomalous or misplaced haemorrhoids, because these diseases remit after a haemorrhoidal bleeding. In regard to molimina fiaemorrhoidalia, we must agree Avith Virchow, avIio regards it as a symptom of returning rectal catarrh. The patient has a feehng of burning and tension in the rectum, just as occurs in other mucous membranes in acute catarrh or relapsing chronic catarrh. There are also severe sacral and dorsal pains, which remind us of the headache in catarrh of the nose and frontal sinus. The general state of the patient is disturbed in the same Avay by catarrh of the rectum as it is by catarrh of other parts; the patients become relaxed, slug- gish, and depressed. The inconveniences Avhich the varices, swelled by the increased hyperaemia, cause, complete the picture of haemor- rhoidal hyperaemia. In many cases, at the height of the attack, there is a haemorrhage, AA'hich has a favorable influence on the catarrh and the fulness of the varices, so that the patient feels relieved, or even free from all trouble. If, after a time, he be again affected Avith mo- limina, Ave cannot blame him for longing for the haemorrhage that re- lieves him. If Ave can remove the catarrh and swelling of the varices in any other AA'ay, as by removing constipation, Avhich has caused the increased congestion and hyperaemia of the rectum, the molimina dis- appear Avithout a haemorrhage. The local difficulties tfiat the haemorrhoids excite vary Avith the number, size, and fulness of the varices. At first they are slight, the patients have the feeling of a foreign body in tfie anus, and pain only occurs Avfien there is a hard stool. When the anus is surrounded- by laro-e varices, or Avhen individual tumors have become very large, and are very tense, the patients have constant pain, cannot sit down, and even a soft passage gives them great suffering, AA'hich only disappears sIoavIv, and Avhich not unfrequently causes the patients foolishly to retain their passages. The pain becomes most severe when large Aarices are protruded through the anus, strangulated there, and become inflamed. 588 AFFECTIONS OF THE INTESTINAL CANAL. Haemorrhoidal bleedings usually occur during defecation; if they are of capUlary origin, only a small quantity of blood adheres to the faeces; if they come from ruptured A'arices, several ounces of blood are often lost. It is only in rare cases that there is sufficient haemorrhage to cause danger. The so-called mucous haemorrhoids consist of the passage of the above-described catarrhal secretion; this is sometimes evacuated Avith the faeces, sometimes squeezed out of the rectum wdthout any admix- ture of faeces. Frequently only the symptoms of mucous piles are present, and it is only subsequently that those of blind and bleeding piles occur. From the usually prolonged action of the injurious influences causing them, it may be readily understood that the course of this disease is usually tedious. If the causes act only for a time, the haemorrhoids may disappear forever, after lasting only a short time. The variation of the symptoms of haemorrhoids, after they haA'e lasted a long time, has led to the most varied hypotheses. They have been compared to menstruation, and even the changes of the moon AA'ere claimed to haA'e an influence on their course. The causes of the unpleasant feelings of the patient at one time, and Iris comfort at an- other, may often be discovered; the occurrence of constipation has ob- structed the escape of blood from the rectum; or a debauch has caused an overfilling of the portal vein, and a consequent congestion of the haemorrhoidal vessels; or they have been exposed to some other source of injury, which in them has not induced a nasal or bronchial catarrh, but has excited an increase of the rectal catarrh, because the rectum was the locus minoris resistentiae. In other cases, the exciting causes cannot be discovered, but this also happens in the temporary exacerba- tions of other diseases, and so Ave are not justified in any adventurous hypotheses. We hear a great deal about the dangerous effect of the arrest of habitual bleeding from haemorrhoids. This belief is not altogether Avithout grounds, but we should not consider the bleeding as Nature's attempt at a cure. The rectum is probably the part whose diseases have least effect on the organism, and patients in Avhom the rectum is the part soonest affected, Avhen they are exposed to injurious influences, are better off than those Avhose stomach or bronchi are affected under simUar circumstances. If they be affected AA'ith disease of one of the last-mentioned organs, Avhen exposed to injury, we may deplore it, but if they have haemorrhoids, they are just as correct in saying " all right" as one is Avho, having been exposed, begins to sneeze, and thereupon concludes he is only going to have a cold in the head, and not a worse disease. In cases Avhere abdominal plethora, dependent on mechanical HAEMORRHAGE FROM THE INTESTINES. 5S9 obstruction, is relieved by an occasional fiaemorrhoidal bleeding, or Avhere there is a remission of bronchial catarrh, or other disease, Avliich usually exists in patients of forty years or upward, who lead a luxu- rious life, the cessation of the bleeding may proA'e serious. But, as in these cases, the relief depends solely on the loss of blood, and as this can be replaced by local blood-letting, the injury practically only occurs Avhen the physician fails to see that the latter is indicated. Treatment.—Where the repeated collection of hard faeces excites the catarrh and varices of the rectum, the causal indications require the regular evacuation of the boAvels ; but we should only use drastic purges, such as aloes and colocynth, AA'hen absolutely necessary, as Ave fear their irritant effect on the mucous membrane of the rectum, and should generally prefer floAvers of sulphur or precipitated sulphur, AA'liich have long been used in the treatment of haemorrhoids; sulphur is generally given in combination Avith tartrate of potash. One of the commonest prescriptions is IjL sulphur, depur. 3 ij, potass, bitart. § ss, syrup, limonis, sacch. albi ana 5 fij, V\. ft. pulv. S. A teaspoonful tAvo or three times daily. If Ave do not succeed Avith this prescription, Ave may add some senna or rhubarb to it. Another popular Avay of prescribing sulphur is the pulvis glycyrrhiza compositus, of Avhich a feAV teaspoonfuls may be taken during the day. Enemata are not generally advisable; for, even if carefully used, they are liable to irritate the rectum. Where cirrhosis of the liver, or diseases of the lungs or heart, cause the haemorrhoids, avc cannot usually fulfil the causal indications. In these cases, also, the administration of sulphur is advisable, so that a second eA'il may not be added to the first. As Ave have mentioned overfilling of the portal veins, from excess in eating and drinking, as among the causes of haemorrhoids, so the casual indications require that such patients should not eat too frequently or too much. Finally, in those patients AAdio, besides other troubles, have haemorrhoids from excessive eatin"-, we must lay doAvn the most stringent rules. If there be a true plethora in such cases, it can only be explained on the supposition that, Avhen the serum of the blood contains an increased amount of protein substances, particularly of albumen, it requires an abnormal fulness of the blood-vessels to cause the separation of the same amounts of fluid that are excreted Avith a normal fulness of the vessels. If the normal amount of albumen exists in the blood, Ave may regard it as proved that the amount of urine excreted diminishes Avith the increase of albumen in the serum of the blood. The above hypothesis also corresponds to the general belief of the laity and physicians: a man does not become full-blooded by eating or drinking too much, but by catino- nourishing food and drinking spirituous liquors. Without en- 590 AFFECTIONS OF THE INTESTINAL CANAL. tering into the question Avhether, in so-called plethora, there is actually an increase of the amount of blood, or only an increase of the blood- cells, or of the albumen in the blood (polycythaemia and hyperalbumi- nosis, Vogel), certain rules of life may be laid down for tfie affected persons Avhich correspond to the physiological and practical view of the affection : 1. The use of protein substances must be limited; the patient should only eat a little meat or egg once a day, but should eat vegetables, fruit, rice, etc. 2. The consumption should be increased; the recommendation of long walks and energetic muscular exercise, and drinking plenty of water, which hasten the transformation of ma- terial, is just as rational as forbidding spirituous liquors, and tea and coffee, which seem to retard the transformation. 3. Such patients are very greatly benefited by saline purgatives, particularly by the moderate and continued use of glauber salts and chloride of sodium, as they occur in the waters of Marienbad, Kissengen, Homburg, Soden, etc. The use of the waters at Karlsbad requires great precau- tions, on account of the high temperature of the springs. If it be proved that, by this treatment, the blood grows richer in salts, and poorer in albumen {C. Schmidt, Vogel), there would be a rational ex- planation of its brilliant results in the treatment of plethora. The indications from the disease do not present any further rules in cases AA-here occasional moderate suffering is speedUy relieved by the occurrence of spontaneous haemorrhage; we content ourselves with ful- filling the causal indications as Avell as possible. But if the patients are tormented Avith severe molimina, which do not disappear after the re- moval of any existing constipation, Ave should apply from four to six leeches about the anus. After the leeches drop off, Ave should encour- age the bleeding, by placing the patient on a night-stool, wdth a vase of warm Avater under it. The same proceeding is advisable when great fulness and excessive tension of the varices cause severe pain, or if haemorrhoids are accompanied by painful tenesmus. We should let moderate bleeding continue, particularly AA'hen it promises relief from troublesome symptoms, and should only use cold or styptics when the loss of blood is considerable. Haemorrhoids that have come down and been strangulated should be replaced by continued careful pressure with a bit of oiled Hnen, while the patient rests on his knees and elbows, Avith the body bent far forward. Inflamed haemorrhoids should be covered with cold-water compresses, or bladders filled Avith cold Avater. We avUI not discuss the operative treatment. With our vieAV of haemorrhoids, we cannot folloAV the ruling custom, and speak also of remedies for " bringing on suppressed piles." Luckily for the patients, the remedies recommended for this end, such as peri- odical abstraction of blood, warm sitz-baths, irritating suppositories, ENTER ALGIA. 59 J and the administration of so-caUed pellentia, rarely cause haemorrhoids, AvhUe the periodical abstraction of blood attains the only object that it Avas sensible to aim at. CHAPTER VIII. NERVOUS AFFECTIONS OF THE INTESTINES—COLIC—ENTERALGIA. Affections of the sensory nerves of the mesenteric plexus— colic, in the strict sense of the Avord—are not by any means frequent. Analogy leads us to suspect their occasional occurrence from structural diseases of the ganglia and plexuses of the sympathetic nerve; but this has not been proved. The frequent occurrence of mesenteric neuralgia in hysterical females speaks for its reflex origin. Lastly, lead- colic is the most striking instance of a nervous affection caused by poisoning. In the latter case, however, there appears to be not a sim- ple affection of the sensory nerves—a hyperaesthesia—but, at the same time, there seems to be a disturbance of the motor nerves—a hyper- cinesis—as the painful intestine is ahvays contracted. The lead, Avhose absorption into the body causes lead-colic—one symptom of lead poisoning—is partly breathed in as fine poAA'der, and partly ab- sorbed from the intestinal and Schneiderian mucous membrane. Hence avc find the disease among Avhite-lead paint-makers, lead and silver- smiths, painters, color-grinders, potters, type-founders, compositors, and others AA'ho Avork in an atmosphere loaded Avith particles of lead. The misuse of medicinal preparations of lead, the adulteration of Avine and other liquors Avith sugar of lead, or by the accidental addition of lead to them, is at present a much rarer cause of lead-colic than those above mentioned. StUl the celebrated colic of Devonshire, Poitou, and other epidemic and endemic colics, which very much resembled lead- colic, appeared due to poisoning from some drink containing lead, and not to poisoning by vegetable substances. In some rare but authen- tic cases, lead-colic has occurred from using snuff that had been packed in lead-foil. The predisposition to lead-colic is very varied, but among the predisposing causes Ave only know the great tendency to the dis- ease left by a preAdous attack; all the other causes Avhich are blamed, as increasing the predisposition to lead-colic, such as debauchery, drunkenness, etc., can hardly be denied, for they are found everyA\diere, AA'hen no other causes can be detected. But by colic, in the Avider sense, Ave understand, besides the nervous affections of the mesenteric plexus, all painful affections of the intes- tines Avhich are not caused by inflammation or textural changes of the intestinal Avails. S\ among the symptoms of helminthiasis, Ave shall s 592 AFFECTIONS OF THE INTESTINAL CANAL. speak of colicky pains, just as Ave mentioned them Avhen speaking of the premonitory symptoms of typhlitis stercoracea, and of contraction and obstruction of the intestines. But Ave haA'e already distinguished the colicky pains AA'hich precede the inflammation from those Avliich accompany and depend on it. The same cause Avhich has to-day in- duced a colic, may to-morroAV excite a colitis. We cannot ahvays ex- plain hoAV these colics can induce increased excitabUity in the sensory nerves of the intestines; but Ave may suppose that the pains are always caused by irritation of the peripheral extremities of the intestinal nerves; so that this form of colic must be distinguished from the proper nervous affection of the intestine. The most frequent cause of colicky pain is, unmistakably, excessive distention of a portion of intestine, causing stretching of the Avails of the intestine, and gases enclosed at some circumscribed part appear particularly to cause this distention. We may often clearly perceive that the gas is driven forward against the faeces, or some other obstruction, and, there arrived, it excites the most severe pains; and, in other cases, that the gases are driven by the contraction of the intestines, from one place to another, and, Avith their change of location, the position of the pain also changes. It is just as improbable that the pain in this colica flatulenta is caused by the irritation of the intestinal gases on the intestinal mucous mem- brane, as that it depends on the pressure from the contraction of the intestinal muscles on the nerves of the intestine. As the decompo- sition of the contents of the intestines is the most frequent cause of the collection of gas, it becomes evident that the diseases in which the contents undergo abnormal decomposition are often accompanied by the symptoms of wind-colic. This is particularly true of intestinal catarrh, Avhich is excited by the passage of undigested food from the stomach into the intestine, or by the long retention of faeces. As in children, undigested and decomposing milk A'ery frequently enters the intestines, colica infantum is an exceedingly frequent disease. If the decomposing substances be removed from the intestines before the in- testinal mucous membrane is affected with catarrh, colic may be tfie sole symptom of the abnormal process. Just as colica flatulenta ap- pears to be caused by a collection of gas in the intestine, colica sterco- racea appears due to a distention of the intestines by faeces, and colica verminosa to a distention of the intestine by a coil of tape-worm, or a bundle of round Avorms. The abdominal pains following the em- ployment of drastics or injurious ingesta are also usually described as colic, but the changes in the secretions of the intestine after the use of these medicines, or after eating unripe fruit, and many other sub- stances, tend to show that there is sfight inflammation, which is of short duration, and disappears AA'ith the removal of the injurious sub- COLIC. 593 stances. We may AveU compare these pains to those that result AA'hen a sinapism is applied to the skin, and which disappear as soon as the sinapism is remoA'ed. Perhaps some cases of colica A'erminosa also be- long here, particularly of those Avhere the attacks of pain are folloAved by the discharge of large mucous masses—so-called worm-nests. In the painful and long-continued attacks of colic occurring after ex- posure of tfie skin, particularly that of the feet and abdomen, to cold, the muscular coat of the intestines appears to suffer in the same way as muscles elseAvhere do in rheumatic affections; hence the affection is Avell-named colica rheumatica. Symptoms and Course.—Romberg describes neuralgia mesen- terlca as folloAVs: " There are attacks of pain spreading from the navel over the abdomen, alternating Avith intervals of ease. The pain is tearing, cutting, pressing, most frequently tAvisting, pinching, intro- duced and accompanied by peculiar bearing-doAvn pains. The patient is restless, and seeks relief in changing his position, and in compressing the abdomen; his hands, feet, and cheeks are cold; his features are pinched; the Avrinkled broAVS and contracted lips betray his agony. The pulse is small and hard. The skin of the abdomen is tense, Avhether puffed up or draAvn imvard. There are often nausea, vomiting, and desire for stool; sometimes there is also tenesmus. There is usu- ally constipation, but sometimes the boAvels are regular, or even too loose. Such an attack may last from a feAV minutes to several hours, relaxing at intervals. It ceases suddenly, as if cut off short, and there is a feeling of the greatest relief. The course is periodical, but less regularly so than in other neuralgias." Lead-colic is almost ahvays preceded by the symptoms of lead- poisoning. The patients are thin and badly nourished, their skin looks dirty and earthy, the gums are dark, almost slate-gray, the teeth them- selves discolored, and the breath bad; the patients have a SAveetish, metallic taste in the mouth. Then there are periodical pains, which are at first dull, and extend from the epigastrium toAvard the back and extremities. The pain soon becomes more severe, so that, during the attack, the patients moan and groan, toss themselves about on the bed, or else leave the bed in despair, and do the most foolish things. At the same time, the pulse becomes much sloAver, the A'oice is lost, and stranar causes no symptoms. Treatment.—The prophylactic treatment for taenia solium follows, as a matter of course, from Avhat lias been said. No pork should be eaten that has not previously been subjected to the procedures by Avhich any cysticerci in it Avould be killed. Cooks should be forbidden to taste raAV sausage, or to hold the kitchen-knife in the mouth. Butchers should be instructed not to cut sausage or ham Avith the knife (302 AFFECTIONS OF THE INTESTINAL CANAL. they use for raw meat. We can offer no prophylactic treatment fo? the other A'arieties of worms, as Ave do not know their mode of origin. Of the numerous remedies Avhich were formerly used for removing tape-Avorm, Ave noAV only employ male fern, pomegranate-rind, koosso, and oil of turpentine [pumpkin-seeds]. Male fern—Radix filicis maris—appears to be chiefly efficacious against bothriocephalus, and often fails when given for taenia solium. Half a drachm or a drachm of the powdered root is given at a dose, and tAvo or three such doses are taken in the morning, fasting, or at bed- time. A feAV hours later, or, if the powder be taken at bed-time, the next morning, Ave give a sharp laxative of gamboge, scammony, or calomel, or an ounce or more of castor-oil. The ethereal extract of male fern, Avhich is usually made into pills, Avith equal parts of the poAvdered root, and given in doses of a scruple or half drachm, divided into two portions, is more certain and more easily taken. Male fern enters into most of the numerous and complicated Avorm-medicines, Avhich are of late more and more neglected. Pomegranate-rind—Cortex radicis punice granati—when fresh, appears to be one of the most certain remedies against taenia solium. We pour a pint or two of water over two or four ounces of it, and, after macerating for twenty-four liours, boU it down to one-half. This decoction is generally divided into three doses, and used in the morn- ing, fasting, and, although very usually efficacious, it is occasionally vomited by the patient, and always causes excessive pain in the abdo- men for hours. I can urgently recommend that, before using the de- coction, the simple maceration should be tried; this is also made from tAvo or four ounces of the rind. This maceration acts much more mildly; the patients suffer scarcely any, and after its use I have fre- quently seen one tape-worm passed, and, in one case three, with their heads, were passed. If the maceration fails, the decoction may be tried in a feAV days. After the exhibition of pomegranate-rind, the worm usually passes, unbroken, and is often rolled into a ball. If it be not passed in from one to three hours after the last dose, we may give one or tAvo ounces of castor-oil. Kuchenmelster recommends malting an extract from four or six ounces of pomegranate-rind, and adding this, Avith from four to six ounces of hot water, to a scruple or half a drachm of ethereal extract of male fern, and four to six grains of gamboge. Tavo cups of this mixture taken, with an interval of three- quarters of an hour, are said to expel the worm. If this do not re- sult in an hour and a half, the third should be administered. Koosso—the dried and powdered floAvers of Brayera anthelmin- tlca—a, remedy recently introduced from Abyssinia, has not fulfilled WORMS IN THE INTESTINAL CANAL—HELMINTHIASIS. 603 the expectations entertained of it; at least, the brilliant results at- tested by some observers have not been attained by others. From tAvo drachms to half an ounce may be macerated in Avater, or made into an electuary AAdth honey, and given in two doses, Avith an interval of half an hour, in the morning, after a cup of coffee has been taken. If nausea occur, Ave may give some lemon-juice. If the patient do not have a passage in three hours, Ave may give a dose of castor-oil or senna. Although oil of turpentine is among the most certain remedies for tape-worm, it should only be used in case of necessity, not only on ac- count of its disagreeable taste, but because in the requisite doses it is apt to irritate the urinary organs. One or two ounces of oU of turpen- tine alone, or mixed Avith honey or castor-oil, or in emulsion, are to be given in one dose, at bed-time. It is best to use any of these remedies at times when some of the links of the tape-Avorm have been passed spontaneously; but it is quite unnecessary to delay treatment till certain phases of the moon, when, according to popular belief, the Avorms may be more readily dislodged. We should employ some preparatory treatment: let the patient live moderately, keep his bowels open AA'ith castor-oil, and let him Hve for a feAV days almost exclusively on herring, ham, onions, and other salty and spicy food. Instead of the above, the patient may eat freely of Avild strawberries, huckleberries, etc., as the numerous seeds of these fruits appear to sicken the Worm {Kiichenmeister). The cure cannot be regarded as perfect till Ave find the head of the animal; nor must we forget that there may be more than one tape-Avorm in the intes- tines. Kameela, a poAvder obtained from the capsules of Rottera tinc- toria { 3 ij—iij, rubbed up with Avater), cortex musene { f i—ij, Avith honey), radixponne { 3 j—ij), and a feAV other medicines, have been more or less lauded as remedies for tape-worm, but after repeated trials no one of them has proved peculiarly efficacious. For ascaris lumbricoides, semina cyne vel santonici, the buds of Artemisia contra, justly enjoy the best reputation. The practice of ghdng an electuary, made of the poAvdered seeds of Avorm-seed, jalap, A'alerian, honey, and other substances, by AA'hich children Avere formerly tortured several times a year, as AveU as its exhibition in the shape of Avorm-chocolate or cakes, is noAv almost displaced by the more certain and agreeable preparations, such as the ethereal extract, and particu- larly santonin. Of the former Ave may give a child gr. v—x during the day, of the latter, gr. Uj—ja*. Apothecaries often keep troches of santonin, containing gr. ss—j each, which taste pleasantly. Kucha meister advises dissolving santonin, gr. ij—iv, in castor-oil § i, a- ghdng- a teaspoonful of this solution every hour till it acts; he 1 601: AFFECTIONS OF THE INTESTINAL CANAL. still better results from the santonate of soda, in doses of gr. ij—iv, given morning and evening for several days. A laxative should al- Avays be given after the use of Avorm-seed, or its preparations. Othei anthelmintics for expelling round AA'orms may be dispensed Avith. Enemata suffice to drive the oxyuris from the rectum. Even in- jections of cold Avater, Avith a little vinegar, are very efficacious ; but they should be very large, so as to reach any of the worms that may be up in the sigmoid flexure, and they should be used for a long time. In obstinate cases Ave may add a Aveak solution of corrosive sublimate (gr. \ to § ij) to the enema. (In my last edition, trichiniasis was considered at this place, but in this one I shall speak of it among the infectious diseases; the reasons for this aatII be stated Avhen speaking of its etiology.) fg CHAPTER X. GASTRIC FEA'ER, CATARRHAL AND BILE-FEVER. Many physicians, particularly among the Germans, describe as gastric fever a disease running an acute course, in which high fever is only accompanied by dyspeptic symptoms, and generally by diarrhoea, Avhile there are usually no symptoms that Avould indicate severe dis- ease of any important organ. Celebrated authorities, particularly those clinical observers Avho have developed in hospital, and have had only hospital practice, consider all cases of so-called gastric fever as mild cases of typhus. I cannot at all agree with this vieAV. Every physician in private practice often has the opportunity of seeing, after errors of diet, without any suspicion of infection, symptoms of variable duration, Avhich exactly answer to those of gastric fever. If this be so, eyen where we can find no error of diet, we must be careful about in- uring that there is an infection, and must acknowledge the possibility that catching cold, atmospheric and telluric influences, and other sources of injury, may excite a similar set of symptoms. But I will not attempt to deny that numerous slight cases of typhus are diagnos- ticated as gastric fever. As a rule, gastric fever begins with several slight chills, rarely with one severe one. The pulse quickly rises to 100 or more. According to the feAV observations that have been made, the temperature is some- times normal, in other cases it is decidedly increased; it may reach "rom 102° to 105°. The constitutional disturbance is very marked. he faintness is so great that the patient remains in bed; the limbs, rticularly at the joints, pain " as if they would burst." The insup- hable headache is usually increased by laying the head on a feather GASTRIC FEVER, CATARRHAL AND BILE-FEYER. 605 pillow, Avliile it is occasionally relieved by binding a towel firmly around the head. The patient does not sleep at all, or is disturbed by dreams. The symptoms of disease of the stomach or intestines vary. Usually the appetite is lost, the tongue coated, the taste slimy or bit- ter, tfie breath is bad, the patients complain of a feeling of pressure and fulness in the epigastrium, and are sensitive to pressure there. There is also eructation of gases and fluids, usually acid products of abnor- mal gastric digestion. Occasionally there is repeated vomiting. At first there is usually constipation; but later, particularly AA'hen the dis- ease is protracted, there is diarrhoea, preceded by more or less cohcky pain ; the stools are fluid, and colored green by bile, and are sometimes mucous. Occasionally these symptoms pass off quickly, and the patient, who is one day in a sad plight, feels quite AveU the next (ephemera). At the same time herpetic vesicles not unfrequently come on the lips. We should not consider this a distinct disease, a febris herpetica. Herpes labialis accompanies gastric fever as often or perhaps oftener than it does pneumonic or intermittent fever, and has the same sig- nificance in the former disease as in the latter. But the disease does not by any means ahvays terminate in one day; it often continues several days, but rarely longer than a Aveek. In persons who do not bear Avell the feverish increase of temperature, or the consumption caused by the increased deA'elopment of heat (Ave have frequently said that individual peculiarities vary greatly in regard to this), there is great depression, the mind is affected; instead of dreams, the patient has delirium ; and, if at the same time the tongue become dry, the similarity Avith typhus is very great. It often happens that the true nature of the case is only explained at the sixth or eighth day, by the sudden improvement and the rapid convalescence. In consideration of the difficulty of diagnosticating gastric fever from a commencing typhus, it is adAdsable to be very guarded in diag- nosis and prognosis during the first Aveek. It Avould be very danger- ous for iUrk reputation of the physician, if, after he has pronounced the disease to be gastric fever, and promised improvement from day to day, it should develop Avith all its terrors in the second or third Aveek. But it avUI compromise the doctor just as much if the supposed nervous fever terminate in cure at the end of the first Aveek, and the patient be able to Avalk out a feAV days later. Even the laity no longer believe that under certain circumstances "gastric feA'er" may become "gas- tric nervous," and this again develop into "nervous fever." They know that these tAvo diseases are of different nature from the first. In making a differential diagnosis during the first Aveek, great atten- tion should be given to the etiology. If there have been injurious GOG AFFECTIONS OF THE INTESTINAL CANAL. influences that could cause gastric and intestinal catarrh, in doubtful cases the presumption avUI be in favor of gastric fever. If, on the other hand, there have been numerous cases of typhus in the city or vicinity, and no errors of diet can be discovered as causes of the dis- ease, Ave should suspect typhus. Secondly, the increase of the bodily temperature is not so regular in gastric fever as in typhus. Thirdly, catarrh of the finer bronchial tubes, with cough and sibilant rhonchi, indicates typhus rather than gastric fever, although bronchial catarrh may occur in the latter also; such cases are usually termed gastro- catarrhal. Fourthly, an eruption of herpetic vesicles about the mouth almost certainly excludes typhus. Fifthly, and lastly, a perceptible enlargement of the spleen, and the appearance of roseola spots on the I upper part of the abdomen at the end of the first week, speak against gastric and in favor of typfius [typhoid] fever. Cases occur AA'here from the great general disturbance the gastric symptoms are throAvn so much in the background, that Ave may doubt AA'hether the disease is venting itself in the intestinal canal, and Avhether the fever and the symptoms caused by it can really be re- garded as symptoms of gastric and intestinal catarrh. It is such cases that have led to the formation of the class called simple (essential) fever, fievre simple continue, or synocha. I doubt the propriety of believing that fever can occur as the sole effect of the action of any injurious influence on the body. It seems much more probable that even in such cases there is structural change, which Ave cannot at piesent discover, in some organ or other. I consider this hypothesis justifiable from the Avell-knoAvn fact that, in numerous cases of pneu- monia, erysipelas, and severe nasal and bronchial catarrhs, the fever and great general disturbance appear before the local symptoms. It is A'ery difficult for me to believe that here also there is at first an essential fever, to Avhich a local affection is subsequently added; and the more so, as, after this occurs, the fever and local disease keep step, and the former disappears when the latter has run its course. Noav, if the delicate organic disease do not reach so high a grade as to cause evident functional disturbances, according to my hypothesis avc have the state usually called essential fever. In any fever there is slight dyspepsia; and simple Avant of appetite, slightly-coated tongue, etc., do not justify us in designating a febrile affection as gastric fever. Even more decidedly than in the case of gastric fevers does Griesinger say that the rare but very regular and characteristic disease called catarrhal fever, febris pituitosa, is also a typhus dis- ease, which has, it is true, a peculiar and unusual course. I do not knoAV Avhether Griesinger himself has made a large number of autop- sies in cases of this disease, or whence he derives his authority for say- GASTRIC FEVER, CATARRHAL AND BILE-FEVER. 607 mg " that Ave find open or even cicatrizing intestinal ulcers in these cases." The long duration of the disease, the slightness of the fever, the great extent of the catarrh, the excessive production of mucus, and other points, decide me to doubt the correctness of Griesinger's belief till I fiave learned the facts on which he bases it. The description AA'hich I shall now give of the symptoms and course of catarrhal fever, I take partly from my OAvn observation, partly from the excellent description of this disease, given in Schonleln's lectures, and Avhich exactly corresponds Avith my own observation. This disease does not begin AAdth frequent pulse, pain in the limbs, severe headache, and restlessness, as gastric fever does. The pulse is usually moderately increased, the temperature sligbtly elevated, but the patients feel very dull and heavy, are apathetic, constantly sleepy, and disgusted at all food. If the patient be compelled to eat some- thing, he soon has a distressing feeling of fulness ; then vomiting oc- curs, and the food is thrown up, enveloped in large quantities of tough mucus. The accompanying oral and pharyngeal catarrh is also pecu- liar : the coating of the tongue is, at first, tfiick and yelloAvish ; teeth and gums, palate and pharynx are covered with tough mucus ; later the Avhole epithelial covering of the tongue is often throAvn off, and it then looks red, like a piece of raw meat, or as if coated Avith varnish. In the morning, especially, the patients raise so much mucus, by spit- ting, haAvking, vomiting, and coughing, that a spittoon will hardly con- tain it all; quantities of mucus are mixed with the undigested food, in the passages from the bowels, Avhile the urine contains a mucous deposit. Even in the subsequent course, the fever remains moderate, and has sometimes a remittent, sometimes a continued type. The patients become very feeble; their apathy increases so, that AvhUe they do not sleep, they lie Avithout any interest in their own state, or in things about them. If the disease begins to mend, Avhich frequently does not occur tUl the third or fourth Aveek, the production of mucus gradually ceases, the appetite sloAA'ly returns, the pulse becomes very sluggish, and the exhausted patients do not recover strength for a long time. The slightest cause induces a relapse; then the process begins aneAV, and months may pass before a perfect cure, or, in weak, decrepit persons, death may result. It is difficult to determine Avhat disease the older physicians meant by bilious, or gall-fever. I hope, however, by my observations during the last £cav years, to have arrived at a better understanding of those fevers accompanied by icteric symptoms. I no longer believe that this icterus is due to a polycholia, where more bUe is produced than can be expelled from the gall-ducts, and that, consequently, part of it is reabsorbed. I rather consider the icterus accompanying excessive 008 AFFECTIONS OF THE INTESTINAL CANAL. fever, as a " haemotogene," that is, as one resulting from disintegration of the blood-corpuscles, and transformation of the released coloring matter of the blood into coloring matter of the bile. When speaking of diseases of the liver, I sfiall return to the subject, and will here confine myself to the folloAving remarks. In pyaemia, in puerperal fever, and in other infectious diseases, probably as a result of the ex- cessive increase of bodily temperature, there is often parenchymatous degeneration of the most varied organs, in Avhich the blood also par- ticipates. More rarely, in the course of inflammatory affections, such as pneumonia, there is a dissolutio sanguinis (which was recognized by the older physicians), and, as a consequence of this, haemotogenous icterus. But lastly, even catarrhal diseases, affecting the intestinal or bronchial mucous membrane, may lead to parenchymatous degenera- tion of the liver, fieart, kidneys, or blood. During the last feAV years I haA'e seen many patients Avith simple bronchial or intestinal catarrh die Avith severe nervous symptoms, icterus, moderate swelling of the liver, irregular and retarded pulse, albuminuria, etc., without there be- ing any suspicion of an infectious disease. Such cases, which, like " bilious pneumonia," are more frequent at certain times, and occur oftener in certain regions, particularly in the tropics, doubtless form part of the bilious fevers of old writers, while another part of them Avere certainly cases of pyaemia and other infectious diseases. Muriatic acid has a great reputation in the treatment of gastric fever. We are undecided as to whether the common prescription of half a drachm of concentrated muriatic acid to six ounces of muci- lage, or of a Aveak infusion of ipecacuanha (gr. viij— § vj), has the favorable effect ascribed to it. At all events, patients usually take this remedy wilfingly, and it moderates the thirst; and it is worthy of remark, that this prescription furnishes the gastric juice Avith the acid to AA'hich, as physiology shoAVS, it OAves its digestive poAvers. In catarrhal fever we prescribe the alkaline carbonates, particu- larly the tinctura rhei aquosa. I have used this prescription, just as advised by Schonlein, in rather large doses, i. e., a teaspoonful every two hours, with excellent effect; and can fully support its recom- mendation as almost a specific in this disease. I have also observed that the patients do not well bear the customary soups, and get along better if we give them, from time to time, a small piece of black bread, sprinkled with salt. In febris biliosa the mineral acids are usually prescribed. Perhaps an antipyretic treatment, such as quinine, in large doses, and the en- ergetic abstraction of heat by cool baths, or repeatedly Avrapping the body in wet sheets, avUI do still better. SECTION VI. DISEASES OF THE PERITONEUM. I CHAPTER I. INFLAMMATION OF THE PERITONAEUM, PERITONITIS. Etiology.—For the pathogeny of peritonitis we may refer to what was said of the pathogeny of pleuritis and pericarditis. The same course that we have described as occurring in • the pleura and pericardium during those diseases is repeated in the peritonaeum during peritonitis; while there is a new formation of young connective tissue, \ a proliferation in the peritonaeum, its surface is covered by a fibrinous exudation, containing a variable number of young cells—pus-cor- puscles. In some cases of chronic peritonitis, however, the inflamma- tion seems to remain limited to tfie proliferation of the peritoneal con- necth'e tissue, and there is no free exudation. It is most probable that the thickenings and adhesions of the peritonaeum, Avhich exactly resemble those of the pleura, and, like these, are formed without symp- toms, occur in this manner. The predisposition for peritonitis, at least for the acute and diffuse form, is not great in strong, healthy persons. Slight causes, such as frequently induce inflammations of other serous and of mucous mem- branes, scarcely ever cause peritonitis. Hence, when a previously healthy person is attacked Avith peritonitis, we should suspect that it is due to one of the serious difficulties beloAV mentioned, and should not consider it as a case of so-called rheumatic peritonitis till these other causes have been excluded, AA'hich is sometimes a difficult task. The tendency to peritonitis is much greater in persons affected Avith tuber- culosis, morbus Brightii, and other exhausting diseases, as well as in women at the menstrual periods, than in healthy persons. Among the former, slight causes not unfrequently suffice to induce peritonitis. We have frequently given our reasons for not considering these cases of peritonitis as secondary symptoms, just as AA'e have done the 39 610 DISEASES OF THE PERITONAEUM. pneumonia and pleurisy Avhich so frequently occur under the same cir- cumstances. Finally, in not a feAV cases, peritonitis is the immediate result of an infection, and comes under the same category as the inflam- mations of the skin in exanthematous diseases. This form will be de- scribed Avhen speaking of puerperal fever, and other infectious diseases which are " localized in the peritonaeum." Among the exciting causes of peritonitis are: 1. Severe contusions and penetrating Avounds of the abdomen. Among the surgical operations, paracentesis rarely leads to diffuse peritonitis, operations for hernia do so more frequently, Avhile gastrot- omy ahva3's causes it. 2. In the same way it may be caused by ruptures or perforations of organs covered by the peritonaeum, and the consequent entrance of foreign bodies into the peritoneal sac. Thus perforating ulcer or can- cer of the stomach, ulceration of the vermiform process, or of the ccecum, typhoid or scrofulous ulcers of the intestine, perforation of the gall or urinary bladder, opening of abscesses of the liver or spleen, etc., may cause peritonitis. In all these cases the inflammation usu- ally spreads rapidly over the entire peritonaeum. It is only rarely circumscribed by old attachments, or recent adhesions of the intestines, protecting other parts of the peritonaeum from contact with the escaped substances. 3. Peritonitis may result from propagation of inflammation from other organs; the peritonaeum participates in the inflammation of or- gans covered by it, just as often as the pleura does in inflammation of the lungs. Of this nature is the peritonitis in typhlitis stercoracea, strangulated hernia, internal strangulations, rotations, and intussuscep- tions of the intestines. Inflammation often extends from the female sexual organs to the peritonaeum. In the same Avay hepatitis or sple- nitis may cause peritonitis. In these cases the inflammation is usually circumscribed at first; and in many cases it remains so during its sub- sequent course; in others, particularly in those caused by incarcera- tion and similar processes, it becomes diffuse. 4. As we have already said, peritonitis very rarely occurs in per- sons previously healthy, from catching cold, or from unknown atmos- pheric influences. When it does occur, it is called rheumatic perito- nitis. Anatomical Appearances.—We shall first speak of the appear- ances in acute diffuse peritonitis. At the commencement of this disease the peritonaeum is reddened partly by hyperaemia, partly by the escape of blood into the tissue. But, to discover this redness, it is usually necessary, first, to remove from the peritonaeum the deposits Avhich will be described hereafter. INFLAMMATION OF THE PERITONAEUM, PEIIITONITIS. Gil Subsequently this redness disappears, apparently because the capU- laries are compressed by the occurrence of oedema in the tissue of the peritonaeum. The surface soon becomes cloudy from loss of its epithe- lium, and has the velvety appearance which, as we have fully described in pleuritis, depends on a proliferation of the connective tissue compos- ing the peritonaeum. Far more noticeable than these structural changes of the perito- naeum, are the exudations which never fail even after a short duration of the peritonitis. Their shape and amount vary greatly. Occasion- ally a thin transparent layer of coagulated fibrin, which may be peeled off like a delicate membrane, coats over the inflamed peritonaeum, and unites the loops of intestine loosely together; fluid exudation is no- Avhere to be found. In other cases the deposit is thicker, less trans- parent, yellow, like croup membrane, and, in the dependent parts of the abdomen, there is a moderate amount of cloudy flocculent serum. In other cases there is a great quantity of exudation; when the abdo- men is opened, an immense amount of turbid, flocculent fluid escapes, AvhUe a still greater quantity remains among the intestines, in the pel- vis, and along the spine. Then, besides the membranous deposits cov- ering the peritonaeum, Ave find numerous yelloAV clumps of coagulated fibrin which partly swim in the fluid, partly sink, and collect in the dependent parts of the abdomen. The scanty, very fibrinous exudation is chiefly found in peritonitis due to injuries or to propagation of inflammation from neighboring organs. On the contrary, the abundant sero-fibrinous exudations are more frequent in peritonitis from perforations, or dependent on infec- tion, particularly puerperal, and lastly in the so-called rheumatic peritonitis. All the coats of the intestines are the seat of collateral oedema, particularly in those cases accompanied by profuse exudation. Con- sequently the intestinal Avail appears thicker; the oedema of the mu- cous membrane has caused serous transudation into the intestine, and the oedema and paralysis of the muscular coat have often led to enor- mous collections of gas in the intestine. The superficial layers of the liver, spleen, and abdominal walls, are often infiltrated and discol- ored. Finally, Ave must mention (more particularly as this partly explains the early death), that the exudation, and still more the dis- tention of the intestines, may press the diaphragm up to the third or second rib, and compress a great part of both lungs. If the patient does not die at the height of the inflammation, the appearances change. In the most favorable cases the fluid part of the exudation is rapidly absorbed. Subsequently the coagula and pus corpuscles, AA'hich are partly enclosed in them and partly suspended in 612 DISEASES OF THE PERITONAEUM. the fluid, also disappear after they have undergone a fatty metamor- phosis, become fluid, and ready for absorption; but partial thickenings and adhesions of the peritonaeum always remain. In less favorable cases the absorption of the fluid part of the exudation is incomplete. The pus-corpuscles, Avhich Avere at first rare in the exudation, now in- crease so as to give it a purulent appearance, and the fibrinous deposits also become yellower and softer. At some places the intestines ad- here quite firmly and enclose tfie fluid, thus limiting its motions. If the patient survive this stage also, which is usually found in persons who have died in the fourth to sixth week of peritonitis, the capsulated fluid may be absorbed or thickened, and changed to a yellow cheesy or even chalky mass, which, enclosed in tough connective tissue, re- mains in the abdominal cavity. In other cases the extensive cell-for- mation occurring in the free surface of the peritonaeum attacks the tis- sue itself, causing ulceration and perforation of the peritonaeum; accord- ing to the location of this perforation, the capsulated fluid reaches the intestines or bladder, breaks through the abdominal walls, or descends into the cellular tissue of the pelvis, and escapes outwardly at some deeper point. In acute partial peritonitis, the changes that Ave have described are limited to the serous coating of the liver, of the spleen, of a portion of intestine, or of "several loops lying near together, and to the immedi- ate Adcinity of these parts. If the exudation be scanty and fibrinous, the process usually terminates AA'ith the adhesion of the inflamed parts. If the exudation be more copious and sero-fibrinous, portions may be capsulated between the inflamed parts, as in the diffuse form, and these capsulations run the course above described. By chronic peritonitis is usually meant, first those cases which, beginning acutely, run a protracted course, and lead to the formation of the collections of pus above described. Secondly, those cases occur- ring, particularly in children, in connection with tuberculosis of the intestine and mesenteric glands, Avhich are chronic from the start, and spread over the whole or the greater part of the peritonaeum. This form is characterized by the excessive proliferation of connective tis- sue, as a result of which there are gelatinous or indurated thickenings of the peritonaeum. The intestines usually adhere in shapeless masses, and between the various convolutions there are caAdties filled with serous, purulent, or bloody fluid. The admixture of blood depends on the rupture of vessels, which usually occurs AA'here a chronic inflamma- tion is repeatedly lighted up, for not only the original tissue, but that Avhich has recently formed on it, and is rich in large and thin-walled capUlaries, becomes the seat of the new inflammation. Tubercles are often found in the thickened peritonaeum, in this form of peritonitis; this INFLAMMATION OF THE PERITONAEUM, PERITONITIS. 613 is most apt to occur Avhere there is haemorrhagic exudation. Thirdly, and lastly, there is very frequently a partial chronic peritonitis, Avhich Ave knoAV better in its results than in its first stages. It occurs in chronic inflammations and degenerations of the abdominal Adscera, and causes partial cloudiness and thickening of the peritonaeum, adhesions of neighboring organs to each other, and distortions and folds of the intestines. Symptoms and Course.—The symptoms of acute diffuse perito- nitis at its commencement A'ary AA'ith the causes which induce it. Traumatic peritonitis usually begins Avith severe pain at the seat of the injury, which quickly spreads over the entire abdomen. In peri- tonitis from perforation also, excessive pain over the AA'hole abdomen is the first symptom, if the perforation has occurred suddenly, and foreign substances have entered the peritonaeum. At first, along Avith the pain there are symptoms of great general depression, and subse- quently there is severe fever. If the perforation occurs gradually, and only a slight amount of foreign substances enters the peritonaeum, the symptoms of general peritonitis are preceded by those of partial peri- tonitis. The commencement of an acute diffuse peritonitis, AA'here the inflammation is propagated from neighboring organs, is far less strik- ing. The pain already existing gradually increases ; it is at first re- stricted to the seat of the affected organ, and thence spreads gradually over the entire abdomen. It is only in rheumatic peritonitis, and those cases resulting from infections, that AA'e have a severe chill and intense fever at the onset of the disease, as in other severe inflamma- tions. No matter Iioav the disease begins, Avhether there is fever at first, or it does not come on till late, pain is ahvays the most troublesome and the most characteristic symptom. Any slight pressure on the ab- domen increases it; even the pressure of the bed-clothes may become unbearable. The patient does not toss about the bed, as he does in colic, but lies on his back Avith the knees drawn up, and dreads every change of position. The slightest cough causes a distortion of the countenance, from pain ; the patient speaks Ioav and carefully, and does not breathe deep, fearing the pressure of the descending dia- phragm. The abdomen soon becomes tense and puffed up. At first the distention depends but little on filling of the abdomen Avith exuda- tion, and is mostly caused by distention of the intestines, Avhich are filled with gas. This tympanitis is not easily explained; it is proba- ble that it is not due to an increased formation of gas, for we can find no cause for a more rapid decomposition of the contents of the intes- tines ; and it is just as unlikely that air should be exhaled from the •vail of the intestine in peritonitis. Hence the meteorismus seems to 614 DISEASES OF THE PERITONEUM. depend, to a small degree, on the expansion of the gases due to relax- ation of the intestinal walls ; to a greater degree on obstructed escape of the gases due to paralysis of the muscular coat. The belly may soon become very much distended. But of course the exudation and the inflated intestines press upAvard against the diaphragm in the same way that they press against the abdominal Avails, and so cause symp- toms which, next to the pain, are the most distressing and most dan- gerous. The compression of the lower lobes of the lung by the up- Avard pressure of the diaphragm, as well as the excessive hyperaemia of the non-compressed portions of lung (resulting from the disturbance of circulation in the compressed portions), induces excessive dyspnoea and a frequency of respiration of 40 to 60 inspirations in a minute. The effect of the disturbance of tfie circulation of the lungs may extend be- yond the right side of the heart to the veins of the general circulation, and give the patient a cyanotic look. In most cases of acute diffuse peritonitis the patient is obstinately constipated; this symptom is ex- plained by paralysis of the muscular coat of the intestines by collateral oedema. In puerperal peritonitis alone there is usually watery diar- rhoea ; for in this form the oedema extends to the mucous coat, and causes copious transudation into the intestines, and, if they become someAvhat full, it flows aAvay in spite of the paralysis of the muscular coati If Ave set such patients up in bed, or if Ave press strongly on the abdomen, watery, slightly-colored masses pass from the anus. Besides the above symptoms, there is often vomiting, provided the peritonitis has not been caused by the perforation of a chronic ulcer of the stomach. At first the vomited masses are mucous and colorless, later they are more Avatery, greenish, or even intensely green. The causes of the vomit- ing, and the circumstances under which it is absent, are obscure. This difference is not explained by the participation of the covering of the stomach in the inflammation, or by its freedom from it. If the inflam- mation extend to the peritoneal covering of the bladder, there arises an incessant desire to urinate, and a feeling of fulness in the bladder. If an inexperienced physician be deceived by this, and be induced, by the patient's desire to urinate, to introduce a catheter, only a few drops of concentrated urine AAdll be withdrawn. Fever is one of the symp- toms of acute diffuse peritonitis, and, where this does not begin with the disease, it occurs very early. The pulse is very frequent and small; the temperature rises to 105° or more. As in any severe fever, the general state of the patient is much affected—the mind is unusually clear. In severe cases the above symptoms become very decided in a feAV days. But the pain is usually worse at first, and subsequently dimin- ishes. The belly is inflated like a drum; the liver and the point of the INFLAMMATION OF THE PERITONEUM, PERITONITIS. 615 Heart are often pressed up as high as the third rib. While at the com- mencement of the disease percussion gave a full tympanitic sound, after the exudation has become abundant, there is a distinct but rarely ab- solute dulness. The anxiety of the patient is pitiful; he beseeches aid, and looks perfectly desperate. If a quantity of blood be not ab- stracted, or the volume of blood be not diminished by extensive exuda- tions, the countenance may become excessively cyanotic. Finally, the mind becomes cloudy, the patient grows apathetic and defirious, the pulse is smaller and more frequent, the body covered wdth cold sweat, and occasionally on the third or fourth day after the commencement of the affection, or more frequently at the end of the first week, the patient succumbs to his disease. If the malady take a favorable course, Avhich usually occurs only Avhen Ave succeed in removing the exciting causes, or when these are not A'ery grave, the pain, tympanites, and fever gradually subside, the respiration becomes freer, and the patient may recover rapidly. But A-ory often, as a result of the adhesions and flexions of the intestines, habitual constipation, and occasionally colicky pains before stool, re- main for life. If the patient does not die during the first Aveek, and if there be no decided improvement during this time, the character of the disease usually changes : it takes on a more chronic course. The pain moder- ates, the abdomen is only sensitive on hard pressure, the tympanitis decreases Avithout disappearing entirely. If, up to this time, the pa- tient has suffered from constipation, he noAv has movements from the boAvels ; if, on the contrary, there was diarrhoea as a result of the ex- cessive transudation into the boAvels, this disappears, or constipation and diarrhoea alternate. The pulse and temperature also sink some- Avhat, Avithout, hoAvever, becoming normal. As the tympanites sub- sides, the dulness at the dependent parts of the abdomen usually be- comes more distinct, and at the dull spots we perceive a gradually increasing resistance ; by degrees the abdomen becomes unsymmetrical and nodular, and the capsulated exudations appear like irregular tu- mors. The feA'er, although moderated, continues and exacerbates from time to time, and it consumes not only the strength of the patient, but his blood and tissues. The fat disappears, the muscles become flabby and relaxed, the skin dry and scaly; not unfrequently there is oedema of the legs, and in the fourth, fifth, or sixth Aveek, the patient dies of exhaustion. If, contrary to our expectation, there be reabsorption of the fluid, convalescence is very slow, and the symptoms of contraction and distortions of the intestines, which remain more constantly after these cases, are the sources of long and severe sufferings. If there be ulceration and perforation of the peritonaeum, the fever increases, and, 616 DISEASES OF THE PERITONEUM. at some circumscribed spot, the abdominal Avails become infiltrated, reddened and finally the pus breaks through, or abscesses form and point at the most varied places, or, in fortunate cases, the abscesses perforate into the intestine, and the pus is passed at stool. In these cases, also, the patients usually die of exhaustion, and but few recover after tedious convalescence. Acute partial peritonitis is usually preceded by premonitory symp- toms, due to the disease of the organs, from Avhich the inflammation extends to the peritonaeum. Thus acute partial peritonitis, beginning in the right iliac fossa, is usually preceded by the symptoms of typh- litis ; that commencing in the hypogastric, epigastric, or right hypo- chondriac regions, by the symptoms of ulcer of the intestines or stomach, or of abscess of the liver. The commencement of the disease itself is characterized by pain extending over the entire abdomen, but the great sensitiveness of the abdomen to pressure, AA'hich is almost characteristic of peritonitis, is limited to a circumscribed portion. Tym- panites is wanting, or is, at least, partial, and the fever is more moder- ate than in the diffuse form. If the exudation be not extensive, these symptoms usually disappear rapidly, and the disease ends in perfect cure, unless adhesions form to disturb the movements of the intes- tines, or the original disease cause some other termination. When the exudation is more extensive, acute partial peritonitis runs a dif- ferent course. In the A'icinity of the peritonitis the percussion gradu- ally becomes duller, the resistance of the abdominal walls more de- cided, till finally, in this case also, palpation shoAvs a tumor in the ab- domen. Such masses occur rarely after perforation of ulcer of the stomach; more frequently in the sIoav perforation of tuberculous in- testinal ulcers, and in ulcerations of the ccecum, and the vermiform process. Its subsequent course is the same as that of capsulated ab- scesses, after protracted diffuse peritonitis. In his clinic of abdominal diseases, Henoch gives a very true de- scription of the chronic peritonitis which occurs, particularly in child- hood, along with tuberculosis of the intestines and mesentery. He pictures the children as weak, scrofulous individuals, in Avhom the occa- sional colicky pains, the diarrhoea, alternating with constipation, and the increasing emaciation, often excite the suspicion of worms, or of tabes mesenterica. On careful examination of the abdomen, during which Ave must guard against mistaking the signs of displeasure for those of pain, Ave find it more sensitive at certain points. Sometimes even the pressure of the abdominal muscles causes pain, so that the child cries when going to stool. While the emaciation progresses rap- idly, and becomes very great in a feAV months, Avhile fever, toward even- ing, occurs regularly, the belly of the child becomes more protuberant, INFLAMMATION OF THE PERITONEUM, PERITONITIS. 617 and gradually assumes a spherical shape. Finally, the abdominal Avails become tense, even shining, and are often traversed by enlarged veins. By pressure on the abdomen, which is stUl painful for the chUd, Ave find an elastic resistance. The results from percussion of the abdomen vary. Only in rare cases can a free exudation be recognized by dulness in the dependent portions of the abdomen, which changes its locality AA'ith the change in position of the patient. More frequently the entire abdomen gives a dull sound, as the intestines are drawn back against the spine by the atrophying mesentery, and the exudation lies on the abdominal Avail. In most cases the percussion is tympanitic at some places (Avhere the intestines He), and dull at others (where the fluid is). If Ave bear in mind this description, Ave shall rarely mistake this disease, Avhich does not often occur, and which alone, or by its complications, ahvays causes death. Chronic partial peritonitis, Avhose remains, in the shape of thick- enings, adhesions, and cicatricial contractions of the peritonaeum, are found in the cadaver just as often as thickenings and adhesions of the pleura, develops just as latently as the pleuritis does, from AA'hich the pleuritic adhesions arise, and Ave cannot give any description of it. Diagnosis.—Peritonitis is not readily mistaken for any other dis- ease, as the great sensitiveness of the abdomen to the slightest pres- sure, the tympanites, and, in the acute form, the fever, give almost certain points for the diagnosis. Those cases dependent on perforation of ulcers of the stomach or intestines, that haA'e not been recognized, present some difficulties of diagnosis. The sunken countenance, cool skin, small pulse, retracted abdomen, and other symptoms of severe general depression, remind us more of colic than of a severe inflam- mation. But if Ave bear in mind how insignificant the symptoms of gastric and duodenal ulcers may be, and if we observe how sensitive the abdomen is to pressure from the commencement, avc shall aA'oid error. On the other hand, colic, and the impaction of bilious and urinary calculi, may be erroneously considered as peritonitis; but the diag- nosis is only difficult in those cases Avhere, hi hysterical Avomen, mesen- teric neuralgia is complicated Avith hyperaesthesia of the skin of the abdomen, in the so-called rheumatic colic, and in that from gall-stones, AA'hen the right hypochondrium is very sensitive to pressure. In these cases it may be necessary to wait for further developments before form- ing a diagnosis. In all other cases, the insensibility of the abdomen to pressure, or even the relief afforded by this, renders the diagnosis certain very early in the disease. Prognosis.—Although most of the patients attacked Avith perito- nitis die of the disease, it is not because this affection is particularly ill borne by the organism, but because it almost ahvays depends on 618 DISEASES OF THE PERITONEUM. grave injuries or severe blood-disease, or occurs in persons previously ill, and haA'ing little power of resistance. If peritonitis be induced by the same causes on which most cases of pleuritis depend, the prognosis is unmistakably better than it is in the latter disease. Thus we fre- quently see the rheumatic peritonitis, which exceptionally occurs in otherAvise healthy persons, particularly in menstruating women, as well as that Avhich accompanies retention of faeces, typhlitis, or even strangu- lated hernia, terminate in cure, proAdded the exciting causes can be removed soon enough. Still less dangerous is the circumscribed chronic peritonitis, Avhich complicates chronic inflammations and degenerations of the abdominal organs. We might regard the final object of this inflammation as an attempt of Nature to guard against future injury. Among the symptoms on Avhich the prognosis depends, in each case, are, in the commencement of the disease, tympanites, and the dyspnoea that it causes; the more oppressive the latter, the greater the danger. Subsequently, particularly in protracted cases, the fever and the strength and nutrition of the patient affect the prognosis more than most of the other symptoms. Treatment.—Where retention of faeces, and consequent ulceration of the intestines, particularly typhlitis stercoracea, or where strangu- lated hernia has caused peritonitis, the causal indication may be an- SAvered by the treatment for the original disease and by operation, respectively. In all other cases Ave cannot fulfil it. This, however, is j the proper place to speak of the treatment of perforation by large and ! repeated doses of opium; by arresting, as much as possible, the move- ments of the intestines, this prevents, to some extent, the contact of the escaped substances with large portions of peritonaeum; and, more particularly Avhen these foreign substances are shut off from the rest of the peritoneal cavity by adhesions, it prevents their breaking through. Statistics shoAV favorable results for this treatment, and, in cases where, instead of opium, purely symptomatic treatment was used, and the constipation Avas treated by enemata and purgatives immediately after the use of these remedies, I have often seen a peritonitis, Avhich was preAdously circumscribed, and might have remained so, spread over the entire peritonaeum. At first Ave give gr. ss—j of the opium every hour, and later do not give it so often. Concerning the indications from the disease, views have changed greatly of late. Formerly every patient treated lege artis Avas bled a pound or tAvo; then the abdomen was covered with leeches, and one to two grains of calomel given every two hours, and at the same time i quantity of mercurial ointment was rubbed into the skin of the thighs and abdomen. " That Avas the proper treatment; the patients died, and no one thought of asking who recovered." It is true, Ave INFLAMMATION OF THE PERITONEUM, PERITONITIS. 619 cannot claim any brilliant results from the treatment noAV in vogue; but that above given Avas just as irrational as it Avas injurious. On examining the bodies of persons Avho had died of peritonitis Avith abundant effusion, even when no blood had been taken, the tissues Avere found uncommonly bloodless, as a result of the excessive exudations. But, on examining the bodies of persons dying from a peritonitis treated lege artis, Ave find so very little blood in the heart and arteries, that Ave are tempted to ascribe death to the treatment rather than to the disease. If to this we add the fact that experience shoAVS that a great loss of blood during labor proves to be no protection against an epidemic puerperal fever, and that all injurious influences Avhich generally act as causes of peri- tonitis are just as active in debUitated, bloodless persons as in the strong and AveU-nourished, Ave silently pass over other reasons for avoiding A'enesection. (Nevertheless, we shall hereafter see that the symptomatic indications occasionally demand bleeding.) Of late scarcely any one believes in the antiphlogistic and antiplastic action of mercury, and Ave do not hesitate to say that we consider calomel and mercurial ointment as at least superfluous in the treatment of peritonitis, and that in purgative doses Ave regard calomel as directly injurious. It is far different AA'ith local blood-letting, Avhich is much less dangerous than A'enesection, and of AA'hose beneficial effect on the pain, at least, there is no doubt; this effect does not fail even in those cases AA'here the peritonitis is caused by perforating ulcer of the stomach. The employment of cold acts in the same Avay, and perhaps it has even more effect on the inflammation itself. If the patient can bear it—Avliich, unfortunately, is not ahvays the case—Ave may cover the entire abdomen AA'ith cold compresses, and reneAV them every ten minutes. From this treatment, AA'hich is recommended by Abercrombie, Kiwisch, and others, I have seen the best results in cases that Avere amenable to any treatment; but I cannot deny that warm cataplasms Avere bet- ter borne than cold compresses by many patients. Recently the re- sults of the opium-treatment in peritonitis, caused by perforation, and the belief that the inflamed parts needed rest more than any thing else, have rendered opium popular in the treatment of all forms of peri- tonitis. We agree fully Avith those Avho consider the application of leeclies to the abdomen, the use of cold, and the internal administra- tion, of opium, as the most effective treatment. If the disease be pro- tracted, and capsulated collections of pus are formed, the persistent use of cataplasms and the early evacuation of fluctuating abscesses are urgently to be adA'ised. The same treatment is indicated in chronic peritonitis, and the internal use of iodide of potassium, and painting the abdomen AA'ith tincture of iodine, should be tried at the same time. 620 DISEASES OF THE PERITONEUM. In regard to the symptomatic indications, an early cyanosis, and still more excessive dyspnoea, if accompanied by symptoms of oedema of the lungs, requires venesection. It is true, this only temporarily removes the danger to fife; but we know of no other remedy to fulfil this urgent indication. The administration of oil of turpentine, long since recommended in England, benefits the cause of the dyspnoea, the tympanites, just as fittle as the absorbents and other remedies, by which it has been attempted to carry gases off from the intestines. The introduction of a small trocar into the abdomen, to draw off the gas, should be avoided, as Ave may attain just as much by the introduc- tion of a tube through the rectum {Bamberger). The vomiting is most benefited by SAvallowing small pieces of ice. Even the mUdest eccoprotics should not be used for the constipation untU the inflamma- tion has ceased; generally, opium is as useless as the astringents in the diarrhoea depending on the oedema of the mucous membrane. In pro- tracted cases, where there seems to be danger from the consumption caused by the fever, Ave should give sulphate of quinine in large doses, 6mall quantities of Avine, and a nutritious and easily-digested diet. CHAPTER II. DROPSY OF THE PERITONAEUM--ASCITES. Etiology.—Dropsy of the peritonaeum—ascites—is a transudation into the abdominal cavity, resembling the normal transudations of the body. The circumstances under Avhich ascites develops are the same as those under which increase of the transudations occurs elseAA'here, and may either be referred to increased lateral pressure in the vessels, or to a diminished amount of albumen in the blood, or, lastly, to a degen- eration of the peritonaeum: 1. Ascites is very often one symptom of general dropsy, Avhether this depend on obstruction to the flow of blood from the veins, by dis- ease of the heart and lungs, or on degeneration of the kidneys, of the spleen, or any other disease inducing poverty of the blood. In all these cases the ascites is usually one of the last in the series of dropsi- cal symptoms, and does not occur till dropsical effusions in the sub- cutaneous tissue (anasarca) of the extremities, face, etc., have existed for some time. 2. In other cases, the ascites is the result of a congestion confined to the vessels of the peritonaeum. As this can only occur from an ob- struction of the portal vein, it is evident that ascites occurring alone, without dropsy of any other part, accompanies diseases of the liver and its blood-vessels. DROPSY OF THE PERITONEUM—ASCITES. 621 3. Lastly, ascites not unfrequently accompanies extensive degenera- tion of the peritonaeum, such as carcinomatous or tuberculous. Of the various forms of carcinoma, however, the alveolar carcinoma of the peritonaeum alone appears to be accompanied by extensive ascites. Anatomical Appearances.—The amount of serum found in the abdomen A'aries. In some cases it is only a feAV pounds, in others it is forty or more. The fluid is sometimes clear, sometimes slightly cloudy, from containing cast-off and fatty epithelium. It is usually bright yellow, rich in albumen and salts, and only rarely contains flocculi of coagulated fibrin. In the fluid which is poured into the abdomen, particularly in de- generation of the peritonaeum, precipitates of " late coagulating fibrin " (fibrin spatergerinntlng) form after it stands awhUe in the air. This i appears to depend on the fact that, in degeneration of the peritonaeum, blood is often mixed Avith the transudations. Since Schmidt has shown that there is a deposit of fibrin after the addition of blood, as in all transudations, the expression " late coagulating fibrin" has ac- quired a different meaning. The peritonaeum itself is usually dull and whitish; the superficial layers of the liver and spleen are slightly discolored. Under the pres- sure of large effusions, the liver, spleen, and kidneys may become bloodless and smaller. Lastly, the diaphragm is occasionally pressed upAvard, to the third or second rib, by the fluid. Symptoms and Course.—It is scarcely possible to give a descrip- tion of ascites, as it is never an independent disease, and as its symp- toms can only be artificially separated from those of the original af- fection. If ascites occur during general dropsy, the subjective symptoms of the neAV disease, Avhen compared with the other troubles of the patient, are usually too unimportant at first to direct attention to the ascites. Then the physical examination, induced by the suspicion that there ma}- be ascites, gives the first certain knoAA'ledge of its existence. The case is different in the ascites accompanying disturbance of the portal circulation or degeneration of the peritonaeum. When cirrhosis of the liver or cancer of the peritonaeum occurs latently, the gradually in- creasing troubles caused by the ascites may be the first anomalies noticed, and may first excite a suspicion of tfie original disease. As long as the abdomen is moderately filled Avitfi fluid, the patients only complain of a feeling of fulness, and are inconvenienced by the tight- ness of clothes Avhich Avere previously comfortable. They also notice sfio-ht difficulty on deep inspiration. If the fulness of the abdomen increase, the sensation of fulness becomes painful, and the slight diffi- culty of breathing increases to severe dyspnoea. The pressure of the fluid on the rectum may cause constipation, and the flatulence induced 622 DISEASES OF THE PERITONEUM. by this may increase the dyspnoea. Still more frequently the secretion of urine is diminished by the pressure of the fluid on the kidneys. It is an old belief that, after diuretics have lost their effect, they reacquire it after tapping the abdomen. This supposition apparently depends on a false interpretation of the fact that ascites adds a neAV difficulty to an already existing obstruction to the urinary secretion, and Avhen it is removed the obstruction is diminished. The pressure on the A'ena cava and the iliac veins, wfiere there is much effusion, causes obstruc- tion of the circulation in the lower extremities, external genitals, and the abdominal walls. This explains the venous dilatation of those parts, and the dropsy of the subcutaneous tissue, which may become very great, and lead to mistaken ideas of the disease. We should never neglect to ask whether the legs and scrotum, or the abdomen, be- gan to swell first. Almost all patients with ascites are in great danger; most of them, however, do not die of the ascites, but of the original disease. The obstruction of the respiration or the excoriations and super- ficial gangrenes, Avhich occasionally result from the excessive ten- sion of the skin of the external genitals and thighs, may hasten the fatal result. Physical examination of the abdomen is most important in the diagnosis of ascites. On inspection, the first thing noticed is the dis- tention and peculiar form of the abdomen. As long as the effu- sion is moderate, the shape of the belly changes with every change of position of the body. If we examine the patient AA'hile he is standing, the lower part of the abdomen appears prominent; if he be lying doAvn, the belly appears very broad. But if the transudation be ex- cessive, the abdomen is protruded everywhere as far as the loAver ribs; the false ribs themselves are elevated and pressed outAvardly. Then the abdomen maintains its shape in all positions. In excessive ascites, inspection almost always shows thick networks of blue veins in the thinned coverings of the abdomen. The navel is protruded, and rup- tures in the tissue of the corium form bluish-white translucent striae, Avhich also occur during pregnancy, if the abdomen be very much dis- tended. If the level of the fluid rise above the brim of the pelvis, Ave may feel fluctuation by placing one hand flat on the abdomen and smartly tapping on the opposite side Avith the fingers of the other hand. Lastly, Avherever the fluid is in contact with the abdominal Avail, percussion is absolutely dull. At the same time it is important to notice that, except in those cases Avhere the Avhole anterior surface gives a dull percussion-sound, the dulness varies Avith any change in position of the patient, because the fluid ahvays goes to the most de- pendent part. DROPSY OF THE PERITONEUM—ASCITES. 023 Diagnosis.—To distinguish free dropsy from ovarian dropsy, it is imperatively necessary to obtain a perfect history of the case by a careful examination of the patient, and to pay particular attention to any possible causes of dropsy that may be discovered. The circum- stances under AA'hich ovarian dropsy occurs are little knoAvn; we only knoAV that it is often found in apparently healthy Avomen Avithout be- ing compficated AAdth any other disease. It is quite different AA'ith ascites. If aac can determine that none of the anomalies of composi- tion or distribution of the blood, described under etiology, have pre- ceded the collection of fluid in the abdomen, and if degeneration of the peritonaeum can also be excluded, in doubtful cases, the chances aa ill be most in favor of ovarian dropsy. There are cases Avhere the differential diagnosis depends entirely on the above factors, as the physical examination gives no decided eA'idence. In small ovarian cysts, it is true, the characteristic form and position of the sac, the lateral deviation of the os uteri, the similar results of percussion Avhile the patient is in different positions, readily distinguish OA'arian dropsy from ascites. But> when the cyst is very large, the peculiar form of tfie sac is lost; it lies in the middle of the belly, the uterus is pressed dowmvard by the Aveight of the sac, but is not laterally displaced; as in extensive ascites, the percussion is dull over the entire anterior ab- dominal wall. Bamberger advises us to pay particular attention to the spot between the crest of the ilium and the tAvelfth rib, for, in ovarian tumors at that point, Ave generally find the full sound of the large intestine, in ascites we do not. Still he acknoAvledges that this sign occasionally fails. After ascites has been recognized, the most important question is, Avhat is its cause ? We haA'e already mentioned that ascites, occurring as one symptom of general dropsy, is never its first symptom. Hence, if ascites occurs in a person Avho has no oedema, it either depends on obstruction of the portal circulation or on degeneration of the perito- naeum ; it is often difficult to decide which of the tAvo is the case. In general Ave may say that the coincident occurrence of symptoms of congestion in other branches of the portal vein, or the signs of dis- turbed action of the liver, indicate the first form ; AA'liUe cachexia, signs of cancer, or tuberculosis in other organs, but, above all, the presence of tumors in the abdomen, indicate the latter form. The color of the urine is very important in the differential diagnosis. For, in those diseases of the liver that lead to ascites, the urine, as a rule, contains either traces of the coloring matter of the bile or abnormal pigment; in degeneration of the peritonaeum, on the contrary, it is almost always of normal color. Treatment.—When the ascites is a partial symptom of genera] 62d DISEASES OF THE PERITONEUM. dropsy, and depends on obstructed evacuation of the vena cava, the causal indications require a treatment of the often-mentioned heart and lung diseases; and when it is the result of excessive hydraemia, a suitable treatment of the exhausting original disease and an improve- ment of the quality of blood. In the former case we are generaUy unable to fulfil the indications. In dropsy resulting from intermittent, morbus Brightii, and the convalescence from severe disease, the fulfil- ment of the latter indications usually has the best result and does much more good than the old-fashioned routine administration of hydra- gogues. When the portal or hepatic veins are compressed or obliter- ated, we cannot render them pervious again, nor can we cause an ex- pansion of the contracting parenchyma of the liver which constricts the vessels in cirrhosis of the liver. In regard to the causal indica- tions in ascites resulting from tuberculosis or carcinoma, we are just as poAverless. The indications from the disease demand the removal of the fluid in the abdomen. Almost all patients Avith ascites have diuretics pre- scribed them, but the number cured by these is hardly Avorth mention- ing. If the ascites be one symptom of general dropsy, diuretics may very properly be given, but, if the result of portal obstruction, they do no more good than they Avould in oedema of the leg from obstruction of the crural vein by a thrombus. The case is different with drastics. Practitioners haA'e long preferred these to diuretics in the treatment of ascites; and, in obstruction of the portal vein, we can readily see why they should be more efficient, as they cause a depletion of the branches of the portal vein, and hence diminish the increased lateral pressure, Avhich is the cause of the ascites. In ascites, the most active among the drastics are usually chosen, and of the various compositions that have gained a reputation as hydragogues, we may mention Heim's pill, which, besides squills and golden sulphuret of antimony, contains chiefly gamboge. As long as the strength of the patient and the con- dition of his abdominal canal permit the use of drastics, they are bene- ficial, but if the strength fail decidedly, or the bowels become irritated, they must be given up. The operation of tapping is almost always free from danger, and it removes the fluid from the abdomen more cer- tainly than any other method of treatment. But the more the sfight danger and certain effect of tapping speak in its favor, the more neces- sary it becomes to enumerate its bad subsequent results. We should never forget that we do not remove water, but an albuminous fluid, from the abdomen, and that the fluid evacuated is almost always soon replaced by a new effusion. This is a severe tax on the patient's strength and supply of blood. DaUy experience teaches that, after the first tapping, emaciation progresses much more rapidly than previ- TUBERCULOSIS AND CANCER OF THE PERITONEUM. 625 ously. From Avhat has been said, it folloAvs that, in ascites, the abdo- men should only be tapped where life is immediately endangered by obstruction of the respiration, or by threatened gangrene of the skin. CHAPTER III. TUBERCULOSIS AND CANCER OF THE PERITONAEUM. Tuberculosis of the peritonaeum hardly ever occurs primarily, but accompanies tuberculosis of either the lungs, intestines, urinary or sexual organs. In other cases it is one symptom of acute miliary tuberculosis. The latter form has no clinical interest; for the deposit of the feAV small, translucent nodules in the peritonaeum causes no symptoms, and has no perceptible influence on the course of acute miliary tuberculosis. The few small white nodules found in the thick- ened serous membrane of the intestines over scrofulous ulcers are also of more pathological than clinical interest. The extensive develop- ment of the proportionately large, whitish tubercles, which are occa- sionally scattered through the peritonaeum, is more important. The Adcinity of the different nodules is either suffused with blood, or the escaped haematin has been changed to pigment, and the Avhite tubercle is surrounded by a black areola. The omentum is usually rolled up, and streAvn Avith tubercles; it forms a nodular SAvelling, resembling a sausage. Besides the tuberculous formations, there is usually thick- ening of the peritonaeum from inflammatory proliferation, and there is a large quantity of fluid, sometimes bloody, in its sac. Cancer of the peritoneum is also rare, as a primary disease, but is usually propagated from neighboring organs, as the liver, stomach, female sexual organs, and, more rarely, from the intestines. Scirrhus and medullary cancer usually occur as numerous granulations and nodules, scarcely so large as a pea, and scattered over the entire peri- tonaeum, or as diffuse, flat degenerations of the peritoneal tissue. Al- veolar cancer occasionally forms large, or even immense, tumors. But along AA'ith these, AA'hich are usually located in the omentum, almost all the organs of the abdomen, as well as the parietal portion of perito- naeum, are also coA'ered with small, gelatinous-looking tumors. In alveolar cancer, the intestines often adhere together in places, and the fluid in the peritoneal sac is consequently capsulated. The symptoms accompanying tuberculosis and cancer of the intes- tines closely resemble those of simple ascites. The most important SAinptom is the gradual distention of the abdomen by the increasing collection of fluid Avithin it. The unusual sensitiveness of the abdomen to pressure, Avhich is absent in other forms of ascites, the rapid occur- 40 626 DISEASES OF THE PERITONEUM. rence of cachexia, and the exclusion of all other causes for the collec- tion of fluid in the abdomen, render it probable that there is a degen- eration of the peritonaeum. This suspicion can only be rendered a certainty by the discovery of one or more tumors. From the shape and extent of these tumors, from the age of the patient, and from the coincident occurrence of tuberculosis or of cancer in other organs, Ave decide which form of degeneration exists in the case before us. DISEASES OF THE LIVER AND BILE-DUCTS SECTION I. DISEASES OF THE LIVER. CHAPTER I. HYPEREMIA OP THE LIVER. Etiology.—The amount of blood in the liver may be increased by greater afflux or by impeded efflux. The hyperaemia due to increased afflux Ave term fluxion [determination], that due to obstructed efflux, congestion. Fluxion to the liver results— 1. From increase of the lateral pressure in the portal vein. Under normal circumstances, there is fluxion to the liver at each digestion. The passage of fluids from the intestines to the intestinal capillaries causes an increased fulness of the intestinal veins; consequently their contents are subjected to greater pressure, and are impelled more strongly toAvard the liver. In persons AA'ho eat and drink immoder- ately, this phj'siological fluxion becomes excessive, continues longer, is often repeated, and, like other frequently-recurring hyperaemias, may cause permanent dilatation of the vessels. 2. There is fluxion to the liver, because its capillaries, which, under normal circumstances, find a support in the parenchyma, dilate AA'hen this parenchyma becomes relaxed, and then offer an abnormally slight resistance to the blood entering the organ. The hyperaemia of the liver occurring after injuries of that viscus, or in the vicinity of inflam- mations and neoplasiae, appears to develop in this Avay. Perhaps those cases induced by the use of spirituous liquors also belong in this class. In all of these cases avc haA'e to do with an irritation of the liver, as the alcohol is conducted directly to the liver by the portal vein; the first action of an irritant appears to consist in changes of the paren- 62S DISEASES OF THE LIVER. chyma of the irritated organ; this is usually accompanied by a diminu- tion of resistance of the parenchyma. This diminution of resistance must result in dilatation of the capillaries, and increased flow of blood to the part. This explanation of the fact, " ubi irritatio ibi affluxus," which is so apparent in the action of warmth on the skin, is here hypo- thetical, it is true, but it is certainly that which best agrees with our present knowledge of the subject. 3. We are just as ignorant as to whether the cases of hyperaemia of the liver from infection of the blood AA'ith miasm, particularly with malaria, or those occurring so frequently in the tropics, depend on re- laxation of the parenchyma, or whether they are due to paralysis of the muscular fibres of the efferent blood-vessels, or to a textural change of their walls, or how else they occur, as we are about the pathogeny of the hyperaemias and textural changes in the other infectious dis- eases. Among the cases of apparently fluxional hyperaemia of the liver, for which we can give no full explanation, are those which occur in some women just before menstruation, and are particularly marked in amenorrhoea. Congestion of the liver is far more frequent than fluxion; all the blood which flows from the liver through the hepatic vein has passed through a double set of capillaries. (This is also true of the blood suppfied by the hepatic artery. The capUlaries formed from the hepatic artery and spreading out in the serous covering of the fiver, and in its substance betAveen the vessels and bUe-ducts, unite to small venous trunks, which do not empty into the hepatic veins but into the portal veins, and Avith these, again break up into capillaries.) Hence the lateral pressure in the hepatic veins is very slight. But the hepatic vein opens into the vena cava at a point where, under normal circumstances, the flow of blood meets proportionately no obstruction, as it can pour freely into the empty auricle, and particularly since during each inspiration there is a tendency of the blood toward the thorax. If there be a disturb- ance of these very favorable conditions for the escape of the blood if the obstruction to its entrance from the hepatic vein into the vena cava be increased, it collects in the fiver. Only a slight obstruction is necessary, for the lateral pressure in the hepatic vein is too insignifi- cant to overcome even a very slight obstruction. According to what we have just said, the circumstances which induce congestion of the liver are those Avliich interfere Avith emptying of the right auricle. Thus it occurs— 1. In all valvular diseases of the heart, it appears soonest in affec- tions of the right side, later in those of the mitral, and latest of all in those of the aortic valves. The date of the appearance of congestion of the liver in valvular disease depends, as we fiave previously fully HYPEREMIA OF THE LIVER. 629 explained, on the complete or incomplete occurrence and on the longer or shorter duration of compensatory hypertrophy of the heart. 2. We may readily understand the congestions accompanying all organic diseases of the heart and pericardium, which induce obstruction to the escape of blood from the veins. 3. Under the same class would come congestions, occurring Avith enfeebled action of the heart, without perceptible organic change of that organ, either AA'hen appearing late in the course of exhausting acute diseases or in chronic marasmus. The effect on the distribution of the blood is the same in commencing paralysis of the heart as in degeneration of its substance. 4. Congestion of the lh'er is often induced by acute and chronic diseases of the lung, by which the pulmonary capillaries are atrophied or compressed, and the right side of the heart and vena cava overfilled, as in emphysema, cirrhosis, compression from pleuritic effusions, etc. 5. Lastiy, in some few cases, compression of the vena cava by tu- mors, particularly aneurisms of the aorta, has been observed as the cause of congestion of the liver. Anatomical Appearances.—According to the degree of the hy- peraemia, the liver is more or less swollen ; sometimes it is very much so; its shape is unchanged, except that it is more increased in thick- ness than in length. When the swelling is decided, the peritoneal coating is smooth, glistening and tense, the resistance of the fiver is increased. When cut, quantities of blood flow over the cut surfaces. The latter either appear evenly dark or are spotted; this is particularly apt to occur AA'hen there has been congestion for a long time; dark spots, corresponding to the dilated venae centrales, the commencement of the hepatic veins, and A'arying in shape with the direction of the cut, alternate AA'ith brighter-colored ones AA'hich do not contain so much blood, and AA'hich represent the termination of the portal vessels. The spotted appearance, AA'hich has given rise to the much misused name of nutmeg liver, becomes still more marked, when the more bloodless spots in the A'icinity of the dilated central veins appear decidedly yel- low from obstruction of the bile-ducts. The latter may be partly due to catarrh of the gall-ducts, induced by the hyperaemia of their mucous membrane; partly to the pressure of the enlarged vessels obstructing the free escape of bile from the small bile-ducts; and it may be partly due to gastroduodenal catarrh, induced by the same causes that excite the hyperaemia of the liver. The enlarged liver may subsequently become smaller, and acquire a granular appearance, so that, on superficial examination, it may be confounded AAdth granular liver. This is usually termed the atro- phied form of nutmeg-liver. According to Frerichs, the atrophy 630 DISEASES OF THE LIVER. and granular appearance are caused by "the venae centrales lobu- lorum, and the capUlaries opening into them, dilating under the strong pressure of the obstructed blood, and thus inducing atrophy of the liver-cells, lying in their network. The cells lying in the midst of the lobuli atrophy, and, in their place, appears a soft, A'ascular tissue, consisting of dUated capUlaries, and neoplastic connective tissue." This explanation is not exactly correct, or, at least, not entirely com- plete. The fiver cannot be diminished in size by a substitution of con- nective tissue, and dilated vessels for liver-cells. The diminution does not occur tUl the neoplastic tissue shrinks, and is reduced to a small A'olume. Moreover, according to Liebermeister, the assertion that, in congestive hyperaemias, the proliferation of connective tissue occurs particularly in the vicinity of the venae centrales, is based on theoreti- cal grounds, and not on direct observation. On the contrary, Lieber- meister found that, in the atrophic form of nutmeg-fiver, as Avell as in cirrhosis, the proliferation affected cfiiefly the Adcinity of the venae in- terlobulares, and in some cases led to a typical development of inter- lobular tissue, which, as is Avell known, hardly exists in healthy human livers. Symptoms and Course.—There are neither subjective nor objective symptoms of the disease until the hyperaemia of the liver lias attained a high grade, and the organ has considerably increased in size. Where the liver is decidedly enlarged, the patients feel that their right hypo- chondrium is unusually full, and this sensation of fulness not unfre- quently increases to a painful feeling of tension, wfiich spreads from the right hypochondrium over the abdomen. The pressure in the right hypochondrium, or the sensation of having a firm fioop around the ab- domen is often, next to the dyspnoea, the chief complaint of patients with heart-disease. And Avhen the liver sAvells, the sufferings of em- physematous patients, and of those affected with cirrhosis of the lungs, or curvature of the spine, are decidedly increased. Patients Avith extensive hyperaemic SAvelling of the liver cannot bear tight clothes, as they interfere with deep inspiration. If, from the causes above mentioned, a slight obstruction of the gall-ducts accompany the Hyperaemia of the liver, there Avill be some icterus; and, as the patient's color is already somewhat bluish (cyanotic), from the obstruction of the venous circulation, he will have the peculiar greenish color character- istic of patients with heart-disease shortly before death. Besides the symptoms just mentioned, and the physical observation that the liver is enlarged, in simple hyperaemia there may be no symptoms of disturbed hepatic function. A slight increase or diminution of the secretion of bile may escape our observation during life; even in the cadaver, Avhere there was excessive congestive hyperaemia, Frerichs HYPEREMIA OF THE LIVER. 631 could not make out such a change. In some feAV cases only, did he find the bile albuminous. Patients with hyperaemia of the lh'er have other complaints, it is true; they suffer from headache, difficulty of di- gestion, irregularity of the boAvels, hemorrhoids, etc. These troubles, however, are not the result of the hepatic engorgement, but may have no connection Avith it, or, as is more frequently the case, they depend on the same causes. Diseases of the heart not only induce hyperaemia of the liver, but also lead to gastric and intestinal catarrh; in the same Avay, excess in eating and drinking excites gastric and intestinal catarrh even sooner than it does hyperaemia of the fiver. It appears to be different Avith those cases of hyperaemia of the liver which fre- quently occur in the tropics, probably from malaria. These begin Avith great constitutional disturbance, severe headache, bilious eA'acua- tions upAvard and doAvmvard, and often with the passage of bloody mucous masses. These symptoms of this disease—Avliich is but little knoAvn—decidedly favor the idea that it is not a simple hyperaemia, but either a coincident anomaly of secretion of the liver, independent of the hyperaemia, or the first stage of a severe organic disease, Avhich, in fact, not unfrequently develops more fully. But perhaps in these cases, also, the hyperaemia of the liver is only the partial expression of a disease affecting all the abdominal organs, particularly the intes- tines ; and this view Avould best explain the constitutional affection, and the other symptoms. When the hyperaemia has reached a high grade, physical examina- tion very clearly shows the swelling of the liver. As we noAv, for the first time, speak of the physical signs of enlargement of the lh'er, Ave must give some account of them. As physical aids for recognizing enlargement of the liver, Ave have inspection, palpation, and percussion. In decided SAvelling of the liver, inspection shoAvs a prominence in the right hypochondrium, extending more or less toAvard the left side, and gradually disappearing inferiorly. At the same time, the right side of the thorax, Avhich even normally is from half an inch to an inch larger than the left, becomes more prominent at its loAver part. Lastly, the inferior ribs may be elevated by the enlarged liver, pressed close together, and their loAver edges turned forward. If Ave do not undertake the examination very quietly and carefully, the contractions of the abdominal muscles, Avhich usuaUy occur, greatly interfere AA'ith palpation. The inexperienced often mistake contracted portions of the rectus abdominis for tumors of the liver. We should never undertake the examination AA'hile the patient is standing or sitting. He should lie doAvn, and draAV up the knees a little. At the same time avc should tell him to respire regularly, and should distract his 632 DISEASES OF THE LIVER. attention from the examination, by questions, etc. In many cases of enlargement of the liver, that can be certainly recognized by percus- sion, it is true, we find great resistance in the right hypochondrium, but we cannot clearly make out the edge of the liver. This is particu- larly the case Avhere the resistance of the liver is not increased, and still more so when it is diminished. In other cases, palpation gives the best evidence concerning the amount of enlargement, and also, about the shape of the margin and surface ; and this is the more dis- tinct the greater the resistance of the enlarged organ. Percussion is the most important physical aid in the diagnosis of the enlargement of the liver. In determining the upper boundary, it is not customary to decide by the commencing flatness of percussion at those points where there is a thin layer of lung between the liver and the walls of the thorax, but by the absolute dulness where the liver comes in contact with the thoracic wall. Hereafter, in speaking of the upper border of the liver, we shall always mean the line of ab- solute dulness. The highest point of the lh'er lies about 3 cm., above this line. Normally, on the mammUlary fine, the upper margin of the liver lies at the lower border of the sixth rib ; on deep inspira- tion it descends to the seventh rib, on complete expiration it ascends to the fifth. In the axillary line the upper margin lies about the eighth rib, near the spine about the level of the eleventh rib. In the median line, the upper margin of the liver lies on a level Avith the union of the xiphoid cartilage and the body of the ster- num, but its position cannot usually be determined, as the lh'er dul- ness passes into that of the heart. Normally, in the mammUlary fine, the lower border of the liver lies at the margin of the ribs or a Httle below; in the axillary line it is usually above the eleventh rib; in the median line about half Avay between the xiphoid cartilage and the navel; near the spine its position caimot be determined. As the thorax is shorter in women and children, the lower border of the liver lies somewhat below the edge of the ribs. Neither the sharp border of the liver, which extends a few centimeters below the ribs, nor its left lobe, if not thickened, causes any decided dulness on percussion. In forty-nine cases, of persons between twenty and forty years of age, examined by Frerichs, the distance from the upper line of dulness to the lower averaged, in the mammUlary line, 9.5 cm., in the axillary line, 9.36 cm., in the sternal line, 5.82 cm. (Tfie observations of Bamberger differ decidedly from these: in thirty measurements made in adults, he found in the mammillary line, in women, 9 cm., in men, 11 cm., in the axillary line, in Avomen, 10.5 cm., in men, 12 cm., and in a line one inch to the right of the median line, in Avomen, 8.5 cm., in men, 11 cm., as the average extension of dulness.) HYPEREMIA OF THE LIVER. 633 If the liver be enlarged, the fiver dulness wiU extend into the right hypochondrium and epigastrium. Near the edge of the liver the dul- ness becomes indistinct or disappears entirely, a fact Avhich we must knoAV, or Ave shall suppose the organ is smaller than it really is. Be- fore deciding, from the extension of dulness into the right hypochon- drium, that the fiver is enlarged, we must determine that it is nof displaced dowmvard. We have already spoken at length of some im- portant points for the diagnosis between enlargement and displace- ment of the liver. Moreover, Avithout being enlarged, a greater part of the liver may lie in contact witfi the abdominal walls, if it has sunk doAvnward from pressure on the lower part of the thorax or from re- laxation of its tissue, or if it has an abnormal form. Among the anomalies of form the most frequent are those induced in Avomen by tight-lacing and still more by wearing their waistbands tight. As a result of this constant pressure on it, without increase of its volume, the liver may become much flattened and so elongated as to descend several finger-breadths below the ribs, or in some few cases even doAvn to the crest of the ilium. We must bear in mind these deAdations in position and form of the liver, if Ave would rightly interpret the results of physical examination. Hyperaemic swelling of the fiver can rarely be perceived by simple inspection. From the decided increase of thickness of the organ, per- cussion gives great dulness, Avhich may extend from the right to the left hypochondrium, and as far doAvn as the navel or even beloAV it. And as the resistance of the liver is increased, Ave can usually feel its mar- gin, and satisfy ourselves that its form is unchanged and its surface smooth. A characteristic of hepatic enlargements caused by hyper- aemia is that they grow more rapidly than any other form, and decrease again rapidly. It is remarkable that the symptoms of atrophic nutmeg-fiver haA'e not received proper attention until lately, AA'hen Liebermeister has paid a great attention to them. As the symptoms of this disease are characteristic, it may be quickly sketched. The patients affected have disease of the heart or emphysema, or some other disease of the lung, Avhich impedes the Aoav of blood through the right side of the heart. This obstruction of the circulation has caused enlargement of the liver, cyanosis, and general dropsy. As is usual in heart and lung diseases, the dropsy began in the loAver extremities, and afterAvard in- vaded the serous cavities. Subsequently the state of affairs is changed: the ascites becomes more decided than the anasarca; or the ascites continues, Avhile Ave may succeed in removing the other symptoms of dropsy for a time by suitable remedies. On examining the liver, we find it smaller than at first, its loAver border is some finger-breadths 634 DISEASES OF THE LIVER. higher than it Avas some weeks or months previously. Not unfre- quently, Avhile the anasarca is moderate, the ascites increases, so that Ave are compelled to tap the patient. In the cases that I have ob- served, where in heart and lung diseases I have been able to diagnose atrophic nutmeg-liver from the disproportion between the ascites and anasarca and from the perceptible diminution in size of the enlarged fiver, I have not found the spleen enlarged. If we rightly understand atrophic nutmeg-liver, the explanation of the above symptoms is not difficult. The contraction of the connective tissue of the liver com- presses the vessels, hence the Aoav of blood from the veins of the peri- tonaeum is opposed in two Avays : first, by the heart or lung affection ; secondly, by the compression of the hepatic vessels. The absence of enlargement of the spleen is the only thing that could appear remark- able ; as, by compression of the vessels of the liver, the Aoav of blood from the spleen is also obstructed, and since in cirrhosis of the liver (see Chapter III.), Avhere the same circumstances prevail, Ave almost ahvays find enlargement of the spleen, and usually ascribe this en- largement to obstruction of the blood in the splenic vein. I propose, when speaking of cirrhosis of the liver and hyperaemia of the spleen, to discuss this apparent contradiction more fully. Treatment.—The causal indications require the removal of the circumstances inducing the fluxion to or the congestion of the fiver. In the fluxions caused by excess in eating and drinking, the diet is to be regulated; in those cases resulting from misuse of spirituous liquors, alcohol should be forbidden. In the same way it may be necessary to advise a change of residence when persons in the tropics, or from the influence of malaria, suffer repeatedly from hyperaemia of the liver. Finally, if severe fluxions to the liver occur just before the menses or during their absence at the time they are expected, the causal indica- tions require the application of leeches to the os uteri or of cups to the inner surface of the thighs. In congestion of the liver we are either unable to fulfil the indicatio causalis or, where Ave can do so, it is al- most always some other trouble than the hyperaemia of the liver, which decides us to interfere. For instance, Avhen Ave bleed in pneumonia, and thus moderate a congestion of the liver, the venesection has not been induced by the latter, but by the congestion in the brain, or some other cause. For the fulfilment of the indications from the disease, the abstrac- tion of blood from the region of the liver, which is so frequently recom- mended, is just as irrational as it is inefficacious, and Henoch is right in saying that the leeches would do just as much good if applied to the Avrist or ankle-joints as Avhen applied to the right hypochondrium. On the contrary, leeches about the anus are strongly to be recom- SUPPURATIVE HEPATITIS. 635 mended, if the sufferings of the patient render it Avortli while to use them at all. They draAv blood from the anastomoses of the branches of the portal vein, and thus lessen the lateral pressure in the portal vein, and consequently the supply of blood to the liver. Laxativas haA'e a similar influence, particularly the neutral salts, as, by abstract ing Avater, they also cause depletion of the intestinal A'eins, and thus diminish the lateral pressure in the portal A'eins. For patients AA'ho habitually suffer from hyperaemia of the liver, the mineral springs at Homburg, Kissengen, Marienbad, etc., are particularly beneficial, for the salts, in the form in which they there enter the body, can undoubt- edly be used for a long time without injury. INFLAMMATIONS OF THE LIVER. For sake of convenience, Ave shall make a general division of the forms of inflammation of the liver, of each of Avhich we shall hereafter give a more accurate description: 1. Suppurative hepatitis ; 2. Chronic interstitial hepatitis, which, in its later stages is called cirrhosis hepa- tis; 3. Syphilitic hepatitis; 4. Pylephlebitis; and 5. Acute yellow atrophy of the liver, which is reckoned among the inflammations of the lh'er, at least by most recent pathologists. We shall not treat of the last form till Ave have considered other affections of the liver, accom- panied by jaundice, that are more readily understood. CHAPTER II. SUPPURATIVE HEPATITIS. Etiology.—According to Vlrchow, the processes observed in this form of hepatitis originally affect the liver-cells themselves. At first these SAvell from imbibition of an albuminous substance ; subsequently there is disintegration of the cells, and consequently of the parenchyma of the liver; finally, there are caAdties in the liver AA'hich are filled Avith the disintegrated elements of the tissue. On the other hand, Lieber- meister thinks that his examinations prove that, in suppurative hepati- tis, the process starts from the interstitial tissue, and that the disinte- gration of the liver-cells is secondary. The etiology of parenchymatous nepatitis is obscure. It is rare in the temperate zones, but more fre- quent in the tropics, particularly in India, although the old accounts of its frequency there are overdrawn. Among the exciting causes, AA'e may mention— 636 DISEASES OF THE LIVER. 1. Wounds and contusions of the liver; but among sixty cases that he observed himself, or collected from other observers, Budd found only one case due to injury. 2. Very similar to the above are the cases induced by impaction of angular concrements in the gall-ducts, but these must be considered as very rare. 3. Suppurative hepatitis develops more frequently from ulceration or other gangrenous affections of the abdominal organs. It has been found complicating ulcers of the stomach, intestines, and gall-bladder, and, in some feAV cases, abscesses of the fiver have been seen to folloAV operations for hernia or about the rectum. In these cases it is most natural to suspect an embolus of the branches of the portal vein or the transfer of injurious irritating matter to the liver by tfie portal blood ; but, so far, it has been impossible to obtain any positive proof of this. Budd believes, and most authors agree with him, that the majority of cases of hepatitis of the tropics belong in this class. It is true that it is very rarely a primary disease, but is almost ahvays secondary to the dysentery endemic in the tropics; but it has not been proved in this form either, that the transfer of particles of gangrenous mucous mem- brane or of putrid fluid, from the large intestine to the liver, has induced the inflammation in the latter, and still less that this is the sole cause of hepatitis in the tropics. The fact that epidemic dysentery in our country is hardly ever complicated by hepatitis, although with us also there are extensive gangrene of the mucous membrane and putrid de- composition of the contents of the large intestine, rather militates against Budd's vieAV of the subject. 4. Lastly, among the exciting causes of parenchymatous hepatitis, Ave must mention injuries, suppurations, thromboses, and inflammations of the veins. The explanation of this form, which, together with the above, is usually called metastatic hepatitis, is very difficult. We have given the views at present prevalent concerning the formation of metastases in the lungs. According to the explanations there given, the occurrence of metastases in the liver from peripheral suppurations should induce the belief that emboli which have passed through the capUlaries of the lungs may plug up the hepatic artery. We must content ourselves AA'ith having mentioned the fact, and called attention to the difficulty of its explanation. The sympathy betAveen the head and the liver, of Avhich we have already spoken a good deal, can only be explained by the fact that Avounds of the skull affecting the diphoe very readily induce metastases, and, under some circumstances, metas- tases to the liver. Anatomical Appearances.—In parenchymatous hepatitis, the entire organ is never inflamed, but there are always inflamed spots. SUPPURATIVE HEPATITIS. 637 These vary in size; often there is only one; in other cases, numbers of them are scattered through the liver. We rarely see the post-mortem appearances of the disease in the commencing stage. The description of the inflamed parts as dark-red, resistant places, Avhich become slightly prominent when we cut into the engorged liver, is probably taken more from analogy than from actual observation. On the other hand, in commencing hepatitis, Ave do find discolored, yellowish, and very soft spots in the hyperaemic liver. Wlien these are superficial, before opening them, we may readily mistake them for abscesses. At these spots, on microscopical exami- nation, Virchow found, according to the degree of discoloration and softening, either that the fiver-cells were cloudy, transparent, and gran- ular, or that their number was decreased, and between those still ex- isting there was effused a finely-granular mass, or, lastly (at the most discolored and softened spots), that the liver-cells had entirely disap- peared, and in their place there was only a finely-granular detritus. Far more frequently, parenchymatous hepatitis is not seen tUl its later stages. Then we find abscesses in the liver, from the size of a pea to that of a hen's egg; if several of these have united, or if the disintegration has progressed further, these form irregular collections of pus, Avhich are often very large. They are surrounded by disinte- grating, discolored parenchymatous substance, and contain a creamy pus, which is often greenish from admixture of bile. When the de- struction advances to the surface, these abscesses of the liver may break. Tfiis may occur into the abdominal cavity, or, if there has been previous adhesion of the liver to the abdominal Avail, the perforation may be outAvardly; in other cases, after the fiver has become adherent to the diaphragm, the latter is perforated, and the pus enters the pleural sac or the lung, if that be adherent to the pleura costarum. In rare cases, abscesses of the liver have been known to perforate into the pericardium, stomach, intestines, gall-bladder, even into the portal \-ein, and into the ascending vena caA'a. If the patient lives after the opening of the abscess, in favorable cases the Avails may unite; then there is a proliferation of connective tissue and finally a hard cicatrix forms, which often contains thickened and calcified masses of pus. And AA'here perforation does not occur, after an abscess has existed a long time, there is usually a proliferation of connective tissue in the wall and vicinity of the abscess; its inner surface becomes smooth, the pus is incapsulated, and gradually thick- ened by reabsorption of its fluid constituents. Then the abscess may be diminished in size by the shrinking of the surrounding connective tissue till finally only a dense cicatrix remains, enclosing a calcareous mass. 638 DISEASES OF THE LIVER. Symptoms and Course.—The typical description usually given of parenchymatous hepatitis answers, as Budd aptly says, only for the traumatic cases, including those induced by impacted gall-stones; but, as Ave have already stated, this is the rarest form of the disease. If, after a blow, or some other violence, affecting the region of the liver, there be severe pain there, if the liver swells, and there be high fever Avith general suffering, there is no difficulty in the diagnosis. The case is altogether different when hepatitis comes on during some gangrenous process in the abdomen, when it complicates a dysen- ter}-, or when it develops during peripheral suppuration, after injuries of the head, great surgical operations, etc. The cases related by Budd, Andral, and others, show a number of instances where abscesses of the liver, occurring in this Avay, were recognized very late, or not at all. In chronic ulcerations of the intestines, in perityphlitis, and similar dis- eases, as well as after operations on the rectum or abdomen, we may suspect the occurrence of hepatitis, if the patient has a chill, if the liver swells and becomes painful, and there be icterus. But none of these symptoms are constant; and cases AA'here local symptoms of hepatic disease are absent, in metastases starting from one of the ab- dominal organs, are at least as frequent as those of metastases in the lungs, which run their course Avithout pain in the chest or bloody ex- pectoration. The chills and fever may also depend on other causes, and cannot, by any means, be regarded as sure signs of secondary hepa- titis. It is still more difficult to recognize the occurrence of hepatitis during endemic dysentery. For, in this disease, the liver is not unfre- quently sAvollen and painful, even when it is not inflamed; the fever present does not decide the question, for it is present in dysentery alone; in many cases there is no icterus, and, when it occurs, it is no sure sign of hepatitis. The parenchymatous hepatitis which occurs in peripheral suppurations, or after surgical operations, and is one symp- tom of the so-called pyaemia, is the most difficult to recognize. Under such circumstances, we* should not expect the prostrate patient, who is much depressed mentally, to complain of pain about the fiver; the chills and high fever, and even excessive icterus, do not render it abso- lutely certain that there is disease of the liver. If we add, to what has already been said, that the abscesses, which have formed during the above-named diseases, always enlarge slowly, and are accompanied by very unimportant symptoms, it may readUy be understood that a subsequent chronic disease, with the symptoms here- after mentioned, may first excite the suspicion, or render it certain that the original disease has been complicated with hepatitis. The symptoms of the abscess which remains and gradually in- creases are quite varied. There is almost alwavs a dull pain in the SUPPURATIVE HEPATITIS. 639 nght hypochondrium, which is increased by pressure. Occasionally there is also a peculiar " sympathetic" pain in the right shoulder, whose frequency and diagnostic importance were formerly much over- rated. The fiver almost ahvays projects beloAV the ribs, and in cases where the abscesses are large or numerous, or the hyperaemia is great, the liver may be double its normal size, and bulge out the right half of the thorax, render the hypochondrium prominent, and project deep into the abdomen. When the abscesses are on the convex surface of the liver and are someAvhat prominent, we may sometimes, on careful palpation, find sfight protuberances or even fluctuation. Icterus is not at all a constant symptom of abscess of the liver, being absent eA'en in the majority of cases. The accumulation and absorption of bile, on Avhich icterus depends, are partly the result of compression of the gall- ducts, and partly due to their obstruction by albuminous and fibrinous coagula {Rokitansky). Large abscesses may compress the ramifica- tions of the portal vein; such as project from the concave surface may compress its trunk. In such cases, besides the symptoms above de- scribed, there are usually SAvelling of the spleen and serous effusion into the abdomen. While the abscesses are small there is little or no accompanying fever, and at this time the general health of the patient is little affected, his strength is good, and he may live for years in passable health. But as soon as the abscess has attained some size the fever becomes higher, chills come on from time to time, as we have seen that they do in chronic suppurations elseAvhere, the strength and nutrition of the patient suffer, he becomes cachectic and exces- sively emaciated, and in most cases finally dies exhausted and dropsical, of " consumption of the liver." If the abscess of the liver perforate into the abdomen, the symp- toms of peritonitis soon set in and quickly cause the death of the patient. If the abscess become adherent to the anterior abdominal Avail, this at first becomes oedematous and finally infiltrated; this renders any formerly perceptible fluctuation indistinct, but a super- ficial fluctuation gradually occurs in the abdominal Avail, and this is finally perforated by the pus. If the perforation take place through the diaphragm, Ave either have the symptoms of pleurisy, or, more fre- quently (as the pleural surfaces have become adherent), dark-red or broAvn purulent masses are suddenly thrown off, from AA'hose appear- ance Budd claims to have frequently made a diagnosis of abscess of the fiver. From perforation into the pericardium, pericarditis rapidly develops and soon causes death. In perforation of the stomach, the peculiarly colored masses are vomited. In perforation of the intestine, on the other hand, there are purulent passages from the boAvels. When the pus is evacuated outwardly or into the stomach, or intes< 640 DISEASES OF THE LIVER. tines, or even Avhen it enters the bronchi and is coughed up, the pa- tients usually feel instantaneously relieved; the improvement rarely remains permanent, however, and, when it does so, it is only in cases Avhere the abscess was small. Budd only saw closure of the abscess and perfect cure of the patient in one case after the evacuation of the pus. The abscess usually continues to suppurate, and the patients sooner or later die of exhaustion from the suppuration and fever. Cases of cure after capsulation and gradual decrease in size of the abscess, Avith inspissation of its contents, are very rare, and during life it must be difficult to decide that this has occurred. Treatment.—It is only in the rare cases of traumatic hepatitis that Ave can hope to induce resolution of the inflammation by the use of cold compresses, and the application of leeches about the anus. In the subsequent course of the disease, blisters over the liver, and the internal administration of calomel, are very generally employed, but are of doubtful efficacy. In all other forms of parenchymatous hepatitis, we have to confine ourselves to the treatment of symptoms, particularly as they are rarely recognized until abscesses have formed. Fortunately for the patient, the Adews on which it was formerly maintained, that the reabsorption of pus Avas aided by the internal and external use of mercurials, are no longer held; although it is said that patients Avith liver-disease are just the ones who can take large doses of calomel without injury. As long as there is no perceptible fluctuation, and we cannot open the abscess, we must limit ourselves to keeping up the strength of the patient by suitable diet, wine, and preparations of iron. For the chills Ave prescribe quinine, which not unfrequently has a very decided anti- periodical action. As experience shows that those abscesses heal best from which pus mixed with blood and broken-down parenchyma of the liver have been evacuated, whUe those containing good or laudable pus rarely healed, we should make it a rule to open the abscesses as early as pos- sible, before a so-called pyogenic membrane has formed in them. Sur- gery teaches us to be pecufiarly careful in opening abscesses of the liver, and that we should use caustics instead of the knife, where we cannot certainly determine that the liver has become adherent to the abdominal walls. CHAPTER III. CHRONIC INTERSTITIAL HEPATITIS, CIRRHOSIS OF THE LIVER, GRANU- LAR LIVER. Etiology.—Interstitial hepatitis affects the fibrous coA'ering of the liver and the scanty connective tissue, Avhich, as the continuation of CIRRHOSIS OF THE LIVER. 641 Glisson's capsule, accompanies the hepatic vessels and traverses the parenchyma of the lh'er. In this form of inflammation there is neither free exudation, suppuration, nor formation of abscesses. The inflam- matory process rather consists in a proliferation of the tissue aboA'e named, by the formation of young connective-tissue elements from those already existing. While the connective tissue of the fiver in- creases, its parenchyma proper is more and more displaced. In the later stages of the disease the neoplastic tissue undergoes a cicatricial retraction, which strangulates and partly destroys the parenchyma of the liver. The blood-vessels and bile-ducts not unfrequently become impervious throughout a considerable extent, and a large part of the liver-cells atrophy and die. Alcohol is the irritant which most frequently induces interstitial hepatitis. Hence English physicians give granular liver the vulgar name of "gin-drinker's liver." Corresponding to the extent to which alcohol is used by the sexes and at different ages, the disease is more frequent in men than in women, and is very rarely seen during child- hood. EA'en the apparent exceptions support the rule. Thus Wun- derlich found typical cases of the disease in two sisters aged eleven and tAvelve years; but on careful inquiry it was found that both of them were great schnapps-drinkers. The use of alcohol, hoAvever, is not the only cause of interstitial hepatitis, and all persons affected with this disease, who deny the ha- bitual use of liquor, are not to be regarded as secret topers. Simple congestive fiyperaemia, Avhich so often occurs in heart-disease, has fre- quently been blamed as a cause of cirrhosis; but, according to Bam- berger's numerous observations, this is probably an error, which Avas due to the atrophic form of nutmeg-fiver being confounded Avith cirrho- sis. We are unacquainted Avith the other causes of interstitial hepa- titis. Budd (as quoted by Bamberger and Henoch) says: " There may be other substances, among the immense variety of matters taken into the stomach, or among the products of faulty digestion, which, on being absorbed into the portal blood, cause, like alcohol, adhesive in- flammation of the liver." Budd himself, hoAvever, terms this vieAV hypothetical. I haA'e seen one case Avhere biliary calculi caused chronic interstitial hepatitis. In this case, which Avas fully detailed by Lieber- meister, most of the large bile-ducts were filled Avith stony concrements, and the liver Avas most strikingly cirrhotic in character. t Anatomical Appearances.—In the first stage, which Ave rarely see, the fiver is increased in size, particularly in thickness ; its perito- neal covering is slightly thickened and clouded; except some sfight elevations, the surface is smooth and even. On section, the parenchyma is seen to be interspersed by a vascular, succulent, grayish-red mass, 41 642 DISEASES OF THE LIVER. which gives the lh'er a fleshy look, and which is shoAvn by the micro- scope to consist of delicate connective-tissue striae AA'ith spindle-shaped cells. Between this tissue, the original parenchyma appears as large and only slightly-prominent granulations. The second stage, into Avhich the first gradually passes, is excel- lently described by Rokitansky. According to him, in typical cases, the liver is much smaller than normal; its form is altered, the edges becoming thinned, and finally changed to an indurated border, which contains no liver-tissue: on the other hand, the thickness, particularly of the right lobe, is relatively greater. Lastly, the whole organ often consists of the spherical right lobe, to which the left is attached as a flat appendix. In this stage we may see granular or ^atecy- projec- tions (granulations) on the surface, to AA'hich the disease owes its name of " granular liver." If the granulations are all of the same size, as large as a hemp-seed, for instance, the surface appears regularly gran- ular ; if they vary in size, it is irregularly granular. BetAveen the prominences the serous coat is whitish, tendinous, shrunken, and re- tracted ; if deep retractions separate large portions of the liver from each other, it appears lobular. The serous coat is also usually attached to the surrounding parts, particularly to the diaphragm, by short, firm adhesions, or by bands. The substance of the cirrhotic liver is very hard and of leathery toughness. On section, there is often as much resistance as on cutting into scirrhus, and on the cut surface Ave find the same granulations as on the surface of the liver. Tfiey are embed- ded in a dirty-white, dense, non-vascular tissue. At some places the parenchyma has entirely disappeared, and the dense tissue alone re- mains. On microscopic examination in this stage, Ave no longer find the first elements of connective tissue, but this is fully formed, and en- closes in concentric layers groups of liver-cells (the granulations). The still existing liver-cells are partly affected AA'ith fatty degeneration and partly intensely yellow, as a result of the retention of bile induced by obstruction of the bile-ducts. The fatty metamorphosis of the liver- cells, and still more the pigment in them, gives the entire liver, but particularly the granulations, the yellow color to which it gives its name, " cirrhosis." Symptoms and Course.—The symptoms of the first stage of cir- rhosis are very similar to those of simple hyperaemia of the liver; the inflammatory process within the liver and in its covering is usually ac- companied by little pain, although the patient may be more sensitive to pressure over the liver than is the case in simple hyperaemia. In some cases, hoAvever, the feeling of fulness in the right hypochondrium increases to painful tension or even to burning pain. Besides these symptoms, there are various troubles in the first stage of chrfiosis. CIRRHOSIS OF THE LIVER. 043 The patients complain of loss of appetite, of a feeling of pressure and fulness after eating; they suffer from flatulence and constipation. The nutrition may be already affected and the appearance cachectic; but the same is true of these appearances as has been said of several of the accompaniments of simple hyperaemia of the liver, tfiat, although they accompany the disease, they are not symptoms of it. The habitual use of liquor almost ahvays causes chronic catarrh of the stomach, and the symptoms depend on this, not on the interstitial hepatitis. The symptoms of the second stage depend almost entirely on me- chanical conditions. Compression of the branches of the portal A'ein must cause symptoms of congestion in those organs from Avliich the portal vein conducts the blood to the fiver; the compression of the bile-ducts (as long as the liver-cells to AA'hich they belong prepare bile) induces absorption of bUe and icterus. Symptoms of congestion are seen soonest and most frequently in the gastric and intestinal mucous membrane. The chronic gastric catarrh accompanying the second stage of cirrhosis is not, as in the first stage, a complication, but is a necessary result of the disease. The symptoms it causes have already been described. Intestinal catarrh, which is just as frequent an accompaniment of cirrhosis, rarely leads to excessive transudations of fluid into the intestines, but, like most chronic catarrhs, to a copious production of cells and to the secretion of tough mucus. We have learned that constipation, tympanites, cachectic appearance, etc., are among the symptoms of this form of chronic in- testinal catarrh, hence Ave readily understand Avhy they should take a prominent part among the symptoms of cirrhosis of the 'wer. Not un- frequently the capillaries of the gastric and intestinal mucous mem- brane become so full as to rupture. Hence, next to ulcer of the stomach, cirrhosis of the liver is the most frequent cause of gastric and intestinal haemorrhages; and as the obstructed evacuation of the portal vein causes overfilfing of the inferior mesenteric artery and the haemor- rhoidal plexus, it is to be mentioned among the causes of haemorrhoids, and these form one of the most frequent symptoms of cirrhosis. As the splenic vein also empties into the portal vein, compression of the branches of the latter AAdll impede the escape of blood from the former ; hence symptoms of congestion of the spleen unite AA'ith those of the gastric and intestinal congestion. In the later stages of inter- stitial hepatitis the spleen has so often been found enlarged to two or three times its natural size, or even more, that Oppolzer, Bamberger, and others, give enlargement of the spleen as one of the most important symptoms of cirrhosis of the liver. Out of thirty-six cases, Frerichs found the spleen enlarged eighteen times. We cannot agree, hoAvever, in referring the enlargement of the spleen solely to obstruction of the 644 DISEASES OF THE LIVER. blood: on the one hand, because it sometimes comes very early, at others very late, Avithout any corresponding change in the other symp- toms of congestion; secondly, because in some cases of cirrhosis, and in all the cases of atrophic nutmeg-liver that we have observed, in spite of the excessive compression of the hepatic vessels, there has been no enlargement of the spleen, or it has been only slightly enlarged. Probably the SAvelling of the spleen depends, partly at least, on a process similar to that affecting the liver. But, that part of the splenic enlargement is due to obstruction of the flow of blood, is shown by the constant diminution in size of the spleen, when a haematemesis, from rupture of the capillaries of the stomach, has facilitated tfie escape of blood from the spleen. As the veins of the peritonaeum also, particularly those of its visceral folds, empty into the portal vein, we may readily understand the occur- rence of ascites, AA'hich is the most apparent symptom of cirrhosis. We may refer to the chapter next to the last of the previous section, where the increased lateral pressure in the veins of the peritonaeum Avas shown to be the most important cause of serous transudations into the { abdomen. As rupture of the capUlaries of the peritonaeum occasion- ally occurs, in some cases, Ave find small quantities of blood mixed Avith the transudation. In other cases, there are flocculi of fibrin in the fluid, AA'hich tend to prove that, AA'hile the inflammation is going on in the liver and its vicinity, small quantities of free exudation are formed. The ascites, which forms a symptom of cirrhosis of the liver, is particu- larly extensive; fience in it, more frequently than in any other form of ; abdominal dropsy, we find the blue veins over the abdomen, oedema of j the loAver extremities, genital organs, and abdominal Avails, resulting j from compression of the vena cava and iliac veins, as Avell as the super- ficial gangrene of these parts that Ave have previously described. Now that we have mentioned chronic gastric and intestinal catarrh, gastric and intestinal haemorrhages, haemorrhoids, enlargement of the spleen, and, lastly, ascites, as the almost constant symptoms of cirrhosis, and as the mechanical results of compression of the branches of the portal vein, it may be asked how Ave explain the exceptions, AA'here these symptoms do not exist, or are insignificant. We shall first re- mark that, occasionally, in spite of advanced cirrhosis, the branches of the portal vein remain quite pervious, so that, according to the obser- vations of Foerster, in some cases, they may be traced a considerable distance in the cadaver. But, besides this, the escape of blood from the stomach, intestines, spleen, and peritonaeum may be facilitated, and tfie congestion in these organs avoided, by the blood seeking other passages, and the development of a collateral circulation. This may- result : 1. From the connection betAveen the inferior mesenteric and CIRRHOSIS OF THE LIVER. 645 the hypogastric A'eins, through the haemorrhoidal plexus; 2. From the anastomoses between the portal A'eins and those A'eins of the perito- naeum Avhich open into the diaphragmatic and oesophageal veins; 3. Through newly-formed vessels in the adhesions between the liver and diaphragm. Besides these ways, and other occasional abnormal com- munications, by Avhich the blood from the portal vein may elude the hepatic vein and reach the vena caA'a, in some cases, 4, a very peculiar form of collateral circulation is set up, Avhich may be recognized, eA'en during life, by \'ery evident symptoms. It was formerly supposed that this form only occurred AA'hen the umbilical vein Avas incompletely closed after birth, and that a fine canal remained in the ligamentum teres during after-life. If considerable congestion of the lh'er occur in such cases, this fine canal is gradually distended by the pressure of the blood, and may become so pervious as to conduct the blood to the anterior abdominal Avail, Avhere it empties into the ramifications of the internal mammary veins. The consequent overfilling of the internal mammary veins impedes the escape of blood from the cutaneous veins, so that these may be excessively dilated, and surround the navel as a blue cushion. The deformity thus induced, the caput Meduse, does not, "hoAvever, depend on dilatation of the incompletely obliterated um- bilical vein, but on dUatation of the branches of the portal vein run- ning from the liver to the anterior abdominal Avail, between the folds of the falciform ligament, which anastomose Avith the roots of the epi- gastric and internal mammary veins {Sappey). It is more difficult to explain AA'hy some of the symptoms of con- gestion occur, Avhile others are Absent, than it is Avhy none of them exist. We only partly knoAV (see above) AA'hy the spleen (which Bam- berger found enlarged in fifty-eight cases out of sixty-four, and Frerichs in eighteen cases out of thirty-six) remains small in some cases, and AA'hy some patients have haematemesis frequently, Avhile others do not have it throughout the disease; and Ave shall not attempt to explain these irregularities. Although, in cirrhosis of the liver, the gall-ducts are subjected to the same pressure as the portal veins, there is rarely much biliary ob- struction. It is true, most of the patients have a dirty-yellow color, a yelloAV tinge of the sclerotic and dark urine; but intense icterus is by no means a frequent symptom of cirrhosis. This symptom is readily explained by the physiology of the formation of bile. There is no bile in the blood going to the liver, but it is prepared there from the materials supplied. Hence obstruction and reabsorption of bile ahA'ays presuppose that at least part of the liver-cells is preserved, and acts normalh'. In cirrhosis of the liver, on the one hand, the bile-ducts are compressed, and the conditions are induced Avhich most frequently lead 646 DISEASES OF THE LIVER to obstruction and reabsorption of bile; on the other hand, numbers of the liver-cells have been destroyed, and the formation of bile is thus greatly limited. Hence we may readily see why icterus is hardly ever absent in cirrhosis, and, at the same time, why it rarely attains a high grade. Generally, a slight degree of icterus, in advanced cirrhosis, is an indication that one factor, the destruction of the liver-ceUs, prevaUs; a higher grade of icterus indicates that the other factor, compression of the gall-ducts, is in excess, or that, from compfication, there is some new obstruction to the flow of bile. These compHcations, particularly catarrh of the bile-ducts, or their obstruction by gall-stones, occur quite frequently in cirrhosis. If the escape of the bile be entirely prevented, even the slight amount formed by the remaining cells is sufficient to cause intense icterus. The light-gray color of the faeces also depends mostly on the compression of the gall-ducts; as this compression hardly ever causes their absolute closure, perfectly pale, clay-colored stools, such as occur in other forms of icterus, are not seen in cirrhosis. The urine usually contains traces of bile pigment, but is far more re- markable for its richness in urates, and in peculiar coloring matters, to which we shall again refer. Besides the symptoms due to compression of the portal vein and bile-ducts, there are others which depend on the extensive destruction of the liver-cells. When speaking of the icteroid symptoms, we said that the atrophy of the liver-cells diminished the production of bile; and, probably, the discoloration of the faeces depends as much on lim- ited formation as on retention of the bile. Little as we know of aU of the functions of the liver, we are, nevertheless, certain that the forma- tion of bile is not the sole function of the cells of the liver. (The times Avhen fel tauri inspissatum Avas given in pill, or the patient took fresh ox-gall by the spoonful, " to replace the functions of the fiver," are not long past, it is true, but the belief from which such prescrip- tions started is obsolete.) The liver is very important for the general nutrition, and particularly for the blood, and it is certain that an ex- tensive destruction of liver-cells affects the general health very seA'erely. The affection of the nutrition in patients Avith cirrhosis of the liver de- pends partly on the existing gastric and intestinal catarrh; perhaps, also, the excessive fulness of the intestinal veins prevents the entrance of substances from the intestines into these vessels; but there must be another cause for the disturbance of nutrition, for the patients become Aveaker, more emaciated, and have a dryer skin and more cachectic ap- pearance than those have AA'ho are suffering from simple gastric and intestinal catarrh, and in whom the escape of blood from the intestinal veins is obstructed in some other way. Physiology does not, at present, teach us whether the affection of the nutrition depends on arrest of CIRRHOSIS OF THE LIVER. 647 the formation of sugar in the liver, or on the arrest of some other un- known function. In isolated cases, severe brain symptoms appear shortly before death; some patients fall into defirium, and finally into deep sopor; otliers have symptoms of depression, coma, or sopor, from the commencement. On autopsy, we find no palpable changes in the brain to explain these symptoms; hence Ave are justified in referring them to an intoxication; but we do not know what substances cause the intoxication. Formerly it Avas universally supposed that these brain-symptoms depended on the absorption of the constituents of the bile, and they Avere, consequently, termed cholemic intoxications. But the fact that their frequency is not at all in proportion to the icterus, that, on the contrary, where there is but fittle jaundice, convulsions, coma, and sopor not unfrequently occur suddenly, wfiUe they are often absent in the severest cases Avhere the overloading of the blood Avith the absorbed constituents of the bile is much more evident, speaks very strongly against the correctness of this explanation. Frerichs has advanced the hypothesis that it is not the reabsorption of bile, the so- called cholaemia, which is dangerous, but the acholia, occurring in ex- tensive degeneration of the liver, i. e., that condition where the exten- sively-diseased liver can no longer prepare bile from the materials supplied to it. When this important process faUs, instead of the' nor- mal products of interchange of tissue, Ave have abnormal products of decomposition and poisonous substances. The above severe disturb- ances of innervation are induced by these substances. The correctness of this hypothesis of Frerichs is by no means beyond doubt. When speaking of icterus, Ave shall return to the relation of the brain-symp- toms in question, to cholaemia, or acholia, and sHoav that some recent observers incline to the first theory, as they regard the reabsorbed bile- acids as the poisonous substances. The occurrence of quantities of abnormal coloring matter, and of urates in the urine of patients suffering from cirrhosis, also appears to depend on the destruction of the liver-cells, and the diminished or altered action of the liver. We do not knoAV Avfiat modifications of the change of tissue induce this condition of the urine. The most Ave can determine is that, if the coloring matter of the urine be derived from the coloring matter of the bile, and this be a derivative from the color- ing matter of the blood, in extensive degeneration of the liver, Avhere the coloring matter of the blood is no longer normally transformed into the coloring matter of the bile, this anomaly must influence the forma- tion of the coloring matter of the mine and its modifications. Lastly, as to the physical signs of interstitial hepatitis, in the first stage, palpation and percussion usually sIioav a very decided in- crease in size and resistance. In the second stage, also, the liver is 648 DISEASES OF THE LIVER. not so much out of the reach of palpation as is generally asserted. If, by placing the patient on the left side, and so remoA'ing the fluid in the abdomen from the liver, Ave succeed in reaching the edge of the liver, Ave perceive that its resistance is even greater than in the first stage, and on the surface Ave may feel hard, roundish prominences of unequal size. If the ascites be not too great, in the second stage also percus- sion shoAvs in some cases an increase, in others (but, according to my experience, not at all frequently) a decrease of the normal liver dul- ness. In estimating the latter symptom, Ave must be more careful than Avhen the extent of the dulness is abnormally great; for, as the numer- ous measurements of Frerichs prove, the size of the liver and tfie ex- tent of its dulness vary greatly within certain bounds. Moreover, any abnormal position of the liver, such as occurs by decided inflation of the abdomen, causes the organ to come in contact Avith the anterior wall of the abdomen and thorax only by its sharp border. FinaUy, portions of the intestines, filled with gases, pressing between the liver and the abdominal wall, may diminish or entirely remove the normal liver dul- ness. If Ave bear these facts in mind, the diminution of liver dulness is a very important symptom in cirrhosis. As the left lobe of the liver is the first to decrease in size, the abnormally clear percussion-sound in the epigastrium is first noticed; subsequently the dulness over the right lobe may so decrease that it avUI be reduced to one or tAvo inches in the mariimillary line {Bamberger). The most certain point in diagnosis is the gradual decrease in size of the previously enlarged organ, as shown by repeated examinations. Having introduced the symptoms of interstitial hepatitis individ- ually, and weighed them as a whole, we avUI add a short and general description of the disease. The patients are mostly men in middle or advanced life, and addicted to drink. In the commencement the symp- toms are slight and obscure; the patients complain of pressure and ful- ness in the right hypochondrium; more rarely, when the serous cover- ing is more affected and intensely inflamed; there is pain in the region of the liver. In this stage, the most prominent symptoms are enlarge- ment of the liver, dyspepsia, flatulence, and emaciation. Gradually, often not for years, the abdomen swells, from an effusion of fluid into the peritonaeum, while there is no simultaneous oedema of the feet. The skin becomes dirty yelloAV, the urine dark red, and rich in urates, the faeces slate-colored; the dyspepsia and emaciation increase. In this stage, the liver is sometimes smaller, the spleen almost always en- larged. In some patients there is bleeding from the intestinal canal; in almost all, haemorrhoids. The increasing ascites interferes with breathing, and induces oedema of the legs, genitals, and abdominal walls. Finally, after months or years, the patients die. excessively CIRRHOSIS OF THE LIVER. 649 emaciated and exhausted. During the last days of life, delirium and sopor not unfrequently develop. Diagnosis.—Cirrhosis Avould not readily be mistaken for any of the previously described diseases of the liver, but its diagnosis from cancer or tuberculosis of the peritonaeum may be very difficult. In these de- generations, as in cirrhosis, there is often ascites, Avliich has been pre- ceded by no other symptoms of dropsy. The patients also soon be- come emaciated and cachectic, and, as the tumors not unfrequently com- press the ductus choledochus, we may have icterus accompanying them. The folloAving points are particularly important in the diagnosis be- tween cirrhosis and these diseases of the peritonaeum : In doubtful cases the dependence of the ascites and other symp- toms common to the two diseases on cirrhosis may be suspected— 1. When there is swelling of the spleen. We have learned that this is an almost constant symptom of cirrhosis; on the other hand, the spleen is almost always unaffected by tuberculosis and carcinoma, and these are not more likely to cause any other form of enlargement of the spleen. 2. The urine is saturated Avith abnormal coloring matter, and urates. While this symptom also is rarely absent in cirrhosis, the urine of cancerous or tuberculous patients, like that of all hydraemic persons, is usually very clear and watery. When the degeneration of the peritonaeum is accompanied by fever, or when compression of the kidneys and renal blood-vessels by the ascites limits the secretion of urine, the scanty urine may, it is true, be quite concentrated, but there is usually no sediment, and the urine is not so dark as in cirrhosis. 3. The knoAvledge that the patient Avas given to drinking. In far the greater number of cases, as Ave haA'e seen, cirrhosis may be referred to the misuse of spirits, Avhile this has no influence on the development of cancer or tuberculosis. On the other hand, the folloAving symptoms speak for degeneration of the peritonaeum, and against cirrhosis: 1. Extensive sensibility of the abdomen to pressure. 2. Rapid development of ascites. 3. Rapid loss of strength. 4. Recognition of cancer, or tubercles in other or- gans. 5. Tumors in the abdomen, Avhich may not be felt tUl after tapping. 6. Occurrence of fibrin, Avhich does riot coagulate for a long time, in the fiuid evacuated by tapping. The peculiar color, usual in cancerous persons—AA'hich is of some importance in distinguishing cancerous degenerations from other diseases—is of little value in diagnosing carcinomatous degeneration of the peritonaeum from cirrhosis; for in the latter also the patient has the dirty-yelloAV, so-called cancerous hue. Treatment.—If, as rarely happens, interstitial hepatitis be recog- nized or suspected in its first stage, Ave should attempt to arrest its 650 DISEASES OF THE LIVER. orogress by strictly forbidding the use of spirituous liquors. The treatment recommended for hyperaemia of the liver is also suited to these cases, particularly the occasional apphcation of leeches about the anus, and the administration of saline laxatives. The latter are best prescribed as natural or artificial mineral waters of Karlsbad, Marien- bad, Tarasp, etc., in which they are better borne than they are without the addition of carbonic acid and the alkaline carbonates. If the nutrition of the patient have already suffered much, we give the prefer- ence to springs containing small quantities of iron, such as the Eger, Franzenbrunnen, Kissengen, Ragoczy, and Homburg springs. In the second stage, even at its commencement, we can no longer hope to arrest the disease. As the neoplastic tissue, which fills a loss of substance in the skin, continues to shrink till a firm cicatrix has formed, so the neoplastic connective tissue in the liver unceasingly contracts till the evil results arise which were depicted under the head of symptoms. But then radical aid is entirely impossible, for the dense tissue can never expand again. Subsequently the treatment of cir- rhosis can only be symptomatic. Among the symptoms of congestion, the gastric and intestinal catarrh demand particular attention, as they increase the emaciation and debility of the patient. According to the rules previously given, it is just in this form of gastric and intestinal catarrh that the administration of the alkafine carbonates is most bene- ficial ; they appear to decrease the toughness of the mucus, and thus to enable the mucous membrane to get rid of its mucous coating more readily. The haemorrhage from the stomach and intestines should also be treated according to the rules previously laid down, although Ave cannot hope for very favorable results. We should only tap the patient when it is imperatively necessary, for the ascites, dependent on obstruction in the portal vein, is particularly liable to return very quickly, as soon as the pressure of the fiuid, which has impeded the transudation, has been removed. But, if we have been obliged to tap, Ave may hope to retard the fresh collection of fluid by compressing the abdomen with a proper bandage. The assertion previously made, that diuretics are as useless as they are irrational in the treatment of ascites, is particularly true of this form of the disease. The most important indication in the treatment of cirrhosis is, to improve the strength and nutrition of the patient. WhUe the state of the digestive organs per- mits it, we should give him nutritious diet and preparations of iron, Avhich are not unfrequently well borne and very beneficial. In one patient, with cirrhosis of the liver, who afterward died of haemate- mesis, under free use of iron, and a diet consisting mostly of milk and eggs, I have frequently seen the fluid in the abdomen diminish, AA'hile it increased again when the patient Avas removed from the hospital, SYPHILITIC HEPATITIS, SYPHILOMA OF THE LIVER. 651 or was not so well cared for, or Avhen he had haemorrhage from the stomach. CHAPTER IV. KA'PHILITIC HEPATITIS, SYPHILOMA OP THE LIVER ( Wagner). Etiology.—Among the internal organs of the body, the liver ap- pears to be the one most frequently affected by constitutional syphilis. At all events, syphUitic hepatitis or syphUoma of the liver is correctly interpreted earlier than the syphilitic affections of any other organ. Syphilitic disease of the liver is not unfrequently found in the bodies of children who have had congenital syphilis. Among the dis- turbances of nutrition due to acquired syphilis, syphUitic hepatitis comes rather late, so that it is classed among the tertiary rather than among the secondary syphUitic diseases. Anatomical Appearances.—From numerous microscropic ex- aminations of organs affected Avith syphUitic disease, it is true Wagner has come to the conclusion that not only the form ap- pearing as circumscribed deposits (gummy tumors of Virchow), but also the diffuse syphilitic degenerations of the organs, depend on the development of a specific neoplasia, syphiloma, but the appearance to the naked eye of livers in Avhich structural change has resulted from constitutional disease varies so greatly, in different cases, that it still appears proper to describe different forms of syphUitic hepatitis. We may distinguish a syphilitic perihepatitis, a simple interstitial syphi- litic hepatitis leading to diffuse induration, and a third form caUed by Virchow gummous hepatitis. The latter, whose syphilitic nature Avas long since recognized by Dittrich, is most readily recognized and distinguished from other forms of liver disease. In it Ave find spots, from the size of a hemp-seed to that of a hazel-nut, or even Avalnut, in the liver, Avhich in recent cases have a medullary appearance, but, after they have existed a long AA'hile, form yellow, cheesy masses. These spots, Avhich, previous to Dittrich's explanation, Avere regarded as cancer in the stage of recovery (Avhich they greatly resemble), are enclosed by a dense tissue, and dense connective-tissue striae extend from them in various directions toAvard the surface of the fiver. On the surface even Ave may notice deep furroAVS, AA'hich give the liver a pecufiar lobulated appearance, and Avhich are caused by the paren- chyma of the lh'er being destroyed in some places and being replaced by contracting connecthe tissue. In the diffuse syphUitic indurations of the liver, Ave find more or less extensive parts transformed into a hard, dense tissue. The gland-substance is mostly destroyed and re- placed by connective tissue. The simultaneous occurrence of the 652 DISEASES OF THE LIVER. above-described spots is almost the only symptom which avUI prevent our mistaking syphilitic induration of the liver for cirrhosis; but the more regular homogeneous appearance of the cut surface and the ab- sence of the granulations, Avhich are rarely never wanting in cirrhosis, furnish some points for the diagnosis. Besides the fact that syphilitic perihepatitis usually complicates the above-described parenchymatous diseases, it is somewhat characteristic of this affection that the thick- enings of the serous covering caused by it are more decided than in other forms of perihepatitis, and that they are peculiarly hard and tough. Symptoms and Course.—In many cases syphilitic hepatitis can- not be recognized or suspected during life. Occasionally we may make the diagnosis from the peculiar form of the enlarged liver, on Avhose surface prominences and retractions may be distinguished, and from the coexistence of other symptoms of constitutional syphilis. In one patient in Greifswald, Avho complained of the symptoms of chronic peritonitis, from the peculiar form of the liver I was able to diagnose the probable existence of hepatitis, before the patient acknowledged to being infected, and before examination of the throat had shown a decided defect in both sides of the soft palate. This patient has since died, and, according to a notice that I have found in the Griefswalder Medicinischen Beitrdgen, the autopsy confirmed my diagnosis. In the former editions of my book I asserted that it was not improbable that, Avhere the process Avas very extensive, compression of the portal vein and bile-ducts might induce a series of symptoms similar to those from cirrhosis. I Avas then obliged to add that, in the cases then pub- lished, there had been a moderate ascites in only one, while icterus had not occurred in any case. Since then I have had the opportunity of observing one case that has fully sustained my conjecture: A pa- tient, avIio denied ever having had syphilis, was received into the clinic Avith icterus, excessive ascites (which required repeated tapping), and very dark urine, Avhich contained quantities of abnormal coloring matter. The liver was enlarged, and on its surface could be felt distinct round protuberances, which Avere not puffy or in the form of ridges. The diagnosis of carcinoma of the liver, with consecutive closure of the portal vein, Avas not confirmed by the autopsy. The liver Avas typi- cally lobulated, its covering much thickened in some places, a large amount of its parenchyma diffusely indurated; deep in the right lobe of the liver were three or four still fresh, medullary-looking gummy tumors. Treatment.—There can hardly be a question of treatment in syph- ilitic hepatitis, for, even in those cases AA'here the disease is recognized during life, it is only toward its end. We cannot depend on relaxing INFLAMMATION OF THE PORTAL VEIN—PYLEPHLEBITIS. 653 or removing the shrunken connective tissue by iodine or mercurial preparations, and consequently are limited to a symptomatic treatment. CHAPTER V. INFLAMMATION OF THE PORTAL VEIN--PYLEPHLEBITIS. Etiology.—By pylephlebitis Ave understand not only those.con- ditions Avhere an inflammation of the wall of the vein induces a clot in the portal A'ein, but also those where coagulation of the contents of the portal vein occurs independently of inflammation in the AvaUs of the vessel. The first form—primary phlebitis—is far rarer than the latter. Its exciting causes are partly injuries of the portal vein, partly inflamma- tion of the parts about it, Avhich extends to the Avail of the vein. Secondary phlebitis, or, as it is now called, thrombus of the portal vein, cannot always be referred to any eAddent causes: 1. In some cases it is due to compression of the trunk of the portal vein, by lym- phatic glands, caseously or cancerously degenerated, or by thickened or cicatricially contracted peritonaeum. 2. In other cases, compression of the branches of the portal vein, as by cirrhosis, so retards the cur- rent of the blood, that coagula form in the trunk or ramifications of the portal vein. 3. It appears to result much more frequently from the gradual increase and extension of a thrombus that has formed hi some branch of the portal A'ein. In the same Avay, Avhere there is thrombus of one of the crural veins, not unfrequently a clot occurs not only in the vein of the corresponding leg, but the thrombus often extends up- Avard also into the vena cava, or even into the renal veins. In such cases there is a primary thrombosis in the portal vein and its branches, even Avhen the original coagulum in one of the roots of the portal vein resulted from inflammation of its walls. In this Avay are most readily explained the thromboses of the portal vein, due to ulcerations and suppurations in the abdomen, to inflammation of the umbilical vein in neAvly-born children, to abscesses of the spleen, ulcers of the stomach, to inflamed and suppurating haemorrhoidal tumors, and to simUar causes. 4. It has not been determined AA'hether emboli, from collections of pus reaching the fiver, can give rise to a coagulum at first circumscribed, subsequently diffuse, in the portal A'ein. Anatomical Appearances.—In the first stage of both forms of pylephlebitis there is ahvays coagulation of the contents of the vein. It is important to note this, to avoid error: suppurative phle- bitis begins AA'ith suppuration in the vein. The clot adheres firmly to the Avail of the A'ein. In primary phlebitis this is from the first 654 DISEASES OF THE LIVER. thickened, infiltrated Avith serum, and shows a cloudiness of the mucous coat, and an injection of the fibrous. In thrombosis, the wall of the vein is at first normal, but it is soon changed in the manner above de- scribed. The coagulation of the contents may be limited to some twigs of the portal vein, but in other cases it extends to the trunk, roots, and branches. The terminations of pylephlebitis vary, and, according to the difference of its termination, it is called adhesive or suppurative. In adhesive pylephlebitis, while the thrombus graduaUy shrinks, undergoes fatty degeneration, and is partly or entirely absorbed, there is inflammatory proliferation of the wall of the vein, which terminates in its obliteration, although we cannot follow the different phases of the process. If we examine a liver that has been the seat of adhesive pylephlebitis, we find on its surface cicatricial retractions, and within it, corresponding to these retracted places, we find a hard tissue, in which may still be recognized the atrophied branches of the portal vein. Occasionally these contain remains of the thromboses, colored more or less yellow by haematin. In suppurative pylephlebitis, instead of atrophying gradually, the thrombus dissolves into a puruloid fluid. This is, for the most part, a finely-granular detritus, containing only a few roundish cells, which may be either white blood-corpuscles or newly-formed pus-corpuscles. The Avhole thrombus rarely breaks down at the same time. In the trunk of the vein there is often a firm coagulum, whUe there is a puruloid fluid in the branches and roots. But more frequently there is no dis- integration in the finer branches of the portal vein, so that the coagula there prevent the disintegrated masses entering the hepatic vein, and reaching the pulmonary circulation. I have had the opportunity of carefully observing this " sequestration " in tAvo cases of suppurative pylephlebitis. It readily explains the frequent escape of the lungs from secondary disease, AA'hich could scarcely fail to occur if the termi- nations of the portal vein were not closed. But, in phlebitis of the peripheral veins, the inflammation not un- frequently extends from the adventitia to the surrounding parts, in- ducing suppuration and formation of abscesses, so that inflammation of the parenchyma of the liver, which terminates in the formation of abscesses, often accompanies suppurative pylephlebitis. Then we often find in the liver numerous deposits of pus, which surround the portal vein, and often communicate with it. Symptoms and Course.—When adhesive pylephlebitis is limited to individual twigs of the portal vein, it runs its course without show- ing any symptoms during life. The pervious branches suffice to trans- fer the blood from the abdominal organs to the hepatic A'ein. If the trunk of the portal vein, or all or most of its branches, be obliterated, FATTY LIVER—IIEPAR ADIPOSUM. 655 the symptoms greatly resemble those of cirrhosis. In both cases the obstruction to the escape of blood from the roots of the portal vein leads to gastric and intestinal catarrh and haemorrhage, to haemor- rhoids, enlargement of the spleen (not constantly), and to ascites. Biliary retention and icterus result more frequently from compression of the gall-ducts in adhesive pylephlebitis than in cirrhosis, because a greater number of the liver-cells are preserved to prepare bUe. The continued secretion of bile and the occurrence of icterus in pylephlebi- tis appear to show that the hepatic artery, as well as the portal vein, furnishes the liver with material for the formation of bUe. The course of the disease is chronic. Recovery is impossible ; but it often lasts for months before death occurs from the same symptoms as it does in cirrhosis. Hence it appears that the disease can only be recognized and distinguished from cirrhosis by aid of the history of the case. If it be found that the patient was not given to drinking, and if the aboA'e symptoms were preceded by chronic inflammation and suppuration in the abdomen, the chances are in favor of adhesive pylephlebitis, par- ticularly if the disease have run its course more rapidly than is custom- ary with cirrhosis. Hitherto suppurative pylephlebitis has rarely been recognized dur- ing life. Its symptoms are pain in the right hypochondrium, enlarge- ment and tenderness of the liver, chills recurring at irregular intervals, high fever, and almost ahvays icterus. If these symptoms join them- selves to an inflammation or ulceration of one of the abdominal organs, Ave may, Avith some certainty, conclude that there is an acute inflam- mation of the liver; but Ave cannot yet say Avhether the parenchyma or the portal vein be inflamed. We are only justified in the latter supposition, Avhen, besides the other symptoms, Ave have those of ob- struction of the portal vein, particularly Avhen there is enlargement of the spleen, slight ascites, and haemorrhage from the stomach. Schonleln Avas the first to recognize a case of suppurative pylephlebitis during life, from the above symptoms; thereby shoAving great diagnostic acu- men and anatomico-physiological knoAvledge. Treatment.—Concerning the treatment of adhesive pylephlebitis Ave may refer to Avhat has been said of cirrhosis; AvhUe that of sup- purative pylephlebitis corresponds exactly Avith that of suppurative hepatitis. CHAPTER VI. FATTY LIVER--HEPAR ADIPOSUM. Etiology.—There are two forms of fatty Hver. In one, superfluous fat is deposited in the liver-cells from the blood of the portal A'ein; in the other, the nutrition of the liver-cells is disturbed by disease of th 656 DISEASES OF THE LIVER. parenchyma of the liver, and they undergo retrogressive metamorpho- sis, during Avhich fat granules appear in them, as happens under sim- ilar circumstances in other cells and other tissues. This second form, fatty degenereition, is one symptom of many structural changes of the liver; Ave have already mentioned it in chrhosis, and shall often refer to it again. Here we shall only consider the first form, fatty liver in the strict sense, or, as we may call it Avith Frerichs, fatty infiltration. On superficial observation, the circumstances under which fatty liver occurs appear very varied: for, on tfie one fiand we find it, along with an excessive production of fat throughout the body, where the supply of nutriment is excessive and its consumption limited; and, on tfie other hand, it occurs Avith excessive emaciation, where there is in- creased consumption of the body. This contrast is, however, only apparent; both circumstances agree in causing an abnormal amount of fat in the liver. In the one case, fat or the substances from Avhich it is formed in the body are supplied from wdthout; in the other case, fat is reabsorbed from the subcutaneous and other tissues rich in fat, and taken into the blood. If Ave inquire more minutely into the first-mentioned mode of de- A'elopment of fat, Ave find that the persons affected with fatty liver are chiefiy those Avho exercise but little, whUe they eat and drink freely. But by this mode of life tfiey are subjected to conditions analogous to those under which we place animals when we wish to fatten them. We do not let the latter work, but shut them up in a pen, and give them plenty of hydrocarbons. But, under this treatment, one animal avUI become fat readUy and quickly, while another avUI do so slowly or not at all; in the same way, of tAvo persons living alike, one Avill become fat and fiave fatty liver, while the other will remain lean and his liver avUI be healtfiy. We do not know the causes of the individ- ual predispositions, which appear to be sometimes congenital and he- reditary in some families, or the causes of immunity of other persons to fat bellies and livers. They may depend either on easy or difficult assimilation of nutritive materials; or on slow or rapid consumption of tissue. If there be a decided predisposition, the disease appears to develop on ordinary mixed diet, if more of it be consumed than is re- quired to supply the place of what has been used up; if the predis- position to fat be slight, it only occurs where there is an excessive supply of fats, hydrocarbons, and particularly of spirituous liquors. It is probable, but not absolutely certain, that the latter act by retard- ing the transformation of tissue. The frequent occurrence of fatty fiver with tuberculosis of the lungs has long been remarked; their connection has been ascribed to incom- plete oxidation of the hydrocarbons, and their transformation into fat, FATTY LIVER—HEPAR ADIPOSUM. 657 due to impaired respiration. But as fatty liver rarely occurs in other lung-diseases Avliere the respiration is also affected, and as it often re- sults from tuberculosis of the bones and intestines, and from carci- nomatous and other diseases in AA'hich the patients emaciate, the ob- structed respiration cannot be the sole cause of its occurrence in tuber- culosis of the lungs. Budd and Frerichs agree Avith the theory first advanced by Leirrey, that it depends on too much fat in the blood, and that this was due to the emaciation and reabsorption of fat from other parts of the body. Perhaps the grade of the fatty liver is someAvhat influenced by the cod-liver oil so much given of late for tuberculosis of the lungs. Anatomical Appearances.—Slight amounts of fatty infiltration do not alter the size or appearance of the liver, and can only be recog- nized by the microscope. In higher grades the liver is enlarged, but usually appears flattened; the edges are generally thickened and rounded off. In many cases the increase in size and weight is but slight, in some it is very decided. The peritoneal covering of the fatty liver is transparent, smooth, and shining; occasionally it is trav- ersed by varicose vessels. According to the grade of the fatty infil- tration, the surface of the liver is yelloAvish red, or distinctly yellow. We often notice that the yellow color is interrupted by reddish spots and figures, Avliich correspond to the A'icinity of the central veins. The consistence of the liver is diminished; it feels doughy, and pits on pressure Avith the finger. On incision, Ave meet little resistance; a coating of fat remains on the warmed knife-blade. But little blood Aoavs from the cut surface, which is also yelloAvish red or yellow, and shows the red spots and figures above mentioned. On microscopic examination, according to the grade of the disease, the enlarged and usually rounded liver-cells appear either filled AA'ith fine fat globules, or these have united to form single larger drops, or, lastly, indiAddual liver-cells are entirely or mostly filled by one large drop of fat. The infiltration ahvays begins at the periphery of the lobules of the liver, that is, near the interlobular veins, the termina- tions of the portal A'ein ; it rarely extends to the vicinity of the central A'ein (Avhose freedom causes the red spots in the yellow liver), and even then the liver-cells in the centre are usually less infiltrated than those at the periphery. The chemical examination of the liver often sHoavs enormous quantities of fat. In one very fatty liver, Vauquelin found 45 per cent, of fat, in one case Frerichs found 43 per cent., and Avhen the substance of the liver AA'as freed from Avater he found 78 per cent. According to Frerichs, the fat consists of olein and mar- garin in Aariable proportions, AA'ith traces of cholesterin. One variety of fatty lher is AA'hat Home and Rokitansky call waxy. 42 658 DISEASES OF THE LIVER. liver. It depends on the same structural changes, but is distinguished by a Avaxy dryness, a peculiar brilliance and intense yelloAV color. Symptoms and Course.—In most cases of fatty fiver there are no subjective symptoms, and, on objective examination also, only high grades of the disease can be recognized. In fat persons, and in those with consumption of the lungs, Ave should examine the region of the liver from time to time, even without their complaining. If, in these cases, Ave find an enlargement of the liver, which is the more readily recog- nized as the liver is usually elongated, has thickened edges, and from the relaxation of its parenchyma hangs far down {Frerichs), and if the enlarged liver be painless, its surface smooth, its resistance sligfit, so that we cannot readily feel the lower border, these symptoms suffice to complete the diagnosis, on account of the frequent coincidence of fatty liver Avith these states. If the fatty liver be of high grade, as occurs particularly in topers, as in any other enlargement of the liver, there may be a feeling of fulness in the right hypochondrium. If the abdominal Avails, the omentum, and mesentery be also very fatty, the fulness of the abdo- men and the tension of its walls may impede the movements of the diaphragm and interfere with respiration. In such persons the secre- tion from the sebaceous glands is usually so increased that their skin shines with fat, and, when they sweat, the sweat runs from their skin in large pearls; this condition of the skin, which is due to the same state of affairs as the fatty liver, is often mentioned as one of its symptoms. ^ As fatty livers rarely cause any trouble, as on post-mortem ex- amination tfie bile is usually found in normal amount and quality, as they can be generally well injected, and as there are usually no symp- toms of congestion in the abdominal organs, the belief has gradually gained ground that the fatty infiltration neither impairs the functions of the organ nor interferes with its circulation. But this supposition only appears correct for the lower and medium grades of the disease. In the highest grades, after death, we often find but little bile in tfie bile-ducts, and the faeces in the intestines are but slightly colored. The Aveakly constitution of such patients, particularly then knoAvn in- tolerance of bleeding, also indicates disturbance of the function of the liver. From the varicosities not unfrequently found on the capsule of the liver, Frerichs concluded that the compression of the blood-vessels also caused a slight congestion of the vessels before they enter the liver. It is true there is no enlargement of the spleen or ascites, but the gastric and the intestinal catarrh appear to depend, at least partly, on this congestion. Rilliet and Barthez consider it not improbable that the profuse diarrhoea AA'hich occurs AA'ithout perceptible structural FATTY LIVER—HEPAR ADIPOSUM. 659 change of the intestines, in phthisical patients who have fatty liver, is caused by the latter. Schbnlein and Frerichs speak in the same Ava}-. I have seen obstinate diarrhoea in non-phthisical patients, where exces- sively fatty fiver Avas the only anomaly found in the abdominal organs on post-mortem examination. Treatment.—In gluttons and topers, the causal indications im- peratively demand a change of the mode of fife. General advice is of no use, as it is badly followed. For such patients we should prescribe the hours of exercise, forbid afternoon naps, give careful directions about their meals, forbidding all gravies and other fatty substances; for supper Ave should only allow water-soup and a little stewed fruit. The use of coffee and tea should be limited, that of Hquor entirely for- bidden. In the fatty fiver occurring in consumptive diseases, particu- larly in pulmonary consumption, we can rarely fulfil the causal indica- tions. The indications from the disease have long been supposed to require remedies for increasing the secretion of bile. And, in the present state of physiology, we must suppose that the success of this intention Avould have the best effect on fatty liver. We find less fat in the hepatic vein than in the portal vein. Frerichs saw the secretory ac- tivity of the liver-cells diminish as their fatty contents increased ; hence avc can hardly doubt that the fat going to the liver is used up in the production of bile, and that the superfluous fat must disappear from the liver-cells AA'hen the secretion of bile is increased. But our knoAvledge of the difficulty of fulfilling this indication increases in proportion AAdth our comprehension of its urgency. At present Ave can scarcely hope that an inert indifferent vegetable extract will decidedly increase the secretion of bile, since we no longer regard the bile as a secretion necessary for digestion, or, at least, only secondarily so, but as a prod- uct AA'hose quantity and quality vary Avith the acceleration or retardation of the change of tissue, or AA'ith its other modifications. It is possible that the freshly-expressed juices of taraxacum, chelidonium, etc., have a curative influence AA'hen used as "spring cures" {Fr id dings cur en), Avhile the patients rise early, live moderately, and exercise freely; but it is probable that the benefit is mostly due to the change in the mode of life. The case is different AA'ith the treatment at Karlsbad, Marien- bad, Homburg, Kissengen, etc. In the results there obtained, the favorable mode of life must be taken into consideration; but the free and continued use of the different solutions of salts must have just as much effect on the change of tissue. It is certain that the superfluous fat of the body soon disappears under the use of these mineral Avaters, and after a month's residence in Karlsbad most patients return home much thinner than AA'hen they Avent there. Simple pedestrian excur 660 DISEASES OF THE LIVER. sions, Avith the most moderate manner of living, have not, by any means, the same effect. Several very crude hypotheses have been ad- vanced concerning the action of the alkaline-saline springs; the body of a Karlsbad patient has even been compared to a soap-factory, and the characteristic passages have been regarded as soap, which was said to be formed from the soda of the Avaters and the fat from the body. We should not, however, Avait to find a better explanation, but should send fatty patients Avith fatty infiltrations of tfie fiver to those Avater- ing-places. This is occasionally very erroneously done with patients whose fatty liver depends on decided emaciation, because the patients or the physician do not recognize the significance of the disease. It is unnecessary to state the contraindications to the use of the alkaline- muriatic springs. If the blood be impoverished, avc should carefully try if the Eger Franzensbrunnen, or the Kissengen Ragoczy waters, are borne, and, if they are not, we should be satisfied with regulating the diet and mode of life. This rule refers also to those cases where patients with fatty liver are inclined to diarrhoea. CHAPTER VII. LARDACEOUS (OR WAXY) LIVER--AMYLOID DEGENERATION OF THE liver—(Virchow). Etiology.—Lardaceous degeneration of the liver depends on a deposit in the liver-cells and in the walls of the hepatic vessels ( Wag- ner) of a substance whose nature Ave do not yet know, but whose re- action to iodine and sulphuric acid closely resembles that of amylum and cellulose. From this similarity of chemical reaction, which may perhaps, be accidental, the title of " amyloid degeneration " has of late been given to that state which Avas formerly called " lardaceous degen- eration," from its external resemblance, but particularly from its pecu- liar lustre. Lardaceous liver never occurs in persons otherAvise healthy; it is more apt to occur in advanced cachexia, particularly in cases resulting from scrofulous, cachectic, or syphilitic affections, from mercurialism, tedious suppurations, and caries of the bones; it is also occasionally found in patients with pulmonary consumption; in some cases it is in- duced by malaria. Anatomical Appearances.—A lardaceous liver is usually de- cidedly increased in size and Aveight, and resembles fatty liver in form, as it appears elongated, flattened, and thickened at the edges. The peritoneal covering is smooth and tense, and the liver is hard as a board. The cut surface is very dry and bloodless, smooth, almost ho- LARDACEOUS LIVER. 661 mogeneous, AAdth a gray color and very lardaceous lustre. When there is a coincident fatty degeneration, the knife-blade is covered with fat. There is almost ahvays a similar degeneration of the spleen, and not unfrequently of the kidneys also. On microscopic examination, the polygonal fiver-cells appear round and enlarged; the fine granular contents, and usually also their nuclei, are atrophied, and the cells filled with a translucent, homogeneous substance. If there be at the same time fatty degeneration, Ave find small discrete fat globules in the degenerated cells, particularly at the periphery of the lobules of the liver. On the addition of a solution of iodine, there is not a yellowish-broAvn but a peculiar reddish-broAvn color; after the addition of sulphuric acid, there is a violet and subse- quently a blue color of the preparation. Symptoms and Course.—The very gradual enlargement of the liver causes no pain; and the patient's attention is first called to his disease, Avhen the enlarged organ fills the right hypochondrium, and causes a feefing of pressure and tension. Budd considers ascites as a constant symptom of lardaceous liver, and refers it to the compression of the portal vessels. He also believes that, in children debilitated by scrofulous diseases of the glands and joints, the recognition of a painless enlargement of the liver, accompanied by ascites, is sufficient for the diagnosis of the disease in question. In opposition to the AdeAv that ascites accompanying lardaceous liver is due to obstruction of the portal vein, Bamberger very correctly says that in such a case there should also be symptoms of congestion in the other abdominal organs, but these never occur. It is far more probable that the dropsy is due to the general cachexia and hydraemia, from which all patients Avith lardaceous liver suffer. In the cases observed by Bamberger, the ascites Avas ahvays preceded by oedema of the feet, and in those re- lated by Budd it does not appear that the ascites preceded the oedema of the feet. The enlarged liver-cells do not compress the bile-ducts any more than they do the blood-vessels, and icterus is absent as a rule. Icterus may, hoAvever, result from complications, such as lar- daceous enlargement of the lymphatic glands at the porta hepatis, so that Frerichs Avarns us against considering the absence of icterus as a diagnostic criterion of lardaceous lh'er. The faeces have little color, on account of the impaired function of the diseased liver-cells. It is difficult to decide Iioav far the bad nutrition of the patient, the pale- ness of his skin and mucous membranes, the hydraemia and dropsy, de- pend on the degeneration of the liver, as this disease only occurs in those avHo are cachectic at any rate, and as the spleen is almost al- ways diseased at the same time, and the kidneys are very frequently so. The etiology, the hard liver-tumor readily felt on palpation, 662 DISEASES OF THE LIVER. the usually coincident enlargement of the spleen, and, lastly, albumi- nuria, Avhen it exists, are important in the diagnosis of lardaceous liver. By paying attention to these points, the higher grades of the disease may be readUy recognized. Treatment.—It has not been proved, nor is it probable, that lar- daceous degeneration is capable of restoration; and, although cases are said to have been observed where lardaceous livers have become smaller and normal, further proof is needed on this subject before we can believe the statement. The long-continued inunction of iodine salve over the liver, although strongly recommended by Budd, de- serves little confidence. Tfie preparations of iodine, particularly syrupus ferri iodidi, are extensively used in lardaceous liver, as are also alkaline batfis and preparations of iron. Although these may not improve the liver-disease, they may do much to arrest its progress. Iodine justly holds the reputation of being a specific for tertiary syph- ilitic affections, and in other dyscrasias also its beneficial effects have been proved; the preparations of iron are indicated by the great pov- erty of the blood. The peculiarities of each case should decide which of these remedies is to be employed. CHAPTER VIII. CANCER OF THE LIVER--CARCINOMA HEPATIS. Etiology.—The liver is so frequently affected with carcinoma that, according to Rokitansky, there is about one case of cancer of the liver to every five cases in all parts of tfie body, and Oppolzer found it fifty-three times in four thousand autopsies, or in about every eightieth patient. In many cases it is primary, in others it is preceded by cancer of the stomach, rectum, or other organs ; it is pe- culiarly apt to develop after extirpation of peripheral cancerous tu- mors. The causes of carcinoma of the liver are just as obscure as those of carcinoma elsewhere. It is true that, when asked, the patients are rarely puzzled to tell what caused their disease, but their accounts give us no true information as to its etiology. Anatomical Appearances.—Medullary cancer is the form most frequently found in the fiver. It sometimes forms circumscribed, sharply-bounded tumors; sometimes it spreads out diffusely between the liver-cells, and has no sharp borders. In the former case we find roundish or glandular and lobulated tumors in the liver; these are enclosed by a delicate, vascular connec- tive tissue capsule, and, Avhere tfiey touch the peritonaeum, are often CANCER OF THE LIVER—CARCINOMA HEPATIS. 663 flattened, or have a shalloAV excaA'ation, a so-called " cancer naA'el." The size and number of the tumors vary; they are found from the size of a pea to that of a child's head; sometimes they are sohtary, again innumerable. The nearer they lie to the periphery of the lh'er, the more readily do knobbed protuberances appear. Their consistence varies from that of firm brawn to that of soft brain-matter. A large amount of " cancer-juice" may be pressed out of the softer cancers, Avliile only a small amount can be expressed from the harder ones. Lastly, the color of the tumor is milk-white or reddish, according as it has feAV or many Aessels; it may also be dark red, from effusions of blood, or black from deposits of pigment. In the unaffected parts of the liver there is usually great hyperaemia, Avhich has something to do Avith the enlargement of the organ, which is often very great. Not unfrequently the lher is rendered intensely yellow by compression cf the gall-ducts and retention of the bile. In the immediate vicinity of the cancerous tumors, the fiver-cells have usually undergone fatty de- generation. Chronic partial peritonitis almost always occurs quite early in the covering just over the tumors, causing thickening and ad- hesion Avith the neighboring parts; in other cases cancerous masses develop in this part, and spread over the entire peritonaeum. The for- mation of the " cancer navel" in carcinoma of the liver, as in carcino- ma elseAA'here, depends on atrophy of the oldest parts of the neoplasia, in which the cellular ^elements undergo fatty degeneration and atrophy; but occasionally Ave meet cases of cancer of the liver where this retro- gression extends to the entire tumor, AA'hich is finally reduced to a yelloAV crumbly mass, enclosed in a cicatricial connective tissue (the remains of the cancerous frameAVOrk). If young cancer be found AA'ith these cicatricial masses in the liver, there can be no doubt about the nature of the latter; but if this be not the case, it AAtill be difficult to decide AA'hether it be indeed cancer that has recovered or the remains of some other process. In rare cases medullary cancer softens, and, by disintegrating, leads to acute peritonitis, or to dangerous haemorrhage. In the second form, Avhich Rokitansky calls infiltrated cancer, Ave find large portions of the liver converted into a wfiite cancerous mass. The obfiterated vessels and gall-ducts, which are surrounded by rudi- mentary liver-cells atrophied, fattily degenerated and colored by bile, often traverse this aadiite mass as a coarse yellow framework. ToAvard the periphery the infiltrated cancer gradually passes into the normal parenchyma, as there are places Avhere cancerous masses, and others ;vhere the fiver-cells, are in excess. The alveolar or gelatinous cancer, Avhich almost exclusively attacks the stomach, intestines, and peritonaeum, in some few cases extends from the latter to the parenchyma of the liver. In one case, observed 064 DISEASES OF THE LIVER. by Luschka, almost the Avhole of the liver Avas transformed into a shapeless mass of the structure of alveolar cancer. Still more rarely small nodules of the structure of epithelial cancer are found in the liver. Occasionally cancer of the liver is accompanied by cancer of the portal vein, the trunk, roots, and branches of the latter being filled by a loosely-connected thrombus of cancerous substance. I have seen one case AA'here the contrary occurred: cancer of the portal vein first complicated cancer of the stomach, and the cancer of the liver found on autopsy had evidently resulted from the extension of the degen- eration from the portal vein to the tissue of the liver. Symptoms and Course.—The symptoms of cancer of the liver are always obscure at first; later they are usually quite distinctive, but cases do occur Avhere a certain diagnosis cannot be made till death. The first complaints of the patient are almost ahvays of a feeling of pressure and fulness in the right hypochondrium, such as accompanies all enlargements of the liver wfien they occur rapidly and become great. When the tumors are near the surface of the liver, and hence induce partial peritonitis early, there is pain in the region of the liver even at the commencement of the disease; this pain often spreads to the right shoulder. Even from the first the region of the liver is usually more sensitive to pressure than in any of the diseases of the organ hitherto described, except suppurative hepatitis. After a time the patients themselves notice that their right side is prominent, and that there is a hard tumor in the right hypochondrium. If the tumors compress large branches of the portal A'ein, there is moderate ascites ; if, on the other hand, they grow on the concavity of the fiver and compress the portal vein itself, the ascites becomes considerable; in other cases there is none, but this is rare; for, besides the obstruction of the ves- sels, consecutive disease of the peritonaeum causes ascites. Gastric and intestinal catarrh, AA'hich often complicate cancer of the liver Avith- out the stomach or intestines being affected Avith cancer, are to be regarded as due to the obstruction of the circulation. The spleen is rarely enlarged, perhaps because the hydraemia favors the early occur- rence of dropsy, and the pressure of the dropsical fluid interferes Avith the SAvelling of the spleen. The same is true of icterus as of ascites. Compression of the large bile-ducts causes partial obstruction of bile and moderate jaundice; but, from the gall-ducts that are not com- pressed, sufficient bile flows into the duodenum to color the faeces nor- mally. If the ductus choledochus be compressed, hoAvever, the obstruc- tion of bile becomes general, the icterus great, and the faeces are col- orless. Lastly, the jaundice and discoloration of the faeces occasion- ally depend on catarrh of the gall-ducts. In more than half of the CANCER OF THE LIVER—CARCINOMA HEPATIS. 665 ?ases there is no jaundice. As icterus does not occur in most of the organic diseases of the lh'er, its presence with enlargement of the liver is strong evidence that this is due to carcinoma rather than to other diseases; but its absence cannot be regarded as proof against carcino- ma. Where the cancer of the liver is extensive, the urine shows the peculiarities before mentioned, and appears peculiarly red or bluish from the presence of abnormal coloring matter, resulting from the de- struction of numerous lh'er-cells. While the above symptoms gradually occur, the diseases may gen- erally be suspected from the appearance of the patient, who looks cachectic, is Avasted aAvay, has a relaxed skin, and oedema about the ankles. In some patients the cancerous marasmus does not appear till very late, and, even when large tumors may be felt in the liver, they appear as Avell nourished and fresh as many patients with carci- noma of the breast, before it has ulcerated. But even these patients do not escape the injurious effects on the general health, which are difficult to understand Avhen the cancer does not suppurate. They gradually become marasmic ; and, Avhen the emaciation and exhaustion have reached the highest grade, they generally die of dropsy. Among the final symptoms Ave not only unfrequently have thrombus of the femoral veins, follicular catarrh of the large intestine, and shortly be- fore death thrush not unfrequently comes in the mouth. Where there are large tumors in the liver, the physical examina- tion not unfreqwently gives important aid in diagnosis. In none of the diseases of the liver, so far described, does the organ attain the size that it may reach in carcinomatous degeneration. The liver, enlarged by this disease, most frequently eleA'ates the loAA'er ribs, pushes them out- Avard, and forms a visible prominence in the abdomen, AA'hich often has the outline of the liver, and may extend from the right hypochondrium to beloAV the naA'el and into the left hypochondrium. On palpation, Ave usually distinctly feel the edge of the indurated organ, and on its surface avc find larger or smaller protuberances, Avhich are almost pa- thognomonic of the disease. If the peritoneal covering of the tumor be the seat of a recent in- flammation, AA'e sometimes feel and hear a distinct friction from the movements of the liver during respiration. If there be considerable ascites, it may prevent exact examination of the surface of the fiver; but if, by pusliing the finger in quickly, Ave displace tfie fluid, we may at least convince ourselves of its increased size and consistence. In most cases the above-described symptoms and course render the diao-nosis of cancer of the liver quite easy; but, as Ave have before said, it is occasionally difficult or even impossible. Where the cancer is in- filtrated, or a few small cancerous nodules deA'elop deep in the liver, 666 DISEASES OF THE LIVER. this is often only sfigfitly enlarged, and even Avhen it projects from beneath the ribs Ave do not find the characteristic peculiarities of its surface, on palpation. There is little or no pain, as the serous covering is not inflamed, and there is usually no ascites or icterus, as neither the branches of the portal vein nor the gall-ducts are much compressed. In such cases Ave often have no sufficient grounds for suspecting the dis- ease, till our suspicion of cancer is awakened by a gradually increasing cachexia, for Avhich we can find no other explanation, as all the func- tions are undisturbed ; and when cancer of the uterus, stomach, etc., Avhere it is more readily recognized, can be excluded. The probability is still greater when the suspicious marasmus has developed after the operative removal of an external cancer. If, besides the cancer of the > liver, which runs its course without decided enlargement and pain of the liver, or icterus, or ascites, there be cancer of the stomach, morbus Brightii, or some other disease, to explain the marasmus, the disease may often escape suspicion. Treatment.—We cannot expect any successful radical treatment of cancer of the liver. In most cases we must satisfy ourselves with maintaining the strength of the patient as long as possible by careful nourishment. If the liver become very painful from intense hepatitis, Ave apply a few leeches, and cover the region of the liver with warm poultices; these means almost ahvays remove or at least relieve the pains. The ascites complicating cancer of the liver may require tap- ping under the previously-mentioned conditions. CHAPTER IX. TUBERCULOSIS OF THE LIVER. Tuberculosis of the liver is never primary, but always accompa- nies an already existing tuberculosis of other organs, or else forms one symptom of miliary tuberculosis. In the latter case, we only find dull, translucent granulations, as large as grains of sand, Avhich occur par- ticularly on the surface of the liver, Avith advanced tuberculosis of tfie intestines and lungs. On the other hand, we occasionally find yellow, cheesy, tuberculous masses, as large as a hemp-seed, pea, or even larger. These very rarely break down into small vomicae, filled with tuberculous pus. But they often compress capillary bUe-ducts, and lead to their dilatation behind the compressed parts; thus forming cavities as large as a hemp-seed or pea, AA'hich are filled "with bile and mucus, and which we must not confound Avith tuberculous cavities. Tuberculosis of the liver cannot be recognized during life. ECHINOCOCCI OF THE LIVER. 667 CHAPTER X. ECHINOCOCCI OF THE LIVER. Etiology.—Echinococci hold the same relation to taenia echinococ- cus {Siebold) that cysticercus cellulosae does to taenia solium; i. e., they are the young, sexless brood of the mature tape-Avorm. Experi- ments of feeding animals Avith echinococci from man haA'e given no decided results, it is true ; but the taenia echinococcus has been found in the intestines of animals that had been fed on echinococci from other animals. It is doubtful hoAV the egg and embryo of the taenia echinococci reaches the human liver, there to develop to echinococcus vesicles. In Iceland they are so common, that physicians there say that one- eighth of all the diseases of that island are due to this disease, and that about every seventh person contains echinococci {Kuchenmeister). From analogy, it is supposed that the migration takes place as folloAvs: Animals affected with the taenia echinococcus evacuate mature links from the bowels; the eggs or embryos contained in these in some way get into the drinking-water, or come in contact with some food that is eaten ra,AV. Entering the intestinal canal with these, the small em- bryos with their six hooks bore into the wall of the stomach or intes- tine, and, Avandering farther, they finally reach the liver. There the microscopic embryo swells to a large vesicle, on Avhose inner wall a colony of young, immature taeniae or scoleces is developed. In most cases, besides the scoleces, daughter vesicles develop in the mother A'esicle, or rather wet nurse ; in these, a second generation of \-esicles is formed, Avhose inner wall is also covered with scoleces. Kuchenmeister refers the endemic occurrence of echinococci in Ice land principally to the number of dogs kept there, and to the warmth of the rh'er-Avater, which is much used for drinking. The dogs prob- ably eat the A'esicles that have been evacuated from the mouth, anus, or suppurating sacs that have not been taken care of. The Avarm tem- perature of the AA'ater is faA'orable for the embryos of the echinococcus, as it is for all the loAver animals. Kuchenmeister considers it as not improbable that, AA'hen the echinococci reach the boAvels of the person in Avhom they exist, they there develop to taenia, and conversely that the embryo escaping into the intestines of persons affected with taenia may become echinococci. Anatomical Appearances.—Echinococcus sacs are sometimes solitary, sometimes very numerous in the liver, and occur more fre- quently in the right lobe than in the left. Their size varies from that Df a pea to that of a fist or a child's head. If they are large and 663 DISEASES OF THE LIVER. numerous, the liver is usually decidedly enlarged. Sacs, deep in the organ, and surrounded by liver parenchyma, change the form but little; very large sacs, or those near the surface, are generally elevated above the liver, and cause decided deformity of the organ. Over the periph- eral cysts the peritoneal coA'ering of the fiver is decidedly thickened, and is attached to the parts around by firm pseudo-membranes. The parenchyma of the liver is displaced by the parasites, and, Avhen these are large and numerous, it is extensively destroyed ; the parenchyma still preserved not unfrequently appears very vascular, as a result of partial congestions. The echinococcus vesicle itself is enclosed by a hard fibrous capsule, Avhich is formed by proliferation of connective tis- sue, but may readily be removed from this. The envelope of the ves- icle itself is a delicate, half-transparent membrane, resembling coagu- lated albumen, which, by the microscope, is shoAvn to consist of numerous fine, concentric lamellae. If we open the vesicle, a clear serous fluid escapes; this almost always contains numbers of smaller vesicles. The fluid contains about 15 parts of firm constituent to the 1,000; no albu- men, but chiefly salts, mostly chloride of sodium, and, according to Heintz, 3 parts of succinate of soda to the 1,000. The daughter ves- icles are like the mother sac; they are as large as a hemp-seed or a large hazel-nut. The larger ones float about freely in the mother sac; the smaller ones are firmly attached to its inner wall. The grand- child vesicles, Avhich are only found in the larger daughter vesicles, are usually about the size of a pin's head. On careful examination, we may discover a Avhitish, gritty coating on the inner surface of the mother, daughter, and grandchild vesicles. The microscope shows this to be a colony of young, immature taeniae or scoleces. The indi- vidual animals are about \ mm. long, and \ mm. broad; they have a thick head, AA'ith four suckers, and a snout which is surrounded by a double roAV of hooks. The head is separated by a constriction from the short body, in which there are numerous round and oval chalk con- crements. The head is generally drawn into the body. The animals are then usually round or heart-shaped, and the circle of hooks is in the middle. At the posterior end of the body is a short pedicle, by Avhich the animal is firmly held till he subsequently breaks loose and floats about in the fluid. The echinococci often die. The mother and daughter vesicles collapse, their contents become cloudy, fatty, and are finally transformed into a smeary or putty-like substance. This con- sists of chalky salts, fat, and cholesterin, and only a feAV of the hook- lets of the echinococcus remain to betray the origin of the mass. Budd compares these hooks to the bones and teeth remaining after the decay of larger animals. In other cases the echinococcus sac gradually distends till it finally ECHINOCOCCI OF THE LIVER. 669 bursts. If the distended and thinned peritoneal covering ruptures at the same time, the contents of the sac enter the peritoneal caAdty, and there is severe peritonitis. In the same way, if the sac has become adherent to the neighboring parts, it may be evacuated into the stom- ach, intestines, gall-ducts, neighboring blood-vessels; or, when the dia- phragm has been gradually thinned, and finally perforated by the pressure, the sac may empty into the pleural cavity or into the lung adherent to the pleura. In still other cases, the hydatid excites in- tense inflammation in its vicinity, particularly in the fibrous envelope be- longing to the liver. This appears to occur particularly in those cases AA'here the sac bursts inside of the liver, and its contents come in direct contact Avith its parenchyma. In such cases, besides shreds of the mother A'esicle, and sometimes single, still perfect daughter vesicles, the cyst contains purulent masses tinged Avith bile. These cases are eA'i- dently not due to inflammation of the mother vesicle, but the pus has entered the sac from without. The abscesses of the liver, thus induced, may have any of the terminations described in Chapter II. If it per- forates externally, rudiments of the echinococcus vesicle are mingled with the pus that escapes. Symptoms and Course.—As a rule, echinococci inhabit the liver for years before they attract attention, or the disease is suspected. The gradual groAvth sufficiently explains the absence of inconvenience, or its tardy appearance. In most cases Avhere the disease is recognized, its discovery is not brought about by the subjective symptoms, but by the patient himself, or the physician accidentally noticing that the right hypochondrium is prominent, and contains a tumor. If the hydatid, and with it the liver itself, attain a considerable size, the feelings of pressure and tension in the right side, so often mentioned, are occasion- ally induced. The diaphragm, pressed upward, may have its action interfered Avith. The compression of the lower lobe of the right lung and the collateral hyperaemia in the non-compressed portions of lung may induce dyspnoea and bronclnal catarrh. In the same way, ascites and icterus of variable amount may result from compression of the branches or trunk of the portal vein of the small ducts, or the excretory duct of the bile; but all these symptoms are excep- tional. Physical examination is the most important, and in the majority of cases is the sole means of diagnosis. Like large and numerous carci- nomatous tumors, large and numerous hydatids in the liver are also often eA'ident on inspection. In tfiese cases also there is a prominence in the right hypochondrium, extending beloAV the navel, and into the left hypochondrium; and, Avhile the shape of the swelling reminds us of the lh-er, Ave notice on it slight elevations of different sizes. At the I 670 DISEASES OF THE LIVER. same time, the right half of the thorax may be dilated, the lower ribs being moved upAvard and outward. On palpation Ave may still more distinctly recognize the enlargement of the fiver, and the inequality of its surface. The protuberances appear more yielding than those due to the softest forms of cancer. Occasionally there is distinct fluctua- tion. The percussion-sound is absolutely dull all over the enlarged liver. On percussing over the hydatid itself, in some cases we notice i a peculiar thrill {Piorry's Fremissement hydatique), similar to that obtained by striking on tolerably stiff glue. J Among the symptoms of the termination of the disease, those of j the gradual atrophy of the sac cannot be given, as this termination J only occurs in small hydatids which cannot be diagnosed. If the i hydatid burst into the peritoneal sac, Ave have the same symptoms as in perforation of ulcers of the the stomach. If the hydatids were not previously diagnosed, Ave cannot tell what substance has entered the peritonaeum. The patients die in a few days of the rapidly-fatal peritonitis. We can only recognize perforation into the stomach, intestines, or lung, when portions of the hydatid are vomited, evacuated at stool, or coughed up. If the echinococcus vesicle excite inflammation in its vicinity, the enlargement of the liver, preAdously free from pain, noAV becomes very painful, and is especially very sen- sitive to pressure. There are chills and high fever, and we have the picture of suppurative hepatitis, and its results, which were described in Chapter II. If the abscess of the liver perforate externally, we may occasionally find traces of the peculiar laminated membrane, or some of the hooks of the hydatid in the pus. Treatment.—Fomentations of strong solutions of common salt over the region of the liver have been recommended for hydatids of that organ, and Budd says that, from the pecufiar attraction and affin- ity of the hydatid cyst for salt, it is possible that the collection of the latter in the fluid thus effected may prevent the further development of the echinococcus, or destroy it altogether. Others recommend prep- arations of iodine and mercurials, on account of their knoAvn " anti- parasitic" effect, and anthelmintics are used for the same reason. These remedies deserve little confidence, as they have been advised on theoretical grounds, and not from actual experience. If we conclude to use them, we should at least choose those least injurious to the organism. In Iceland they appear to open hydatids boldly; in this country very bad results have occurred from opening them without precaution; and, when we decide on puncturing them, the same rules are necessary as in opening abscesses of the liver. MULTILOCULAR HYDATIDS. 671 CHAPTER XI. MULTILOCULAR HYDATIDS. Etiology.—Recently, on post-mortem examination, large portions of the fiver have been found transformed into a peculiar mass, which consisted of a connective-tissue stroma, and numerous large and small cells filled Avith a gelatinous substance. The first observers considered these growths as alveolar carcinoma; but careful microscopical exam- ination shoAved that the gelatinous contents of the cells consisted of the tissue peculiar to the echinococcus, and hence placed it beyond doubt that the affection was due to a brood of hydatids. It is difficult to determine the mode of origin of these tumors, Avhich, according to Virchow are designated multUocular echinococcous tumors; but it is most probable that this is not a peculiar species of parasite, but only that there is a peculiarity about the migration, seat, and groAvth. Virchow believes that this form of the disease results from the echinococcus embryo entering the lymphatics of the lh'er, and their sacs developing there: Leukart locates these pro- cesses in the blood-vessels; Friedreich, who, in one case found the hepatic duct plugged with echinococci, locates them in the gall-ducts. I am indebted to a letter from Kuchenmeister for the following simple explanation, which I believe to be the correct one: " After the emi- gration of an echinococcus embryo, instead of the usual form of the dis- ease, Ave have a multUocular hydatid cyst, if no connective-tissue sac form around the embryo, or if this sac be ruptured by the parasite before it has become hard and resisting. When the echinococcus has no firm envelope, it can groAV freely in all directions, and spreads par- ticularly in the directions Avhere it finds least resistance. If in its Avanderings it has entered one of the many channels that traverse the liver, or if it has subsequently broken through the Avail of one of these canals, it ach-ances along it, and may finally fill the entire canal sys- tem thus affected. As Virchow, Leukart, and Frieelreich, AA'ho are certainly trustAvorthy observers, reached different results, as each of these observers found different canal systems of the liver filled AA'ith echinococci, Ave are justified in supposing that the emigrations and perforation of the parasites may occur into the lymphatic, or blood- vessels, or into the bile-ducts, but that each of these canal systems may remain free from them. Anatomical Appearances.—MultUocular hydatids almost ahvays occur in the right lobe of the liver; in only one of the three cases that I have seen Avas the left lobe affected. They may reach the size of a £72 DISEASES OF THE LIVER. child's head or become even larger. The connective-tissue stroma is generally far advanced in fatty metamorphosis. The cells opened by an incision strongly remind us of the holes on the cut surface of a piece of Avell-baked black bread. On microscopic examination of the gelatinous substance contained in them, we immediately recognize the characteristic membrane of the echinococcus, Avhich is streAvn with numerous chalk concrements. On the other hand, it usually requires. a long search to discover a circlet of hooks or single members from it, and we rarely find perfect scoleces. In a single one of my cases, at the periphery of the tumor there Avere vesicles as large as a cherry, Avhose inner AA'all was thickly covered with a colony of well-preserved scoleces. In all reported cases, except my last one, the centre of the mass had suppurated; the cavity resulting from the suppuration con- tained a dirty brownish-gray fluid, which consisted mostly of detritus masses, chalky concrements, fat globules, and cholesterin crystals. The wall, rendered uneven by numerous small fossae (opened alveoli), had in many places an ochre-colored coating in which beautiful haema- toidin crystals could be seen microscopically. Symptoms and Course.—Of course the symptoms of multilocular hydatids must A'ary Avith the canal system of the fiver, which is filled and obstructed with the echinococcous masses. This explains the remarkable fact that the somewhat hasty description of the symptoma- tology given by Friedreich of the multilocular hydatid cyst so ex- actly suits some cases, that the disease has been repeatedly diagnos- ticated from that description; while in other cases even the most prominent points of his description have been wanting. I shall try to avoid Friedreich's errors in the following description, which is taken partly from my own comparatively numerous observations, partly from a careful analysis of the reported cases of other observers, which are not very numerous : The disease is almost ahvays latent at the commencement; as a rule, the first symptoms appear after it has made considerable progress. Some patients have their attention called to the disease by a feeling of pressure and fulness in the right hypochondrium, or by the acci- dental discovery that they have a tumor in the abdomen. They have nothing else to complain of; the appetite and digestion are good; the strength and nutritive condition leave nothing to desire; there is no jaundice or symptoms of obstruction in the roots of the portal vein. On examining the abdomen, we find in the right hypochondrium a tumor, which unmistakably belongs to the liver; the liver may either retain its normal shape, or there may be slight elevations on its surface, such as occur in carcinomatous and syphilitic diseases. Even where there is extensive central suppuration, the resistance of the liver tumor MULTILOCULAR HYDATIDS. 673 js usually very decided; fluctuation Avas only noticed in one of the cases observed by Griesinger. When the disease commences and runs its course with the above symptoms, it can never be recognized Avith certainty, or absolutely dis- tinguished from other diseases of the lh'er, particularly carcinomatous or syphUitic. In the first case I saAV, death Avas caused by apoplexy; the preparation Avas presented to me as an immense suppurating cancer of the liver. The attending physician had not made out the nature of the nodular, stony tumor of the liver, Avhose gradual groAvth he had Avatcl ed for years. The patient had no icterus during the latter years of his life; he only had a slight jaundice, of short duration, about ten years before his death. In a second case, carefully observed for several months, at my clinic, besides the above symptoms, there were albumi- nuria and general dropsy; the case Avas diagnosed as syphiloma of the liA*er and amyloid degeneration of the kidneys. Only the second half of the diagnosis Avas confirmed by the autopsy. Instead of a syphi- loma, the liver contained a multilocular hydatid tumor, as large as the head. This patient was never jaundiced. In both patients the pas- sages and excretory bile-ducts were entirely pervious. These observations not only disprove Friedreich's assertion, that marked icterus is among the most constant symptoms of multilocular hydatid, but they also prove that, in cases Avhere there is no obstruction of the bile-ducts by echinococci, and, consequently, where there is no obstruction and reabsorption of bile, the patient's state may long re- main as endurable as in the ordinary form of hydatid. After a long time, the advancing suppuration of the tumor and the fever accompa- nying it appear to impair the nutrition, and to develop a cachexia, Avhich finally carries off tfie patient, if he does not die of some inter- current disease. In my second case, death Avas hastened by the second- ary disease of the kidneys (Avhose occurrence, in multilocular hydatids, Frieelreich expressly denies). The s3rmptoms and course of the disease are entirely different Avhen the bile-ducts are obstructed by echinococci locating in them, or break- ing into them from AAdthout. In these cases, at least in their later stages, the disease is not unfrequently so characteristic that an approxi- mate, or even an absolute, diagnosis may be made. The series of symptoms is opened by an apparently inoffensive icterus, but this steadily increases; all remedies used for it prove unavailing, and it gradually becomes excessive. The faeces usually soon lose their color, a proof that all the gall-ducts or the excretory ducts are closed. As there are no dyspeptic symptoms, and as the occurrence of the icterus is preceded by no severe paroxysms of pain, Ave may, Avith great proba- bility, exclude catarrh of the excretory bile-ducts and their obstruction 43 674 DISEASES OF THE LIVER. by calculi; but the true ground of the obstruction is at first entirely obscure. In one patient, Avhere there Avas finally no doubt about the diagnosis, at the first consultation, I Avas obliged to limit myself to saying, " There is an obstruction of the excretory bile-ducts, from some cause unknoAvn to me." Early in the disease, on examining the abdo men, Ave find the liver enlarged; but even this symptom does nol enable us to make a diagnosis until the enlargement has become very marked, or the resistance of the liver has greatly increased, and whUe its surface remains smooth. Where the faeces are discolored and the icterus excessive, Ave are most apt to ascribe the enlargement of the liver also to biliary obstruction. On tfie other hand, if, while there is excessive and obstinate icterus, and complete discoloration of the faeces, Ave find enlargement of the liver, but not of the gall-bladder, we should suspect multilocular hydatids. Under such circumstances, the obstruc- tion is, most probably, not in the ductus choledochus, but in the ductus hepaticus, for Avhen the former is obstructed, the gall-bladder also is usually distended by the obstructed bUe. Obstruction of the hepatic duct is rare, but probably its most frequent cause is multilocular hy- datids, and hence, Avhen Ave think Ave have found it obstructed, avc should suspect this disease. Tfie suspicion that there is a multilocular hydatid cyst in the liver increases, and may become a certainty, if, be- sides tfie above symptoms, the liver becomes uneven and nodular as the disease progresses. From that time, swelling of the liver, from simple biliary obstruction, may be excluded; tfie case can only belong to one of the varieties of liver-disease where the form of the organ is thus changed—that is, it must be cirrhosis, syphilitic, or carcinomatous disease, or hydatids. The rest of these diseases are fiardly ever accom- panied by complete discoloration of tfie faeces, and excessive and obsti- nate biliary obstruction, in wfiich the gall-bladder does not participate, wlnle these are very frequent accompaniments of multilocular hydatids. Hence, if Ave find a hard nodular enlargement of the liver with those symptoms, Ave are justified in diagnosing a multilocular hydatid. In many cases, in the course of the disease, there are ascites, enlarge- ment of the spleen, gastric and intestinal haemorrhage, occasionally also haemorrhage from other mucous membranes, and effusion of blood into the cutaneous tissue. But none of these symptoms are pathogno- monic of multilocular hydatid; they result from the great biliary ob- struction and reabsorption of bile, and, as Ave shall sHoav in the next chapter, occur just as often in other forms of obstinate obstruction and reabsorption of bUe. Treatment.—Treatment can accomplish nothing in multilocular hydatids; occasionally the inefficiency of the remedies used for the icterus strengthens the diagnosis. Of course, there is no Avay of re- JAUNDICE. 675 ducing the size of the tumor, or of improving the jaundice and incon- veniences dependent on it, or of permanently maintaining the strength and nutrition of the patient. Nor does the attempt at tapping, made in Griesinger's case, encourage imitation. CHAPTER XII. BILIARY OBSTRUCTION IN THE LIA'ER, AND CONSEQUENT ICTERUS-- HEPATOGENOUS ICTERUS [JAUNDICE]. Etiology.—The gall-ducts have no contractUe elements to urge their contents onward. Hence we are led to the conclusion that the bile in the biliary passages is pressed forward by tfie same force that caused it to enter the ducts, the secretory pressure. The compression to which the liver is subjected, from the descent of the diaphragm during inspiration, assists the evacuation of the bile-ducts, it is true, but we should not over-value this force, for the gall-bladder, on AA'hich the pressure must be greater than on the firm fiver, may be greatly distended Avith bile, while the movements of respiration go on unin- terruptedly. At all events, the forces that pass the bile along its ducts are so Aveak that they cannot readily overcome even the slightest ob- stacle, and a very inconsiderable obstruction to the evacuation of the bile suffices to cause it to collect in the fiver—that is, to induce reten- tion of bile. If the bile-ducts and the liver-cells become very full, and tfie lateral pressure in them attains a certain height, a large part of their contents enters (filters into) the blood-vessels and lymphatics. This is the most frequent cause of jaundice. Recent investigations have placed it be- yond a doubt that, in the icterus due to obstruction and reabsorption of bile (also called resorption jaundice or' hepatogenous jaundice, in contradistinction to hemeitogenous, Avhich avUI be described hereafter), not only the coloring matter of the bile, but its other constituents, particularly the acids, are taken into the blood. As has been proved by numerous experiments, these acids possess to a pecufiar degree the property of dissolving the red-blood corpuscles. By injecting Aveak solutions of them into the blood of animals, Ave may artificially induee the so-called haematogenous icterus, as the liberated coloring matter of the blood is transformed into biliary coloring matter. As it is firmly established, both that in biliary obstruction the bUe-acids enter the blood, and that the absorption of these acids into the blood sets free the coloring matter of the latter and transforms it into biliary coloring matter, we may correctly say that eA'ery hepatogenous icterus is accompanied by a haematogenous, or, more accurately, every hepa- togenous induces a haematogenous icterus. 676 DISEASES OF THE LIVER. Of the diseases of the liver that have already been described, some, such as fatty and lardaceous liver, neA'er induce icterus, as they never cause compression of the bile-ducts; others, such as cirrhosis, cancer, and hydatids, sometimes induce biliary obstruction, sometimes they do not. Where the bile-ducts are compressed, if the retention of bile be only partial, its reabsorption and the icterus do not become excessive; the unimpeded flow of bile from the bile-ducts, Avhich are not obstruct- ed, gives some color to the faeces. The case is different when the ductus hepaticus or choledochus is compressed by tumors of the liver or plugged up by hydatids; then the biliary obstruction becomes ab- solute, the icterus very marked, and the faeces totally discolored. Total retention of bile, Avith its results, is much more frequently caused by disease or compression of the excretory bile-ducts than by disease of the fiver. This condition avUI occupy us in the next sec- tion ; in this chapter Ave shall only speak of the changes induced in the liver by biliary obstruction, and of its results. Anatomical Appearances.—The size of the liver may be in- creased by general excessive biliary obstruction, just as by decided congestion of the blood ; but the SAvelling rapidly subsides as soon as the obstruction to the Aoav of bile is removed. The form of the liver is not altered by the enlargement. In high grades of the affection, the larger as well as the smaller bile-ducts appear dilated and dis- tended Avith bUe. The color of the liver is deep yellow, and, in the highest grades, olive green; it is not usually regular, but mottled. According to Frerichs, on microscopical examination, we sometimes find the entire contents of the liver-cells pale yelloAV, sometimes tliere is a deposit of fine granular pigment, particularly in the vicinity of the nuclei. After the disease has lasted some time, the fiver-cells contain firm collections of pigment in the form of yellow, reddish-broAvn, or green rods, spheres, or angular fragments. The cells containing pig- ment lie chiefly in the vicinity of the central veins. Even when the obstruction to the excretion of bUe is not removed, the previously-enlarged fiver may become smaller, and may even be reduced beloAV .its normal size; at the same time it acquires a dark- green or even black color, and loses its consistence, becoming soft and capot. In such cases the nutrition of the liver-cells has been impaired by compression of the afferent blood-vessels, and by pressure from the distended bile-ducts, perhaps also from the pressure of the bile collect- ed in the cells. On microscopical examination, Ave find most of the cells broken doAvn into a fine granular detritus, Avfiile some still con- tain pigment. On autopsy of jaundiced bodies, collections of bile-pigment may be found in almost all the organs and fluids. Besides the characteristic JAUNDICE. 677 color of the skin, conjunctiva, and urine (of Avhich Ave shall speak more particularly AA'hen describing the objective symptoms of the disease), as soon as the body is opened Ave notice the lemon-color of the fat in the subcutaneous tissue, mesentery, pericardium, and elsewhere. The fibrinous coagula in the heart and blood-vessels, the fluid in the peri- cardium, and any pathological transudations or exudations of the peri- cardium, pleura, and peritonaeum, have a distinctly jaundiced appear- ance. The less red the normal color of the different tissues is, the more marked is the pathological yellow color; hence it is more evident in the serous and fibrous membranes, the Avails of the vessels, the bones, cartilages, etc., than in the muscles, spleen, etc. Only the brain, spinal marroAV, and nerves form an exception, as only a slight color can be seen in them. Frerichs supports the previous observations, according to Avhich the secretions proper, the safiva, tears, and mucus, contained no bile-pigment, AA'hile the albuminous and fibrinous exuda- tions are rich in it. The changes in the kidneys, Avhich were first fully described by the above observer, are very interesting. In old and in- tense cases of icterus he found the kidneys of an olive-green color, and some of the uriniferous tubules filled with a brown or black deposit. On more careful examination, in the pale uriniferous tubules, he saAV the epithelial cells, Avhich Avere really perfect, colored broAvn by pig- ment : the dark uriniferous tubules Avere filled Avith a coal-black, fiard, brittle mass. The pigmentation of the epithelium began in the Mal- pighian. capsule, increased in the convoluted tubuli uriniferi, Avfiile the black, coal-like masses Avere chiefly found in the straight tubules. Symptoms and Course.—Premonitory symptoms almost ahvays precede the characteristic signs of biliary obstruction. These consist of the symptoms of the disease that lead to contraction and closure of the bile-ducts ; and, as this is most usually catarrh of the duode- num, they are most frequently those of gastro-duodenal catarrh. If these have existed for a longer or shorter time, the passage of the catarrh to the ductus choledochus, or the closure of the bile-ducts in any Avay, is almost always first sliOAvn by the peculiar dark color of the urine, and the light color of the faeces. But generally it is not these symptoms, but it is yelloAvness of the skin and eyes, that induces the patient to seek medical aid. Sometimes the skin is only slightly yel- Ioav, sometimes it is an intense saffron color; later, and in the higher grades, called melan-icterus, it may be greenish or even mahogany color. At those parts of the body AA'here the epidermis is thin, so that the deeper layers of the rete Malpighii, where the pigment is located, shine through, the color is most intense, as on the forehead, alae nasi, elboAVS breast, etc. The yelloAV hue of the sclerotic, Avhich may also be quite dark, is very characteristic of icterus, and is important in the 678 DISEASES OF THE LIVER. diagnosis betAveen jaundice and other discolorations. The yellow tint of the skin and sclera completely disappears by artificial ligfit, so tliat Ave cannot recognize jaundice at night. We may see that the exter- nal mucous membranes are also yelloAV, by pressing the blood from the lips or gums of a patient Avith jaundice; when the finger is removed, the spot left will not be Avhite, but yellow. Sometimes the urine is light brown, like thin beer, sometimes dark, like porter; after stand- ing in the air, it almost always becomes greenish. If we agitate the discolored urine, its froth is distinctly yellow, and a strip of linen or Avhite paper dipped in it becomes yellow, and this often suffices to dis- tinguish between the coloring matter of the bile and other coloring matter in the urine. The test with nitric acid containing some nitrous acid is more certain. On adding this, the brown of the bile-coloring matter successively becomes green, blue, violet, red, and finally pale yelloAV. To note the changes Avell, we should carefully let some of the acid run down the inside of a champagne or test glass, containing the urine to be tested, so that it will reach the bottom, and there will be only a gradual admixture of the acid with the urine. If there be any bile-coloring matter present, and we let the urine stand a while, the various layers immediately above the nitric acid show different colors, and the above series of colors may be perfectly or partly dis- tinguished from above downward. The reaction may be incomplete, or may fail entirely, if the urine has stood exposed to the air for some time, and already has a greenish color. According to Frerichs, the opposite occurs occasionally; the reaction does not take place till the urine has stood in the air for some time; until quite recently the oc- currence of the bile-acids in the urine during icterus has been denied by celebrated authorities. There are certain difficulties in then detec- tion in jaundiced urine by Pettenkofer's test, which shoAVS very small quantities of the bUe-acids by inducing a purplish-red color, when to the solution containing them we add a small amount of sugar, and then gradually add concentrated sulphuric acid. This reaction cannot be directly used Avhen the fluid to be examined, as the urine, also con- tains substances which are directly colored by the addition of sulphuric acid. Hoppe-Seyler deserves the credit of having disproved the erro- neous belief that in jaundice the urine contained only the coloring matter of the bile, and not the bile-acids, and of having proved the presence of the latter in the jaundiced urine by a complicated but per- fectly reliable process. Bile-pigment constantly occurs in the sweat also, so that the linen is colored yelloAV, particularly at those parts where the patients SAveat much. The milk of nursing-Avomen has also been found colored yellow. The most noticeable change in the faeces, from obstruction to the JAUNDICE. 679 Aoav of bile into the intestines, is their more or less complete discolora- tion. Where the excretory duct of the bile is incompletely closed, or the bifiary obstruction partial, they have a loamy color, AA'hile they are clay-colored Avhere the ductus hepaticus or choledochus is completely obstructed. As the amount of bile poured into the intestines during tAventy-four hours is estimated at about tAvo pounds, Ave may readUy understand AA'hy the faeces are almost ahvays dry. But, moreover, physiology teaches that, by excluding bile from the intestines, the ab- sorption of fat is restricted, if not arrested; this explains the long- known fact that the faeces of jaundiced patients contain far more fat than do those of healthy persons. Professor Trommer, who examined the faeces of two of my students, Avho ate exactly the same amount of bread, butter, and cold meat, but of Avhom one Avas jaundiced, the other perfectly healthy, found far more fat in the faeces of the former than in those of the latter. Lastly, the putrid decomposition of the contents of the intestines appears to be avoided by the action of the bile on them; hence patients, in whom no bile is emptied into the boAvels, usually suffer from flatulence, and the flatus passed, as well as the faeces, have a very disagreeable odor. Besides the abnormal color of the skin, sclerotica, urine, SAveat, milk, and besides the discoloration of the faeces, and the difficulties connected Avith the absence of bile from the intestines, we find that almost all patients Avith jaundice due to biliary obstruction rapidly emaciate, and become very languid and sleepy. As both the amylacea and protein substances are digested while there is no bile in the intestines, if there be no coincident gastric and intestinal catarrh, the emaciation can only be ascribed to the change in the absorption of fat. As has been previously stated, Bischoff has experimentally shoAvn that a plentiful supply of fat may cause less consumption of the tissues of the body. It is very probable that the AvithdraAval of fat may have the opposite effect, and induce an increased use of the fat collected in the body. Even the exceptions, AA'here jaundiced patients remain well nourished, although no bile reaches their intestines, do not disprove this explanation. For it has been observed that, while most dogs Avith artificial biliary fistula emaciate greatly, some remain well nourished, and it is particularly those that eat a great deal. In the same Avay, it has been observed that it is just those persons that have an excellent appetite and good digestion during their jaundice, Avho do not emaciate. Hence Ave may assume that failure of the supply of fat can be re- placed by increased supply of hydrocarbons, and protein substances. The discoverv, that in icterus the bile-acids are reabsorbed, and that their presence in the blood induces the disintegration of the red-blood corpuscles, sIioavs another cause for the poverty of the blood, the emaci 880 DISEASES OF THE LIVER. ation and the cachexia, which often become very marked in protracted icterus. The languor, also, and the great inclination to sleep appear to depend not only on the bad nutrition, but to be greatly due to the toxic influence of the bile-acids on the nerves and muscles. The slow pulse of patients Avith jaundice appeared to be intimately- associated Avith the emaciation and loss of strength. It Avas not con- sidered necessary to refer this symptom to the entrance of the constit- uents of the bile into the blood, and to compare their action to that of digitalis, for the retardation of the pulse AA'as observed in the so-called hunger-cure, and in the convalescence from severe illness after the fever had stopped; but the useful experiments of Rohrig have shoAvn that, in patients Avith icterus, the slow pulse mostly depends on the presence of bile-acids in the blood. The same is true of the itching Avliich annoys many patients Avith icterus. This has been referred to the dry, scaly state of the patients' skin, as it was also seen in senile marasmus. But its proportionate frequency in icterus, and its rare occurrence in marasmic conditions, render it probable that it is due to an irritation of the cutaneous nerves by the constituents of the bile deposited in the rete Malpighii. It is true, the itching is often absent in the highest grades of icterus, Avhile in moderate grades it is very troublesome ; and it is almost ahvays periodical—peculiarities difficult to explain if the symptom be due to irritation from the acids or coloring matter of the bile. Yellow vision—Xanthopsia—very rarely occurs in icterus. It is doubtful Avhether this be due to the yelloAV hue of the transparent media of the eye, or Avhether it depends on abnormal innervation, and is one of the first symptoms of acholia, of which Ave shall pres- ently speak. The course and termination of the disease depend chiefly on whether the obstruction to the evacuation of the bile can be removed soon, late, or not at all. In the first case, when the obstruction is over- come, the symptoms of retention of bile disappear quite rapidly, and the disease ends in recovery. At first, the faeces resume their normal hue, and the dark color of the urine and the symptoms due to satura- tion of the tissues, with pigmented nutritive fluid, soon pass off. The discoloration of the skin disappears last, particularly when the epider- mis is thick. If enlargement of the liver has been observed Avhile the flow of bile was obstructed, this also subsides Avhen the Aoav becomes free. The strength and nutrition also improve rapidly. Since, in icterus dependent on obstruction of the excretory gall- ducts, the return of the normal color to the faeces is almost always the first sign of improvement, the physician, and often also the patients, usually aAvait its occurrence Avith great anxiety. Sometimes, Iioav- JAUNDICE. 681 ever, the faeces acquire a weak, bilious color, Avithout the bile-ducts having become pervious. This depends on their admixture with jaun- diced blood-serum, or jaundiced inflammatory products. (E\'en in high grades of icterus the intestinal mucus contains no bile-coloring mat- ter, otherAAdse the faeces Avould never lose their color.) Small haemor- rhages into the intestines, such as quite frequently occur during con- tinued obstruction of the excretory bile-ducts, most commonly lead to error; they do so the more readily, as a very slight admixture of blood Avith the faeces does not induce any characteristic color, particularly Avhen the blood-serum is jaundiced. If the biliary obstruction continue for some time, or if it depend on causes that cannot be removed, the jaundice attains the highest grade, and the nutrition may suffer so much that the patient Avill finally die of marasmus or dropsy. In rare cases the final result is hastened by the occurrence of gastric or intestinal haemorrhage. These result from the same causes as in cirrhosis and pylephlebitis. The escape of blood from the vessels of the gastric and intestinal mucous membrane is just as much obstructed in the former case by the compression of the capillaries of the liver from the distended gall-ducts, as it is in the latter by the compression of the hepatic A'essels from the contracting connective tissue, or by the ob- struction of the portal vein. But in explaining these haemorrhages, besides the mechanical obstruction to the Aoav of blood, we must also take into consideration the disturbed nutrition of the gastric and in- testinal capillaries, especially as, in the course of icterus, haemorrhages also occur in other parts, particularly in the skin, as petechiae. We have repeatedly said that the inclination to bleeding, tfie so-called haemorrhagic diathesis, can only be explained by disturbed nutrition of the walls of the vessels, and that the latter very frequently occurs in advanced anaemia and cachexia. The occurrence of seA'ere disturbances in the nervous system during an attack of jaundice is far more dangerous. These rarely begin Avith delirium or convulsions; they are rather apt to commence Avith para- lytic symptoms. The patients are insuperably sleepy, finally become soporose, and die in this state. Henoch calls attention to the fact that Hippocrates had recognized the bad prognostic indication of this sign, for he says, Ex morbo regio fatuitas aut stupiditas mala est. The most varied hypotheses have been started about the occurrence of these brain and nervous symptoms. Recently the inclination has been mostly toward the AdeAV that these symptoms depend on poisoning by the bile-acids, for, on injecting these into the blood of animals, we ob- serve symptoms of poisoning indicative of paralysis of the nervous system. To this it is objected that the bile-acids exist in the blood in 382 DISEASES OF THE LIVER. every case of icterus, Avhile these severe nervous affections are very rare. Ley den attempts to meet this objection by calling attention to the fact that the severest symptoms are avoided by the continued excretion of the bUe-acids through the kidneys, which prevents their excessive collection in the blood. The correctness of this explanation appears to be supported by the fact that a remarkable fatigue is scarcely ever absent, no matter how slight the jaundice, as well as the fact that a diminution of the secretion of urine has been always con- sidered as having a bad effect on the course of jaundice. On the other hand, it is opposed by the fact that, in haematogenous icterus, in Avhich, as Ley den very particularly notices, no bile-acids can be discov- ered in the urine, the same severe nervous difficulties are observed even more frequently than in hepatogenous icterus. I do not consider the question as settled. The proportionately frequent occurrence of severe disturbances of innervation in cases where there is only a slight amount of icterus, but a severe and extensive degeneration of the liver, may be far more readily explained by the hypothesis of Frerichs, already alluded to, than by the equally hypothetical poisoning by the bile-acids. Moreover, the assertion, that the excessive collection of bUe- acids in the blood and in the tissues is avoided by their continued ex- cretion through the kidneys, is opposed by the fact that the excessive collection of the bile-pigment is not prevented by its continued and plentiful excretion through those organs. If the affair Avere as simple as Ley den suggests, the frequency of the occurrence of symptoms of poisoning Avould still be in some proportion to the intensity of the icterus, which is not the case, as is well known. In slight grades of biliary obstruction, physical examination does not shoAV any enlargement of the liver. In higher grades, on the contrary, such as those due to complete closure of the ductus hepaticus or choledochus, Ave may often recognize very decided enlargement of the liver by palpation and percussion. Its surface appears smooth, and as the consistence is increased the lower border is very distinct. If the ductus choledochus be closed, we may generally feel the dis- tended gall-bladder as well as the liver-tumor. If the hver-dulness diminish without decrease of the icterus, it is a bad sign, for it indi- cates consecutive atrophy of the liver. Treatment.—We can only treat those cases of biliary obstruction successfully where we are in a position to fulfil the causal indications. Hence Ave are poAverless against the cases caused by most hepatic dis- eases, such as echinococcus, carcinoma, or cirrhosis, while Ave are some- times successful in treating those cases due to obstructions in the bile- ducts. The remedies vaunted as specifics in icterus are such as have a favorable effect on the diseases of the bile-ducts; Ave shall speak of them JAUNDICE. 683 in the next section. This is particularly true of the Karlsbad springs, Avhich have a world-wide reputation for their efficacy in jaundice. Many patients, Avho have gone to Karlsbad AA'ith the most intense jaundice, return cured in a feAV Aveeks; but these are only persons AA-hose icterus depended on catarrh of the bile-ducts, or on their ob- struction by gall-stones. If jaundiced patients, with an incurable ob- struction of the bile-ducts, go to Karlsbad, their jaundice is not im- proA'ed by the use of the waters; but they die sooner than they other- Avise Avould, because the symptoms of congestion are increased, and the destruction of the liver-cells is hastened by the augmented secre- tion. This assertion is Avell supported by cases. The internal use of nitrate of potash, calomel, of the bitter and soluble extracts, of emetics and purgatives, does just as fittle good as the Karlsbad waters in icterus, unless it fulfil tfie causal indications. When we succeed in removing the obstacle to the excretion of bile, the indications from the disease do not require any thing further; aa hen Ave cannot succeed, they cannot be fulfilled. The symptomatic indications require, first of all, an improvement of tfie depressed state of the patient by a proper diet. We should order meats, particularly cold meats and strong soups ; but as fat is not ab- sorbed Avhen the bUe does not enter the intestines, and consequently is not Avell borne, the use of graAdes, butter, etc., should be just as strictly forbidden, while the patients remain at home, as AA'hen they go to Karlsbad, AA'here, according to the diet list, the use of these articles is A'ery reprehensible. In the next place, Ave should particularly attend to the constipation, from AA'hich most patients Avith jaundice suffer, and which depends partly on dryness of the faeces, partly on absence of irritation of the intestinal mucous membrane from the bile; but Ave should avoid saline laxatives, using instead slight drastics, such as in- fusion of senna, lenitive electuary, and rhubarb and aloes. As quan- tities of bile-pigment are evacuated AA'ith the urine, we may attempt to hasten the disappearance of the icterus by prescribing diuretics, such as bitartrate of potash, soluble cream of tartar, acetate and carbonate of potash. These are urgently indicated AA'hen the amount of urine is diminished, as the obstruction of the uriniferous tubules, to AA'hich Frerichs has called attention, may cause a retention of the con- stituents of the urine, and it is possible that the obstructions may be Avashed aAvay by an increased secretion of urine. When the biliary obstruction has been removed, Ave may advise lukewarm baths, steam, soap-and-potash baths, to cause a more rapid removal of the epidermis, and thus relieve, as quickly as possible, the annoying itching and the jaundiced color. *» 684 DISEASES OF THE LIVER CHAPTER XIII. ICTERUS AA'ITHOUT REABSORPTION OF BILE—HEMATOGENOUS ICTERUS. Etiology.—Physicians have long- observed that there are cases of jaundice that cannot be referred to retention and reabsorption of bile. The supposition, that in severe and extensive degenerations of the fiver the constituents of the bile collect in the blood, because they are not excreted by the affected organ, is completely refuted by the reli- able observation that the bile and its constituents are not formed in the blood and simply excreted by the liver, but that the bile is first formed by the liver. The attempt also to refer some cases of jaundice to spasm of the excretory bile-duct, because no obstruction to the excretion of the bile could be found on autopsy, may be regarded as a failure. As the ex- cretory bile-ducts contain muscular elements, it is of course possible that they may be temporarily closed by spasmodic contraction, but it is excessh'ely improbable that such a spasm Avould continue so long, as physiological experiments prove is necessary, as to induce the grade of biliary obstruction requisite for the passage of bile from the bile- ducts into the blood-vessels and lymphatics, and the production of icterus. The occurrence of icterus spasticus is more than doubtful. Lastly, it is also very improbable that, under certain circumstances, more bile is prepared than the bUe-ducts can accommodate, and that icterus is induced because part of the excess of bile enters the blood- vessels and lymphatics. Frerichs has advanced a neAV hypothesis for the explanation of this form of jaundice: he considers it probable that a filtration of bile from the bUe-ducts into the blood-vessels results not only from an overfill- ing of the bile-ducts, but from too little fulness of the blood-vessels. The icterus not unfrequently seen Avith thrombus of the portal vein is explained thus: blood is supplied to the fiver only by the hepatic artery, and thus the hepatic A'ein and capillaries are not so Avell filled; some cases of icterus neonatorum are explained by the sudden cessa- tion of the supply of blood to the liver through the umbilical vein, and the icterus in yellow fever because the roots of the portal vein are emptied by the large intestinal haemorrhages. The views regarding the occurrence of jaundice without retention and reabsorption of bile have totally changed since the observations of Virchow, Kuhne, and Hoppe-Seyler have shown that bile-coloring matter may be formed from the free coloring matter of the blood with- out the action of the liver; and we may induce artificial jaundice in animals, by injecting substances that dissolve the blood-corpuscles. ICTERUS WITHOUT REABSORPTION OF BILE. 685 There is noAv no doubt that some of the formerly enigmatical forms of icterus are due to the disintegration of blood-corpuscles, and the transformation of the freed coloring- matter circulating- in the blood into bile-coloring matter. This is particularly true of those cases of icterus occasionally caused by poisoning from chloroform or ether; for, as experiment proves, these substances possess the poAver of dissolving blood-corpuscles. The slight icterus in excessive hydraemia, to the ex- planation of Avhich but little attention has been paid, also doubtless depends on the fact that blood-corpuscles are destroyed by a large amount of Avater in the blood. This mode of origin is very probable, although not absolutely proved, for other A'arieties of jaundice—as in that occurring after snake-bites, in that observed constantly in yellow fever, quite often in recurrent fever, septicaemia, and puerperal fever, and more rarely in other infectious diseases, and acute diseases accompanied by severe feA'er. It is a very interesting fact that in the latter diseases even the older physicians suspected a dissolutio sanguinis when they ran a per- nicious course, when the fever Avas very high, vrhen there was great prostration, and Avhen severe nervous symptoms, jaundice of the skin and conjunctiva, appeared. We avUI not discuss the question as to Avhether the disintegration of the blood-corpuscles in the above dis- eases is the result of the high temperature, or Avhether, in high fever, products form from the excessive transformation of tissue Avhich dis- solves the blood-corpuscles. The jaundice in pylephlebitis also, and even some of the cases Avhere it occurs Avith abscess of the fiver, belong to the haematogenous form. A short time since I had the opportunity of observing a patient Avith a large abscess of the liver, Avho suffered from symptoms of jaun- dice as long as an intense fever, Avith very typical intermittent course and severe chills, lasted. When the fever ceased, the bile-coloring matter and the albumen that had occurred coincidently in the urine disappeared, and the jaundiced hue of the skin and conjunctiva was soon lost. The jaundice, Avhich, as previously stated, occasionally occurs AA'ith ulcerative endocarditis, appears also to be haematogenous; but I think it A'ery doubtful AA'hether any of the cases of icterus neona- torum belong here. Lastly, I must repeat my former opinion that eA'ery hepatogenous icterus, resulting from reabsorption of the bile-acids, leads to a haemato- genous icterus. Anatomical Appearances.—Jaundice that is not due to reten- tion and reabsorption of bile rarely reaches a high grade; on autopsy we usuall}' find only a faint yellow color of the outer coat of fat and of the other tissues. A more important point in the post-mortem 686 DISEASES OF THE LIVER. diagnosis of haematogenous icterus, and for distinguishing it from the hepatogenous, is the circumstance that in the former the fiver is not strongly jaundiced, while in the latter the signs in the liver of reab- sorption of bile are always the most prominent. The normal color of the contents of the intestines, particularly the greenish hue of the con- tents of the duodenum, as well as the positive obserA'ation that the bile-ducts and excretory passages are quite pervious, leaves no doubt that it is a case of haematogenous icterus. But, in judging of the per- viousness of the bile-ducts, Ave must guard against mistakes. The fact, that by pressing on the gall-bladder Ave may press a few drops of bile from the ductus choledochus into the duodenum, does not at all prove that during Hfe this passage was perfectly free; on the contrary, this may be done where, from the presence of a gray plug of mucus and epithelium, in the intestinal portion of the ductus choledochus, we may be quite certain that there was catarrh of the duct, and a hepatogenous icterus. Buhl and Liebermeister have the credit of first calling attention to the changes found in the liver and other organs in haema- togenous icterus. According to Liebermeister, the changes in the liver-cells and in the epithelium of the uriniferous tubules consist " in an excessive collection of small and fine fat globules, or else only of cloudy, probably albuminous substance in them;" in other cases, " the cells have fallen into detritus and numerous fat globules have appeared; analogous changes also occur in the substance of the heart." These parenchymatous degenerations {Liebermeister) of the liver, kidneys, and heart, show that, under the influence of the same injurious causes that induce a disintegration of the blood-corpuscles (that is, a parenchymatous degeneration of the blood), the firm tissues of the body may be affected in the same way. Symptoms and Course.—As Ave have already shoAvn, haemato- genous icterus is only one symptom of extended disturbances. Hence we cannot Avell give an exact description of its symptoms and course, and we must confine ourselves to calling attention to those points Avhich, occurring in icterus, show that it is not due to reabsorption of retained bile, but to a transformation of the coloring matter of the blood into that of the bile in the circulation. Attention to the etiology aids us greatly. If icterus occurs after the action of the injurious influences mentioned in the first part of this chapter, or in the course of some of the diseases there mentioned, the presumption is that the case is one of haematogenous icterus. This supposition is strongly supported if the faeces appear of a normal or very dark color. If, with the commencement of the symptoms of jaun- dice, the beat of the heart and pulse become irregular and intermittent; if, along Avith the coloring matter of the bile, albumen appear in the ACUTE YELLOW ATROPHY OF THE LIVER. ^S7 urine; and if, besides these symptoms, Ave haA'e severe disturbances of the nervous system, I consider the diagnosis of haematogenous icterus as quite certain. Leyd.en also reckons among its criteria the discolora- tion of the urine, which is A'ery sligfit in proportion to tfiat of the skin, and particularly the absence of bile-acids from the urine. If it Avere proved that, eA'en in moderate grades of hepatogenous icterus, the bile- acids could be constantly and certainly found, their absence from the urine Avould, indeed, be a certain criterion of haematogenous icterus. Treatment.—Haematogenous icterus does not require any par- ticular treatment; it disappears as soon as Ave can remove the original disease. But, unfortunately, Ave are rather powerless in this respect; still, in those cases occurring during very intense fever, we may expect most from an antipyretic course of treatment. CHAPTER XIV. ACUTE YELLOW ATROPHY OP THE LIVER. Etiology.—In acute yelloAV atrophy of the liver—a very obscure disease, for Avhich Ave find no analogy—in a sfiort time the liver becomes smaller, soft, and pulpy, and, on microscopical examination of the atro- phied and softened organ, Ave find that the liver-cells are mostly de- stroyed. From the fact that the liver, Avhich has been sAvollen by continued biliary obstruction, occasionally becomes smaller, and softens, and that, in this form of atrophy, the liver-cells are also found disintegrated, acute yelloAV atrophy has been referred to obstruction of the bile in the finer bile-ducts. But this supposition is opposed, on the one hand, by the circumstance that, in acute yelloAV atrophy of the liver, the gall- ducts are found empty, or filled with mucus; and, secondly, that no obstruction to the Aoav of bile can be found in them. Other observers take the vieAV that the destruction of the fiver-cells is, it is true, the result of pressure on them, or on the A'essels nourish- ing them, and that this pressure is exercised by the distended bile- ducts, but that the over-filling and distention of the bile-ducts do not depend on stasis of their contents, but on excesshe formation of bile, on polycholia. But since, neither at the commencement of acute yellow atrophy of the liver, nor during its first stages, are there signs of increased Aoav of bile into the intestine, the supposition of excessive formation of bile, as the cause of this disease, appears neither proved nor probable. Most recent pathologists consider acute vcIIoav atrophy of the liver as the result of a peculiar form of hepatitis; and, indeed, its acute 6SS DISEASES OF THE LIVER. course and the rapid and extensive destruction of the liver-cells, would indicate an inflammatory process. Moreover, Frerichs claims to fiave found a free exudation surrounding the lobuli of tfie liver, in some parts of the organ, Avhere the process Avas not yet far advanced. Leav- ino- out of the question this interstitial exudation, which is probably not constant, acute yellow atrophy of the liver would appear to belong to the parenchymatous inflammations, i. e., to those forms of inflam- mation where there is no free exudation between the elements of the tissue, but where the elements of the parenchyma themselves SAvell by. taking up an albuminous substance, and subsequently undergo a com- bined molecular and fatty degeneration. Against this view, AA'hich was adA'anced by Liebermeister, or, at least, first precisely stated by him, the most Ave can say is, that the course of inflammations in other organs, particularly in the kidneys, is entirely different, and that there is no parenchymatous inflammation in which, in a very short time, Avhile the affected organ rapidly becomes smaller and softer, the tissue elements are destroyed, as they are in acute yellow atrophy of the liver. Whether the destruction of the parenchyma-cells of the liver, in acute yellow atrophy, be of inflammatory origin or not, this disease is apparently not primary and idiopathic, but the result of a severe con- stitutional affection. The supposition that this constitutional disease is due to the action of a poisonous, miasmatic substance taken into the blood, to an infection, cannot at present be proved, although the occa- sional epidemic occurrence of the disease is favorable to such a vieAV. The popular comparison of acute yelloAV atrophy of the liver Avith the fatty liver seen after poisoning by phosphorus, is unsound, and has caused many mistakes. In phosphorus-poisoning Ave have a fatty in- filtration / in acute yelloAV atrophy there is a fatty degeneration of the liver-cells: these are decidedly different forms of disease. I con- sider the attempt to refer acute yelloAV atrophy of the liver to poison- ing by the bile-acids as a failure. Even the slight grade of the icterus ^existing in most cases refutes the correctness of this hypothesis. It must be acknoAvledged that the greater or less intensity of the jaundice gives the best means of judging whether much or little bile lias been reabsorbed; for, although Ave can only determine from this the amount of bile-coloring matter that has been reabsorbed, still this gives the means for deciding the amount of bile-acids absorbed. It is true, Ley den has attempted to explain the frequent absence of symptoms of poisoning by the bile-acids in excessive and protracted icterus, by say- ing that, in most cases, their collection in the blood is avoided by their elimination through the kidneys. But this explanation is very doubtful. Daily experience teaches that, in closure of the excretory bile-ducts, in spite of large quantities of bile-pigment being steadily thrown out by ACUTE YELLOW ATROPHY OF THE LIVER. 0S9 the kidneys, the icterus increases regularly as long as the bile-ducts remain closed. What right have Ave to suppose that absorption of the bile acids into the blood is compensated for by then excretion through the kidne}'s, AA'hen it is so evident that this does not occur in the case of the coloring matter ? The disease is very rare; it never occurs in childhood. It is met Avith more frequently in Avomen than in men, and most frequently during pregnane}'. It is interesting to note that pregnancy, which greatly favors the occurrence of parenchymatous inflammation of the kidneys, is undoubtedly accompanied by a predisposition to analogous disease of the fiver. Anatomical Appearances.—In fiigh grades of acute yelloAV atrophy of the liver, tfie organ is much diminished in bulk, occasionally being less than half its normal size. Its thickness is particularly di- minished, so that it appears flattened. Its serous covering is loose, often even in folds. The parenchyma is relaxed and flabby, and the liver is sunk in against the posterior wall of the abdomen. The organ is dull yelloAV, its consistence diminished, and its acini irrecognizable. On microscopical examination, instead of the normal liver-cells, we only find detritus masses, fat globules, and pigment granules. In the right lobe, where the changes were less advanced, Frerichs found " betAveen the lobules, surrounded by hyperaemic vessels, a dirty gray- ish-yelloAV mass, which separated them. Farther off the hyperaemia of the capillaries disappeared, the lobules became smaller and yellow- er, and the intervening gray substance was in excess." The gall-ducts and bladder usually contain a scanty mucous secretion. The faeces are generally only slightly colored; the contents of the intestines are often bloody. The spleen is enlarged in most cases. Ecchymoses are frequent, particularly in the peritonaeum and in the gastric and intestinal mucous membrane, and not very rarely in the other serous membranes and in the skin. In the kidneys, Frerichs not only found deposits of pigment in the epithelium, but also fatty degeneration and disintegration of the epithelial cells. The same observer found quan- tities of leucin in the blood, and in the urine evacuated from the blad- der; in the latter there AAere also tyrosin and a peculiar extractive matter. Symptoms and Course.—The first stage of the disease has no very characteristic symptoms. The patients suffer from loss of appe- tite, pressure and fulness in the epigastrium, and other symptoms that remind us of gastro-intestinal catarrh. There is also in most, but not in all, cases a moderate jaundice, which may excite the suspicion that the catarrh of the duodenum has invaded the ductus choledochus. Not a single symptom betrays the great danger overhanging the patient. 44 690 DISEASES OF THE LIVER. In the second stage the jaundice increases, the region of the liver be- comes sensitive to pressure, the patients complain of severe headache, become restless, excited, and finally delirious. Occasionally the ex- citement extends to the motor nerves, so that there are local or general muscular tAvitchings. But soon, and sometimes without any previous symptoms of irritation, the patient is seized with insuperable depres- sion and lassitude; he falls into a deep sleep, from which he can at first be aroused momentarily, particularly by pressure OA'er the liver, but later cannot be awakened at all. Tfien the preAdously normal or even retarded pulse almost always becomes frequent. The tempera- ture rises very high; tongue and gums become dry and covered Avith sordes; the faeces and urine are evacuated involuntarily. The collapse increases, the very frequent pulse becomes smaller, there is copious perspiration, and, without arousing from his coma, the patient usually dies the second day, more rarely the fourth or fifth day, or later. We might be tempted to regard the icterus in acute yellow atrophy of the liver as haematogenous, and to explain it by saying that the blood-corpuscles are destroyed in the same Avay as the liver- cells by the exciting cause of the disease. But the discoloration of the contents of the intestines, although incomplete, and the jaundiced appearance of the liver, as compared Avith the other organs, render the correctness of this explanation very questionable. The intensely bilious color of the liver shoAvs that the discoloration of the contents of the intestines is not due to arrested production of bile, that is, to acholia. Nor can the icterus be referred to catarrh of the excretory bile-ducts, of Avhich the first symptoms of the disease remind us, for neither the gall-bladder nor ducts are distended with bile. I agree Avith Buhl and Bamberger, Avho refer the obstruction and reabsorption of bile to a blocking up of the origin of the bile-ducts by fatty and molecular detritus of the liver-cells. It is difficult to explain the brain- symptoms, which are the most prominent symptoms of acute yellow atrophy of the liver. We have already spoken of our reasons for not referring them to poisoning by the bile-acids. Bamberger also says : " So much is certain, the brain-symptoms cannot be regarded as cho- laemic, for both the grade and duration of the jaundice are too sligfit for this to be the case." Since in acute yellow atrophy the liver-cells are extensively destroyed, and as in this disease abnormal products of destructive assimilation have been found in the urine, there is some ground for attributing the brain-symptoms in acholia to poisoning by noxious substances, Avhich are formed instead of the normal products of the change of tissue. But I do not consider even this explanation as proved. It is possible that the same cause may induce both the degeneration of the liver and the brain troubles. The haemorrhages ACUTE YELLOW ATROPHY OF THE LIVER. 691 occurring during the disease are apparently the result of disturbed nutrition of the capillary Avails, of an acute haemorrhagic diathesis, Avhich is also seen to occur in many other severe diseases that affect the composition of the blood. Frerichs refers the intestinal haemorrhage, and the enlargement of the spleen, partly to compression of the capil- laries of the liver. Physical examination gives very important results, as it shows very rapid decrease of the liver-dulness, the sole pathognomonic symptom of acute yellow atrophy of the lh'er. At first tfie percussion-sound becomes A'ery full in tfie epigastrium, because the diminution in size be- gins in the left lobe of the liver; but often, even after a feAV days, Ave can find no trace of liver-dulness. The total disappearance of liver- dulness is partly due to the relaxed organ shrinking together and be- ing pressed against the spine by the inflated intestines. Besides the decrease of liver-dulness, the increase of spleen-dulness is important; but the enlargement of the spleen is not always so marked that it can be made out by physical examination, and sometimes it does not occur. Treatment.—It is evident that Ave can say nothing that is re- liable and founded on experience, concerning the treatment of a dis- ease of Avhich it is doubtful whether it ever ends in recovery. If Ave could distinguish the first stage of this disease from that of catarrhal jaundice, Ave should apply leeches about the anus, cold compresses over the right hypochondrium, and give saline laxatives. In the second stage, according to all observations made, abstraction of blood has an injurious effect on the course of the disease. On the other hand, poAverful drastics, aloes, extract of colocynth, croton-oil, etc., are recommended, particularly by English physicians. While there are symptoms of irritation in the nervous system, great excitement, delir- ium and subsultus, ice is usually applied to the head; when paralysis occurs, cold douches are given; this treatment, having been found of occasional benefit in inflammatory brain affections, has been applied to the cases from poisoning. Although almost all comatose patients re- Adve momentarily during the douche, Ave cannot count on a permanent benefit from it in acute yelloAV atrophy of the liver. The same is true of the internal and external use of irritants, Avhich are recommended for the paralvtic symptoms ; of the mineral acids given Avhen petechiae occur and of the ice-pills that are prescribed for the severe vomiting, and for the gastric and intestinal haemorrhage. SECTION II. DISEASES OF THE GALL-DUCTS. CHAPTER I. CATARRH OF THE GALL-DUCTS—ICTERUS CATARRHALIS. Etiology.—The larger bile-ducts of the liver, the ductus hepati- jus, cysticus, choledochus, and the gall-bladder, are lined with a mucous membrane, haAdng cylindrical epithelium and racemose glands. This, like other mucous membranes of similar texture, is quite often the seat of catarrhal inflammation. The small calibre of tfie gall-ducts and excre- tory passages gives peculiar importance to this otherwise mild disease. The narrow canals are easily obstructed by the swelling of their mucous membrane, and by collections of mucus, and these are the most frequent causes of obstruction and reabsorption of bile. In some cases catarrh of the bile-ducts results from excessive hyper- aemia of the liver, in which the mucous membrane of the bile-ducts par- ticipates. Thus hyperaemia of the parenchyma of the liver and of the gall-ducts accompanies the development of cancer of the liver. If this reach a high grade, it may lead to catarrh of the bile-ducts, and thus to icterus. Too little attention has hitherto been paid to this mode of origin of icterus in carcinoma of the liver. Cases of carcinoma of the fiver occur in which there is not the slightest doubt that the icterus depends on this catarrh of the bile-ducts. If the jaundice be only tem- porary, and the faeces are more or less discolored as long as the jaun- dice lasts, and are again normally colored when it disappears, we can- Hot refer the jaundice to compression of the bile-ducts or excretory passages by a cancerous tumor, but must refer it to a cause that comes and goes, or at least increases and diminishes. We have such a cause in the hyperaemia which is present in all organs in the vicinity of new formations, particularly of carcinoma, and Avhich occasionally becomes excessive, and at other times diminishes. The same is true of the temporary icterus in multilocular echinococci, and in many of the cases CATARRH OF THE GALL-DUCTS—ICTERUS CATARRHALIS. 693 accompanying heart-disease, emphysema of the lungs, and other dis- eases which impede the escape of blood from the liver. We shall speak in a separate chapter of the intense catarrh caused by gall- stones, as they readily induce ulceration, and then lead to severe and peculiar symptoms. Lastly, perhaps the irritation from abnormal bUe may induce catarrh of the bile-ducts; but this has never been proved, and is very problematical. By far the most frequent cause of catarrh of the bUe-passages is the propagation of the catarrhal inflammation about the opening of the ductus choledochus into the duodenum. This duodenal catarrh is almost ahvays accompanied by gastric catarrh, and hence the jaundice caused by it is usually called gastro-duodenal jaundice, or icterus sim- plex, on account of its frequency, freedom from danger, and its mild course. The gastric and duodenal catarrh which extends to the gall- ducts may arise from the most various causes, and for the etiology of gastro-duodenal jaundice Ave refer to Avhat has been said of the etiology of gastric and intestinal catarrh. Anatomical Appearances.—In acute catarrhal inflammation the mucous membrane of the gall-ducts is reddened, relaxed, and SAVoUen. Its surface is coA'ered Avith mucous and epithelial masses. If the SAvell- ing of the mucous membrane be considerable, the ductus choledochus becomes impassable, particularly that part AA'hich traverses the Avail of the duodenum transversely, running for some lines betAveen the layers of the Avail (the " portio intestinalis "), while the bile-ducts in the liver are dilated, and filled AA'ith bile containing more or less mucus. The parenchyma of the liver also sIioavs the previously-described characters of moderate biliary obstruction. After the catarrh has lasted some time, the redness of the mucous membrane subsides, but its SAvelling and hypertrophy, together AA'ith a plug of mucus and epithelium, form an insuperable obstacle to tfie Aoav of bile. In such cases the bile- ducts are often enormously dilated, and the enlarged liver sIioavs the signs of great biliary obstruction. The dilatation and distention AA'ith bile often commence in the ductus choledochus immediately above the obstructed portio intestinalis. (For the state of the gall-bladder in contraction or closure of the excretory bile-ducts, see Chapter III.) Symptoms and Course.—In most cases catarrh of the bUe-ducts is readily recognized by the symptoms of obstruction and reabsorption of bile. When these appear gradually, and increase slowly, our sus- picions should first be directed toAvard catarrh of the bUe-ducts, be- cause catan-hal jaundice is so frequent, as compared with other forms of the disease. But this is scarcely ever a primary affection ; it almost ahvays accompanies catarrh of the gastric and intestinal mucous mem- brane ; hence it is almost characteristic of catarrh of the bile-ducts, 694 DISEASES OF THE GALL-DUCTS. that symptoms of gastric and intestinal catarrh precede the jaundice for days, or even Aveeks, and continue while the disease lasts. In this sense, Ave may consider the coated tongue, bad taste, eructations, and other dyspeptic symptoms, as among the premonitions and symptoms of catarrhal jaundice. The longer the catarrh of the bile-ducts con- tinues, and the more completely the excretory duct is closed by it, the greater Avill be the discoloration of the faeces, and the more intense the jaundiced color of the skin and urine, and the more the general health and nutrition of the patient avUI suffer. The liver appears distinctly- swollen in many cases, and in some of them it is considerably en- larged. If the disease run a favorable course, the improvement shoAVS itself in a Aveek or two, by a return of appetite, by the tongue cleaning off, and by decrease of the dyspeptic symptoms. Then we may hope that the catarrh of the bile-ducts will subside with the gastro-duodenal catarrh, and in fact, after a few days, the returning color of the faeces shows that the ductus choledochus is open, and the clearer color of the urine indicates that the biliary obstruction is less, and that less bile is reabsorbed. The bile-pigment deposited in the rete Malpighii disap- pears more slowly. After the faeces are strongly colored with bile, and the urine has regained its normal tint, the skin remains jaundiced for a time, and finally this last symptom of the disease disappears. In other cases the catarrh of the bile-ducts, as well as that of the stomach and duodenum, becomes chronic. The disease drags on for weeks or months, the jaundice becomes excessive, the patients emaciate de- cidedly, and the liver enlarges considerably. But these cases also almost ahvays terminate in recovery, particularly under proper and energetic treatment; and the biliary obstruction caused by catarrh of the ducts very rarely runs an unfavorable course Avith the symptoms before described. Treatment.—Experience teaches that catarrh of the bile-ducts rapidly disappears when the catarrh of the intestinal mucous mem- brane, which has attacked the gall-ducts, subsides. Hence the causal indications require the same measures that Ave have recommended in the treatment of gastric and intestinal catarrh. Under the circum- stances there mentioned, an emetic may be indicated; in other cases diaphoretics, in still others, careful regulation of the diet suffices. We shall not repeat in detail Avhat we have previously said, but only call attention again to the excellent effect in gastric and intestinal catarrh of the carbonates of the alkalies, particularly as existing in the Karls- bad and Marienbad waters. While we have denied all direct infiuence of the Karlsbad Avaters on biliary obstruction and jaundice, still there is no better treatment for most patients than the use of these Avaters, CROUPOUS AND DIPHTHERITIC INFLAMMATION". 695 because in the majority of cases none better fulfils the causal indica- tions. If the circumstances of the patient do not alloAV of his being sent to a Avatering-place, Ave may let him use the " Karlsbad diet" at home, and order soda-Avater or artificial Marienbad or Karlsbad water. From this treatment alone Ave shall see the most favorable and speedy results in catarrhal jaundice. In some cases the indications from the disease may be fulfilled by the administration of an emetic. During the act of vomiting, the bile is forced out of the gall-ducts and bladder, toward the mouth of the ductus choledochus, and an obstructing plug of mucus may thus be pressed out of the latter. We might give emetics far more frequently, if the obstruction of the ductus choledochus were not more frequently caused by the SAvelling of the mucous membrane than by mucous plugs, and if we did not fear that the untimely use of an emetic might render worse the gastro-intestinal catarrh. Nitro-muriatic acid has a great reputation in the treatment of catarrhal jaundice; it is used externally, in the form of foot-baths ( § ss—j. to a foot-bath) and as fomentations over the liver, or internally ( 3 ss—j. to 3 vj. of muci- lage, a tablespoonful every tAvo hours). The internal administration might possibly have a favorable infiuence on the intestinal catarrh; perhaps it might also excite contractions in the excretory bile-ducts, and thus cause the expulsion of obstructing coagula. The external use of aqua regia Avould scarcely be of any benefit. The action of the drastics is explained by the effect they have of increasing the peristaltic action of the intestines, Avhich extends to the ductus choledochus. But generally these have no favorable inAuence on the catanhal jaun- dice, for AA'hich they are given so much. The exhibition of calomel (gr. j every eA'ening), and of the Vienna decoction (t\vo tablespoon- fuls every morning), according to the so-called English method, is ob- jectionable, although many patients with catarrhal jaundice recover in spite of this treatment. Slight laxatives are only advisable when there is obstinate constipation. Then Ave may use some one of the tartrates, particularly tartrate of potash, or a decoction of tamarinds ( o j—ij *° 3 VJ—^j) with acid, tartar. (3j— 3 ss.) and syrup, sennae c. manna1; or Ave may prescribe infusum sennae compositum or lenitive electuarj-. CHAPTER II. CROUPOUS AND DIPHTHERITIC INFLAMMATION OP THE GALL-DUCTS. Inflammations of the gall-ducts Avith fibrinous exudations are ex ceedingly rare, and AA'hen they do occur it is only in the course of severe diseases, such as protracted typhus, septicaemia, cholera, etc. 696 DISEASES OF THE GALL-DUCTS. In croupous inflammation, we find the mucous membrane of the gall- bladder covered with a more or less firm false membrane, and in the ducts Ave find tubular coagulations, enclosing inspissated bUe, and caus- ing biliary obstruction. In diphtheritic inflammation, the tissue of the mucous membrane is infiltrated at certain places Avith a fibrinous exuda- tion, Avhich causes sloughing of the mucous membrane, and from sepa- ration of the slough deep losses of substance occur. These processes cannot be recognized during life. Even an intense icterus occurring during typhus, septicaemia, cholera, etc., cannot be referred to a croupous or diphtheritic inflammation of the bUe-ducts, as it far more frequently occurs Avithout any perceptible change in them. CHAPTER III. OBSTRUCTION AND CLOSURE OF THE EXCRETORY GALL-DUCT AND CON- SECUTIVE DILATATION OF THE BILE-DUCTS. Etiology.—The excretory gall-ducts are most frequently con- tracted and closed by catarrhal swelling of tfieir mucous membrane and by collection of mucus. Among the further causes of this contrac- tion and closure, and of consecutive dilatation of the bile-ducts above the contraction, are: 1. Tumors pressing on the excretory ducts, or groAving into them. Sometimes they are caused by carcinoma of the liver, pancreas, stomach, or duodenum; sometimes by caseous or other degeneration of the lymphatic glands; sometimes by abscesses; rarely by hydatid cysts, aneurisms, or collections of hard faeces in the colon ; and lastly, in a few cases, by multilocular echinococci, that have wan- dered into the gall-ducts or broken through into them, and have thence reached the ductus hepaticus. 2. Occasionally there is a more or less complete closure of the ductus choledochus, hepaticus, or cysticus, from cicatricial contractions, AA'hich remain in the excretory bUe-ducts, or in the duodenum after ulcers have healed, or the thickening and consecu- tive atrophy of the peritonaeum after peritonitis, particularly AA'hen the excretory bile-ducts are at the same time distorted or bent. 3. Lastly, foreign bodies, particularly stony concretions, obstruct or close the excretory bile-ducts. When the ductus hepaticus is constricted or closed, the consecutive dilatation of the gall-passages is limited to the bile-ducts of the fiver. But if the ductus choledochus becomes impervious, the ductus hepati- cus, cysticus, and the gall-bladder, are all dilated. Finally, if the duc- tus cysticus alone be closed, no bile can enter the gall-bladder, it is true, but its mucous membrane continues to secrete mucus, and the DILATATION OF THE BILE-DUCTS. 697 gall-bladder becomes more and more distended by the secretion. This state is called hydrops vesice fellee. Anatomical Appearances.—According as one or other of the above causes prevails, the anatomical appearances vary so greatly, except in the general effect of the constriction or closure of the excre- tory bile-ducts, that Ave shall refrain from giving a detailed description of them. If its mouth be entirely closed, the ductus choledochus may attain the size of the small intestine, and the dUatation extends through the ductus hepaticus and its branches to the capillary gall-ducts. The gall-bladder is also dilated, but its dUatation is not in proportion to that of the gall-ducts, because, from the acute angle at which it opens, it is compressed by the dilating ductus choledochus. The liver sIioavs the changes that Ave have described as characteristic of the highest grade of biliary obstruction; it is at first enlarged, and on section the dilated gall-ducts look like large cysts filled Avith bile; subsequently, they may become smaller, from atrophy of the liver. In hydrops vesice fellee, the gall-bladder becomes a translucent, tense cyst, as large as a fist, or a child's head even, AA'hich contains a serous fluid, re- sembling synovia. Its muscular filaments are separated and atrophied, the mucous membrane has lost its structure, and has acquired the look of a serous membrane. In some cases closure of the cystic duct leads to atrophy of the gall-bladder; its mucous and bilious contents become inspissated, and changed to a chalky mass, while the walls are thick- ened and atrophied by chronic inflammation. Finally, there remains only a hard tumor, as large as a pigeon's egg, filled Avith a chalky pulp. Symptoms and Course.—Contraction and closure of the ductus hepaticus and choledochus are characterized by the symptoms of exces- sive biliary obstruction, uncomplicated by those of gastro-duodenal catarrh, but occasionally accompanied by those of neoplasia or other groAvths in the abdomen, or of chronic peritonitis, or of gall-stones, etc. The icterus is more decided, and the faeces more discolored than in any other form of bihary obstruction. We usually find the liver enlarged, and if the ductus choledochus be closed Ave also feel the full and distended gall-bladder. Later the consecutive dilatation of the liver may also be observed. If Ave find cancerous tumors in the abdo- men, if there has been colic from gall-stones, or if any other symptoms indicate the variety of the closure, the diagnosis becomes more certain. In most cases it is only possible to recognize the closure, AAdthout being able to make out its cause. Hydrops vesice fellee is readily diagnosed, if it be simple and not complicated Avith obstruction and closure of the ductus hepaticus or choledochus. If we find a pear-shaped, movable, occasionally fluctuat- ino- tumor starting from the incisura vesicae felleae, in a patient who is 698 DISEASES OF THE GALL-DUCTS. not jaundiced, Ave may diagnose closure of the cystic duct and disten- tion of the gall-bladder by mucous secretion, or hydrops vesicae felleae. As it is almost ahvays impossible to remove the cause of the con- traction or closure of the bile-ducts, it is impossible to treat them suc- cessfully. CHAPTER IV. GALL-STONES AND THEIR CONSEQUENCES—CHOLELITHIASIS. Etiology.—In spite of numerous works on this subject, the origin of gaU-stones is very obscure. Particles of mucus, or (far more rarely) foreign bodies in the gaU-passages, appear to play an important part in the formation of gall-stones, for they form the nucleus in almost all cases, and they at least form the point on which the solid constituents of the bile may be deposited. It cannot be decided whether such deposits occur when the bile is normal, or only when it is somewhat concentrated, or when of abnormal composition. As a combination of chalk with bile-pigment is almost always deposited immediately around the above-mentioned nucleus, and as this combination almost always occurs in greater or less quantities, it is thought that excess of chalk in the bile, from drinking lime-water, has something to do Avith the formation of gall-stones. But, besides this, it is probable that the bile from which gall-stones, rich in cholesterin, are formed, has only a slight solvent power over cholesterin; and as it has been found that both cholesterin and biliary coloring matter with lime are dissolved by tauro-cholic acid and tauro-cholate of soda, it was very natural to con- sider a lack of tauro-cholic acid in the bile, or a decomposition of the tauro-cholic acid in the gall-bladder, as the possible cause of gall-stones. Gall-stones occur more frequently in women than in men, far more frequently in old than in young persons; and, without our being able to explain why, they are particularly frequent in patients with carci- noma of the stomach or liver. Perhaps this is somewhat due to the catarrh of the bile-passages, which, as we said in Chapter I., often ac- companies carcinoma of the fiver. Anatomical Appearances.—The size of gall-stones varies from that of a hemp-seed to that of a hen's egg. The smallest concrements are distinguished from gall-stones proper by the name of " biliary sedi- ment." Most frequently there is only one calculus, in other cases there are a great number of them. Solitary stones are usually round or egg-shaped, or they have exactly the shape of the gall-bladder. Their surface is sometimes smooth, sometimes more rough and glandu- lar. If there are several stones, they have almost ahvays become smoothed on the sides that touch, and have a polyhedral form, with GALL-STONES AND THEIR CONSEQUENCES—CHOLELITHIASIS. 699 edges, corners, and smooth surfaces, or they have convex and concave facettes, AA'hich give them a peculiar appearance. Biliary calculi have a Ioav specific gravity; Avhen recently removed, they may be mashed by the fingers; when dried, they usually split, and finally break down into dust. Biliary calculi vary greatly in color; some are wfiitish, or pale yellow, from slight imbibition of bile, others are dark broAvn, and others still are greenish or blackish. They often consist of va- rious layers, and light-colored strata may alternate with dark ones. Calculi, consisting chiefly of cholesterin, have a marked, striated crys- talline structure, while those that contain chiefly bUiary coloring mat- ter Avith lime have an earthy fracture. Most biliary calcufi are chemi- cally composed of cholesterin, and have a small amount of biliverdine only about their nucleus; others consist of a mixture of cholesterin and biliverdine; the latter is sometimes distributed regularly through the mass, sometimes there are alternate layers of cholesterin and of the coloring matter of the bile Avith lime. We rarely meet calculi con- taining no cholesterin, but composed of bile-pigment and lime, or of carbonate and phosphate of lime {Lehmann). In most cases no structural changes can be discovered in the coats of the gall-bladder, even when it contains numerous calculi witfi sharp edges. But occasionally, particularly in the fundus of the bladder, Ave find a considerable injection and puffing of the mucous membrane, or there is an ulcerative loss of substance of variable size and depth. The ulceration may lead to perforation of the gall-bladder. If this occurs before the Avail has become adherent to neighboring parts, the contents enter the peritonaeum and cause general peritonitis. If, on the other hand, the gall-bladder be perforated after it has formed firm adhesions AA'ith neighboring parts, there may be communication with the intestines or perforation outwardly. In some cases the inflamma- tion induced by gall-stones is less destructive. The walls of the blad- der are thickened, and, after a Avhile, undergo cicatricial retraction; the contents become dry and chalky. And, finally, in such cases Ave find tfie biliary calculi embedded in a chalky mass, and firmly enclosed by the shrunken and atrophied gall-bladder. In the gall-ducts of the liver, biliary calculi may excite suppurative hepatitis. In the excretory ducts, large calcufi either cause ulceration and perforation or complete closure of the duct, so that the states de- scribed in Chapter IH., excessive biliary congestion, or, if the cystic- duct be closed, hydrops vesicae felleae result. In some cases the bile- ducts are so dUated, by the pressure of the bUe from behind, that the latter squeezes past the calculi, or that even comparatively large cal- cufi are forced into the duodenum. Symptoms and Course.—On autopsy, large calculi or numeious 700 DISEASES OF THE GALL-DUCTS. small concrements are often found in the gall-bladder, Avhich apparent- ly had no effect on the health of the patient during fife. We may even say that it is exceptional for calculi in the gall-bladder to cause trouble, or betray themselves by any definite symptoms. Calculi of small size may even pass through the ductus cysticus or choledochus Avithout exciting pain or any other symptom. The experiences at bathing-places, such as Karlsbad, where the stools are carefully ex- amined for gall-stones, afford numerous examples of this. Among the morbid processes which gall-stones induce, as above stated, Ave have already described suppurative hepatitis and' obstruc- tion of the excretory bile-ducts, so that Ave may here limit ourselves to describing tfie symptoms tliat arise during the passage of large gall- stones through the excretory passages, and, during their impaction there, the so-called gall-stone colic, as weU as tfie symptoms of inflam- mation and ulceration of the gall-bladder and excretory ducts, which are excited by gall-stones in some few cases. Gall-stone colic begins unexpectedly and suddenly at the moment a concrement passes from the gall-bladder to the ductus cysticus and becomes impacted there. The patient is seized with a piercing or griping, insupportable pain, which starts from the right hypochondrium and spreads over the AA'hole abdomen, often also to the right side of the thorax, and even to the right shoulder. The abdominal muscles are cramped and very sensitive to pressure; the patients sigh and moan, double up, and roll about on the bed or floor. During aU this there is no fever, but there are a number of other symptoms. The pulse becomes small, the skin cool, the face pale and distorted; occa- sionally the patient actually faints. In some cases the patients are affected Avith spasmodic trembling or chUls; in other cases there are convulsions either general or limited to the right half of the body. There is most frequently obstinate sympathetic vomiting. After a few hours, or in severe cases not till next day, the sufferings of the patient are usually moderated, and the general disturbance quieted. This remission, during AA'hich, however, the patient stUl suffers severe- ly, and still has a small pulse, and pale, cool skin, appears to corre- spond to the passage of the concrement from the cystic duct into the ductus choledochus, which, except the portio intestinafis, is a somewhat Avider canal. The symptoms do not change very much till the concre- ment has passed the ductus choledochus and entered the duodenum. Then the patient is entirely free from pain and uneasiness; the pulse rises, the Avarmth of the skin returns, and the distortion of the counte- nance disappears. This passage, from great agony to complete ease, often occurs in a very short time, and then the contrast is very strik- ing. In other cases the pain does not cease suddenly, but subsides GALL STONES AND THEIR CONSEQUENCES—CHOLELITHIASIS. ?01 gradually; this is probably because the irritated nerves of the gall- ducts are only gradually quieted, just as, Avhen the eye is irritated by a foreign body, it remains irritable for a time after the body has been removed. Very rarely gall-stone colic terminates fatally with the symptoms of excessive faintness, passing into true palsy. SomeAvhat more frequently it is folloAved by the symptoms of permanent closure, or of inflammation and ulceration of the excretory bile-ducts. Jaundice is not by any means a constant symptom of gall-stone colic. Tfiere can be no obstruction and reabsorption of bile from im- paction of tfie calculus in the cystic duct; and, as Ave have before stated, even a temporary closure of the ductus choledochus does not result in icterus. Usually, after the symptoms of impaction have sub- sided, there is a slight jaundice, Avhich is very temporary if the impac- tion in the ductus choledochus has not continued long. After reaching the duodenum, the calcufi are rarely vomited; far more frequently they are passed at stool, and this passage is only exceptionally accompanied by abdominal pain or muco-bloody diarrhoea. It is almost ahvays unnoticed, so that the calculus is only discovered on careful examina- tion of the faeces. After the attack has passed, we are often unable to find any calculus, even if we place the faeces on a sieve and wash them through it. In such cases the probabilities are tfiat the impact- ed concrements have gone back from the cystic duct into the gall- bladder. There are still some dark points in our knoAvledge of gall-stone colic. It is remarkable and unexplained that, in some persons, gall- stones do not sIioav any inclination to leave their place in the gall- bladder, AA'hile in others they very frequently pass through the ducts. We are not even clear as to hoAV the calculi are pressed from the gall- bladder into the cystic duct, although it is most probable that they are floated onward, as it were, by the bile Avhich is driven forward by the contractions of the gall-bladder. This vieAV is supported, among other things, by the fact that gall-stone cofic is particularly liable to occur during digestion. Lastly, Ave would suppose tfiat, during a gall-stone colic, Ave might, from a variation in the intensity of the symptoms, dis- tinguish three periods, the first corresponding to the impaction of the calculus in the very narroAV cystic duct, the second to its passage into the someAvhat AA'ider ductus choledochus, the third to its impaction a«-ain in the very narroAV portio intestinalis of the ductus choledochus; but Ave usually observe nothing that can be referred to these phases. The inflammations and ulcerations caused by gall-stones do not in- duce any uneasiness till the peritonaeum participates in the inflamma- tion ; then avc have the above-described symptoms of partial chronic, and, occasionally, of acute peritonitis. The seat of the pain over the 702 DISEASES OF THE GALL-DUCTS. gall-bladder, as Avell as attacks of gall-stone colic that have preceded the pain, and, in rare cases, the discovery of a distention and fulness of the gall-bladder by calcufi ( Oppolzer), may excite the suspicion that the walls of the gall-bladder are inflamed and ulcerated on account of the concrements in it. If the gall-bladder be perforated before it has become adherent to the surroundings, we have the symptoms so often described, AA'hich are almost pathognomonic of the entrance of foreign bodies into the peritonaeum, and, in a feAV days, the patient dies of diffuse peritonitis. If the neighboring organs have become adherent to the gall-bladder, when this is perforated, the pain is limited to the region of the gall-bladder; besides the above symptoms, there is dis- turbance of the functions of the bowels, and the symptoms of the dis- ease often remain obscure till they are explained by the passage of a calculus, which is so large that it could not possibly have passed the ductus choledochus. Concrements entering the intestines through an abnormal communication between them and the gall-bladder may be so large as to pass through the bowels with difficulty, and may give rise to the symptoms of obstruction of the intestines. I have a choles- terin calculus larger than a pigeon's egg, which was given to me as an intestinal calculus, and which was passed with great pain by a lady, " after repeated attacks of hepatitis." If the inflamed bladder adhere to the anterior wall of the abdomen, Ave may occasionally feel it as a hard circumscribed tumor; subsequently the abdominal walls them- selves become inflamed, an abscess forms in them, from which pus, bile, and often a great number of gall-stones, may be evacuated. The ab- scess does not ahvays open at the part of the wall lying over the gall- bladder, but occasionally opens at a distance, after fistulous passages have formed in the Avails. The fistula rarely closes after one or a few concrements have been evacuated; it more frequently lasts for a long while or ahvays, constantly or at intervals pouring out bile, and, if the cystic duct be closed, a limpid fluid. Inflammation and ulceration of the excretory bile-ducts, caused by calculi, are preceded by the symptoms of gall-stone colic; but tins, instead of terminating, as it might, in complete recovery, leaves pain in the region of the liver, and great sensitiveness to pressure. When the impaction of the calculus, and the consequent inflammation, has affected the ductus choledochus, there is also intense icterus, and other symptoms of excessive biliary obstruction. Far more rarely, from its angular form, tfie calculus closes the excretory duct incompletely, so that small quantities of bile continue to reach the intestine. In such cases the faeces are not entirely discolored, and the icterus does not become so intense. In this case, also, there may finally be perforation, and consequent peritonitis {Anelrat). But more frequently, the pa- GALL-STONES AND THEIR CONSEQUENCES—CHOLELITHIASIS. 703 tients die of the results of biliary obstruction, AA'ith the symptoms of marasmus, or of acholia. Treatment.—We should try to preserve patients, who haA'e had one or more attacks of gall-stone colic, from neAV attacks, and from tfie other consequences of biliary calculi. The more frequently the attacks have been repeated, and the more the surfaces, angles, and facettes of the calculi passed induce the belief that there are others remaining in the gall-bladder, the more imperative are the rules for insuring protec- tion. Experience shows that, under the use of the Karlsbad Avaters, immense quantities of gall-stones are evacuated, AA'ith proportionately little difficulty. The same is true of the use of other alkaline mineral waters, of the waters of Vichy, Marienbad, Kissengen, etc. We can- not explain this fact. We do not know whether their efficacy depends solely on the rich formation of a thin, fluid bile, by Avhich the gall- stones are readily Avashed doAvmvard, or Avhether the bile is rendered so strongly alkaline by the use of these Avaters as to dissolve the color- ing matter and lime, or the cholesterin; but we should not delay pre- scribing the treatment till its mode of action can be explained. In the treatment of the states induced by gall-stones, Durande's remedy also enjoys a great reputation; this consists of ether 3 iij, and oil of tur- pentine 3 ij. According to the original prescription, half a drachm of this is to be given in the morning, and the dose is gradually increased until about a pound of the mixture has been taken. The fact that ether and oil of turpentine dissolve bUiary calculi placed in them does not justify the hope that they will dissolve any concrements in the gall-bladder, if they are introduced into the stomach. Hence, if Du- rande's remedy has a favorable influence on the conditions induced by gall-stones, as Ave must suppose it has, from the recommendations of numerous and good observers, this can only take place in some other Avay, Avhich is entirely unknoAvn to us. Recently various substitutes for Durande's remedy, and variations from the original dose, have been proposed. There is a popular mixture of oil of turpentine, 3ij, Avith spirits of ether, 3 j, AA'hich is prescribed, in drop-doses, by Rademacher and his folloAvers, not only for gall-stones, but for all possible liver- diseases, whether avc know what they are or not. In the treatment of gall-stone colic, the bold employment of opium deserA'es the most reliance. We may give twelve drops of laudanum or a quarter of a grain of acetate of morpfiia at a dose, and repeat it every fiour or tAvo till there is slight narcotism. If the patients A'omit, so that they cannot retain medicines given by the stomach, Ave may give subcutaneous injections of a strong solution of morphia, or ene- mata of laudanum, or let the patient carefully inhale chloroform. Warm baths, also, as Avell as Avarm narcotic compresses over the liver occa- 704: DISEASES OF THE GALL-DUCTS. sionally, appear to moderate the pain and shorten the attack. If this be, nevertheless, protracted, and the region of the liver become very sensitive to pressure, Ave should apply a number of leeches to the right hypochondrium; in such cases they appear to have a favorable effect, although we cannot understand why. The patient not unfrequently becomes so collapsed that, besides the aboA'e-mentioned remedies, we are obliged to give analeptics. Pieces of ice are most efficacious for the severe, and occasionally very obstinate, vomiting. Emetics and laxatives, given during the attacks, increase the pain, and, moreover, thqfy may prove dangerous. On the contrary, after the attack, we Apuld administer mild laxatives for a whUe, so that any concrements Hrthe intestines may be evacuated as soon as possible. In inflammations and ulcerations of the bile-passages caused by gall-stones, we must limit ourselves to the treatment of symptoms, as we are unable to remove the exciting cause. Fluctuating abscesses in the abdominal walls should be opened early; any remaining fistulae should be treated according to the rules of surgery. Obstructions of the intestinal canal by large gall-stones are to be treated as previously advised; severe and distressing pain should be relieved by narcotics. DISEASES OF THE SPLEEN. CHAPTER I. HYPEREMIA OF THE SPLEEN. Etiology.—The variations in the amount of blood in an organ may be the more decided, the more yielding its parenchyma and en- velope, and the more numerous its vessels, and the thinner their walls. The spleen has a very yielding capsule, its numorous vessels have very thin walls, and appear to communicate with large cavities within. This explains hoAV the spleen may be enormously distended by injections of water, or by blowing up, as well as the fact that, during fife, the amount of blood in it may be very much increased, and it may, conse- quently, be very decidedly enlarged. The slighter the elasticity of the envelope, and of the walls of the vessels of an organ, the slower the disappearance of distention induced by any temporary cause. If we imagine an organ where the envelope and the walls of the vessels have no elasticity, it would remain perma- nently enlarged, if once distended by a momentary increase of the blood AoAving in, or by a momentary obstruction to that flowing out; just as a Avax-tube, that has a fluid passing through it, remains perma- n mtly dilated if Ave momentarily increase the pressure on its inner av dl. As the capsule, trabeculae, and Avails of the splenic vessels offer but little opposition to its enlargement, so also, from their slight elas- ticity, they can only sloAvly remove any enlargement of the organ. If the spleen be SAVollen during a paroxysm of intermittent fever, after the subsidence of the paroxysm, it remains enlarged longer than other organs that Avere enlarged at the same time, but Avhich were richer in elastic elements, and particularly such as had vessels with more elas- ticity than the vessels and caAdties of the spleen. We shaU hereafter shoAV that the decrease of SAvelling of tfie spleen is probably caused by its contractile elements. In the spleen as in other organs Ave must distinguish two forms of hyperaemia, fluxion and obstructive engorgement. 45 706 • DISEASES OF THE SPLEEN. Fluxion causes.—1. Splenic enlargements in the acute infectious diseases; the enlargement in typhus and intermittent feA'ers, in the acute exanthemata, puerperal fever, septicaemia, etc. We do not know whether the increased flow of blood into the spleen in these diseases be due to a relaxation of the aheady yielding tissue of the spleen, or to a paralysis of the muscular elements of the walls of the vessels, and of the trabeculae. {Jaschkowitz observed that, after dividing the branches of the sympathetic going to the spleen, it became very large and excessively vascular. If he only divided some of the nerves, the hyperaemia Avas limited to tfie parts of the spleen supplied by the divided nerves.) The manner in which the infected blood may alter the elasticity of the tissue of the spleen, or the contractUity of its muscular elements, is just as obscure. The swelling of the spleen in intermittent fever has been explained by saying that, during the chUl, the chculation on the surface of the body is decidedly disturbed, and, on account of the ischaemia of the skin, the internal organs, and among these the spleen particularly, are overloaded with blood. But these conditions are of only secondary importance, as is proved by the fact that the amount of splenic enlargement is not at all in proportion to the severity of the chill, that the spleen also enlarges during the hot stage, and finally, because enlargement of the spleen occurs from mala- rial infection when there is no fever. 2. Fluxion to the spleen occurs in anomalies of menstruation ; we might repeat of this form all that was said of the occurrence of hyperaemia and haemorrhage from the gastric mucous membrane arising from the same cause. 3. Injuries, inflammations, and neoplasiae in the spleen induce Auxions. We mav best observe this form of hyperaemia in haemorrhagic infarction of the spleen (see Chapter IV.). There is a physiological engorgement of the spleen a few hours after every meal, that is, at the time when the lateral pressure in the portal vein is greater from the increased supply of blood coming from the filled intestinal veins, and when the flow of blood from the splenic vein is obstructed. Abnormal congestion is induced by obstruction and closure of the portal vein, such as occur in numerous diseases of the liver, as cirrhosis, pylephlebitis, and others. Since most of these last a long Avhile, besides the hyperaemia of the spleen, Ave usually find its results which will be spoken of in the next chapter. Engorgement of the spleen is far less constant and excessive in heart and lung dis- eases, where the Aoav of blood from the vena cava is obstructed, and this obstruction extends through the vessels of the fiver to those of the spleen. It is difficult to explain why, in spite of excessive cyano- sis and general dropsy, the spleen often remains of normal size, and not very vascular in heart and lung disease. It is even more remark- HYPEREMIA OF THE SPLEEN. 707 able that, in atrophic nutmeg-liver, hyperaemia of the spleen is even absent as a rule. Anatomical Appearances.—Except in cases Avhere the capsule of the spleen is thickened and unyielding, we find the hypertrophied organ larger and heaAder than a healthy spleen. The increase in size and weight may be so great that the organ will have from four to six times its normal weight. The normal spleen of a healthy adult is four to five inches long, three to four inches wide, and one to one and a half inches thick; its weight is about eight ounces. The spleen enlarged by hyperaemia maintains its form, its capsule usually appears tense and smooth, and where the swelling has somewhat subsided, it is occasion- ally relaxed and wrinkled. The consistence of the spleen is dimin- ished. This is also true of the enlargement of the spleen occurring in malarial diseases, as long as it is recent, and as long as other changes, that will be spoken of hereafter, have not occurred. The enlarged spleen, found in patients who have died of typhus, puerperal fever, septicaemia, etc., is often so soft that, when cut through, the paren- chyma flows off like pulp. In judging of the consistence of this tumor, avc must, however, remember the early decomposition of the bodies. The color of the spleen is darker in proportion as the hyperaemia is recent and excessive. In the most recent cases and in high grades of hyperaemia, the parenchyma often looks like a blackish red-blood coagulum, later it appears lighter colored, or from admixture of pig- ment is somewhat gray. On microscopical examination, Ave find no foreign elements with the normal cells of the spleen pulp, and numerous blood-corpuscles, so that Ave have no right to refer this enlargement of the spleen to a process of inflammation and exudation. Acute splenic enlargement appears to depend either solely on increase of the blood contained in it, and serous infiltration of the tissue, or on a coincident temporary increase of the substance of the spleen. When the hyperaemia has existed a long time, the increase of the pulp of the spleen is unmistakable; it greatly changes the appearance and consistence of the organ; the spleen remains permanently en- larged, and Ave have the state called " chronic spleen tumor " or hyper- trophy of the spleen, Avhich Ave shall describe in the next chapter. Symptoms and Course.—Hyperaemic swelling of the spleen al- most ahvays develops AAdthout the patient complaining of pain; usually he is only sensitive on deep pressure in the left hypochondrium. This observation corresponds to the general experience that tension of tis- sues Avhich are very expansible causes little pain, whUe tension of membranes, ligaments, etc., Avhich are stretched Avith difficulty, excites severe pain. If, during an intermittent, a typhus or simUar state, the 708 DISEASES OF THE SPLEEN. patients of their OAvn accord complain of pain in the region of the spleen, it may either be because the capsule of the spleen has become thickened and unyielding from former disease, or from the occur- rence in the spleen or its capsule of inflammatory processes, which may also occur during these affections. In most cases there are no other subjective symptoms either, at least such as can be certainly referred to hyperaemia of the spleen, and not to the original disease. Hence the splenic affection Avould almost always be overlooked if the physician did not know that it very con- stantly occurred in certain diseases, and if he did not examine each case by palpation and percussion, to find Avhether any enlargement of the organ existed. I will call attention to one symptom of excessive hyperaemia of the spleen, which I think can be readily explained, and referred to mechanical causes. Experience shoAVS that some patients Avith intermittent fever are very pale and anaemic after a very few paroxysms, and tha*t the palfidity of the skin and mucous mem- branes disappears in a few days when a few doses of quinine have ar- rested the paroxysms. This symptom cannot depend on the rapid con- sumption of the blood and its speedy restoration. Although the tem- perature rises A'ery high during the paroxysm of the intermittent, and Ave know that high fever is accompanied by decided and rapid con- sumption of the blood, still in no other disease where the temperature reaches the same height, and remains there even longer than in inter- mittent, does the patient become anaemic in so short a time. On the other hand, if a continued and high fever has caused poverty of the blood, the symptoms disappear far more slowly than does the paleness resulting from a few paroxysms of intermittent fever. My observa- tions and those of others, particularly of Griesinger, show that the rapidity with which the symptoms of anaemia develop and the grade that they attain are in direct proportion to the rapidity with which the spleen enlarges, and to the grade that this enlargement reaches; that, particularly in children, in whom the spleen usually acquires a propor- tionally large size after very few paroxysms, threatening symptoms of excessive hyperaemia develop early, but disappear very quickly after the arrest of the paroxysms and the subsidence of the tumor. Hence it can hardly be doubted that the appearance and disappearance of these anaemic symptoms are associated Avith the occurrence and subsi- dence of the hyperaemia of the spleen. It is not probable that the excessive anaemia, which develops in a feAV days in intermittent fever, depends on disturbance of the spleen, caused by the hyperaemia, al- though, in severe disease of the spleen, the blood is gradually impov- erished, apparently from disturbance of the influence of that organ on the formation of the blood. On the other hand, although not posi- HYPEREMIA OF THE SPLEEN. 709 lively certain, it is Aery probable, from what AA'as said above, that the overloading of the spleen Avith blood induces anaemia in the rest of the body, and consequently that the pallor of the patient depends less on impairment of the quality of the blood than on its abnormal distribu- tion. We may compare the effect that overloading of the spleen Avith blood has on the rest of the body, to that induced by a large aneurism filled Avith blood, or by the overloading of one of the lower extremities with blood from the application of Junod's boot. If, after the cessa- tion of the intermittent paroxysms, or after the administration of quinine, the spleen regains its normal size from its elasticity, or from the contraction of the irritable elements of the tissue, the anomalous distribution of the blood will cease. This explains hoAV the redness of the skin and lips, Avhich has been lost during the intermittent fever, may return in a feAV days. The hyperaemia of the spleen that occurs in the course of typhus and similar diseases usually subsides when they have run their course, Avithout leaving any structural change. The case is different Avhere the enlargement depends on intermittent or other fluxionary or obstruct- ive hyperaemia, if it continues for a long time, on account of continued action of the exciting cause. In the next chapter Ave shall attempt to prove that so-called hypertrophy of the spleen is a necessary result of long-continued hyperaemia. In very rare cases hyperaemia of the spleen proves fatal, from rupture of the distended organ. This termination has been seen both in paroxysms of intermittent fever, and in typhus and cholera. Death results Avith the symptoms of internal haemor- rhage either immediately after the rupture of the spleen, or else not for seA'cral hours or days. Physical examination furnishes the most important, and often the sole means, of diagnosis of hyperaemia of the spleen. WhUe speaking here of the physical signs that occur in hyperaemic SAvelling of the spleen, avc shall say a feAV Avords concerning the physical diagnosis of diseases of the spleen in general. The upper part of the spleen lies in the hollow of the diaphragm, and is covered by the loAver border of the left lung; its loAver part lies in immediate apposition Avith the wall of the thorax, and normally does not quite reach to the angle of the ribs. Percussion is frequently the sole means of recognizing an enlargement of the spleen, as that oro-an frequently does not reach below the margin of the ribs even when decidedly enlarged. The normal dulness of tne spleen extends from the upper margin of the eleventh rib to the ninth rib; anteriorly it is bounded by a line draAvn from the anterior end of the eleventh rib to the nipple; posteriorly the spleen-dulness cannot be defined from that of the left lddney. Its greatest thickness is about twc 710 DISEASES OF THE SPLEEN. inches. If the spleen enlarges, its dulness partly extends forward and doAvmvard, and partly, by pushing the diaphragm before it, upward, but rarely higher than the fifth rib. If the intestines be distended by gas, and the abdominal walls be tense, the dulness extends more upward; if the intestines be empty, and the abdominal walls relaxed, it extends more anteriorly and downward. The spleen-dulness changes its place during respiration, being about an inch lower on deep inspiration, and about an inch higher on full expiration. When the patient lies on the right side, the spleen-dulness is less ; hence it is well to examine the patient in different positions, and, if we wish to determine whether the extent of dulness varies from time to time, we should carefully note in what position of the patient the preAdous examination was made. If tumors of the spleen project beloAV the ribs, and be not too soft, we may readily recognize them, and distinguish them from other tumors by palpation. WhUe they haA'e only a moderate extent, they can often only be felt when the patient inspires deeply; on expiration, they disappear beneath the ribs. When the growth is considerable, the swelling graduaUy extends from tfie left fiypochondrium, obliquely, toward the navel. It almost always maintains the characteristic form of the spleen, particularly the shallow excavation in the anterior rounded edge. The tumor follows the movements of the diaphragm, can be readily moved, and changes its position with the position of the body. When the spleen is very large, instead of taking an oblique direction, it often passes directly downward into the pelAds, and, be- coming less movable, no longer follows the motions of the diaphragm. The spleen-dulness may disappear from the thorax, as'a result of elongation of the ligament attaching the spleen to the diaphragm, from the Aveight and size of the enlarged organ. In some cases even inspection shows the enlargement of the spleen by a prominence of the left hypochondrium and left half of the abdo- men, in which the contours of the spleen are occasionally noticed. The spleen enlarged by hyperaemia does not by any means always extend below the ribs, and, even Avhen it does, may escape detection by palpation if it be very soft. If hyperaemia of the spleen accompany abdominal typhus, on per- cussion we usually find the dulness extending more backward, on ac- count of the meteorism of the intestines; if, on the other hand, it ac- eompany an intermittent, the dulness rather extends toward the axUla, and occupies the left hypochondrium. Treatment.—In accordance with what we have said of its course, hyperaemia of the spleen is rarely the object of treatment. If Ave can remove the original disease, it almost always disappears in a short HYPERTROPHY OF THE SPLEEN. 711 time Avithout our interference. For those forms that do not sub- side spontaneously, particularly for those caused by malaria, we have a very effective remedy. If we avoid all exaggeration, and rely on trustworthy observations, it still appears probable that, in the whole materia medica, there are very few remedies that act certainly against any diseases as quinine and the preparations of Peruvian bark do in the hyperaemia of the spleen resulting from malaria. We do not knoAV whether quinine acts by directly inducing contraction of the muscular elements of the spleen, or AA'hether it acti as an antidote to the malaria, and, by destroying the cause, arrests its results, or Avhether it removes the hyperaemia of the spleen in some other way; but we do Ioioav that, if, after the attacks have ceased, the spleen remains en- larged or decreases in size very slowly, the disappearance of the swell- ing is caused or hastened by giving large doses of quinine. It is cer- tain that the effect of quinine on hyperaemia of the spleen cannot be solely due to its arresting the fever. According to Fleury's observations, the enlarged spleen is reduced several centimetres during the application of the cold douche. Fleury refers to the observations of Andral and Plorry in support of his as- sertions. This procedure deserves attention in treating hyperaemia of Uie spleen, if circumstances permit it. CHAPTER II. HYPERTROPHY OF THE SPLEEN--CHRONIC ENLARGEMENT OF THE SPLEEN—ANAEMIA ET CACHEXIA SPLENICA. Etiology.—I consider the name of hypertrophy of the spleen as best suited for that form of enlargement of the organ, Avhere its size and weight are increased, Avithout any change in its texture being ob- servable. But in the form of enlargement of the spleen under consid- eration, the increase of the trabecular tissue is unimportant, as com- pared Avith the far greater increase of the pulp, and the latter forms the most important factor in the enlargement. With our present knoAvledge, in most cases we cannot fully an- swer the question as to Avhether the increase of the pulp of the spleen be due to excessive formation, a " hyperplasia" of its cellular ele- ments or to their abnormal accumulation as a result of obstruction to their escape. It is almost universally befieved that the spaces betAveen the trabeculae of the spleen, Avhich contain the pulp, in some Avay communicate with the vessels. If this view is the true one, that is if the blood Aoavs through those spaces, and constantly car- ries cellular elements out of them, just as the lymph floAving through 712 DISEASES OF THE SPLEEN. the cells in the lymphatic glands carries cellular elements from them into the lymph, it is most probable that, if the stream of blood in the spleen is much retarded, the pulp of the spleen must increase, be- cause less of its cells are carried into the blood. The increased size of the current due to distention of the vessels, and still more to disten- tion of the intertrabecular spaces from the hyperaemic SAvelHng, very decidedly retards the current of blood in the spleen; and, since long- continued hyperaemia of the organ constantly induces hypertrophy, it is very probable th#t this form of hypertrophy of the spleen, at least, is due to accumulation of the pulp, and not to its excessive formation. When speaking of leuchaemia (see appendix to this chapter), we shall mention a degeneration of the spleen which cannot be ana- tomically distinguished from the one under consideration, but Avhich must be separately considered, because the changes it induces in the composition of the blood are so pecuhar that we must suspect a de- cided functional difference. We shall shoAV that in leuchaemia the en- largement of the spleen is not due to retention of the cellular ele- ments, but to their multiplication. Among the different forms of fluxionary hyperaemia, those caused by malaria most frequently induce hypertrophy of the spleen; and we find chronic enlargement of that organ, not only when the malarial in- fection assumes the form of an intermittent fever, but also Avhen it induces remittent fever, or a chronic disease, without paroxysms. Where malaria is endemic, numbers of persons have immense spleens, and it even appears as if the largest tumors are found in persons who escape regularly recurring paroxysms of fever. Among the congestive hyperaemias, those caused by cirrhosis of the liver and obliteration of the portal vein most frequently result in hypertrophy of the spleen, and this is the strongest proof of the cor- rectness of the hypothesis that this form of spleen-disease is caused in a purely mechanical Avay, by accumulation of cellular elements, as a result of obstructed escape of the blood. Recently a number of cases of decided hypertrophy of the spleen, occurring without any perceptible cause, have been observed and de- scribed. As the anatomical appearances of these "idiopathic" en- largements of the spleen appeared to correspond entirely Avith those of leuchaemic spleens, of Avhich Ave shall hereafter speak, and as the symptoms observed during life (except the increase of the colorless corpuscles of the blood) were very simUar to those of leuchaemia, the name of pseudo-leuchaemia has been proposed for this disease, whUe other observers designate it as anaemia or cachexia splenica. In the so-called pseudo-leuchaemia, besides the affection of the spleen, there is almost ahvays an analogous affection of the lymphatic glands, that is, HYPERTROPHY OF THE SPLEEN. 713 their decided enlargement depending on simple increase of the normal elements. In some cases the spleen is most affected (splenic form), in others the lymphatic glands (lymphatic forms). Anatomical Appearances.—As a result of hypertrophy, the spleen may become so enormous as to measure one foot to a foot and a half long, over six inches wide, and over four thick. It may attain a weight of tAvelve pounds or more. The form of the enlarged organ is not changed; its resistance is increased, so that it occasionally be- comes as hard as a board. In recent cases, the color of the paren- chyma is dark-brownish red, in older ones it is usually the color of the muscles or pale red. If the hypertrophy has resulted from malarial affection, the pale, homogeneous, and dry cut surface usually has a gray tinge, or we find dark spots in it. In tfie appendix to this sec- tion, when speaking of melanaemia, we shall more particularly describe the extensive deposits of pigment which occasionally remain in the spleen after pernicious intermittent fever. The capsule of the hyper- trophied spleen is usually thickened, cloudy, and not unfrequently ad-* herent to its surroundings. The thickened and rigid trabeculae of the spleen appear as white striae on the cut surface. Besides the closely-packed normal elements of the pulp of the spleen and interspersed pigment, microscopical examination does not shoAV any foreign formations. In the idiopathic as AveU as in the leuchaemic enlargements of the spleen, we not unfrequently find Avedge-shaped masses simUar to the haemorrhagic infarctions to be described in Chap- ter IV. Symptoms and Course.—While examining a previously healthy and fresh-looking person for an acute disease, Ave not unfrequently find a great enlargement of the spleen. Such cases prove either that a morbidly-enlarged spleen can fulfil its functions, or that other organs may act vicariously for it. In favor of the latter supposition is the vvell-knoAvn fact that dogs, from Avhich the spleen has been removed, may live a long AA'hile, be well nourished, propagate the species, etc. The relative or even perfect good health, often found in persons Avith old enlargement of the spleen, is very analogous to the perfect health and blooming looks of persons Avho, for years, have had enlarged lymphatic glands in the neck or elsewhere. If Ave carefully examine the history we shall find that when the enlargement of the spleen or the swelling of the glands occurred, the patient's state Avas not by any means so fair as at the time of examination, but that there Avere at that time more or less decided signs of anaemia and cachexia. This appearance of anaemic symptoms, at the time of the occmrence of the enlargement of the spleen and lymphatic glands in question, and the subsequent disappearance of the anaemia, in spite of the continuance of 714 DISEASES OF THE SPLEEN. the tumors, are perfectly in accordance with the doctrine that the spleen and lymphatic glands are the places where the blood-corpuscles are formed. Apparently the state of affairs is as folloAVS: When the ceUs formed in the intertrabecular spaces of the spleen, or in the cells of the lymphatic glands, are retained in any way, and are not normally borne along by the blood and lymph, they accumulate in these places; the spleen or the lymphatic glands, as the case may be, swell up and the blood becomes poor, as the used-up blood-corpuscles are not replaced by others. If the obstruction to the passage of the young cells into the circulation be removed, the growth of the spleen and lymphatic glands ceases, and the blood is gradually improved by a sufficient sup- ply of young cells, even if the enlarged spleen or lymphatic glands do not decrease in size. If the spleen continues to enlarge for a long time, there is great impoverishment of the blood. The patients become excessively dull and feeble; then skin grows waxy, and brunettes acquire a clayey look * (" splenetic "). The lips and visible mucous membranes also appear very pale and bloodless. Since the number of blood-corpuscles aerated in the lungs is diminished, the usual number of inspirations no longer suffices to supply the blood with oxygen, and to remove the carbonic acid. Hence the patients are short-breathed, and, where bodUy ex- ertion and similar causes increase the demands for oxygen, they suffer from dyspnoea. The nutrition of the walls of the capillaries also suffers from the impoverishment of the blood, and they become morbid- ly fragile, causing a haemorrhagic diathesis. CapUlary haemorrhages occur AA'ithout perceptible cause, apparently spontaneously, particularly epistaxis, and we have petechiae from haemorrhages in the tissue of the skin. The common assertion, that in disease of the spleen the bleed- ing usually proceeds from the left nostril, is false. If the disease con- tinues to progress, the anaemia, or more properly the hydraemia, finally increases to a so-called dropsical crasis; there is usually oedema of the lower extremities, and in severe cases there is gneeral dropsy. If the above symptoms be observed in a patient Avho has enlarge- ment of the spleen, as a result of malarial infection, or as a complica- tion of chrhosis of the liver, it may be difficult to decide what part of the symptoms is due to the disease of the spleen, and what to the original disease; nevertheless, the fact that the grade of the hydraemia, both in the malarial infection and in the cirrhosis, has a certain relation to the amount of enlargement of the spleen, justifies us in not rating too tow the effect of the spleen-disease on the impoverishment of the blood even in such cases. This influence is far more striking in cases where the enlargement of the spleen is independent of other diseases, and occurs as a primary and idiopathic affection. HYPERTROPHY OF THE SPLEEN. 715 I would find it difficult to make a distinction between the so-called pseudoleuchaemia (a very unsuitable name) and the chronic spleen-dis- ease Avhich has been recognized for ages and has frequently been care- fully described. Steadily increasing impoverishment of the blood, great paleness of the skin and visible mucous membranes, haemorrha- gic diathesis, and in severe cases dropsical symptoms, together Avith the enlargement of the spleen which is often decided, form the symp- toms of the pretended new disease. These symptoms, which are often considered as pathognomonic of spleen-disease, reach a very high grade, and finally cause death in idiopathic enlargement of that organ: first, because avc cannot arrest the enlargement; secondly, because in many cases the affection of the spleen is accompanied by a simUar disease of the lymphatic glands. In most of seven cases of idiopathic enlargement of the spleen that have come under my OAvn observation, and have been reported by my assistant, Dr. Mutter, in the " Berliner klinischen Wochenschrift," besides the enlargement of the spleen, there was de- cided swelling of numerous lymphatic glands. After what we have pre- viously said, it cannot appear strange that the simultaneous disease of the spleen and of the lymphatic glands, which also participate in the formation of the blood-corpuscles, is a very dangerous compfication, and tfiat it should induce the highest grade of impoverishment of the blood. As hypertrophy most frequently causes very great enlargement of the spleen, the enlargement may be recognized, on physical examina- tion, both by1 inspection and palpation as well as by percussion. The tumor preserves the characteristic form of the spleen; its resistance is increased, although not so much so as lardaceous spleen, which Ave shall describe in the next chapter. Treatment.—Recent hypertrophy of the spleen, resulting from malarial infection, calls for the same treatment that Avas recommended in chronic hyperaemia of that organ. Change of residence and the use of the preparations of PeruAdan bark, particularly of quinine, are exceed- ingly useful; but the patient should not return to the malarial region too soon, and should perseveringly use the quinine for a long time. Even in old cases of hypertrophy Ave should try the effect of these remedies. Of the numerous derivatives recommended for the treatment of chronic enlargement of the spleen, the cold douche alone appears serviceable, while, blistering-plaster, issues, the actual cautery, etc., OA-er the spleen, promise but little benefit. The preparations of iron are very extensively and very properly used in the treatment of this affection; among these, muriate and iodide of fron are particularly celebrated. We will not undertake to say whether they have any in- fluence in decreasing the size of the spleen, or whether then beneficial effect is due to the improvement of the quality of the blood. The effect 716 DISEASES OF THE SPLEEN. is best when Ave combine the preparations of iron Avith quinine, or if Ave order the use of chalybeate mineral Avaters in some mountainous region, and at the same time let the patient take quinine continually. Treatment does no good in hypertrophy of the spleen due to cirrhosis, pylephlebitis, etc. CHAPTER III. LARDACEOUS SPLEEN--AMYLOID DEGENERATION OF THE SPLEEN. Etiology.—In lardaceous spleen the Avails of the vessels and the cellular elements of the pulp degenerate just as the liver-cells do in lardaceous liver. More rarely, in tfie so-called sago-spleen, the pulp is unaffected, the cells and nuclei only undergoing the lardaceous or amy- loid degeneration. Regarding the etiology of lardaceous spleen, Ave may refer to what was said of the analogous disease of the liver. The dyscrasiae there mentioned, scrofula, rachitis, tertiary syphilis, and mercurialism, also induce amyloid degeneration of the spleen. Lardaceous spleen only exceptionally complicates tuberculosis; on the other hand, it occurs quite frequently in malarial diseases, although far more rarely than simple hypertrophy. Anatomical Appearances.—Amyloid degeneration may cause as great enlargement of the spleen as results from the Irypertrophy men- tioned in the last chapter. The lardaceous spleen is very heavy, and excessively hard; if Ave attempt to bend it, we find that, besides being hard, it is A'ery friable. The color is usually a pale violet red; the fittle blood contained in it is watery ; the cut surface is homogeneous, smooth, dry, and has a lardaceous, waxy lustre. On microscopical ex- amination, we find the cellular elements of the pulp enlarged, of a dull color, with pale, homogeneous contents. On adding a solution of iodine, the preparation becomes yellowish red, and on a further ad- dition of sulphuric acid it becomes Adolet and blue. If the degeneration be limited to the Malpighian bodies, the organ is not usually so much enlarged. On incising the spleen, we find roundish, gelatinous granulations, resembfing SAVoUen sago, scattered through the moderately firm parenchyma. Microscopical examination shows that the cells and nuclei of the Malpighian bodies are changed in the manner above described for the spleen-pulp. Symptoms and Course.—In lardaceous degeneration of the spleen also, the patients are very anaemic and cachectic. Epistaxis, petechiae, and dropsy, are more frequent than in simple hypertrophy. And in this form of enlargement of the spleen it is even more difficult than in the preceding ones, to say hoAV far these symptoms depend on the HEMORRHAGIC INFARCTION OF THE SPLEEN. 717 original disease, and hoAV far on the degeneration of the spleen. More' over, besides the lardaceous degeneration of the spleen, there is usually an analogous affection of the liver and kidneys, which increases the im- poverishment of the blood. Physical examination often shows enor- mous enlargement of the organ. In spite of the similarity of the symptoms, the diagnosis between the two forms of chronic enlargement of the spleen is usuaUy easy. The occurrence of enlargement of the spleen in the course of one of the above-mentioned diseases, coincident disease of the liver and kid- neys, steady growth of the tumor, which never recedes, and its un- common firmness, speak in favor of lardaceous spleen, and against simple hypertrophy. Treatment.—Treatment is useless in lardaceous spleen. It is true, iodide of iron has a certain reputation, and it is possible that the impoverishment of the blood, and the dyscrasia causing the splenic disease, may be improved by its use; but, even if this happens, it is not probable that the size of the spleen avUI decrease, or that its struc- ture avUI again become normal. CHAPTER IV. HEMORRHAGIC INFARCTION AND INFLAMMATION OF THE SPLEEN— SPLENITIS. Etiology!—In no organ is haemorrhagic infarction more frequent than in the spleen, and in most cases it undoubtedly proceeds from ob- struction of a small artery by an embolus. The size of the splenic artery and the rapidity with which the blood Aoavs through it (a necessary result of the slight obstruction the blood meets in the spleen) explain why emboli from the aorta most readily enter the splenic artery. The emboli usually iriginate in the left heart, and are fibrinous coagula that have been deposited on rough places on the valves, in endocarditis and valvular disease, and have subsequently been Avashed off by the blood. When autopsy reveals extensive valvular disease, with roughness or rupture of the valves and chordae tendineae, it is almost a rarity not to find old or recent infarctions in the spleen. Far more rarely the emboli come from necrosed spots in the lungs, and have passed through the pulmonary vein and left heart, before entering the aorta and splenic artery. Haemorrhagic infarctions of the spleen also exceptionally occur in those diseases AA'hich usually induce only excessive hyperaemia of that oro-an. We find it as Avell in malarial infection as in typhus, septi- caemia, and the acute exanthemata. Jaschkowitz found that, when he had dhdded some of the nerves of the spleen, the pathological changes 718 DISEASES OF THE SPLEEN. usually called haemorrhagic infarctions sometimes occurred in the parts of the spleen supplied by the nerves that had been divided. As it is doubtful whether the parenchyma of the spleen be nor- mally separated from the current of blood by the Avails of the vessels, it becomes a question whether haemorrhagic infarction be due to an escape of blood from the vessels, or whether it be not rather owing to a coagulation of the blood in the vessels and in the intertrabecular spaces. In the latter case haemorrhagic infarction would represent thrombus of those spaces, as it were, and, like other thrombi, would be the result of a retardation of the current of blood. Primary inflammation of the spleen is an exceedingly rare disease. Even injuries are more apt to cause rupture than inflammation of that organ. Consecutive inflammation and suppuration of the spleen are more frequently induced by haemorrhagic infarctions, particularly by those occurring during infectious diseases. If the infarction be a primary coagulation in the vessels and in the intertrabecular spaces (which is at least as probable as the opposite view), then the splenitis would hold the same relation to the infarction that phlebitis does to thrombus of the veins. Anatomical Appearances.—Haemorrhagic infarctions of the spleen are roundish, or more frequently wedge-shaped collections (with the bases outwardly) of the size of a pea or a hen's egg. At first they are dark broAvn, or brownish red, and quite hard. The entire spleen is enlarged by fluxionary hyperaemia, the peritonaeum over the infarction is freshly inflamed. Later the collections become of a dirty-yellow color, starting from the centre. The final result varies : either fatty degen- eration occurs, and the mass is reabsorbed, and in place of the infarc- tion Ave have a retracted, callous cicatrix, or else a yellow, cheesy mass, which may become calcareous, remains; or, lastly, the infarction softens, and there is an abscess filled Avith detritus, in which pus-cor- puscles also appear after a time. The latter course chiefly is taken by those cases where small but numerous infarctions occur in typhus and similar diseases. We know nothing about the anatomical changes in primary splenitis before it has induced abscess. Occasionally Ave find the abscess in- capsulated in a proliferation of connective tissue; in other cases it is surrounded by disintegrated connective tissue, or the entire spleen, except its capsule, has become disintegrated, so that the latter forms a large sac, which is filled AA'ith pus. Finally the capsule of the spleen is perforated, and the contents of the abscess either enter the abdo- men, or, if the capsule has preAdously become adherent to the parts around, it enters some neighboring organ. Cases have been reported where the pus, from an abscess of the spleen, has entered the stomach, HEMORRHAGIC INFARCTION OF THE SPLEEN. 719 or colon, or, passing through the diaphragm, has reached the pleural sac, or has perforated outwardly, through the abdominal walls. It is only in very rare cases that an abscess of the spleen dries up, its con- tents becoming inspissated and calcareous, or breaking through the capsule, and being evacuated. Symptoms and Course.—Where haemorrhagic infarction occurs in the course of an infectious disease, it is almost always first recognized at the autopsy. On the other hand, where it accompanies heart-disease it can often be recognized during life. If endocarditis or valvular dis- ease has been diagnosed in a patient, and he complains of pain in the left hypochondrium, which is increased by pressure; if there be vomit- ing also, and physical examination shows enlargement of the spleen, Avhich did not exist a few days preAdously, Ave may decide that there is haemorrhagic infarction of that organ. The pain is due to the partial peritonitis Avhich almost always accompanies the infarction. The vom- iting is a sympathetic symptom. And, lastly, the enlargement of the spleen is the result of fluxionary hyperaemia. In almost all the cases I have seen, the above combination of symptoms commenced AAdth a chill, and Avas accompanied by repeated chUls. We have already said that these do not justify us in deciding on a septicaemic affection. Most cases of abscess of the spleen that have been described have been latent, and were not recognized during life. Chills, hectic fever, cachectic appearance, rapid emaciation, and dropsical symptoms showed that there Avas some severe disease, but its nature Avas not discovered. If, besides these symptoms, there Avas pain in the left hypochondrium, and enlargement of the spleen could be detected, it was occasionally possible to form a probable diagnosis. Distinct fluctuation Avas very rarely found. If the .abscess perforate the capsule of the spleen, and its contents be emptied into the abdomen, Ave have the symptoms of diffuse peri- tonitis ; or, if they have entered a capsulated space, those of a cir- cumscribed peritonitis. If its contents enter the stomach or colon, mixed blood and pus are vomited or passed at stool. If the perfora- tion take place into the pleura, into the lungs, or outAvardly, the symp- toms are similar to those described for perforation of abscesses of the liver in these directions. Treatment.—In haemorrhagic infarction, as in suppurative spleni- tis, treatment is of no avail. We can only give palliatives for the mobt urgent symptoms. Where the pain is severe, Ave should order local abstraction of blood and cataplasms ; for the sympathetic vomit- ing carbonates and bicarbonates of the alkalies, or, if it be very obsti- nate, Ave may give narcotics; fluctuating abscesses should be opened earlv, and AA'ith the same precautions as in abscesses of the liver. 720 DISEASES OF THE SPLEEN. CHAPTER V. TUBERCULOSIS, CARCINOMA, HYDATIDS OF THE SPLEEN. Tuberculosis of the spleen occurs, sometimes, under the form of numerous gray miliary tubercles, as one part of miliary tuberculosis; sometimes it complicates tuberculosis of the intestines and mesenteric glands, under the form of yellow, cheesy conglomerations of tubercle, which rarely attain the size of a hazel-nut, and only exceptionally break down and form vomicae. Tuberculosis of the spleen cannot be recognized during life, and hence there can be no question about its treatment. Carcinoma also is rarely observed in the spleen. Medullary car- cinoma is the only one of the various forms that ever occurs here. In almost all the cases on record, the disease did not affect the spleen primarily, but accompanied carcinoma of the stomach, liver, or retro- peritoneal glands. The spleen may acquire an uneven, nodular ap- pearance from large cancerous tumors. From the great rarity of car- cinoma of the spleen, it should be the last disease thought of when we are trying to determine the nature of an enlargement of that organ; AA'e should only make the diagnosis of carcinoma of the spleen when the enlargement no longer retains the characteristic form of the spleen, but has an irregular, nodulated surface, and when there is at the same time carcinoma of the stomach or liver. Hydatids of various size and number are also seen rarely in the spleen, and almost exclusively in cases where they also occur in the liver. During life they can only be recognized when hemispherical pro- tuberances, with the previously-described peculiarities of hydatid cysts, can be felt on the enlarged spleen. APPENDIX TO THE DISEASES OF THE SPLEEN. We do not propose to treat of leuchaemia and melanaemia, in the second volume, among diseases of the blood, but to class them among diseases of the spleen, as they generally depend on affections of that organ. But, as there are also cases of leuchaemia, and even some of melanaemia, Avhere the blood-affection cannot be referred to disease of the spleen, these affections must be described in an appendix. CHAPTER I. leuchaemia (leucocyth^emia—Bennett). Etiology.—A temporary increase of the colorless corpuscles of the blood takes place in a number of physiological and pathological conditions, as, during pregnancy, inflammatory diseases, or after great loss of blood. This A'ariation of the blood, from its normal state, is no more an independent disease than hyperinosis and hypnosis, anaemia, or hydraemia, but it is the result of various states. The case is different Avith leuchaemia. This very interesting dis- ease is defined by Virchow as a " change in the constitution of the tissue of the blood," the blood being classed among the tissues; in it Avhite corpuscles are to a great extent formed instead of red ones, so that the number of the former increases, AA'hile that of the latter dimin- ishes. We found our description on the classical work of Virchow, Avho has shoAvn that leuchaemia may depend either on disease of the spleen, or of the lymphatic glands, and that there are two forms of leuchaemia, the splenic and lymphatic. The changes of the spleen in the former, and of the lymphatic glands in the latter, consist chiefly in an increase of the cellular elements composing the pulp of the spleen, or filling the cells of the lymphatic glands. Since in leuchaemia Ave find the blood loaded Avith the elements, whose accumulation in the spleen and lymphatic glands causes the SAvelling of these organs, it Avould appear that the leuchaemic tumors 46 722 APPENDIX TO THE DISEASES OF THE SPLEF.X. are due to an increased formation of cellular elements, and not to their retention, as Ave thought Avas probable in the other forms of enlarged spleen and lymph glands. It is a question whether the cells, so plen- tifully formed in the spleen and lymphatic glands during leuchaemia, differ in any Avay from those formed under normal circumstances. If we could suppose that only the white corpuscles of the blood origi- nated from the colorless cells of the lymph and spleen pulp, leuchaemia might be regarded as a simple hyperplasia. Although the transfor- mation has not been directly observed, still it cannot be doubted that, under normal circumstances, the red corpuscles also originate from the ' dorless lymph-corpuscles, and from colorless cells of the spleen-pulp; hence, in explaining leuchaemia, Avhere tins transformation is much limited, Ave must suppose that the numerously-formed cells do not possess the power of becoming red blood-corpuscles. In certain cases of this disease, described by Virchow, Friedreich, and Bottcher, other oigans also, as the liver, kidneys, intestinal mu- cous membrane, and pleura, produced lymphatic elements at circum- scribed spots ; so that, as Virchow says, in these cases there was not only a lymphatic dyscrasia, but at the same time a lymphatic dia- thesis. The etiology of leuchaemia is entirely obscure. The disease is met Avith in both sexes, but more frequently in males than in females; it is very rare in childhood. Most cases recorded have affected persons of middle age. No connection has been proved betAveen this disease and malarial infection, or scrofula. In a feAV cases the disease ap- peared to have a certain relation to menstruation and to the puerperal state. Anatomical Appearances.—While, in normal blood, there are about three hundred and fifty red blood-corpuscles to one white one, in leuchaemia the number of white corpuscles may become so much in- creased, and that of the red ones so much diminished, that the former wUl become a sixth or even half as many as the latter. In the splenic form of the disease the Avhite blood-corpuscles are not distinguishable from those of normal blood; they are distinct, Avell-deA'eloped cells. In the lymphatic form, on the other hand, Virchow and other observ- ers found numerous free nuclei and small cells, both of Avhich corre- sponded exactly with the elements found in the lymphatic glands. If the spleen and lymphatic glands Avere diseased at the same time, if the spleen-disease preA-ailed, there Avere more of the larger, cellular ele- ments in the blood; on the other hand, the more extensive the dis- ease of the glands, the more numerous Avere the small lymphatic ele- ments. Examinations of leuchaemic blood have shown that its specific gravity is much less than that of normal blood: whUe the latter may be LEUCILEM1A—LEUCOCYTH.EMIA 723 considered as 1055, that of leuchaemic blood Avas found to be from 1036 to 1049. The diminution of the specific gravity of the serum of the blood Avas slighter and less constant. In the leuchaemic blood the proportion of Avater had increased, while, in spite of the increase of the white corpuscles, that of the solid constituents Avas decreased, as a result of the excessive diminution of the red corpuscles. This, together with the Ioav specific gravity of the white blood-corpuscles, explains the diminution of the specific gravity of the blood as a whole. The albu- men, fibrin, and salts of the blood sIioav no decided or constant anom- aly. The diminution in the amount of iron, which is considerable, is explained by the deficiency in red blood-corpuscles. And lastly, in leuchaemic blood, Scherer found certain constituents of the splenic fluid, such as hypoxanthin, lactic, formic, and acetic acids, and a body Avhose reactions corresponded Avith those of glutin; however, other con- stituents that Scherer has found in the spleen-fiuid, particularly uric acid, leucin, etc., have not been found in leuchaemic blood. On autopsy of persons avHo have died of leuchaemia in the heart, particularly the right one, and in the large blood-vessels, Ave often find yellow or yelloAvish-green, soft, smeary coagula, like thickened pus. In the smaller branches of the pulmonary artery, also, and in the A'eins of the heart and cerebral membranes, discolored puruloid contents haA'e occasionally been found. The proportion of Avhite blood-corpuscles varies in blood taken from different parts of the body. In that from the right heart, vena cava, and pulmonary artery, it is greater than in that from the left heart, and, in a case observed by De Pury, it Avas tAvice as great in the splenic as in the jugular A'ein. In most of the cases of leuchaemia that haA'e been published, the spleen Avas found greatly enlarged; its Aveight not unfrequently reached five to seven pounds, or more. In some cases the resistance of the enlarged spleen Avas increased but little, or not at all; in others (ap- parently older cases) it was decidedly greater. There was always plenty of spleen-pulp present; the thickened trabeculae formed white striae through it. Microscopic examination showed " the normal ele- ments, only they Avere more closely packed together" ( Virchow), just as in the aboA'e-described hypertrophic enlargement of the spleen, Avith Avhich the leuHicemic also agrees hi its general appearance. In most cases the capsule of the spleen was thickened, and was often adherent to the parts around. In many cases, besides the hypertrophy, there Avere recent or old haemorrhagic infarctions in the spleen. In the lymphatic form, the lymph-glands often formed immense tumors. Of the glands situated AAdthin the body, chiefiy the mesen- teric, lumbar, and epigastric have been found enlarged; of the periph- eral, the cervical, axillary, and inguinal glands. Usually, the spleen 701 APPENDIX TO THE DISEASES OF THE SPLEEN*. AA-as also diseased, but Virchow saAv one case AA'here the spleen Avas of normal size. I myself have seen a case on AA'hich there Avas no au< topsy, but hi which no decided enlargement of the spleen could be observed during life, Avhile the lymphatic glands Avere enormously en- larged. In all the cases the enlarged lymphatic glands Avere quite soft and pale, their surface smooth and Avatery-looking, the cortical substance was particularly SAVoUen, in some cases to the thickness of one-half to three-fourths of an inch ; it had a homogeneous, almost me- dullary, appearance, and, on pressure, evacuated a turbid, Avatery fluid. Microscopic examination shoAA'ed that the enlargement Avas entirely due to an excessive formation of cells, nuclei, and granules, similar to those occurring in normal glands. In most cases of this disease, the liver Avas found enlarged; it Avas occasionally soft, but usually hard and dense. An exceedingly interesting pathological new formation of lymphatic elements, outside of the lymph-glands, has been observed in some cases of leuchaemia. In tAvo cases, in the parenchyma of the fiver, and in one case in the kidneys also, Virchow found small white spots, from Avhich, on pressure, there Avas evacuated a Avhitish fiuid, consisting only of closely-packed free nuclei, and some small cells, which Avere almost filled by their nuclei. The new formation Avas enclosed by a fine mem- brane, could be quite readily freed from the surrounding parenchyma, and appeared to come from the walls of the blood-vessels and bile- ducts. Bottcher obseived a similar case. And, in one case of leuchae- mia, Friedreich found extensive proliferation of nuclei and small cells, not only in the liver and kidneys, but also at circumscribed spots in the pleura, and in the gastric and intestinal mucous membrane, Avhich caused partial thickenings of the pleura, and numerous elevations, of A-aried extent and prominence, in the stomach, small intestines, and rectum. Friedreich also succeeded in proving that the leuchaemic tumors of the pleura and intestinal mucous membrane originated from the connective-tissue corpuscles of those membranes. Symptoms and Course.—Usually the first symptoms of leuchaemia are SAvelling of the abdomen, a feeling of pressure and fulness in the left hypochondrium, and other signs of enlargement of the spleen. The enlargement has either come on without pain or fever, so that the time of its occurrence could not be dated, or it has taken place at in- tervals, during which there was pain in the region of the spleen, and the patient was feverish. And in the lymphatic form, also, the en- largement of the glands in the neck, axilla, etc., which has taken place sloAA-ly, or at intervals, first calls attention to the disease. In a feAV well-observed cases, which throAV a very clear ligfit on the dependence of the dyscrasia on the disease of the spleen and lymphatic glands, it LEUCILEMIA—LEUCOCYTHiEMIA. 725 was found that the enlargement of the spleen and glands existed for months and years before the disorder of the blood showed itself. As the blood becomes impoverished in red corpuscles, the patient becomes pale and cachectic; and as the corpuscles not unfrequently become fewer in leuchaemia than in the highest grades of chlorosis, the patients have a waxy appearance in typical cases. There are also almost ahvays complaints of Avant of breath and hastened respiration, for Avhich symptoms no sufficient explanation can be found in the respi ratory organs, and which appear due to decrease of red blood-corpuscle, by which the exchange of gases in the lungs is apparently effected. If the diaphragm be much pressed upward by the enlarged spleen, or if, as often happens, bronchial catarrh develop in the course of the dis- ease, the dyspnoea may become very great. Such a combination of symptoms should ahvays excite the suspicion that the patient is suffer- ing from leuchaemia, and induce an examination of the blood. For this purpose Ave do not need a large A'enesection, and the debUitated and bloodless state of the patient almost ahvays forbids this. In the blood that has been drawn we find at the border, betAveen the buffy coat and the clot, single clumps, or a connected, loose, grayish layer, consisting of colorless blood-corpuscles. If, by beating, Ave free the blood that has been draAvn of its fibrin, after standing for some time in a narroAV glass, the heavy red corpuscles sink, and the lighter colorless ones form a whitish, purulent-looking, or milky layer in the upper part of the vessel. If we place a drop of the blood, recently draAvn, under the microscope, Ave do not see a very feAV AA'hite corpuscles in the field, as Ave do in normal blood, but there are quantities of them which are not scattered around among the red corpuscles, but are more apt to be congregated in irregular clumps, as they are very adherent. The course of the disease varies. In some, but, by no means, in all cases, besides the above symptoms, there is a haemorrhagic dia- thesis. The patients have numerous haemorrhages, from the nose par- , ticularlv, more rarely from the intestinal canal, or into the tissue of the j skin, sometimes into the brain. The fatal termination is hastened by this complication. The patients either die suddenly of apoplexy, or are so exhausted by repeated and abundant loss of blood that they soon die of exhaustion and anaemia. If a haemorrhagic diathesis does not develop, the disease almost ahvays runs a tedious course, and may even continue for years. In such cases the enlargement of the spleen and lymphatic glands reaches a very high grade; the tension of the capsule of the spleen, and the infiammatory irritation in it, developed, perhaps, by the tension, or by haemorrhagic infarctions accompanying the hvpertrophy, cause occasional pain in the region of the spleen and febrile svmptoms. In these protracted cases the liver also is gener- 72G APPENDIX TO THE DISEASES OF THE SPLEEN. ally enlarged. The patients become much emaciated, and haA'e a very pale, cachectic look; the dyspnoea increases, and becomes extreme. Sediments of the urates, or of pure uric acid, are very frequently found in the urine. It is possible that their formation is partly due to the dyspnoea and fever; but there is also a probability that the uric acid is formed by the higher oxidation of the hypoxanthin that is so abun- dant in the blood. In many cases there is bronchial catarrh, so thpt the patients have severe cough, with mucous expectoration. Still mor» frequently there is intestinal catarrh, which leads to obstinate diarrhoea. Dropsy often occurs toward the end. That this does not occur sooner, as we should expect from the analogy with other conditions where the patient is pale and cachectic, is doubtless due to the fact that, in leu- chaemia, the decrease of the red blood-corpuscles is not accompanied by a corresponding decrease of the serum of the blood, as it is in other exhausting diseases. In the later stages of leuchaemia, the fever, which AA'as at first temporary, usually becomes permanent. Uhle, who care- fully measured the temperature, in one case, found a constant increase of one to one and one-half degrees during the latter Aveeks of fife. If no complication occurs, death results from gradual exhaustion; it is often preceded by symptoms of disturbed brain-function, delirium, or stupor. Treatment.—Up to the present time no case of recovery from leuchaemia is known, hence we cannot recommend any treatment that has actually proved successful. Quinine, iron, and iodine preparations have been used on account of their efficacy in some diseases of the spleen, and in anaemia. In the case of lymphatic leuchaemia that Avas under my observation, the enlargement of the glands temporarily sub- sided under the opposite mode of treatment, under the use of Zitt- mann's decoction. I afterward sent the patient to a Avater-cure es- tablishment, Avhere he improved and became healthy-looking. After a few months, however, the disease returned, advanced rapidly, and ended in death. CHAPTER II. MELANJEMIA. Etiology.—In melanaemia there is found in the blood a granular pigment, partly free, partly enclosed in cells, partly embedded in small hyaline coagula. There is no doubt that this pigment comes from the coloring matter of the blood, but it is a question where and under j Avhat circumstances it is formed. ( Almost all observers regard the spleen as the place where the pig- ment is formed in melanaemia. The frequent occurrence of pigmented MELANJEMIA. 727 ) cells in the spleens of animals, which some observers regard as phys- iological, others as pathological, as well as the fact that in melanaemia \ the pigment is almost alw s most abundant in the spleen, certainly \ faA'ors the idea that the pigment is chiefiy formed in the spleen, but V does not prove that it is formed there only, and is not formed in other (organs at the same time. Frerichs describes a case Avhere he found n.-» pigment in the spleen, while he found so much in the lh'er, that he i ras obliged to regard this organ as the place where it was formed. ' The extensive occurrence of pigment in the blood presupposes extensive destruction of red blood-corpuscles. Whether this takes place exclusively in the spleen or whether it takes place in other organs at the same time, all observations prove that it is due to the infiuence of malarial infection. The milder forms of simple intermit- tent feA'er do not, however, appear to cause the formation of pigment in the blood at all or else only moderately, and only the severe and obstinate forms, but particularly the pernicious intermittent, appear to cause the higher grades of melanaemia in this country. The corre- sponding reports of physicians in the tropics, about the dark color of the different organs, particularly of the brain, in the bodies of patients that have had remittent fever, render it very probable that this form of malarial disease also constantly, or at least very frequently, causes melanaemia. It is very probable tfiat the dilatation of the blood-A-essels and the consequent retardation of the current of blood (see page 711) become so great in pernicious intermittent, and in remittent marsh-fevers of the tropics, that the blood stagnates in the spleen. We might further suppose that the corpuscles in the stagnating blood are destroyed, and hence an altered pigment is developed from their hematin, processes Avhich avc often observe in stagnating extravasated blood. This ex- planation of the formation of pigment in a purely mechanical way is refuted by the fact that in intermittent fever the enlargement of the I spleen, and consequently the retardation of the current of blood through it, may be very decided without the occurrence of melanaemia; and on the contrary, melanaemia is found in cases where the spleen is only moderately enlarged. Hence AA*e must suppose that marsh miasm has a pernicious influence on the red corpuscles in some other way that Ave do not yet knoAV; and that in our country only in certain epidemics, but in the tropics in the endemic fevers, this influence fre- quently or constantly causes an extensive necrosis of the red blood- corpuscles, and the formation of pigment from its hematin {Grie- singer). Virchow's labors on the subject of pathological pigments readily explain why the pigment found in the blood appears not only as free 728 APPENDIX TO THE DISEASES OF THE SPLEEN. granules, but also as enclosed in colorless cells. This observer saAv that, in dissolving the hematin in a drop of blood by adding water, the hematin became most distinct in the colorless blood-corpuscles, and hence it is probable that, in the extensive destruction of blood- ceUs in the spleen, the hematin enters the colorless elements of the spleen-pulp, and with these reaches the blood. It is more difficult tc explain the occurrence of pigment in the blood in the form of irregular flakes. It is possible that these flakes consist of fibrin that has pre- cipitated on the angular granules; but it is more probable that the substance adherent to the pigment-granules, surrounding them like a bright border, consists of the protein substance that Avas combined AA'ith the fibrin in the blood-corpuscles that were destroyed ( Virchow). Anatomical Appearances.—In melanaemia the pigment found in the blood of the heart and vessels is black ; more rarely besides the black Ave find broAvn or yellowisfi-brown, rarely yellowish-red pigment. With acids and caustic alkalies it shows the following conditions, which Virchow has found peculiarly characteristic of pathological pigment: the more recent formations become pale and finally lose then color en- tirely, while the older ones resist the reaction of these reagents a long time {Frerichs). The small pigment-granules haA'e an irregularly roundish form. As Meckel, the first observer of pigment in tfie blood, saw, a larger or smaller number of these is almost always united, by a colorless substance, to roundish, spindle-shaped, or irregular flakes. The cells containing pigment sometimes have the size and form of the white corpuscles of the blood ; sometimes they are larger, and club or or spindle shaped; the latter resemble the spindle-shaped cells in the spleen-pulp, which Kolliker considers the epithelium of the splenic vein. Besides these forms, Frerichs observed large clumps of pig- ment of irregular shape, as Avell as cylindrical bodies that looked like small vessels. With the blood the pigment enters all the organs of the body, and, according to the amount collecting in the capUlaries, colors them more or less. According to Planer and Frerichs, we almost always find the most pigment in the spleen, so that it appears slate-gray and often almost black. Next to the spleen, the greatest amount of pigment is found in the liver and brain, particularly in the cortical substance. The liver is often steel-gray or blackish; the cortical substance of the brain chocolate or graphite color. Not unfrequently there is also a con- siderable collection of pigment in the kidneys, as a result of which usually the cortical substance has gray points in it. In the pulmonary vessels, particularly in the smaller ones, there is occasionally a large amount of pigment. In the vessels of the other tissues and organs it is never accumulated to any great extent; but the skin, mucous mem- Missing pages 729 to end. « s \ ^ y /\ r'Hii •..r.'.-.-.V.^.*jft'f ,,.jr!..,.»r.^icsjj :n «>•''* ■ iff-.■•* ••' Vwfvia: vj* LIBRARY OF MEDICINE NLM 02022526 D NLM020225280